Fat infiltration into dermal layer induces aged facial appearance by decreasing dermal elasticity.

BACKGROUND: Facial morphology changes with aging, producing an aged appearance, but the mechanisms involved are not fully established. We recently showed that subcutaneous fat infiltrates into the dermal layer with aging, but it is not yet clear whether and how this drastic change of the dermal layer influences facial appearance. PURPOSE: We aimed to establish the role of fat infiltration in producing an aged facial appearance and to clarify the mechanism involved. METHODS: We analyzed the severity of fat infiltration in cheek skin of 30 middle-aged female volunteers by means of ultrasonography. Severity of the nasolabial fold, an established age-related morphology, was evaluated based on our photographic grading criteria as a measure of aged appearance. Skin elasticity was measured with a Cutometer. RESULTS: Fat infiltration to the dermal layer was detected at the cheek skin noninvasively by means of ultrasonography. Fat infiltration severity, measured as the minimum depth of the fat inside the dermal layer from the skin surface, was positively correlated with the magnitude of the nasolabial fold. Further, fat infiltration severity was significantly negatively correlated with dermal elasticity. CONCLUSIONS: Our results suggest that fat infiltration into the dermal layer is a critical factor inducing aged appearance of the face. The infiltrated fat decreases the dermal elasticity, which exacerbates nasolabial folds, namely producing an aged facial appearance.

New Insights Into 3-Dimensional Anatomy of the Facial Mimetic Muscles Related to the Nasolabial Fold: An Iodine Staining Technique Based on Micro-Computed Tomography.

BACKGROUND: This study aimed to introduce a novel approach to study the facial mimetic muscles (FMMs) related to the nasolabial fold (NLF) and realize the visualization of complex 3-dimensional (3D) structures of the FMM. METHODS: Micro-computed tomography (micro-CT) and iodine staining technique were used to obtain the 2-dimensional radiographs of the FMM. Materialise Mimics software was then used to reconstruct the 3D model of the FMM. RESULTS: The zygomaticus major muscle was not directly connected to the orbicularis oris muscle (OOM). The terminal fibers of the zygomaticus major muscle were located in the levator anguli oris. The surface of the FMM was covered with some unknown muscle fibers in the NLF. The terminal fibers of the zygolabialis ended in the middle of the ipsilateral OOM rather than the edge of the OOM. At the same anatomical level, the FMM fibers were so closely connected to each other that they were not separated by adipose tissue. A detailed 3D sequence of the muscle fibers in the modiolus at the corner of the mouth was determined. The muscle fibers in the modiolus were organized rather than disorganized. The terminal fibers of the levator anguli oris were located at the terminal fibers of the musculus depressor anguli oris at the corner of mouth. CONCLUSIONS: Although the micro-CT had many disadvantages, the micro-CT combined with iodine staining technique enabled the 3D anatomical study of the FMM related to NLF. We imported the 2-dimensional images obtained by micro-CT scanning into Mimics software, successfully reconstructed the FMM related to the NLF, and finally obtained images of complex 3D structures of the FMM related to the NLF. The shapes, positions, and 3D spatial relationships between the FMM related to the NLF were clearly visualized. The novel insights into the 3D anatomy of the FMM related to NLF may help understand the formation of the NLF. Finally, the results of this study may help improve rejuvenation surgery of the NLF in the near future.

The Americleft Project: Comparison of Ratings Using Two-Dimensional Versus Three-Dimensional Images for Evaluation of Nasolabial Appearance in Patients With Unilateral Cleft Lip and Palate.

This study was conducted to determine if nasolabial appearance is rated with comparable results and reliability on 3-dimensional stereophotogrammetric facial images versus standard clinical photographs (2-dimensional). Twenty-seven consecutively treated patients with repaired complete unilateral cleft lip and palate were selected. Six trained and calibrated raters assessed cropped 2- and 3-dimensional facial images. Nasolabial profile, nasolabial frontal, and vermillion border esthetics were rated with the 5-point scale described by Asher-McDade using the modified Q-sort method. Cropped 3-dimensional images were available for viewing by each rater, allowing for complete rotational control for viewing the images from all aspects. Two- and three-dimensional ratings were done separately and repeated the next day.Interrater reliability scores were good for 2-dimensional (κ = 0.607-0.710) and fair to good for 3-dimensional imaging (κ = 0.374-0.769). Intrarater reliability was good to very good for 2-dimensional (κ = 0.749-0.836) and moderate to good for 3-dimensional imaging (κ = 0.554-0.855). Bland-Altman analysis showed satisfactory agreement of 2- and 3-dimensional scores for nasolabial profile and nasolabial frontal, but more systematic error occurred in the assessment of vermillion border.Although 3-dimensional images may be perceived as more representative of a direct clinical facial evaluation, their use for subjective rating of nasolabial aesthetics was not more reliable than 2-dimensional images in this study. Conventional 2-dimensional images provide acceptable reliability while being readily accessible for most cleft palate centers.

