Clinical anatomy considerations on the muscular and vascular components of the midface by ultrasonographic imaging.

The first signs of face aging appear in the midface, so procedures such as botulinum toxin and filler injections are performed there. However, no guidelines based on clinical anatomy describing the muscular and vascular components in vivo have been published. The aim of this research was to describe the depths of the midface muscles and the locations of vessels using ultrasonographic (US) imaging. US was applied at 12 landmarks on the midface in 88 volunteers (49 males and 39 females; 19-36 years) to detect sex differences in the depths of muscles and the locations of the vessels. The depths of the orbicularis oculi (OOc), levator labii superioris alaeque nasi (LLSAN), and zygomaticus minor (Zmi) differed significantly with sex at P7 (p = 0.001) and P8 (p = 0.017), P1 (p = 0.028), and P4 (p = 0.035), respectively. The facial artery, facial vein, angular artery, angular vein, and perforator vessels were found at P9, P2 and P10, P1, P1 and P5, and P8, P11 and P12, respectively. The findings indicate that the depths of the OOc, LLSAN, and Zmi muscles differ between the sexes and that the vessels appear at specific landmarks. This information could help in developing anatomical guidelines for several procedures.

Somatic GNAQ mutation in different structures of port-wine macrocheilia.

BACKGROUND: Port-wine macrocheilia (PWM) involves a congenital, progressive capillary malformation that results in soft-tissue hypertrophy in the lips. Its aetiology has not yet been fully elucidated. OBJECTIVES: To investigate frequencies of GNAQ mutation in different tissues from patients with PWM, including skin, mucosa, gland and muscle, using samples obtained during cheiloplasty. METHODS: Targeted next-generation sequencing of GNAQ was designed and performed to assess DNA extracted from 80 different affected tissues from 20 patients with PWM. RESULTS: The GNAQ R183Q mutation was not detected in gland samples but was found in 90%, 95% and 95% of the skin, mucosal and muscle samples, respectively. The lowest levels of mutations were found in the glands (P < 0·001 vs. skin, mucosa and muscle), and levels were second lowest in the skin (P = 0·023 vs. mucosa; P = 0·012 vs. muscle). The mutation frequencies in mucosa and muscle were the highest and showed no statistically significant difference (P = 0·92). CONCLUSIONS: In patients with PWM, GNAQ was mutated in all tissues except for glands. PWM is congenital, and all tissue layers exhibit primary hypertrophy rather than acquired or partially related hypertrophy. Given the advantages of mucosal biopsy, including practicality, lack of scarring and rapid healing, GNAQ mutation in the lip mucosa may be a useful predictor for early-stage PWM in patients with port-wine stains affecting the lips.

The facial artery: A Comprehensive Anatomical Review.

The facial artery is the major vessel supplying blood to the face so its location and course are very important for the safe manipulation of both surgical and non-surgical interventions. This study documents current anatomical information about the facial artery and its tributaries. The terminology of the facial artery tributaries was revisited with reference to the Terminologica Anatomica and novel nomenclature was suggested with anatomical features. The tributaries to the lower lip (inferior labial artery), labiomental region (horizontal and vertical labiomental artery), upper lip (superior labial artery), nose (inferior and lateral alar artery and nasal septal artery), angular and ocular region (angular artery and detoured branch) and the course, layers and location of the facial artery main trunk were revisited with contemporary anatomical studies. The facial artery and its tributaries have close topographical connections to the facial expression muscles, nasolabial groove, and vermilion border, and these also distinguish facial landmarks comprising the cheilion, stomion, and gonion. Interestingly, in contrast to previous descriptions, some terminal branches did not take a straight course but a detoured course. The angular artery was connected to the ophthalmic artery branches and in some cases did not originate from the facial artery. Vascular complications of the facial artery tributaries are frequently seen in the angular, dorsum of the nose, tip of the nose, and glabellar region. This detailed review focusing on facial arterial topography in the various areas of the face would help to enhance quality of treatment. Clin. Anat. 31:99-108, 2018. © 2017 Wiley Periodicals, Inc.

