title: An Anatomical Study of the Middle Temporal Vein and the Drainage Vascular Networks to Assess the Potential Complications and the Preventive Maneuver During Temporal Augmentation Using Both Anterograde and Retrograde Injections.
abstract: BACKGROUND
  Non-thrombotic pulmonary embolism has recently been reported as a remote complication of filler injections to correct hollowing in the temporal region. The middle temporal vein (MTV) has been identified as being highly susceptible to accidental injection.
  
  
  METHODS
  The anatomy and tributaries of the MTV were investigated in six soft embalmed cadavers. The MTV was cannulated and injected in both anterograde and retrograde directions in ten additional cadavers using saline and black filler, respectively.
  
  
  RESULTS
  The course and tributaries of the MTV were described. Regarding the infusion experiment, manual injection of saline was easily infused into the MTV toward the internal jugular vein, resulting in continuous flow of saline drainage. This revealed a direct channel from the MTV to the internal jugular vein. Assessment of a preventive maneuver during filler injections was effectively performed by pressing at the preauricular venous confluent point against the zygomatic process. Sudden retardation of saline flow from the drainage tube situated in the internal jugular vein was observed when the preauricular confluent point was compressed. Injection of black gel filler into the MTV and the tributaries through the cannulated tube directed toward the eye proved difficult.
  
  
  CONCLUSIONS
  The mechanism of venous filler emboli in a clinical setting occurs when the MTV is accidentally cannulated. The filler emboli follow the anterograde venous blood stream to the pulmonary artery causing non-thrombotic pulmonary embolism. Pressing of the pretragal confluent point is strongly recommended during temporal injection to help prevent filler complications, but does not totally eliminate complication occurrence.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .
authors.affiliation: The Chula Soft Cadaver Surgical Training Center and Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand, tansatitapinuntrum@gmail.com.
authors.forename: Tanvaa
authors.initials: T
authors.lastname: Tansatit
authors.forename: Prawit
authors.initials: P
authors.lastname: Apinuntrum
authors.forename: Thavorn
authors.initials: T
authors.lastname: Phetudom
mesh_terms: D002102:Cadaver; D002404:Catheterization / Q000379:methods; D000067548:Dermal Fillers / Q000009:adverse effects*; D004210:Dissection; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D011322:Primary Prevention / Q000379:methods; D012060:Rejuvenation; D012965:Sodium Chloride / Q000494:pharmacology; D013703:Temporal Muscle / Q000033:anatomy & histology* / Q000098:blood supply*; D014680:Veins / Q000033:anatomy & histology*
chemical_list: D000067548:Dermal Fillers; D012965:Sodium Chloride