Nasal Arterial Vasculature:  Medical and Surgical Applications

Figure 1. Dissection of the main branches of the facial artery, showing the initial step in the dissection of the facial artery and its main branches. The facial artery (1) is visible lateral to the oral commissure; it then forms the subnasal artery (2), marginal alar artery (3), angular artery (4), and lateral nasal artery (5).

Figure 2. One of us (D.B.) performing an ultrasonography Doppler investigation on the right side of a patient. The device tip is placed on the pyriform aperture. The screen shows the registration of the blood flow of nasal arteries; tracking corresponds to the facial artery. The patient is ready to perform compression of the facial artery at the level of the mandible using his thumb.

Figure 3. Typical (type 1) facial artery. In its typical aspect, the facial artery courses directly to the oral commissure, lies in the upper lip medial to the nasolabial fold, reaches the alar-facial groove, and divides into terminal branches, which are the subnasal, lateral, and angular arteries. In this case (as in 80% [33 of 40] of our dissections), note the existence of the marginal alar artery, which follows the lower lateral cartilage caudal border, as the lateral nasal artery courses along the cranial artery. In most cases, the dorsal artery is not a direct branch of the facial artery.

Figure 4. Long (type 2) facial artery. In 15% of our cases (6 of 40), the facial artery ran into the cheek, parallel to the facial vein, forming the lateral nasal artery and branching into the angular artery. In this dissection, the ophthalmic artery was not colored by the red liquid dye injected only in the facial artery but has been dissected and is clearly visible at the superior medial orbit angle.

Figure 5. Short (type 3) facial artery and nasal vasculature. In this case, which corresponds to the dissection continued in Figure 3, the right facial artery ends in the parasymphyseal area, and the nasal blood flow comes from both the ipsilateral ophthalmic and contralateral facial arteries. The right ophthalmic artery forms the angular artery and the radix artery, which divides into the dorsal arteries.

Figure 6. Relationships among the lower lateral cartilage lateral crus, marginal alar arcade, and alar valve arcade. The right facial artery was injected with red methylmethacrylate dye. The photograph was taken after dermal resection and lower lateral cartilage lateral crus exposure. The angular artery is atrophic; the subnasal artery is clearly visible and runs into the nostril floor. In this anatomic situation, the facial artery culminates at the lateral nasal and marginal alar arteries. At the level of the radix, the dorsal nasal artery appears large, probably branching from the ophthalmic artery.

Figure 7. Alar valve and marginal alar arcades, showing the nostril circle. From a lateral basal view, this dissection demonstrates nasal anastomoses among the marginal nasal, rim, and columellar (branch of the superior labial and subnasal arteries) arteries, creating arcades at the level of the nostril rim and lower lateral cartilage caudal margin.

Figure 8. Polygonal system of superficial nasal arteries. In this dissection, the main nasal arteries were identified on both sides, forming intercarotid vertical and transfacial horizontal anastomoses.

Figure 9. Nasal ultrasonography Doppler investigation, showing blood flow inversion. In this tracking, the facial artery blood flow gives high positive peaks, while the ophthalmic artery blood flow gives shorter negative peaks. The first 3 positive peaks (ie, from the facial artery) are followed by 3 negative peaks (ie, from the ophthalmic artery). This blood flow inversion occurred when compression of the facial artery was performed, demonstrating a physiological intercarotid anastomosis. When both ipsilateral arteries are simultaneously compressed, the contralateral blood flow (ie, from the transfacial anastomosis) becomes effective, as illustrated by the remains of peaks in 50% of cases (20 of 40).

Figure 10. Concept of the nasal arterial vasculature, showing a complete anastomotic polygonal system. This is not present in all patients but demonstrates the basic data, from which anatomic and physiological variations can occur.

Figure 11. Complete nasal arterial vasculature, demonstrating the polygonal system. One can consider the nasal blood flow as a multidirectional system of interconnected arteries forming a vascular network. In this system, 3 arcades (marginal alar, alar valve, and radix) connect both hemifaces and are considered transfacial arcades; furthermore, these transfacial arcades are interconnected by longitudinal arteries (angular, intermediate, and dorsal), which are considered intercarotid vessels, forming a polygonal system whose blood flow can be provided by the facial artery or by the ophthalmic artery depending on physiological or pathologic situations.

Figure 12. Facial and nasal angiosome variations seen after injection of red saline into both facial arteries. The left facial artery was injected with dark red dye, and the right facial artery was injected with light red dye. The left temporal artery was injected with blue saline. The right facial angiosome is “normal” and includes the whole right nose, the columella, and the nasal tip.