Comparison of EMG activity and blood flow during graded exertion in the orbicularis oris muscle of adult subjects with and without lip incompetence: a cross-sectional survey.

Background/Objectives: The peri-oral muscles-including orbicularis oris-are critical in maintaining equilibrium in tooth position. Lip incompetence (LI) can thus be a factor in malocclusion. We therefore aimed to validate a technique to evaluate not only muscle activity via electromyography (EMG) but also muscle endurance and fatigue via blood flow (BF) for LI. Subjects/Methods: Subjects were classified into increased muscle tension/lip incompetent (experimental) and normal muscle tension/lip competent (control) groups. Each subject then exerted force on a custom-made traction plate connected to a tension gauge. Using laser speckle imaging and electromyographic measurements, we characterized muscle activity and corresponding BF rates in these subjects in various states of resting, loading, and recovery. Results: Results showed a significant difference between the experimental and control groups, notably in the rate of change in BF to the inferior orbicularis oris muscle under conditions of increasing load (graded exertion). Furthermore, the data suggested that the muscles in the control group undergo a more prolonged (and therefore presumably more complete) recovery than muscles in the experimental group. These factors of reduced BF and short recovery may combine to accelerate muscle fatigue and produce LI. Limitations: The sample used here was controlled for malocclusion (including open bite) to eliminate this type of confounding effect. Conclusions/Implications: From these findings, we conclude that reduced BF and inadequate recovery in the orbicularis oris muscles may be more significant than EMG activity in the assessment of LI.

The use of facial artery musculomucosal (FAMM) readvancement flap in closure of recurrent oronasal fistula.

High failure rate for recurrent palatal fistulas closure pose a great challenge to plastic surgeons. Tongue and facial artery musculomucosal (FAMM) flaps are the more commonly used flaps for closure of these recurrent fistulas. We report a case of a formerly inset FAMM flap to effectively close a previously repaired oronasal fistula.

Novel Anatomic Description of the Course of the Inferior Palpebral Vein for Minimally Invasive Aesthetic Treatments.

BACKGROUND: The inferior palpebral vein (IPV) receives tributaries from the inferior palpebral part of the orbicularis oculi muscle (OOc). The aim of this study was to elucidate the venous distribution pattern of the IPV for dermal filler injection. MATERIAL AND METHODS: Fifty hemifaces from 34 cadavers were used in this study. The various distribution patterns of the IPV were classified according to its relationship with the angular vein (AV) and facial veins. RESULTS: The IPV can be classified into the following 4 types: Type I (58.0%), in which the origin of the IPV is located beneath the lateral part of the OOc; Type II (12.0%), in which the origin of the IPV is located beneath the inferior part of the OOc; Type III (8.0%), in which the origin of the IPV is located beneath both the lateral and inferior parts of the OOc; and Type IV (22.0%), in which the IPV is undeveloped. CONCLUSION: The course of the IPV can be approximated by connecting the lateral orbital rim to the C point (the meeting point between the IPV and the AV). The lateral rim can be palpated and the location of the C point is suggested as a columnar area inferior to the pupil.

Facial Artery Perforator and Depressor Anguli Oris Muscle Chimeric Flap: A New Design of an Old Flap.

BACKGROUND: The aim of this study was to investigate the reliability and outcomes of the facial artery perforator and separately elevated depressor anguli oris (DAO) muscle chimeric flap for the reconstruction of partial or total lower lip defects. METHODS: Eleven patients with malignant skin tumors located at the lower lip were operated between 2013 and 2015. After the excision of the tumor with adequate clear margins using margin controlled excision technique, an appropriate flap fitting to the resultant defect based on the perforators of the facial artery and DAO muscle was prepared and placed into the defect. The DAO muscle activity was tested with electromyography in the postoperative first year examination. RESULTS: Besides 1 patient with transient venous insufficiency, all the flaps healed well without a partial or total flap loss. The mean follow-up period was 10 months. No new primary tumor or recurrence was observed. Although in 1 patient, transient asymmetric smiling and mild drooling was observed, the overall oral competence results were found to be quite satisfactory. The electromyography evaluation of DAO muscle of 5 patients who reached the postoperative first year examination showed action potential results in normal limits with a slight decrease. All patients were satisfied with the final esthetic and functional result. CONCLUSIONS: The facial artery perforator and depressor angel oris muscle chimeric flap is a valuable option for reconstruction of lower lip defects providing esthetically and functionally good results.