Surgical Approach to the Thick Nasolabial Folds, Jowls and Heavy Neck-How to Approach and Suspend the Facial Ligaments.

Patients with thick skin typically present with a redundant, baggy, lax skin envelope together with prominent nasolabial folds, jowls, and a heavy neck. Durable and natural-appearing rejuvenation is not possible unless the deformities are addressed adequately and harmoniously in these patients. Traditional superficial musculoaponeurotic system techniques do not include surgical release of the zygomatic cutaneous ligaments and repositioning of descendent malar fat pad, and may lead to an unbalanced, unnatural appearance and the lateral sweep phenomenon. Additional attempts to improve unopposed nasolabial folds such as fat grafting to malar region are more likely to result with a "stuffed" look, far from a natural and rejuvenated appearance, and must therefore be avoided. The facelift techniques including true release of the anchoring ligaments of the midface and allowing adequate repositioning of saggy tissues are ideal for these patients to obtain harmonious, natural result. Despite the extensive dissections, maximal release, and maximal lateral pull, additional maneuvers, e.g., platysmaplasty, subplatysmal fat removal, or partial resection of submandibular glands may be required for satisfying result in patients with heavy neck. In this article, the authors outline the relevant anatomy of the facial retaining ligaments and their implications to surgical management of patients with heavy skin are discussed.

Age-Related Changes in the External Noses of the Anatolian Men.

OBJECTIVE: Knowledge of age-related nasal region measurements in Anatolian men; growth changes between adult and old age. BACKGROUND: The nose plays a critical role in determining the external appearance of an individual. Craniofacial anthropometry has been commonly used in forensic anthropology and medicine. METHODS: A total of 300 men (100 between 20-40 years; 100 between 40-60 years and 100 60-up years) were measured using a photographic technic from the Image J program. From the landmarks, 13 linear distances and 3 angles were calculated and averaged for age groups. RESULTS: The means of nasal bridge lengths of three age groups were 60.30, 63.43 and 64.63 mm, respectively. The average nasal tip protrusions of three groups were 24.31, 26.69 and 27.53 mm, respectively. Nasolabial angle, nasal bridge length and tip protrusion, anatomic and morphologic nose width and root width were statistically different between the three age groups (p < 0.05). CONCLUSION: Results collected in this study could serve as a data bank for nasal anthropometry during aging and development. The assessment of teratogenic-induced traumas, craniofacial alteration, facial reconstruction, aging of dead person and personal identification may be assisted by age data from Anatolian men from age data banks. LEVEL OF EVIDENCE III: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ethnic Rhinoplasty in Female Patients: The Neoclassical Canons Revisited.

BACKGROUND: Despite the substantial amount of research devoted to objectively defining facial attractiveness, the canons have remained a paradigm of aesthetic facial analysis, yet their omnipresence in clinical assessments revealed their limitations outside of a subset of North American Caucasians, leading to criticism about their validity as a standard of facial beauty. In an effort to introduce more objective treatment planning into ethnic rhinoplasty, we compared neoclassical canons and other current standards pertaining to nasal proportions to anatomic proportions of attractive individuals from seven different ethnic backgrounds. METHODS: Beauty pageant winners (Miss Universe and Miss World nominees) between 2005 and 2015 were selected and assigned to one of seven regionally defined ethnic groups. Anteroposterior and lateral images were obtained through Google, Wikipedia, Miss Universe, and Miss World Web sites. Anthropometry of facial features was performed via Adobe Photoshop TM. Individual facial measurements were then standardized to proportions and compared to the neoclassical canons. RESULTS: Our data reflected an ethnic-dependent preference for the multiple fitness model. Wide-set eyes, larger mouth widths, and smaller noses were significantly relevant in Eastern Mediterranean and European ethnic groups. Exceptions lied within East African and Asian groups. CONCLUSION: As in the attractive face, the concept of the ideal nasal anatomy varies between different ethnicities. Using objective criteria and proportions of beauty to plan and execute rhinoplasty in different ethnicities can help the surgeon plan and deliver results that are in harmony with patients' individual background and facial anatomy. 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 .

