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New Insights into the Anatomy of the Midface Musculature and its Implications on the Nasolabial Fold

  • Original Article
  • Face and Neck Surgery
  • Published:
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Abstract

Background

The prominent nasolabial fold is a distinct feature of the aging midface. As minimally invasive procedures have become mainstream, chemodenervation is a preferred method for treating dynamic facial rhytids. We therefore sought to identify relevant nasolabial fold and midfacial muscular anatomy to determine the ideal location of neuromodulation to improve the aesthetics of the midface and nasolabial fold without altering the upper lip and smile.

Methods

Twelve hemifacial cadaveric dissections were performed to identify midface muscle origin, insertion, width, vector of pull, and neighboring structures. Attention was focused on the levator labii superioris alaeque nasi (LLSAN), levator labii superioris (LLS), nasalis, and orbicularis oculi. Measurements were obtained based on surface landmarks including the medial canthus for future neurotoxin injection.

Results

The LLSAN inserts into the medial nasolabial fold and alar base, while the LLS inserts into the middle third of the nasolabial fold. The broadest portion of the superior LLSAN was on average 8.4 mm inferior and 4.6 mm medial to the medial canthus. A separate muscle obliquely oriented between the orbicularis oculi and LLSAN was identified and found to insert into the malar fat pad. This “malar levator” was present in all specimens and has implications on medial periorbital rhytids and the tear trough deformity.

Conclusion

This study further defines midfacial and nasolabial fold muscular anatomy and provides new insights into the use of neuromodulators for these areas without affecting upper lip position. The malar levator muscle appears to be a separate midfacial muscle with independent action.

Level of Evidence V

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References

  1. Hamra ST (1990) The deep-plane rhytidectomy. Plast Reconstr Surg 86:53–61 discussion 62–53

    Article  CAS  PubMed  Google Scholar 

  2. Riefkohl R (1985) The nasolabial fold lift. Ann Plast Surg 15:1–6

    Article  CAS  PubMed  Google Scholar 

  3. Rubin LR, Mishriki Y, Lee G (1989) Anatomy of the nasolabial fold: the keystone of the smiling mechanism. Plast Reconstr Surg 83:1–10

    Article  CAS  PubMed  Google Scholar 

  4. Pessa JE (1992) Improving the acute nasolabial angle and medial nasolabial fold by levator alae muscle resection. Ann Plast Surg 29:23–30

    Article  CAS  PubMed  Google Scholar 

  5. American Society of Plastic Surgeons (2015) Plastic surgery statistics report. National Cosmetic Procedures

  6. Carruthers J, Fagien S, Matarasso SL, Botox Consensus G (2004) Consensus recommendations on the use of botulinum toxin type a in facial aesthetics. Plast Reconstr Surg 114:1S–22S

    Article  PubMed  Google Scholar 

  7. Goldman A, Wollina U (2010) Elevation of the corner of the mouth using botulinum toxin type a. J Cutan Aesthet Surg 3:145–150

    Article  PubMed  PubMed Central  Google Scholar 

  8. Kane MA (2005) The functional anatomy of the lower face as it applies to rejuvenation via chemodenervation. Facial Plast Surg FPS 21:55–64

    Article  CAS  PubMed  Google Scholar 

  9. Sykes JM, Trevidic P, Suarez GA, Criollo-Lamilla G (2015) Newer understanding of specific anatomic targets in the aging face as applied to injectables: facial muscles-identifying optimal targets for neuromodulators. Plast Reconstr Surg 136:56S–61S

    Article  CAS  PubMed  Google Scholar 

  10. Trevidic P, Sykes J, Criollo-Lamilla G (2015) Anatomy of the lower face and botulinum toxin injections. Plast Reconstr Surg 136:84S–91S

    Article  CAS  PubMed  Google Scholar 

  11. Rubin LR (1974) The anatomy of a smile: its importance in the treatment of facial paralysis. Plast Reconstr Surg 53:384–387

    Article  CAS  PubMed  Google Scholar 

  12. Patel D, Megtha F, Trivedi R, Thakkar S, Suthar J (2013) Botulinum toxin and gummy smile—a review. IOSR J Dent Med Sci 4:01–05

    Article  CAS  Google Scholar 

  13. Hwang WS, Hur MS, Hu KS et al (2009) Surface anatomy of the lip elevator muscles for the treatment of gummy smile using botulinum toxin. Angle Orthod 79:70–77

    Article  PubMed  Google Scholar 

  14. Sucupira E, Abramovitz A (2012) A simplified method for smile enhancement: botulinum toxin injection for gummy smile. Plast Reconstr Surg 130:726–728

    Article  CAS  PubMed  Google Scholar 

  15. Barton FE Jr, Gyimesi IM (1997) Anatomy of the nasolabial fold. Plast Reconstr Surg 100:1276–1280

    Article  PubMed  Google Scholar 

  16. Lassus C (2002) A surgical solution to the deep nasolabial fold. Plast Reconstr Surg 109:358–360 discussion 361–352

    Article  PubMed  Google Scholar 

  17. Pessa JE, Brown F (1992) Independent effect of various facial mimetic muscles on the nasolabial fold. Aesthet Plast Surg 16:167–171

    Article  CAS  Google Scholar 

  18. Kane MA (2003) The effect of botulinum toxin injections on the nasolabial fold. Plast Reconstr Surg 112:66S–72S discussion 73S–74S

    Article  PubMed  Google Scholar 

  19. Pessa JE, Zadoo VP, Adrian EK Jr, Yuan CH, Aydelotte J, Garza JR (1998) Variability of the midfacial muscles: analysis of 50 hemifacial cadaver dissections. Plast Reconstr Surg 102:1888–1893

    Article  CAS  PubMed  Google Scholar 

  20. Haddock NT, Saadeh PB, Boutros S, Thorne CH (2009) The tear trough and lid/cheek junction: anatomy and implications for surgical correction. Plast Reconstr Surg 123:1332–1340 discussion 1341–1332

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Institute for Plastic Surgery, Southern Illinois University, 747 North Rutledge Street, 3rd Floor, Springfield, IL, 62702, USA

    Chelsea C. Snider, Lauren E. Hutchinson & Nicole Z. Sommer

  2. Department of Plastic Surgery, University of Rochester Medical Center, Rochester, NY, USA

    Ashley N. Amalfi

Authors
  1. Chelsea C. Snider
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  2. Ashley N. Amalfi
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  3. Lauren E. Hutchinson
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  4. Nicole Z. Sommer
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Corresponding author

Correspondence to Chelsea C. Snider.

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Malar levator activation (MP4 41456 kb)

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Snider, C.C., Amalfi, A.N., Hutchinson, L.E. et al. New Insights into the Anatomy of the Midface Musculature and its Implications on the Nasolabial Fold. Aesth Plast Surg 41, 1083–1090 (2017). https://doi.org/10.1007/s00266-017-0889-9

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  • DOI: https://doi.org/10.1007/s00266-017-0889-9

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