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Sonographic Analysis of the Upper Labial Orbicularis Oris and Its Clinical Implications
Abstract
Background
Purse string lips, which include the vertical wrinkles over the lips are frequently observed in aged individuals. Botulinum toxin (BoNT-A) and fillers are routinely injected into these areas to remove the wrinkles; however, the anatomy of the orbicularis oris muscle (OOr) near the vermilion border area has not been well defined.
Objectives
The aim of this study was therefore to identify any morphological differences of the upper OOr via sonographic imaging.
Methods
The upper lip muscles as observed using an ultrasound device were divided into two muscles (pars peripheralis and pars marginalis) that were subsequently divided into a further two types (Type I and Type II) associated with the development of the pars marginalis. Type II was further divided into Type IIa and Type IIb depending on whether the muscle fibers were well developed and connected.
Results
On the midline of the lip, Type I, in which the pars marginalis was rarely observed and only appeared in traces, was observed in 20.0% of the volunteers. Type IIa, in which the pars marginalis was well-developed and appeared continuous, was observed in 42.9% of the volunteers. Type IIb, in which the pars marginalis was observed but appeared discontinuous, was observed in 37.1% of the volunteers.
Conclusions
The shapes of the upper pars marginalis of the OOr varied markedly between volunteers. Type classification of the OOr based on its shape and the lip appearance serves as a reliable source of reference information to be used when injecting BoNT-A into the upper lip.
... The use of US for minimally invasive procedures is increasing [17][18][19][20]. As already revealed in many facial US studies, the different echogenicity of the muscle and intramuscular tendon structures can be clearly demonstrated during dynamic movements [21]. ...
When botulinum neurotoxin (BoNT) is injected to treat glabellar frown lines, the corrugator supercilia muscle (CSM) and procerus muscles are the main targets. Although there have been many studies on the treatment of glabellar frown lines, no study has confirmed the dynamic movement under ultrasonography (US). This study examined and evaluated dynamic muscle movements under US, thereby providing more effective BoNT injection guidelines for glabellar frowning. Glabellar frowning was categorized as either Type A or B. Type A is the general frowning pattern in which vertical wrinkles are made by contracting the CSM and procerus muscles (81%, n = 13). On US images, the procerus muscle thickens and the bilateral CSMs contract. Type B is an upward frowning pattern demonstrating upward elevation of vertical wrinkles due to hyperactive contraction of the frontalis muscle during frowning (19%, n = 3). On US images, the hypoechoic frontalis muscle thickens, forming horizontal forehead lines. After BoNT injection into the CSM and frontalis muscle but not the procerus muscle, Type B patterns showed improvements in the vertical crease and horizontal forehead line. Both types showed improvement in glabellar frown lines after conventional injection, but the horizontal forehead line did not improve in Type B. Type B wrinkles improved after additional injections into the frontalis muscle. This study provided novel anatomical findings related to the injection of glabellar frown lines with BoNT. Preliminary analysis and optimized procedures using US will enable more effective and safer injections.
Background
The depressor anguli oris muscle (DAO) is a pivotal treatment target in creation of harmonic jawline. However, evidence of its live morphology remains scarce.
Objectives
This study aimed to reevaluate DAO by a facile ultrasound analysis and hereby guide safer and more effective botulinum toxin type A (BTX-A) injection.
Methods
A prospective ultrasound assessment was conducted in 41 patients. Morphology of DAO and its relative position with neighboring structures were appraised at the ubiquitous facial landmark, labiomandibular fold (LMF). Three-dimensional images were captured before and after receiving BTX-A injection based on sonographic evidence.
Results
The skin-to-muscle depths of DAO on average (measured from the medial to lateral border) were 5.26, 5.61, and 8.42 mm. DAO becomes thinner and wider from zone 1 to 3 (p < 0.001). Overlapping lengths between DAO and DLI increased from zone 1 to 3: 4.74, 9.68, 14.54 mm (p < 0.001). The medial border of DAO was located at 4.33, 6.12, 8.90 mm medial to LMF (zone 1-3), and no muscle fibers of DAO was observed at zone 1 and 2 in near one-third of patients. Mouth corner downturn angle improvement upon receiving BTX-A injection at zone 2 and 3 were 88.3%, 32.3%, and 14.7% for the neutral, maximum smile, and down-pulling mouth corner expressions.
