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The External Nose: The Nasal Arteries and Their Course in Relation to the
Nasolabial Fold and Groove

Article  in  Plastic & Reconstructive Surgery · November 2016

DOI: 10.1097/PRS.0000000000002626

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 COSMETIC

The External Nose: The Nasal Arteries and

Their Course in Relation to the Nasolabial
Fold and Groove
Ulrike Pilsl, M.D.
Background: The blood supply to the external nose is poorly described. The
Friedrich Anderhuber, M.D.
aim of this study was to identify the different types of blood supply to the
Graz, Austria external nose and the course of the arteries in relation to the nasolabial fold
and groove and to the facial muscles.
Methods: With 96 facial halves of 48 adult specimens, the arteries of the outer
nose were dissected, and three-dimensional computed tomographic recon-
structions and horizontal sections were made.
Results: Three main types of blood supply to the external nose were identified,
associated with the different types of facial arteries. Moreover, a deep course of
the nasal arteries in relation to the nasolabial fold and a very superficial course
in relation to the nasolabial groove were found.
Conclusion: Knowledge regarding the nasal arteries is clinically relevant for fill-
er injection for aesthetic improvements of the nose and nasolabial fold and for
planning local flaps in facial reconstructions and also for rhinoplasty.  (Plast.
Reconstr. Surg. 138: 830e, 2016.)

T
he blood supply to the external nose comes
from two arterial sources: the external and
the internal carotid arteries. The internal
carotid artery releases the ophthalmic artery
within the cranial cavity, which in turn provides
the dorsal nasal artery. The dorsal nasal artery
runs over the medial palpebral ligament, reaches
the dorsum of the nose, and mainly supplies the
osseous part of the external nose. The external
carotid artery releases the facial artery, which
then provides the cartilaginous part of the exter-
nal nose with branches not described in detail in
the anatomical terminology. Almost all older and
newer reports on the blood supply to the outer
nose describe a lateral nasal artery or branch.
Some authors describe the lateral nasal artery
as the superior continuation of the facial artery,
which runs lateral to the nose and then in turn is
followed by the angular artery.1,2 Others describe
the lateral nasal branch as a small branch of the
facial artery, which runs to the ala of the nose.3
These different descriptions have caused some
confusion, but the latter interpretation is the
From the Institute of Macroscopic and Clinical Anatomy,
Medical University of Graz.
Received for publication February 11, 2016; accepted June
7, 2016.
Copyright © 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002626
correct one and the one described in the official
anatomical terminology.
The blood supply to the external nose is clini-
cally relevant for filler injections in the area of
the nasolabial fold and for planning local flaps
in facial reconstructions and also for rhinoplasty.
We have previously described four types of facial
arteries.4 The type 1 facial artery ended as an
angular artery in the medial angle of the eye, the
type 2 facial artery ended bowed at the dorsum
of the nose, the type 3 facial artery already ended
as the superior labial artery and, with type 4, the
facial artery, was divided into an anterior and a
posterior branch. The present study was a follow-
up and aimed to identify the different patterns of
blood supply to the external nose associated with
the four types of facial arteries. We also investi-
gated the relationship of the nasal arteries to the
superficial fat compartments of the face and their
course in relation to the mimic muscles.
MATERIALS AND METHODS
The blood vessels of the outer nose were stud-
ied in 96 facial halves of 48 specimens (23 female
and 25 male cadavers; aged 47 to 93 years). The
Disclosure: The authors have no financial interest
and the study is not supported by any funding source.

