Finger Compression Technique with an OK Gesture on the Bilateral Emerging Points of the Ophthalmic Artery: A Simple Three-Step Method with Dual Real-Time Imaging to Reduce the Risk of Filler-Associated Blindness.

Abstract

Filler injections to the glabella, nose, or forehead have increased probabilities of catastrophic, irreversible vascular complications, including skin necrosis, blindness, and cerebrovascular accidents.1 Filler-associated blindness is mainly attributed to intravascular injection of filler material through the branches of the ophthalmic artery (OA), such as the supratrochlear artery, supraorbital artery, and dorsal nasal artery.1 The ophthalmic artery runs through the emerging points of the OA (EMP/OA), giving branches through the superior part of the medial orbital rim (SMOR) and supraorbital foramen or notch [SOF(N)] to nose, glabella, and forehead.1 Because intravascular occlusions are rare, recommendations for prevention have been based on expert consensus.2 Finger compression is one of the measures used to reduce the risk of filler-associated blindness in facial danger zones,2 but no demonstrations of precise positioning and hand gestures are available. In addition, patterns of the OA main branches emanating from the orbital fossa and the precise location of EMP/OA of the SMOR are variable within individuals.3 We propose a practical finger compression method under dual real-time imaging guidance that has been used in our daily practice of filler injection to the danger zones of the face. First, the SOF(N) can be palpated easily and is marked. Second, a transillumination device (Vein Viewer; Christie Medical Holdings, Inc., Memphis, TN) is used on the SMOR to determine the precise location of EMP/OA (Fig. 1), which are subsequently marked. Then, Doppler ultrasound examination (LeSono LU700L; Leltek, Inc., New Taipei City, Taiwan) is performed to confirm the locations of the EMP/OA of the SMOR and the SOF(N). [See Figure, Supplemental Digital Content 1, which shows the EMP/OA of the SMOR demonstrated in Doppler ultrasound examination. High Doppler signals indicate the EMP/OA with a 10-MHz ultrasound transducer (LeSono LU700L; Leltek, Inc.), https://links.lww.com/PRS/F601. See Figure, Supplemental Digital Content 2, which shows the EMP/OA of the SOF(N) demonstrated in Doppler ultrasound examination. High Doppler signals indicate the EMP/OA with a 10-MHz ultrasound transducer (LeSono LU700L; Leltek, Inc.), https://links.lww.com/PRS/F602.] Third, the bilateral EMP/OA of the SMOR and SOF(N) are compressed with the fingers of the nondominant hand in an “OK” gesture (Fig. 2) as fillers are injected with the dominant hand simultaneously. Additional compression force of the fingertips and finger pulps is targeted at the EMP/OA of the SMOR and SOF(N), respectively. Finger compression with an OK gesture is a basic and one-person technique to reduce the risk of filler-associated blindness during nose and forehead augmentation with a blunt cannula or for filling deep wrinkles of the glabella with a sharp needle.Fig. 1.: The emerging points of the ophthalmic artery (EMP/OA) shown by a transillumination device. The superior part of the medial orbital rim (SMOR) and supraorbital foramen or notch [SOF(N)] can be palpated and marked. Next, the precise emerging point of the ophthalmic artery of the superior part of the medial orbital rim is demonstrated by a transillumination device (Vein Viewer).Fig. 2.: OK gesture finger compression method. After the anatomic landmarks have been confirmed, bilateral emerging points of the ophthalmic artery of the superior part of the medial orbital rim and supraorbital foramen or notch are compressed with the nondominant hand in an OK gesture at the same time; fillers can be injected by the dominant hand simultaneously.Other finger compression techniques are modified based on the same concept and can be used to temporarily occlude unilateral or bilateral main branches of the OA [See Figure, Supplemental Digital Content 3, which shows the application of various finger compression techniques for injections in different danger zones. Various finger compression techniques can be used to temporarily occlude unilateral or bilateral main branches of the OA https://links.lww.com/PRS/F603.] This three-step method with dual real-time imaging is not aimed to eliminate vascular complications attributable to other coexistent pathways associated with filler-associated blindness, such as arteriovenous shunting and true anastomoses with the external carotid artery. Other strategies for reducing the risk of filler-associated blindness are encouraged to be performed simultaneously or sequentially to enhance the safety of facial volumetric rejuvenation.2 Investigation of the effectiveness of this method in large-scale studies is worthwhile. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this article.