Conclusions
This work established an informative ultrasound portrait of the DAO and structures in the perioral region, which suggests LMF as a convenient landmark to locate DAO. Injections at the middle and lower thirds of LMF at a 4-5 mm depth is recommended.
Background:
Crow's feet are bilateral orbital wrinkles formed by the orbital portion of the orbicularis oculi muscle, which is the target muscle for botulinum neurotoxin (BoNT) injection.
Objectives:
This study's aim was to demonstrate a novel BoNT injection guideline by assessing muscle width, thickness, and dynamic features using ultrasonography.
Methods:
Twenty healthy Korean volunteers (10 men, 10 women; mean age, 25.6) participated. The width, thickness, and dynamic movement of the orbicularis oculi muscle were measured using ultrasonography. Two volunteers were selected to receive BoNT injections. Injections were administered using a novel method with two curved reference lines passing a point 15 mm lateral to the lateral canthus (conventional injection) and a point 5 mm lateral to the lateral margin of the frontal process of zygomatic bone (additional injection).
Result:
At the lateral canthus level, the distance between the lateral margin of the frontal process and the most lateral margin of the orbicularis oculi muscle was 12.5 ± 1.3 mm. The thickness of the orbicularis oculi muscle at the midpoint of the frontal process, the lateral marginal of the frontal process, and 5 mm lateral to the lateral marginal of the frontal process was 0.7 ± 0.3 mm, 1.1 ± 0.3 mm, and 1.2 ± 0.3 mm, respectively. The crow's feet of the two volunteers began to disappear from day 3 and completely disappeared on day 7 after the injection.
Conclusion:
The novel injection technique based on the ultrasonographic anatomy resulted in improvements in the appearance of crow's feet.
Platelet-rich plasma (PRP) rejuvenation’s efficacy has been reported by numerous uncontrolled clinical case studies of inconsistent quality rather than large randomized and placebo-controlled trials. It was suggested that PRP could be considered as a valid anti-aging and rejuvenation treatment modality. The current literature review summarizes available evidence so far described in the literature with special critical attention to higher quality comparative studies published over the last 10 years. The few studies that could be retrieved and included in this review documented less favorable results. So far, there is no international consensus on clinical PRP use for esthetic rejuvenation. Whether a mix of growth factors does in fact generate a clinically significant more youthful look and whether PRP injections result in comparable or better rejuvenation than what can be expected from other simpler non-surgical modalities. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
The perioral area includes several anatomical regions: the upper lip including the philtrum area, lower lip, nasolabial fold region, mouth corner, cheek, and chin. The appearance of the perioral region changes with the aging process, repeated movements, loss of bony support, and sagging of the fat tissue. Other environmental factors, such as smoking, sunlight hazard, and poor oral hygiene, can accelerate the aging process. Rejuvenation of the perioral region can be challenging. However, the perioral region is a high risky area in minimally invasive procedures; therefore, anatomical understanding is critical to prevent serious complications.
Various recently introduced minimally invasive treatment modalities are now widely used for enhancing the aging face. In a special, filler is used to increase the volume of tissue, and so understanding the regional thickness and distribution of the facial superficial fat is essential for optimizing minimally invasive procedures. The aim of this study was to establish the overall facial skin and superficial fat thicknesses using a three‐dimensional (3D) scanning system. From 53 adult Korean and Thai embalmed adult cadavers, the undissected and serially‐dissected facial specimens were scanned and reconstructed. The facial skin and superficial fat thicknesses on seven facial regions were calculated from the superimposed images. The facial skin tended to become thicker in the order of the radix and dorsum, and the temple, supraorbital, forehead, perioral, cheek, and infraorbital areas. The skin was thinnest at radix and dorsum (1.51 ± 0.55 mm), and thickest in infraorbital region (1.97 ± 0.84 mm). The facial superficial fat thickness tended to increase in the order of the radix and dorsum, supraorbital, forehead, temple, cheek, infraorbital, and perioral regions. The superficial fat was thinnest at the radix and dorsum (1.61 ± 1.07 mm), and thickest in the perioral region (5.14 ± 3.31 mm). The facial superficial fat thickness tended to increase in the order of the radix and dorsum, supraorbital, forehead, temple, cheek, infraorbital, and perioral regions. The present findings indicate that 3D scanning system can yield crucial anatomical information about depths of the facial skin and superficial fat layers for utilization in various clinical procedures. Clin. Anat. 32:1008–1018, 2019. © 2019 Wiley Periodicals, Inc.