Analysis of morphological changes after facial massage by a novel approach using three-dimensional computed tomography.

BACKGROUND/PURPOSE: Photograph-based visual scoring has been used for evaluation of facial morphological changes. Here, we describe a three-dimensional computed tomography (3D-CT) method for objective analysis of facial and intra-facial (subcutaneous) changes. The effects of facial massage were examined using both methods. METHODS: Subjects were 12 healthy female volunteers without facial scars or deformation (age 30-54 years, mean 39.4 years). Photograph-based scoring of massage-induced morphological changes was done at the nasolabial folds, upper, lower and lateral cheeks and lower eyelids. For 3D-CT evaluation, the virtual center axis (VCA) was set as the cranio-caudal longitudinal line, and the VCA-skin surface distances (VSDs) were measured. Massage-induced changes of VSD were calculated (facial massage-induced change rate, FMCR). Intra-facial (subcutaneous) changes were also evaluated. RESULTS: Photograph-based scoring revealed marked morphological changes of the nasolabial folds after facial massage, and changes of the lower, upper and lateral cheeks and lower eyelid were also observed in more than half of the subjects. FMCR values were significantly changed in the paranasal area, nasolabial fold area and cranial part of the mandibular area. Photograph-based scores at the lower cheek and lower eyelid were well correlated with FMCR in the inferior part of the nasolabial fold and the mandibular area, respectively. Massage-induced changes of subcutaneous fat tissues and facial expression muscles were also apparent on CT images. CONCLUSION: 3D-CT imaging is useful for objective evaluation of the effects of facial massage, including anatomical changes in subcutaneous structures.

Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery.

BACKGROUND: The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue. OBJECTIVES: This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures. METHODS: Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue. RESULTS: Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer. CONCLUSIONS: The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.

Detailed Anatomy of the Nasolabial Muscle in Human Fetuses as Determined by Micro-CT Combined With Iodine Staining.

PURPOSE: This study aims to investigate the 3-dimensional (3D) anatomical structure of the orbicularis oris and nasalis, which are closely associated with the appearance of the upper lip and lower part of the nose. The relationship of the complicated 3D anatomical structure with the outline shape was also determined. METHODS: Microcomputed tomography combined with iodine staining was used to scan the nasolabial tissues of 3 aborted fetuses. The strictly aligned, corrected, full-capacity, 2-dimensional (2D) grayscale images obtained were then used to reconstruct 3D structures using a 3D reconstruction software. RESULTS: 2D grayscale slices and a 3D anatomical model of the orbicularis oris and nasalis of the specimens were obtained. The 2D images and the 3D model confirmed the orbicularis oris anatomical structure reported in previous studies and also provided new insights (such as the close association of the formation of the philtral dimple, lip peak, philtral ridge, and nasal sill with the orbicularis oris). In addition, the results show that the nasolabial muscle consists of muscle fibers from different sources and is divided into four distinct parts: pars marginalis, pars peripheralis, muscle fibers of the levator labii superioris, and nasalis muscle fibers. CONCLUSION: The 3D anatomical structures indicate that the orbicularis oris and nasalis are closely associated with the appearances of the upper lip and lower part of the nose. The results may aid plastic surgeons in performing cleft-lip correction surgery.

Soft tissue cephalometric norms for orthognathic and cosmetic surgery.