Evaluation of blood flow and electromyographic activity in the perioral muscles.

BACKGROUND/OBJECTIVES: Although the electromyographic (EMG) activity of the perioral muscles, including the orbicularis oris and mentalis muscles, has been described in individuals with lip incompetence during lip sealing, blood flow through these muscles remains to be elucidated. The purpose of this study was to examine the blood flow associated with EMG activity in the perioral muscles using laser speckle imaging in individuals with lip incompetence. SUBJECTS/METHODS: Blood flow and EMG activity of the superior and inferior orbicularis oris and mentalis muscles were measured with the lips in contact (C condition) and apart (O condition) in lip incompetence (experimental) and control subjects (n = 15 in each group; mean age: 29.5 years). The change ratios of blood flow and EMG activity in the C condition versus O condition (C/O ratios) were calculated and plotted in a scattergram. The Mann-Whitney U-test, Wilcoxon signed-rank test, discriminant analysis using the Mahalanobis generalized distance, and Spearman correlation were used for statistical analysis. RESULTS: In the experimental group, blood flow and EMG activity in all muscles were significantly greater in the C condition than in the O condition. The plots of C/O ratios in the experimental group showed a distinct and wide distribution and were significantly different than those in the control group. In both groups, a significant positive correlation was observed between blood flow and EMG activity in the mentalis muscle. CONCLUSIONS/IMPLICATIONS: The present findings suggest that observing blood flow in the mentalis muscle is an effective and easily performed method of evaluating lip incompetence.

Understanding the Perioral Anatomy.

Rejuvenation of the perioral region can be very challenging because of the many factors that affect the appearance of this area, such as repeated muscle movement causing radial lip lines, loss of the maxillary and mandibular bony support, and decrease and descent of the adipose tissue causing the formation of "jowls." Environmental issues must also be addressed, such as smoking, sun damage, and poor dental health. When assessing a client for perioral rejuvenation, it is critical that the provider understands the perioral anatomy so that high-risk areas may be identified and precautions are taken to prevent serious adverse events from occurring.

Anatomical study of medial zygomaticotemporal vein and its clinical implication regarding the injectable treatments.

BACKGROUND: The medial zygomaticotemporal vein (MZTV), clinically known as sentinel vein, has been observed in the vicinity of the temporal branch of the facial nerve during endoscopic procedures aiming to lift the upper face. The aim of the present study was to describe the topography of the MZTV with reference to the superficial landmarks for providing detailed anatomical information during injectable treatment procedures. METHODS: Eighteen hemifaces were harvested from nine embalmed Korean adult cadavers (5 males and 4 females, mean age 76 years). The piercing location, vascular diameter, drainage pattern of the MZTV, and its relationship with the orbicularis oculi muscle (OOc) were recorded photographically, and using diagrams and written notes. RESULTS: The piercing point of the MZTV was located 26.8 ± 5.9 mm from the lateral epicanthus, 18.8 ± 6.9 mm lateral to the plane (HP) through the tragus and the lateral epicanthus, and 19.0 ± 5.4 mm superior to the plane (VP) through the lateral epicanthus point and perpendicular to the HP. The diameter of the MZTV at the piercing point was 1.9 ± 0.8 mm. All of the MZTV ultimately connected with the middle temporal vein (MTV). In particular, the MZTV was connected the MTV by anastomosing with the periorbital vein. Anastomosis of the MZTV and a well-developed periorbital vein was found in 27.8 % of cases. CONCLUSION: The physician must determine the location of the MZTV and should be able to accurately estimate its connection with significant veins at the temple to reduce the risk of severe complications during injectable treatments.