Aim
To investigate the exact location and position of hyaluronic acid fillers in the perioral region by ultrasound and optical coherence tomography.
Introduction
To date, there are few in vivo investigations in humans on the exact positioning of injectable hyaluronic acid fillers, and severe complications such as hematoma and thromboembolism are rarely addressed.
Materials and methods
There were nine female patients investigated in this pilot study. All of them were periorally injected with hyaluronic acid. The exact product, amount, and locations, as well as the injection techniques, were recorded and compared. Before, immediately after, and 18 days after injection, photo documentation as well as high-resolution ultrasonography and optical coherence tomography of the lip surface were performed.
Results
Minor bruising occurred, which resolved within 7 to 9 days. On day 18, no more hemorrhage could be detected. Injected material distributed well in the tissue, and no embolism or thrombosis occurred. However, the injected material came close (up to 1 mm) to important structures such as blood vessels. Lip wrinkles improved, and the lip surface was smoother and more even.
Conclusion
Hyaluronic acid injections can improve aesthetics and reduce fine wrinkles of the lips. In the patients investigated in this study, compression of structures such as vessels and nerve fibers did not occur, nor did any severe complications result from injection. However, one must be aware of serious complications (eg, hematoma, thromboembolism) and the important anatomic structures (eg, orbicularis oris muscle, vessels, and nerves), and injecting physicians should always have hyaluronidase as a rescue medication at hand.
Summary
Hyaluronic acid is a suitable tool for lip augmentation and reduction of fine lines; however, one must be aware of anatomic structures when injecting filler material into the lips and perioral area, and be familiar with the injection techniques.
Lips and the perioral area are of outstanding importance in youthful appearance, attractiveness, and beauty. In contrast to younger and middle aged females, there is only scant published data on minimally invasive procedures to restore and revitalize lips and perioral soft tissue in elderly females. In this review we report the signs of aging in this particular region and the underlying anatomy. We review studies on lip restoration in younger females and present our techniques for elderly women. With an individually tailored approach, elderly females benefit from minimally invasive techniques.
Sihler's staining allows visualization of the nerve distribution within soft tissues without extensive dissection and does not require slide preparation, unlike traditional approaches. This technique can be applied to the mucosa, muscle, and organs that contain myelinated nerve fibers. In particular, Sihler's technique may be considered the best tool for observing nerve distribution within skeletal muscles. The intramuscular distribution pattern of nerves is difficult to observe through manual manipulation due to the gradual tapering of nerves toward the terminal end of muscles, so it should be accompanied by histological studies to establish the finer branches therein. This method provides useful information not only for anatomists but also for physiologists and clinicians. Advanced knowledge of the nerve distribution patterns will be useful for developing guidelines for clinicians who perform operations such as muscle resection, tendon transplantation, and botulinum toxin injection. Furthermore, it is a useful technique to develop neurosurgical techniques and perform electrophysiological experiments. In this review, Sihler's staining technique is described in detail, covering its history, staining protocol, advantages, disadvantages, and possible applications. The application of this technique for determining the arterial distribution pattern is also described additionally in this study.
