Anatomical relationships of the procerus with the nasal ala and the nasal muscles: transverse part of the nasalis and levator labii superioris alaeque nasi

Wireless high-resolution surface facial electromyography mask for discrimination of standardized facial expressions in healthy adults

Wired high resolution surface electromyography (sEMG) using gelled electrodes is a standard method for psycho-physiological, neurological and medical research. Despite its widespread use electrode placement is elaborative, time-consuming, and the overall experimental setting is prone to mechanical artifacts and thus offers little flexibility. Wireless and easy-to-apply technologies would facilitate more accessible examination in a realistic setting. To address this, a novel smart skin technology consisting of wireless dry 16-electrodes was tested. The soft electrode arrays were attached to the right hemiface of 37 healthy adult participants (60% female; 20 to 57 years). The participants performed three runs of a standard set of different facial expression exercises. Linear mixed-effects models utilizing the sEMG amplitudes as outcome measure were used to evaluate differences between the facial movement tasks and runs (separately for every task). The smart electrodes showed specific activation patterns for each of the exercises. 82% of the exercises could be differentiated from each other with very high precision when using the average muscle action of all electrodes. The effects were consistent during the 3 runs. Thus, it appears that wireless high-resolution sEMG analysis with smart skin technology successfully discriminates standard facial expressions in research and clinical settings.

Reconsideration of the alar base cinch suture technique involving the perinasal musculature: an in-depth review

Orthognathic surgery affects both function and aesthetics. An important aesthetic complication is the nasal alteration that can result from Le Fort I osteotomy. A common method for countering this complication is the alar base cinch suture technique. Although the method for this suture has been standardized, the results vary and are inconsistent; further improvements are therefore required. The objective of this study was to review the literature data on the alar base cinch suture technique and associated results. In this review, the PubMed, Ovid, and Ichushi-Web electronic databases were searched using logical combinations of keywords related to the perinasal musculature and alar base cinch suture technique. Following screening of the results, 42 publications were included. The review findings prompted several conclusions. The anatomy of the myrtiformis muscle and depressor septi nasalis may differ between ethnicities, and it is essential to take certain factors related to ethnicity into account when implementing the alar base cinch suture technique. It is also important to consider factors such as the patient's aesthetic preferences.

Sonoanatomy of injecting botulinum neurotoxin into the facial muscles

INTRODUCTION

Ultrasonography (US) has become an essential tool for guiding botulinum neurotoxin (BoNT) injections in facial muscles, enhancing precision and safety. This narrative review explores the role of US in BoNT administration, particularly in complex anatomical regions, highlighting its impact on treatment customization, real-time visualization, and complication reduction.

MATERIALS AND METHODS

A comprehensive literature search was conducted using PubMed, MEDLINE, Embase, and Cochrane Library for articles published from January 2018 to December 2023. Search terms included "Botulinum neurotoxin," "facial anatomy," "ultrasonography guided injection," and "facial muscle sonoanatomy." Studies focusing on US-guided BoNT injections in facial muscles were included. Data extraction and synthesis were performed independently by two reviewers, focusing on study design, ultrasonography techniques, outcomes, and conclusions.

RESULTS

The review found that US guidance significantly enhances the precision of BoNT injections by providing real-time visualization of facial muscles and blood vessels, thereby reducing the risk of adverse events. US enables tailored injection strategies, ensuring symmetrical facial expressions and minimizing over-treatment. The technique also offers immediate feedback, allowing for on-the-spot adjustments to improve treatment efficacy and safety. However, the review identified limitations, including potential selection bias and variability in US techniques across different studies.

CONCLUSION

US guidance for BoNT injections into facial muscles offers substantial benefits in terms of precision, safety, and treatment customization. Despite the identified limitations, the integration of US into clinical practice is poised to enhance patient outcomes in aesthetic and therapeutic procedures. Further research is needed to standardize US techniques and broaden the inclusivity of studies to validate these findings comprehensively.