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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 138, Number 5 • Arteries of the External Nose

cadavers were embalmed with the Thiel method,5,6
and the arteries were injected with the Thiel arte-
rial mass.7 Three-dimensional computed tomo-
graphic reconstructions were obtained. Then, the
arteries of the nose were dissected and horizontal
sections were made.
RESULTS
We identified three main types of blood supply
to the external nose associated with the four types
of facial arteries described previously, as follows.4
Type A Nasal Supply
Type A nasal supply (Fig. 1, above) was defined
as a blood supply to the cartilaginous part of the
external nose from a type 1, type 2, or type 4 facial
artery. This was seen in 59 hemifaces (61.5 per-
cent). In all 59 of these cases, we found three
branches formed as arterial arcades, which we
named branches R1, R2, and R3. Branch R1 origi-
nated above the superior labial artery at the level
of the lateral edge of the nostril and ran along the
inferior margin of the nostril to the base of the
nose. In the median, it anastomosed with branch
R1 from the contralateral side of the face and the
nasal septal branch of the superior labial artery.
Branch R2 originated several millimeters above
branch R1, followed the superior margin of the
nostril, and branched out into several small arter-
ies at the tip of the nose. Branch R3 originated
from the facial artery above branch R2 and trav-
eled in an arc a few millimeters underneath the
osteochondral border to the dorsum of the nose.
Here, it anastomosed with the dorsal nasal artery
and branch R3 of the contralateral side of the face.
As mentioned above, these three branches origi-
nated from a type 1, type 2, or type 4 facial artery.
This means that if there was a type 1 facial artery
(textbook course) (type A1 nasal supply) (Fig. 1,
above, left), the artery simply released branches R1,
R2, and R3and ended as the angular artery in the
medial angle of the eye. This was seen in 28 hemi-
faces (29.2 percent) (Fig. 2). If the three branches

Fig. 1. Different types of nasal supply. (Above, left) Type A1. (Above, center) Type A2. (Above, right) Type A3. (Below, left) Type B1.
(Below, center) Type B2. (Below, right) Type B3. Red, facial artery; green, dorsal nasal artery; blue, infraorbital artery.