The orbicularis oris muscle plays a role in the production of primate facial expressions and vocalizations, nutrient intake, and in some non-human primates it is used as a prehensile, manipulative tool. As the chimpanzee (Pan troglodytes) is the closest living relative of humans, a comparison of the orbicularis oris muscle between these species may increase our understanding of the morphological specializations related to the differing functional demands of their lips and the factors responsible for their divergent evolution. To this end, this study compares the microanatomy of the mid-line upper fibers of the orbicularis oris muscle between chimpanzees and humans. A mid-line portion of the orbicularis oris muscle was harvested from the upper lips of three chimpanzee and five human cadavers. The sampled blocks included the area between the lateral borders of the nasal alar cartilages in both species. Each sample was processed for paraffin histology, sectioned and stained with a variety of protocols. Sections were examined for fiber direction and relative thickness of muscle layers. Ratios of cross-sectional connective tissue area vs. cross-sectional muscle tissue area, muscle fiber diameter and relative dermal thickness were calculated for each species. In both species, a clear pars marginalis layer was recognized, contrary to previous reports that only humans possess this layer. In chimpanzees, the relative fiber diameter and relative amount of muscle tissue (i.e. based on ratio of connective tissue area : muscle tissue area) were significantly (P < 0.05) greater than in humans. In contrast, measurements of relative dermal thickness showed that humans have a greater average dermal thickness of the upper lip than chimpanzees. Taken together, these results suggest that both human and chimpanzee orbicularis oris muscle upper fibers meet the specific functional demands associated with their divergent vocal and facial display repertoires, the development of human speech, and the use of the upper lip as a prehensile tool in chimpanzees.
To determine if there is an anatomic basis for subepithelial orbicularis oris muscle defects by directly comparing ultrasonographic images of the upper lip with corresponding histological sections obtained from cadavers.
Ultrasound was performed on the upper lips of previously frozen, unpreserved cadaver heads (n = 32), followed by dissection and sectioning of the upper lips. The ultrasound sequences were scored by a panel of raters, classifying the orbicularis oris muscle as negative, positive, or unknown for the presence of an orbicularis oris discontinuity (subepithelial defect). Based on ultrasound, six lip specimens were chosen for histological sectioning, were stained with hematoxylin-eosin and Gomori trichrome stain, and were evaluated with light microscopy at low (8x) and intermediate (100x) magnification.
One cadaver was scored positive for an orbicularis oris muscle discontinuity based on ultrasound; whereas, the remaining cadavers were scored negative. Of the cadavers with negative ultrasound scores, two were noted to have orbicularis oris muscles with "irregular" features (e.g., excessive localized thinning or asymmetry). From histology, the area of discontinuity as visualized on the positively scored ultrasound was characterized by both disorganized orbicularis oris muscle fibers and excess connective tissue within the muscle belly. In contrast, the localized thinning observed on some of the negatively scored ultrasounds was not confirmed by histology.
Abnormalities of the orbicularis oris muscle visualized by ultrasound have an anatomic basis as revealed through histology. Ultrasound is a useful tool for noninvasively identifying discontinuities of the orbicularis oris muscle.
Cigarette smoking is the single biggest preventable cause of death and disability in developed countries and is a significant public health concern. While known to be strongly associated with a number of cardiovascular and pulmonary diseases and cancers, smoking also leads to a variety of cutaneous manifestations.
This article reviews the effects of cigarette smoking on the skin and its appendages.
A literature review was based on a MEDLINE search (1966-2004) for English-language articles using the MeSH terms cutaneous, dermatology, tobacco, skin, and smoking. An additional search was subsequently undertaken for articles related to smoking and associated mucocutanous diseases, with the focus on pathogenesis and epidemiologic data. Articles presenting the highest level of evidence and latest reports were preferentially selected.
Smoking is strongly associated with numerous dermatologic conditions including poor wound healing, wrinkling and premature skin aging, squamous cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, oral cancers, and other oral conditions. In addition, it has an impact on the skin lesions observed in diabetes, lupus, and AIDS. The evidence linking smoking and melanoma, eczema, and acne is inconclusive. Anecdotal data exist on the possible protective effects of smoking in oral/genital aphthosis of Behçet's disease, herpes labialis, pyoderma gangrenosum, acral melanoma, and Kaposi's sarcoma in AIDS patients.