Advanced Injection of Botulinum Toxin in the Nasal Muscles: A Novel Dynamic Change in Facial Expression

BACKGROUND

Among the nasal muscles, the levator labii superior alaeque nasi (LLSAN) acts as a transitional muscle that conjugates with other nasal and perinasal muscles. Thus, when treating the nasal region with Botulinum toxin (BTX), it is important to understand local nasal muscular dynamics and how they can influence the muscular dynamics of the entire face.

METHODS

This is a retrospective analysis of cases treated by an injection pattern encompassing the face, including nasal muscles. Photographs were taken at rest and during motion (frontal and oblique views), before and after treatment.

RESULTS

A total of 227 patients have been treated in the last 18 months with the following results: eyebrow tail lifting, softness of crow's feet, improvement of the drooping of the tip of the nose, and shortening of the lip philtrum when smiling. We present cases illustrating the use of this approach.

CONCLUSIONS

Treating the facial muscles globally (including the frontal, corrugators, procerus, orbicularis oculi, platysma, DAO, and nasal muscles) can improve the smile and facial expressions. This is believed to occur because the elevated portion of the upper lip muscle becomes stronger as the nasal part of the LLSAN is paralyzed.

LEVEL OF EVIDENCE IV

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 .

Novel Anatomical Guidelines on Botulinum Neurotoxin Injection for Wrinkles in the Nose Region

Botulinum neurotoxin injection surrounding the nose area is frequently used in aesthetic settings. However, there is a shortage of thorough anatomical understanding that makes it difficult to treat wrinkles in the nose area. In this study, the anatomical aspects concerning the injection of botulinum neurotoxin into the nasalis, procerus, and levator labii superioris alaeque muscles are assessed. In addition, the present knowledge on localizing the botulinum neurotoxin injection point from a newer anatomy study is assessed. It was observed that, for the line-associated muscles in the nose region, the injection point may be more precisely defined. The optimal injection sites are the nasalis, procerus, and levator labii superioris alaeque muscles, and the injection technique is advised. We advise the best possible injection sites in association with anatomical standards for commonly injected muscles to increase efficiency in the nose region by removing the wrinkles. Similarly, these suggestions support a more precise procedure.

Anatomical connections among the depressor supercilii, levator labii superioris alaeque nasi, and inferior fibers of orbicularis oculi: Implications for variation in human facial expressions

The aim of this study was to determine how the depressor supercilii (DS) connects to the levator labii superioris alaeque nasi (LLSAN) and inferior fibers of the orbicularis oculi (OOc INF) in the human midface. While grimacing, contraction of the DS with fibers connecting to the LLSAN and OOc INF can assist in pulling the medial eyebrow downward more than when these connecting fibers are not present. Contraction of these distinct connecting fibers between the DS and the LLSAN can also slightly elevate the nasal ala and upper lip. The DS was examined in 44 specimens of embalmed adult Korean cadavers. We found that the DS connected to the LLSAN or the OOc INF by muscle fibers or thin aponeuroses in 33 (75.0%) of the 44 specimens. The DS was connected to both the LLSAN and OOc INF by muscle fibers or aponeuroses and had no connection to either in 5 (11.4%) and 11 (25.0%) specimens, respectively. The DS was connected to the LLSAN by the muscle fibers and thin aponeuroses in 6 (13.6%) and 4 (9.1%) specimens, respectively. The DS was connected to the OOc INF by the muscle fibers and thin aponeuroses in 5 (11.4%) and 23 (52.3%) specimens, respectively. Our findings regarding the anatomical connections of the glabellar region DS to the midface LLSAN and OOc INF provide insights on the dynamic balance between the brow depressors such as the DS and brow-elevating muscle and contribute to understanding the anatomical origins of individual variation in facial expressions. These results can also improve the safety, predictability, and aesthetics of treatments for the glabellar region with botulinum toxin type A and can be helpful when performing electromyography.

Can Procerus Transection Alter the Radix Morphology and Influence the Nasal Length? A Study of Photogrammetric Assessments and Anthropometric Measurements on Asian Patients

BACKGROUND

The procerus is the main muscle across the radix that needs to be operated during rhytidectomy, however, it is unclear whether transecting it can morphologically affect the nose.

METHODS

A retrospective study of Asian patients who underwent procerus transection during rhytidectomy in our single institution was performed to assess whether the radix profile had any change postoperatively. The procerus was transected at a plane above the nasion.

