Pulmonary Embolism During Temporal Filling: The Middle Temporal Vein

In an article published online on February 27, 2014, in JAMA Facial Plastic Surgery, Jiang et al reported on a potentially fatal complication during the use of autologous fat transfer for facial augmentation. They described 3 patients with a nonthrombotic pulmonary embolism during autologous fat injection to the temple area. Two of 3 patients were under local anesthesia and 1 patient was under general anesthesia. The 2 patients under local anesthesia complained of sudden diaphoresis, dyspnea, and tachypnea. The other patient who was under general anesthesia had sudden cardiac and respiratory arrest and subsequently died. Autopsy confirmed a pulmonary embolism. The authors identified the middle temporal vein (MTV) as the culprit vessel that was cannulized. In this report, 10 cadaveric dissections were done to identify and characterize the MTV.

What’s the issue?

Facial augmentation with autologous fat as well as other filler materials has become increasingly popular. Therefore, knowledge of anatomy and vasculature are of utmost importance to help mitigate potential complications. The anatomic levels of the temporal region from superficial to deep include the epidermis, dermis, subcutaneous adipose, superficial musculoaponeurotic system, superficial temporal fascia, superficial layer of the deep temporal fascia, superficial temporal fat-pad, deep layer of the deep temporal fascia, and temporalis muscle. The MTV arises from 2 to 4 tributaries at the area of the lateral orbital angle. It is lifted by the superficial temporal fat-pad, and because it lies between the superficial and deep layers of the deep temporal fascia, the vein walls are kept patent and do not collapse during injection. The sentinel vein is one of the MTV’s tributaries and has the same characteristics. It lies lateral to the lateral orbital rim and perforates through the superficial layer of the deep temporal fascia. Another reason why the MTV is a risk factor for cannulization is its large caliber. The stem can be as wide as 3.15 +/- 0.13 mm. This study found a mean (standard deviation) of 2.06 (0.17) mm from the point of origin and 3.02 (0.23) mm at the palpebral fissure plane. The authors made the recommendation to use blunt-tipped needles during fat augmentation in this area as well as multiple injection sites with slow injection. This technique also can be applied to filling with other materials. Pulling back on the syringe before injection also can help as well as injecting small amounts in a steady retrograde fashion. Before your next filler patient, is it time for an anatomy review?

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