An appreciation of the adverse cutaneous consequences of smoking is important. Dermatologists can play an integral role in promoting smoking cessation by providing expert opinion and educating the public on the deleterious effects of smoking on the skin.
Background
Cigarette smoking is the single biggest preventable cause of death and disability in developed countries and is a significant public health concern. While known to be strongly associated with a number of cardiovascular and pulmonary diseases and cancers, smoking also leads to a variety of cutaneous manifestations.
Objective
This article reviews the effects of cigarette smoking on the skin and its appendages.
Methods
A literature review was based on a MEDLINE search (1966–2004) for English-language articles using the MeSH terms cutaneous, dermatology, tobacco, skin, and smoking. An additional search was subsequently undertaken for articles related to smoking and associated mucocutanous diseases, with the focus on pathogenesis and epidemiologic data. Articles presenting the highest level of evidence and latest reports were preferentially selected.
Results
Smoking is strongly associated with numerous dermatologic conditions including poor wound healing, wrinkling and premature skin aging, squamous cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, oral cancers, and other oral conditions. In addition, it has an impact on the skin lesions observed in diabetes, lupus, and AIDS. The evidence linking smoking and melanoma, eczema, and acne is inconclusive. Anecdotal data exist on the possible protective effects of smoking in oral/genital aphthosis of Behçet's disease, herpes labialis, pyoderma gangrenosum, acral melanoma, and Kaposi's sarcoma in AIDS patients.
Conclusions
An appreciation of the adverse cutaneous consequences of smoking is important. Dermatologists can play an integral role in promoting smoking cessation by providing expert opinion and educating the public on the deleterious effects of smoking on the skin.
This book, containing more than 200 cadaveric photos and 200 illustrations, aims to familiarize physicians practicing botulinum toxin type A (BoT-A) and filler injection with the anatomy of the facial mimetic muscles, vessels, and soft tissues in order to enable them to achieve optimum cosmetic results while avoiding possible adverse events. Anatomic considerations of importance when administering BoT-A and fillers are identified and in addition invaluable clinical guidelines are provided, highlighting, for example, the preferred injection points for BoT-A and the adequate depth of filler injection. Unique insights are also offered into the differences between Asians and Caucasians with regard to relevant anatomy. The contributing authors include an anatomist who offers distinctive anatomic perspectives on BoT-A and filler treatments and three expert physicians from different specialties, namely a dermatologist, a plastic surgeon, and a cosmetic physician, who share insights gained during extensive clinical experience in the use of BoT-A and fillers.
Background:
Knowledge of topographic skin thickness is important to plastic surgery of the face as it may guide resection and restoration in oncologic, aesthetic, and reconstructive procedures.
Objective:
The purpose of this study is to report the relative thickness of the face throughout 39 distinct subunits.
Methods:
Full-thickness punch biopsy samples were obtained at 39 predetermined anatomic locations of the face from 10 human cadaveric heads. Tissue was fixed in paraffin-embedded slides and analyzed using triplicate measurement of dermis and epidermis using computerized measurements. Data were analyzed using univariate statistical analysis and expressed as mean thickness values and relative thickness (RT) values based on the thinnest portion of the face.
Results:
The area of the face with the thickest dermis was the lower nasal sidewall (1969.2 µm, dRT: 2.59), and the thinnest was the upper medial eyelid (758.9 µm, dRT: 1.00). The area with the thickest epidermis was the upper lip (62.6 µm, eRT: 2.12), and the thinnest was the posterior auricular skin (29.6 µm, eRT: 1.00). Our results confirm that eyelid skin is the thinnest in the face. The thickest portions of the skin appeared to be in the lower nasal sidewall, but the measurements are comparable to those in the ala and posterior auricular skin, which are novel findings.
Conclusions:
The greatest epidermal, dermal and total skin thickness are found in the upper lip, right lower nasal sidewall, and left lower nasal sidewall respectively. The least epidermal skin thickness is in the posterior auricular skin. The least dermal skin thickness, and the least total skin thickness, are both in the upper medial eyelid.