RESULTS

Ninety-four patients were included. All of them were female with an average age of 50.7 ± 5.2 years and a mean follow-up time of 7.8 ± 3.2 months. Twenty-seven (28.7%) had moderate horizontal wrinkles preoperatively, and sixty-seven (71.3%) had severe rhytides. Different degrees of wrinkle improvement were seen on 91 (96.8%) patients, and no improvement occurred to 3 (3.2%) patients after procerus transection. The anthropometric measurements on these patients did not find any significant difference between the preoperative and postoperative nasal heights, radix projections, nasal lengths, or nasofrontal angles (all p >0.05).

CONCLUSIONS

Procerus transection primary contributes to wrinkle improvement. The morphological change of the radix following this operation is too subtle to be observed. This conclusion should be further verified on large samples as well as on other ethnic cohorts in a long-term follow-up.

LEVEL OF EVIDENCE IV

This journal requires that authors 10 assign a level of evidence to each article. For a full 11 description of these Evidence-Based Medicine ratings, 12 please refer to the Table of Contents or the online 13 Instructions to Authors www.springer.com/00266 .

Morphological Classification of Nostrils and the Role of Sill Augmentation

BACKGROUND

Nostril sill asymmetry is one of the most challenging problems in rhinoplasty. Some studies have been performed regarding nostril shape; however, no studies have been conducted on nostril shape in the Persian population. Additionally, the shape of the nostril in frontal view has rarely been evaluated. This study has two aims. The first is to evaluate nostril shape in Persian patients who were candidates for primary rhinoplasty in basal and frontal views. The second is to assess augmentation silloplasty in patients with different sill heights to resolve nostril asymmetry.

METHODS

This research was performed in two phases. The first phase was a cross-sectional study carried out on the deidentified photographs of 122 patients nominated for rhinoplasty surgery at the facial plastic clinic of a tertiary university hospital. The second phase of the research was an interventional study without a control group consisting of 22 patients. The subjects were categorized as Phase 1. Next, an attempt was made to symmetrize nostril heights by sill augmentation surgery. One year after silloplasty surgical outcome was evaluated by measuring the differences in sill heights.

RESULTS

In the first phase, classification was performed of the nostril shapes of the patients using two views: frontal and basal. Morphologic study has revealed that there are two types of nostrils in the frontal view and three types in the basal view. In the second phase of this research, augmentation silloplasty was employed for the correction of asymmetric sill heights between the right and left sides. The results show that the height differences in the two sills decreased by 44.26% one year after surgery compared to before surgery (CI: 95%, range  - 20.59 to - 67.93), which is statistically significant (p = 0.0002) CONCLUSIONS: Classification of nasal base and nostrils relying on visual inspection is still an important tool for clinical evaluation and communication among physicians. This classification is also crucial in selecting the proper method for correcting nasal base asymmetry. Augmentation silloplasty can help surgeons correct nostril asymmetry due to sill height discrepancy.

LEVEL OF EVIDENCE IV

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 .

Applied Anatomy for Botulinum Toxin Injection in Cosmetic Interventions

Purpose of Review

To provide the reader with a clear overview of facial anatomy as it relates to injection of botulinum toxin.

Recent Findings

The review suggests the presentation of multiple combinations of facial musculature, with the forehead, glabellar, and nasal base areas as particular areas of variation. Differences in musculature result in different wrinkling patterns; with age, these changes first become apparent in the upper face, particularly in the forehead and glabellar area.

Summary

Botulinum toxin is well suited to achieve the optimal outcome: it is popular, safe, and non-invasive and presents with few adverse effects. Though limited, when adverse effects do arise these are primarily related to poor injection technique, often fuelled by poor anatomical knowledge. For clinicians to achieve the best outcomes with botulinum toxin use, an understanding of the facial muscles’ anatomy, actions, and interactions is key. This paper discusses the broad and intricate detail regarding the key target muscles of botulinum toxin, based on both literature review and cadaveric dissection carried out by the authors.