PURPOSE: Proportionality of the lower and middle thirds of the face is a key determinant of successful orthognathic treatment. A flatter profile and marked variance of the soft tissue envelope in the Japanese population complicates the accurate assessment of these proportions. This study aimed to identify gender differences and establish norms for Japanese young adults using the method of soft tissue cephalometric analysis (STCA) by Arnett et al (Am J Orthod Dentofacial Orthop 116:239, 1999). MATERIALS AND METHODS: Lateral cephalograms of 49 young normal Japanese subjects (19 men, 30 women) were selected from the archival records and analyzed with STCA. The Student t test was used to compare mean values of the male and female groups. RESULTS: Significant differences were found between women and men. Men had a flatter occlusal plane and a more acute nasolabial angle than women. Men showed larger values for upper and lower lip thickness, menton soft tissue thickness, and vertical face length, especially in the lower third of the face. Women had a more projected midface than men. Compared with established STCA norms, the Japanese have more midfacial projection. CONCLUSIONS: Significant gender differences were found in the thickness, lower third length, and midface projection in Japanese young adults, which should be taken into account when interpreting measurements for orthognathic surgical planning. These differences can serve as norms for STCA in young Japanese adults. Differences were noted between the reference values of Arnett et al and Japanese subjects.

Histomorphologic approach for the modiolus with reference to reconstructive and aesthetic surgery.

The modiolus is strongly associated with facial expression, beauty, and aging, and so it is often viewed as the main facial landmark, both functionally and aesthetically. This study examined the modiolus and the surrounding structures histomorphologically with the aim of providing useful information for reconstructive and aesthetic surgery. Nineteen embalmed cadavers (38 hemifaces; 8 males and 11 females; mean age at death, 66.9 years) were examined in this study. For macroscopic observations, the modiolus and facial artery in the perioral region of 28 hemifaces were revealed by meticulous dissection. The modiolus and its surrounding structures were then prepared from 12 hemifaces for routine histology and stained with hematoxylin-eosin and Masson trichrome. A tendinous tissue nodule in the modiolus was found in 21.4% of cases (ie, 6 hemifaces). The facial artery passed approximately 1 mm lateral to the lateral border of the modiolus. In the central region of modiolus, which was an area of convergence of muscle fibers, the tendinous structure appeared as dense irregular collagenous connective tissue. Particularly in the middle layer between the skin and the oral mucosa, it appeared as a dense, compact, and prominent shape horizontally. The finding of the existence of a tendinous structure in the central region of the modiolus, which could act as an anchor for the converging facial muscles, is expected to provide critical information in the field of facial plastic surgery.

The causes of the nasolabial crease: a histomorphological study.

There are two main conflicting theories on how the nasolabial crease is formed: a muscular theory and a fascial theory. The muscular theory states that the nasolabial crease is mainly formed by the musculodermal insertions of the lip elevator muscles. The fascial theory claims that the nasolabial crease is mainly formed by dense fibrous tissue and by the firm fascial attachments to the fascia of the lip elevator muscles. If the muscular theory was true, the musculodermal insertions of the facial muscles could be interrupted directly by intradermal injections of low doses of botulinum toxin. Eight cadavers who presented with bilateral nasolabial creases were enrolled in the study. The nasolabial creases were harvested from 14 facial halves in their entire lengths and breadths with 5-mm medial and lateral rims. The horizontally cut samples were stained with hematoxylin-eosin (H&E) and Elastica van Gieson (EVG). Immunohistochemistry for the smooth muscle marker actin and the skeletal muscle marker desmin was also performed. In each of the nasolabial creases, numerous skeletal muscle fibers were found in the dermis, which confirmed the muscular theory of the cause of the nasolabial crease. In addition, muscle fibers were present in the dermis 4 mm medial and 4 mm lateral to the nasolabial crease, but the amounts were significantly less than the amount located directly in the crease. Botulinum toxin injected intradermally into the nasolabial crease might constitute a new treatment option to minimize or even eradicate the crease and the fold.

Aging changes of the periorbita, cheeks, and midface.

The periorbita, cheeks, and midface are an area of complex facial form and function. There is a particular pleasing visual harmony of these regions in the youthful face. With time, the robust glow and fullness of youth fades and diminishes. The skin is the first component to show the passage of time as it dulls, wrinkles, and blemishes. This is followed by a slow loosening and sagging of soft tissues as they descend from their once-fixed points of the skeletal foundation. The smooth transitions between regions are separated and hollows and ridges appear. These processes continue throughout life and eventually are accompanied by the visible consequences of bone resorption. The faces age, and as the countenance of the human spring turns through summer into autumn, function follows form, and symptoms accompany signs. A thorough understanding of both youthful and elder anatomy as well as the stigmata of aging is prerequisite to perform rejuvenating procedures. This article discusses these changes and how the older anatomy becomes the new norm.