High-resolution ultrasonography of the lips offers the opportunity to investigate the orbicularis oris muscle (OOM) and evaluate its morphology and function.
The goals of this paper are verification of the lip structures visible on ultrasound images by using histological section preparations and recommendation of uniform standards for sonographic examinations of the lips.
The lips of 78 healthy volunteers (age 4-77 years) where scanned with a Hitachi Hi Vision Avius ultrasound device equipped with a linear transducer (L75, variable frequency range 5.0-18.0 MHz). Systematic B-mode examination was performed at five defined points, and the lips where also scanned dynamically in multiple directions. The ultrasonography findings were verified by using histologic samples from five male body donors (age 72-83 years).
All parts of the OOM could be well distinguished from one another both histologically and ultrasonographically. Sonographically visible lip structures could be verified histologically. Labial glands and blood vessels of the mucosa could be identified with both methods.
Ultrasonography allows identification of lip structures and all parts of the OOM. Scars, injuries and atrophy of the lip musculature are well detectable. Functional examinations can visualize muscular dysfunctions and may support the diagnosis of dystonic or hypotonic functional deficits. The following parameters are mandatory for a standardized examination of the lips: sagittal and transverse images of upper and lower lips; use of anatomical "landmarks"; functional diagnostics in tensed and relaxed conditions.
The infraorbital nerve (ION) is a cardinal cutaneous nerve that provides general sensation to the mid face. Its twigs are vulnerable to iatrogenic damage during medical and dental manipulations. The aims of this study were to elucidate the distribution pattern of the ION and thus help to prevent nerve damage during medical procedures and to enable accurate prognostic evaluation where complications do occur. This was achieved by treating 7 human hemifaces with the Sihler modified staining protocol, which enables clear visualization of the course and distribution of nerves without the accidental displacement of these structures that can occur during classic dissection. The twigs of the ION can be classified into the usual 5 groups: inferior palpebral, innervating the lower eyelid in a fan-shaped area; external and internal nasal, reaching the nosewing and philtrum including the septal area between the nostrils, respectively; as well as medial and lateral superior labial, supplying the superior labial area from the midline to the mouth corner. Of particular note, the superior labial twigs fully innervated the infraorbital triangle formed by the infraorbital foramen, the most lateral point of the nosewing, and the mouth corner. In the superior 3-quarter area, the ION twigs made anastomoses with the buccal branches of the facial nerve, forming an infraorbital nervous plexus. The infraorbital triangle may be considered a dangerous zone with respect to the risk for iatrogenic complications associated with the various medical interventions such as implant placement.
The phenotypic variability of non-syndromic cleft lip (CL) is broad. We demonstrate that the prevalence of orbicularis oris (OO) muscle anomalies, detectable only by ultrasound, is higher in first-degree relatives of individuals with overt CL than in the general population. These findings suggest that occult OO defects may be part of the spectrum of the CL phenotype, that offspring of individuals with such defects are at an increased risk to develop overt CL, and that ultrasound may be a useful tool in future population studies designed to identify CL susceptibility genes. Am. J. Med. Genet. 90:155–161, 2000. © 2000 Wiley-Liss, Inc.
The phenotypic variability of non-syndromic cleft lip (CL) is broad. We demonstrate that the prevalence of orbicularis oris (OO) muscle anomalies, detectable only by ultrasound, is higher in first-degree relatives of individuals with overt CL than in the general population. These findings suggest that occult OO defects may be part of the spectrum of the CL phenotype, that offspring of individuals with such defects are at an increased risk to develop overt CL, and that ultrasound may be a useful tool in future population studies designed to identify CL susceptibility genes.
The lateral bulge deformity may result after primary cleft lip repair. In a pilot study, greater orbicularis oris thickness and levator width underlying the lateral bulge were identified using ultrasound. The purpose of this study was to evaluate postoperative results of anatomic muscle repair for lateral bulge correction.