Ultrasonographic and Three-Dimensional Analyses at the Glabella and Radix of the Nose for Botulinum Neurotoxin Injection Procedures into the Procerus Muscle

Botulinum neurotoxin (BoNT) injections are widely used for facial rejuvenation procedures, and the procerus muscle is a major target in cases of glabellar transverse lines or rhytids. Although there have been many cadaveric studies of the procerus, its depth and thickness have not been investigated thoroughly. The aim of this study was to measure the depth and thickness of the procerus and identify the location of the intercanthal vein using ultrasonographic (US) imaging and the three-dimensional scanning method, which is needed to know to avoid side effects during BoNT injections. The morphology of the procerus was classified into two types based on the US images obtained at the glabella. The procerus was located deeper below the skin surface at the glabella than the sellion (3.8 ± 0.7 mm versus 2.7 ± 0.6 mm). The width of the procerus in US images increased from the sellion (10.9 ± 0.2 mm) to the glabella (14.5 ± 4.6 mm), whereas its thickness decreased (from 1.6 ± 0.6 mm to 1.1 ± 0.5 mm). The intercanthal vein was located 5.1 ± 4.0 mm superior to the sellion and 3.0 ± 0.6 mm below the skin’s surface. The present findings provide anatomical knowledge as well as the reference location information for use when injecting BoNT into the procerus.

Changing the Paradigm in Medial Canthal Reconstruction: The Bridge Principle and the Croissant-Like Keystone Island Perforator Flap as An Alternative for Medium Size Soft Tissue Defects in Internal Canthus Reconstruction

INTRODUCTION

Medial canthus is a common area of skin cancer prevalence. Defects in this region represent a challenging reconstructive task. The nasal version of keystone perforator island flap (KPIF) has proven its versatility. The aim of the present study was to expand its utilization in the neighbor medial canthus area. A modified croissant-like KPIF (CKPIF) was used resolving inner convexity-related problems. The presence of procerus in the glabella area, bridging a surface from nasalis up to the frontalis, changed the traditional dissecting flap technique. Thus, the authors introduce the bridge principle, which consists of the indirect transfer of the flap to the defect site through a muscular "bridge" (the procerus). The authors report their experience in medial canthal reconstruction combining a modified KPIF with a new dissecting "principle."

METHODS

From November 2016 to July 2017, a series of patients presenting soft tissue defects of various dimensions in the medial canthus, secondary to tumor extirpation, sustained reconstruction with a CKPIF dissected with the bridge principle.

RESULTS

A total of 15 patients were treated with this new technique. Their mean age was 75.3 years. The mean size of the defect was 2.08 cm (length) × 1.5 cm (width). All flaps survived without any sign of venous congestion. A transient epiphora presented in 4 patients (4/15 or 26.6%), which was subsided 2 months later.

CONCLUSION

A new approach following a novel paradigm was introduced to resolve an old problem. Initial outcomes are encouraging. However, longer series are needed to extract definitive and safer conclusion.

A congenital accessory skin appendage of the nasal columella and nostril sill: a rare anatomical variation

PURPOSE

An accessory skin appendage of the nasal columella and nostril sill is an extremely rare congenital anatomical malformation; only a single case has been reported in the literature. However, no pathophysiology has been proposed. The purpose of this study is to present a review of the anatomical distribution of accessory skin appendages and provide a comprehensive review of their pathophysiology based on embryological development.

METHODS

We present four cases of a protruding skin appendage of the nasal columella or nostril sill. All lesions were present from birth with no family history of skin appendages. Three patients underwent surgical excision under local anesthesia.

RESULTS

The lesions were located at the upper and lower lateral borders of the nasal columella and the medial and lateral borders of the nostril sill. There has been no sign of recurrence over a mean follow-up of 11 months.

CONCLUSIONS

Any obstacle or injury during the migration process of embryonic development may result in maldevelopment. If an obstacle or injury occurs during the medial migration of the medial nasal process, congenital polypoid remnant tissue may remain along the migration route, resulting in an accessory skin appendage of the nasal columella. The location of the accessory columellas ranged from the nostril sill to the soft triangle along the anterior border of the medial crus of the alar cartilage. These anatomical distributions correspond exactly to the migration route of the medial nasal process during embryonic development. We believe that it supports our suggested pathophysiology.