Involvement of upper cheek sagging in nasolabial fold formation.

BACKGROUND: Nasolabial folds are a well-known feature of aging, but the mechanism of their formation remains unclear. OBJECTIVES: To clarify the mechanism of nasolabial fold formation, we established grading criteria for severity and explored the influence of dermal elasticity and subcutaneous adipose mass. We also investigated the involvement of facial morphological changes, such as wrinkling and sagging. METHODS: Faces of 108 healthy Japanese female volunteers (age range: 20-60) were photographed at the angle of 45°, and a six-grade photograph-based grading scheme for nasolabial fold severity was established and evaluated. In 70 Japanese female volunteers (middle-aged: 30-50), dermal elasticity was measured with a Cutometer MPA 580® and subcutaneous adipose layer thickness was measured by ultrasound using a Prosound alpha 5®. RESULTS: Nasolabial fold severity was significantly and positively correlated with age in subjects in their twenties to sixties (R = 0.777, P < 0.001). Nasolabial folds were drastically reduced, or disappeared, when the facial position was changed (subjects lay down instead of sitting) to reduce sagging; only 13.8% of subjects showed fixed wrinkles at the positions of the nasolabial folds after the facial position change. Nasolabial fold severity in middle-aged volunteers was significantly and negatively correlated with dermal elasticity parameters, i.e., net elasticity excluding viscoelastic creep (Ur/Ue), overall elasticity including creep and creep recovery (Ua/Uf), ratio of elastic recovery to total deformation (Ur/Uf), and the negative value of the amount of deformation that did not recover to the original state [-Uf-Ua)], all of which were significantly and negatively correlated with age. Subcutaneous adipose layer thickness was significantly and negatively correlated with dermal elasticity parameter Ua/Uf, and also significantly and positively related to nasolabial fold severity (R = 0.285, P < 0.017). CONCLUSIONS: Nasolabial fold severity increases with decreasing dermal elasticity and with increment of the subcutaneous adipose layer. These changes might induce sagging formation in the upper cheek area, promoting fold formation at the border between the inner and outer nasolabial areas.

Validated assessment scales for the lower face.

BACKGROUND: Aging in the lower face leads to lines, wrinkles, depression of the corners of the mouth, and changes in lip volume and lip shape, with increased sagging of the skin of the jawline. Refined, easy-to-use, validated, objective standards assessing the severity of these changes are required in clinical research and practice. OBJECTIVE: To establish the reliability of eight lower face scales assessing nasolabial folds, marionette lines, upper and lower lip fullness, lip wrinkles (at rest and dynamic), the oral commissure and jawline, aesthetic areas, and the lower face unit. METHODS AND MATERIALS: Four 5-point rating scales were developed to objectively assess upper and lower lip wrinkles, oral commissures, and the jawline. Twelve experts rated identical lower face photographs of 50 subjects in two separate rating cycles using eight 5-point scales. Inter- and intrarater reliability of responses was assessed. RESULTS: Interrater reliability was substantial or almost perfect for all lower face scales, aesthetic areas, and the lower face unit. Intrarater reliability was high for all scales, areas and the lower face unit. CONCLUSION: Our rating scales are reliable tools for valid and reproducible assessment of the aging process in lower face areas.

Improving the hanging ala.

The hanging ala can be lifted via removal of a piece of triangular vestibular skin shaped like a sail; the alar rim skin is rolled and sutured into the defect to form a new lifted rim margin.

Nuances with the mestizo tip.

Mestizo nasal tips are a challenge. A gradual approach is presented, emphasizing minimal tissue resection, reinforcement of support structures of the nasal tip, and use of sutures and grafts in a judicious manner. The final result should be tips with improved definition, rotation, and projection.

A novel prospective three-dimensional analysis of nasolabial fold augmentation.