Patients with a lateral bulge after primary unilateral cleft lip repair were prospectively recruited. Oronasal musculature and connective tissue dimensions were measured using ultrasound, preoperatively and postoperatively. Guided by preoperative ultrasound findings in each patient, lateral bulge correction consisted of total lip takedown and anatomic orbicularis oris reapproximation. Within each group, measurements between sides at corresponding landmarks were compared using t-tests. Ratios between sides at corresponding landmarks preoperatively and postoperatively were compared using parametric and nonparametric tests. Repeat measurements were performed to calculate intrarater reliability. Standardized video assessments of dynamic lip function were recorded preoperatively and postoperatively.
Average patient age was 17.4 years. Patients were evaluated preoperatively and postoperatively (n=14) at 7.8 months' mean follow-up. Cleft-side orbicularis thickness and levator width were greater preoperatively versus postoperatively (P=0.003 and P=0.018, respectively). Postoperatively, no differences were seen between sides for both orbicularis thickness (P=0.763) and levator width (P=0.626). All patients demonstrated improved lip contour and symmetry, both static and dynamically, on video assessments.
Lip contour, function, and aesthetics improved clinically, and lip muscle anatomy normalized postoperatively as assessed using ultrasound. Complete orbicularis oris takedown and anatomic reapproximation effectively addressed the lateral bulge deformity.
The lateral bulge is a common secondary deformity after primary cleft lip repair; however, its underlying anatomy remains undefined. The purpose of this study was to use real-time high-resolution ultrasound to better understand the anatomy underlying the lateral bulge deformity. Twenty-three patients with a lateral bulge were included in addition to 12 patients without clefts to validate ultrasound measurements. Muscle and connective tissue dimensions were recorded at standardized landmarks using ultrasound, both at rest and with movement. The cleft and noncleft sides (right and left in noncleft patients) were compared within groups, and ratios between sides were compared across groups using parametric and nonparametric tests. Repeat measurements were recorded to calculate intrarater reliability. Orbicularis oris thickness was greater on the cleft side in the lateral bulge group at rest, both at the philtral column and alar crease (P < 0.001), and with facial movement at the corresponding landmarks (alar crease: smile P < 0.001 and pucker P = 0.003; philtral column: smile P < 0.001 and pucker P = 0.001). The ratio for levator width was also greater in the lateral bulge group (P < 0.001). No differences were identified between sides at the corresponding landmarks in the noncleft group. Ultrasound enabled real-time high-resolution evaluation of anatomic differences underlying the lateral bulge deformity. It was associated with greater orbicularis oris thickness and levator width on the cleft side. Findings from this study may guide future surgical correction of the lateral lip bulge.
Women tend to develop more and deeper wrinkles in the perioral region than men. Although much is known about the complex mechanisms involved in skin aging, previous studies have described histologic differences between men and women with respect to skin aging only incidentally and have not investigated the perioral region.
The purpose of this study was to investigate gender-specific differences in the perioral skin.
To determine wrinkle severity, skin surface replicas of the upper lip region in 10 male and 10 female fresh cadavers were analyzed by using the dermaTOP blue three-dimensional digitizing system (Breuckmann, Meersburg, Germany). In 30 fresh male and female cadavers, three full-thickness lip resections were investigated in a blinded fashion for specific histologic features. All results were statistically analyzed in a linear regression model with SPSS software (version 15.0; SPSS, Chicago, IL).
The female replicas showed more and deeper wrinkles than the male replicas (P < .01). Histologic analysis revealed that the perioral skin of men displayed a significantly higher number of sebaceous glands (P = .000; 95% confidence interval [CI] 23.6-53.2), sweat glands (P = .002; 95% CI 2.1-8.1), and a higher ratio between vessel area and connective tissue area in the dermis (P = .009; 95% CI 0.003-0.021). The amount of hair follicles did not significantly differ between men and women, although the average number of sebaceous glands per hair follicle was greater in men (P = .002; 95% CI 0.33-1.28).
Women exhibit more and deeper wrinkles in the perioral region and their skin contains a significantly smaller number of appendages than men, which could be a feasible explanation for why women are more susceptible to development of perioral wrinkles.