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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • November 2016
Fig. 2. Distribution of different types of nasal supply.
originated from a type 2 facial artery (type A2 nasal
supply) (Fig.  1, above, center), the artery released
branches R1 and R2 and finally ended as branch
R3 at the dorsum of the nose. This was seen in
19 hemifaces (19.8 percent). In the third case,
branches R1, R2, and R3 originated from a type
4 facial artery (anterior and posterior branch)
(type A3 nasal supply) (Fig. 1, above, right). Here,
we found two possibilities: one was that branch R1
originated from the anterior branch of the facial
artery, which then itself ended as branch R2, and
branch R3 was released by the posterior branch
of the facial artery. The second possibility was that
the anterior branch of the facial artery released
all three branches (R1, R2, and R3) and the pos-
terior branch did not take part in the supply of
the cartilaginous part of the nose. This was seen
in 12 hemifaces (12.5 percent). Overall, 59 facial
halves (61.5 percent) showed a type A nasal sup-
ply (Fig. 2), which means that the blood supply to
the cartilaginous part of the external nose arose
from the facial artery. The osseous part of the
nose was then consistently supplied by the dorsal
nasal artery.
Type B Nasal Supply
This type resulted from a facial artery, which
already ended as the superior labial artery (type
3 facial artery); thus, arteries other than the facial
artery had to provide the blood supply to the car-
tilaginous part of the nose (Fig.  1, below). Seven-
teen hemifaces (17.7 percent) showed this pattern.
Within type B, we again saw three subtypes. With
type B1 (Fig. 1, below, left), the cartilaginous part of
the external nose was supplied by the dorsal nasal
artery, but instead of releasing branches R1, R2,
and R3, the artery sent numerous small branches
to the cartilaginous part of the nose. Thus, the dor-
sal nasal artery supplied both the osseous part and
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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
the cartilaginous part of the nose. This was seen in
eight hemifaces (8.3 percent). With type B2 (Fig. 1,
below, center), the dorsal nasal artery released an
angular artery, which then provided the three
branches R1, R2, and R3. This means that, with
type B2, the dorsal nasal artery again supplied the
whole external nose as in type B1. Five facial halves
(5.2 percent) showed this pattern. With type B3
(Fig. 1, below, right), the three branches R1, R2, and
R3 also were found, but they originated from the
infraorbital artery, whereas the osseous part again
was supplied by the dorsal nasal artery. This pattern
was seen in four hemifaces (4.2 percent).
Type C Nasal Supply
Here, the blood supply to the nose was inde-
pendent of the present type of facial artery. There
were different patterns; for example, the facial
artery showed a type 1 course, but did not release
branches R2 and R3, and thus the main blood
supply to the cartilaginous part of the nose again
came from the dorsal nasal artery. Another possi-
bility within type C was a type 1 facial artery, but the
blood supply for the cartilaginous part of the nose
came from the infraorbital artery, which sent out
numerous small branches. In our study, 20 hemi-
faces (20.8 percent) showed this type (Fig. 3).
We did not find remarkable variations in the
blood supply of the osseous part of the external
nose by the dorsal nasal artery. The dorsal nasal
artery was found in all specimens and supplied
the root and the dorsum of the nose. Variations
of this artery primarily concerned the additional
blood supply of the cartilaginous part of the nose.
Overall, in 70.9 percent of our specimens (types
A1 to A3, B2, and B3), we found the three arterial
arcades (R1, R2, and R3) supplying the cartilagi-
nous part of the nose. In most cases, these arcades
originated from a type 1, 2, or 4 facial artery; in
 Volume 138, Number 5 • Arteries of the External Nose
Fig. 3. Computed tomographic three-dimensional reconstruc-
tion of the left facial half showing the type C nasal supply. The
facial artery (FA) releases branch R1 and ends as branch R2.
Branch R3 is released by the dorsal nasal artery (DNA).
Fig. 4. Cross-dissection of the left half of a face showing a type C
nasal supply. The facial artery ends as the superior labial artery.
The dorsal nasal artery (DNA) replaces the angular artery and
releases branches R1 and R3. Branch R2 comes from the right
side, where the specimen showed a type A1 nasal supply.
occasional cases, they originated from the dorsal
nasal artery or the infraorbital artery.
As our results refer to facial halves, it must of
course be mentioned that there may exist differ-
ent types of blood supply on both halves of a nose.
Thus, it is possible that, for example, one half
belongs to type A and the other half to type C, as
is shown in Figure 4.
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 5. Horizontal section at the level of the nasal wing. N, Naso-
labial compartment (fold); NLG, nasolabial groove; red arrow,
facial artery; blue arrow, branch R2.
Concerning the position of the arterial arcades
(R1, R2, and R3) in relation to the superficial fat
compartments of the face,8 we have previously
described that the facial artery is located deep to
the border between the nasolabial compartment
and the medial cheek compartment, and thus a
few millimeters lateral to the nasolabial groove.4
In consequence, the arterial arcades to the nose
initially travel deep to the nasolabial compart-
ment and become quite superficial in the nasola-
bial groove (Fig. 5).
In addition, the position of the arteries in rela-
tion to the facial muscles was studied. We have
recently described that the course of the facial artery
to the mimic muscles varies significantly.4 However,
the three arterial arcades (R1, R2, and R3) to the
nose appear at the medial edge of the zygomaticus
minor muscle and either run superficially to the
levator labii superioris and the levator labii supe-
rioris alaeque nasi muscles or penetrate them and
then travel superficially to the muscles of the nose.
DISCUSSION
Many descriptions in anatomical textbooks of
the blood supply to the external nose are impre-
cise. Small alar and dorsal branches arising from
the facial artery have been reported, albeit without
number, localization, or other detail.1–3 Our inves-
tigations show that in 70.9 percent, three arterial
arcades to the cartilaginous part of the nose are
present. Branch R2 most likely corresponds to
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 Plastic and Reconstructive Surgery • November 2016