BACKGROUND: There are many products approved for aesthetic soft tissue augmentation. Despite this abundance, there is limited objective data regarding safety, longevity, and complication rates. Instead, most reports rely on subjective measures to report volume changes and outcomes, making product comparison difficult. OBJECTIVES: The authors developed and validated a mathematical model to prospectively calculate and analyze three-dimensional (3D) volumetric changes associated with nasolabial fold augmentation based on human acellular dermis. METHODS: Seven consecutive patients were included in this prospective review. The patients underwent nasolabial fold treatment with BellaDerm (Musculoskeletal Transplant Foundation, Edison, NJ), administered by a single surgeon. 3D photographs were obtained and analyzed with a novel mathematical model to determine absolute volumetric changes and objective longevity. RESULTS: Mean preoperative nasolabial fold volume was 0.17 mL. The mean one-, three-, and six-month postoperative fill volumes were 0.35, 0.19, and 0.07 mL, respectively. Fill volumes and contour changes returned to baseline by 24 weeks postoperatively in the majority of patients. CONCLUSIONS: The mathematical model utilized in this study provided prospective and objective data regarding longevity and volumetric changes associated with nasolabial fold augmentation. The analysis demonstrated minimal objective filler permanence beyond six months, with peak volume enhancement between one and three months. Adoption of objective 3D mathematical metrics into the assessment of soft tissue filler outcomes is critical to obtaining more accurate product-to-product comparisons.

Cable-Stayed Face Lift: An Innovative Short-Scar Lift for Better Correction of Nasolabial Folds in East Asians.

BACKGROUND: The improvement of nasolabial folds by either lateral superficial musculoaponeurotic system rhytidectomy or minimal access cranial suspension lift alone is commonly performed, but patient satisfaction is often limited in East Asians. An innovative technique, termed the cable-stayed face lift, which combines the strengths of lateral superficial musculoaponeurotic system rhytidectomy and minimal access cranial suspension lift, was developed for improved results. METHODS: Between 2016 and 2019, 20 cable-stayed face lifts were performed in a single hospital. Two plastic surgeons independently evaluated postsurgery outcomes using a five-point Likert scale, where 5 = excellent, 4 = good, 3 = fair, 2 = no change, and 1 = worse. Patient satisfaction was assessed by relevant items from the FACE-Q questionnaire. RESULTS: Twenty patients with a mean age of 51 years underwent face-lift surgery. The mean follow-up ± SD was 11.3 ± 9.8 months. The five-point Likert scale score evaluated by surgeons was 3.65 ± 1.08. Patient-perceived age visual analogue scale (7.8 ± 4.4) exhibited a difference between preoperative actual age and postoperative apparent age. Patients demonstrated high satisfaction with outcome (67.5 ± 16.2) and satisfaction with lower face and jawline (76.2 ± 14.9). No major complication, hematoma, or seroma was observed. CONCLUSION: The authors' approach-cable-stayed face lift-offers a good alternative to provide a more effective effacement of nasolabial folds, by lifting the nasolabial folds with parallel vector and lower face and neck with the vertical vector. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Heights and spatial relationships of the facial muscles acting on the nasolabial fold by dissection and three-dimensional microcomputed tomography.

The aim of this study was to clarify the heights and spatial relationships of the facial muscles acting on the nasolabial fold (NLF) by dissection and three-dimensional microcomputed tomography for use in aesthetic treatments. This study used 56 specimens from 34 embalmed adult Korean. A reference line (RF) was set to imitate the NLF after removing the skin, from the superior point of the alar facial crease to the lateral point of the orbicularis oris muscle at the level of the corner of the mouth. The heights and spatial relationships of the facial muscles along the RF could be categorized into five main patterns. The dominant pattern was that the levator labii superioris alaeque nasi muscle (LLSAN), levator labii superioris muscle (LLS), zygomaticus minor muscle (Zmi), and zygomaticus major muscle (Zmj) were on the medial third, medial half, middle third, and lateral third of the RF, respectively. In micro-CT imaging, beneath the skin of the medial half of the NLF, the LLSAN and Zmi fibers inserted into the dermis of the NLF and adjacent to the NLF. Beneath the skin of the middle third of the NLF, the Zmi fibers were found before the muscle inserted into the dermis of the NLF and adjacent to the NLF. Beneath the skin of the lateral third of the NLF, the lateral margin of the orbicularis oris muscle and some Zmj fibers were found at the location of the NLF. The present study utilized dissections and micro-CT to reveal the general pattern and variations of heights and spatial relationships of the facial muscles passing beneath the NLF. These findings will be useful for understanding which muscles affect specific parts of NLFs with various contours, for reducing the NLF in aesthetic treatments, and for reconstructing the NLF in cases of facial paralysis.