Real-time ultrasound with a high frequency probe is used to image the circumoral musculature with the lips relaxed and contracted. The ultrasonic images show that muscle tissue makes up only a part of the total thickness of the lip, and varies among individuals in shape, transonicity (clearness) and thickness. The muscle layer in the upper lip is sandwiched between layers of facial and lingual connective tissue, while the muscle image in the lower lip lies close to the lingual surface. In a relaxed state the muscle layer in the lower lip is significantly thicker than that in the upper lip, and a mean difference also occurs in contraction, but to a considerably lesser degree. Thus the upper lip muscle appears to increase in thickness during contraction relatively more than does that of the lower lip. Furthermore, the contraction in the upper lip seems to occur fairly uniformly along the lip from left to right. The muscular changes in the lower lip are more complex, even though embryologically complexity is ascribed properly to the upper lip. In the lower lip contraction seems to occur in the lateral parts and in the mentalis muscle, but in the midline the orbicularis oris muscle remains quite inactive. More complex arrangements are essential merely to ensure support of the lower lip against gravity.
The determination of human skin thickness has been achieved through various methods, both in vivo and in vitro. Ultrasound and histometric analyses have been the most commonly used. However, absolute values of epidermal and dermal thicknesses have demonstrated variability among the different modalities, leaving questions regarding the ability to standardize or compare results of different studies.
A cadaver study was designed to examine skin thicknesses in multiple anatomical sites from the same subject. Using three fresh adult cadavers, skin biopsy specimens were obtained at 15 facial sites that were identified as clinically relevant locations: upper lip vermilion, lower lip vermilion, philtral column, chin, upper eyelid, lower eyelid, brow/forehead, submental crease, right cheek, left cheek, right neck, left neck, malar eminence, nasal dorsum, and nasal tip. Histometric measurements were obtained at each location.
In all subjects, the upper eyelid had the thinnest skin and was used as the denominator to calculate relative ratios of skin thicknesses with respect to other sites of the face. Using the upper eyelid average skin thickness, the nasal tip skin thickness was 3.30 times thicker and the brow/forehead was 2.8 times thicker.
The authors propose a standardized and clinically useful method of skin thickness analysis by defining the relative thickness index. By examining relative values of skin thickness, using each subject as his or her own control, the authors demonstrated consistent ratios of dermal and epidermal thickness from one facial site to another.
The aim of this study is to elucidate the muscular structure of the pars marginalis of the upper orbicularis oris muscle. Full-thickness upper lips of 11 Korean adult cadavers were used. Four sagittal sections were made and stained with trichrome. Throughout the vermilion zone of the upper lip, the pars marginalis is substantially anterior to the adjacent bundles of the pars peripheralis. The breadth was 1.3 to 2.5 mm above the vermillion border (2.5 +/- 0.8 mm on the midline of philtrum, 1.3 +/- 0.6 mm on the peak point of Cupid's bow, 1.6 +/- 0.5 mm at midlateral side, and 1.6 +/- 0.4 mm at mouth corner). The lowest limit of the pars marginalis was located 2.5 to 3.1 mm below the vermillion border (3.1 +/- 0.4 mm on the midline of philtrum, 3.0 +/- 0.7 mm on the peak point of Cupid's bow, 3.0 +/- 0.7 mm at midlateral side, and 2.5 +/- 0.7 mm at mouth corner). The thickness of the pars marginalis varied between 1.1 and 2.0 mm (2.0 +/- 0.5 mm on midline of philtrum, 1.8 +/- 0.5 mm on the peak point of Cupid's bow, 1.9 +/- 0.5 mm at midlateral side, and 1.1 +/- 0.3 mm at mouth corner). An anatomic knowledge is conducive to precise repairs of the upper lip, particularly in cheiloplasty of congenital cleft lips.
- Benedetto
- AV. Benedetto
Regional thickness of facial skin and superficial fat: application to the minimally invasive procedures
- YS Kim
- KW Lee
- JS Kim
Botulinum Toxins in Clinical Aesthetic Practice
- A V Benedetto
Benedetto AV. Botulinum Toxins in Clinical Aesthetic
Practice. 2nd ed. New York, NY: Informa Healthcare; 2011.