the lateral nasal branch described in the anatomi-

cal terminology, but branches R1 and R3 are not
described.
Nakajima et al.,9 Pinar et al.,10 and Lang11 found
only two branches of the facial artery running to
the anterior part of the external nose. The first
branch (inferior alar branch) corresponds to our
branch R1, and the second (superior alar branch)
corresponds to our branch R3. They did not find
a vessel that corresponds to our branch R2, but
they describe small branches of the superior alar
branch, descending to the area where we found
branch R2. Lang11 found, in 5 percent, variations
where the blood supply to the outer nose came
from the opposite side or from the infraorbital or
the transverse facial artery. We did not find arter-
ies to the external nose originating from the trans-
verse facial artery, but we did see blood supply
from the opposite side. In one specimen (Fig. 4),
Fig. 6. The pink box represents a danger zone for percutaneous
we found a type A1 nasal supply emerging from
filler injection, but also a region of high density of perforators to
a type 1 facial artery on the right side; on the left
the nasolabial compartment.
side, this specimen showed a type 3 facial artery,
the dorsal nasal artery replaced the angular artery
and released branches R1 and R3, and branch R2 Therefore, the often used injection area for naso-
for the left half of the nose originated from the labial fold augmentation, located in the upper
right facial artery and ran bowed over the dorsum third of the nasolabial fold a few millimeters lat-
of the nose. Rohrich and Pessa12 described ana- eral to the nasal wing, is a danger zone (Fig. 6),
tomical compartments of the nose, bordered by a because here the arterial arcades to the nose cross
superior, a middle, and an inferior arterial arcade. the injection area, and an injury of the vessels
This most likely corresponds to our findings. with a consecutive intravascular filler injection is
There are numerous reports of facial and alar possible. Thus, we recommend filler injections
necrosis after filler injections into the nasolabial into the nasolabial groove deep to the arteries,
fold and nose, especially with hyaluronic acid.13–15 either by a percutaneous injection very close to
In this context, the terms “nasolabial fold” and the bone (supraperiosteal) or better by an intra-
“nasolabial groove” are usually used synonymously, oral approach,18 with a very low risk of injuring the
which can cause confusion. In our view, the nasola- arterial arcades. The fact that the arterial arcades
bial fold is one of the superficial fat compartments; to the nose travel in this danger zone implicates
whereas the nasolabial groove, which usually is at the same time the advantage that this is an area
reduced by filler injection, is a furrow that delim- with a high density of perforators, which is essen-
its the nose and upper lip from the cheek (Fig. 5). tial for the planning of lateral nasal artery perfo-
Not only necrosis of the skin of the nose, but also rator flaps.19 Because the cartilaginous part of the
loss of vision and central nervous system compli- outer nose can also be supplied by the dorsal nasal
cations after injection of autologous fat into the artery, and because of anastomoses between the
above-mentioned regions are reported.16,17 These branches of the facial artery to the nose and the
complications correspond well with our outcomes dorsal nasal artery, it is also possible that a filler
of the arterial supply of the face, in this particular material, inadvertently injected into one of those
case, of the nose. As described above, not the facial vessels, can embolize into the ophthalmic artery
artery itself, but the investigated arterial arcades or into the internal carotid artery with the con-
(R1, R2, and R3) travel behind the nasolabial sequence of vision loss or central nervous system
compartment (fold) and become very superficial complications.
in the nasolabial groove. This explains the local-
ized nasal alar necrosis after an accidental filler
injection into one of these arcades with nasola- CONCLUSIONS
bial fold augmentation, on condition that these The knowledge of the blood supply to the
arcades are present (70.9 percent in our study). external nose is clinically relevant for filler

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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 138, Number 5 • Arteries of the External Nose
injections and for rhinoplasties and for planning
flaps in facial reconstruction (e.g., the lateral
nasal artery perforator flap and the melolabial
flap for repair of the ala and the nasal sidewall
or the dorsal nasal flap for repair of caudal and
midnasal defects).9,19
Ulrike Pilsl, M.D.
Institute of Macroscopic and Clinical Anatomy
Harrachgasse 21
8010 Graz, Austria
ulrike.pilsl@medunigraz.at
references
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4. Pilsl U, Anderhuber F, Neugebauer S. The facial artery:
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7. Thiel W. An arterial substance for subsequent injection dur-
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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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8. Rohrich RJ, Pessa JE. The fat compartments of the face:
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