A novel method for in vivo visualization of the microcirculation of the mandibular periosteum in rats.

OBJECTIVE: The periosteum plays an important role in bone physiology, but observation of its microcirculation is greatly limited by methodological constraints at certain anatomical locations. This study was conducted to develop a microsurgical procedure which provides access to the mandibular periosteum in rats. METHODS: Comparisons of the microcirculatory characteristics with those of the tibial periosteum were performed to confirm the functional integrity of the microvasculature. The mandibular periosteum was reached between the facial muscles and the anterior surface of the superficial masseter muscle at the external surface of the mandibular corpus; the tibial periosteum was prepared by dissecting the covering muscles at the anteromedial surface. Intravital fluorescence microscopy was used to assess the leukocyte-endothelial interactions and the RBCV in the tibial and mandibular periosteum. Both structures were also visualized through OPS and fluorescence CLSM. RESULTS: The microcirculatory variables in the mandibular periosteum proved similar to those in the tibia, indicating that no microcirculatory failure resulted from the exposure technique. CONCLUSION: This novel surgical approach provides simple access to the mandibular periosteum of the rat, offering an excellent opportunity for investigations of microcirculatory manifestations of dentoalveolar and maxillofacial diseases.

Reliability of muscle blood flow measurements in orbicularis oculi.

PURPOSE: Orbicularis oculi muscle tension and muscle blood flow have been shown to be objective measures of eyestrain during visually demanding activities, such as computer work. In line with this, positive associations between eye-related pain and muscle blood flow in orbicularis oculi have been observed. A hypothesis regarding work situations with cognitive tasks and low-level muscle activity, such as computer work, proposes that muscle pain originates from the blood vessel-nociceptor interactions of the connective tissue of the muscle. Noninvasive muscle blood flow measurements in the orbicularis oculi muscle are preferable to using an invasive technique. The aim of this study was to test reproducibility and stability of muscle blood recordings in orbicularis oculi using photoplethysmography. METHODS: In the reproducibility tests, 12 subjects were tested twice within 1 to 5 weeks. To study the stability of the method, six of the subjects were randomly selected and tested four more times within 2 to 6 weeks. Test subjects were doing identical visually demanding computer work for 10 minutes in each test. RESULTS: The short-term repeatability of muscle blood flow measurements was considered good, but the stability of blood flow recordings over time in orbicularis oculi was low because of a greater within-subject maximum variability compared with between-subject average variability. CONCLUSIONS: Investigators should be aware of the effect of time, possibly attributed to confounding factors such as environmental changes and mental stress, when comparing photoplethysmography muscle blood flow recordings.

Hypertrophy in labial capillary malformations: clinical and pathological findings in 11 patients.

Hypertrophy in capillary malformation (CM) may be present at birth or manifest itself later in life. To gain insight into the pathology of hypertrophic CM, we investigated a series of 11 excisional biopsies of hypertrophic lips.All biopsies showed dilated thin-walled microvessels in the superficial dermis without a neural component. However, large multinodular conglomerates of thick-walled vessels with a substantial increase in nerve fibers were found in the deeper parts of the lesions. These veins extended deep into the facial musculature. Hypertrophy in CM is caused by venous malformation underlying the CM. So CM associated with hypertrophy should be considered as Capillary Venous malformations.

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.

Venous architecture of the glabellar to the forehead region.

The precise venous anatomy of the glabellar to the forehead region remains unknown. This study aimed to detail the venous architecture of the glabellar region to the forehead in conjunction with that of the supratrochlear artery to reduce the risk of venous congestion of flaps in this area. Fifteen fresh human cadavers were examined here. In five specimens, contrast medium was injected only into the venous system; in 10 specimens, two different types of contrast media were injected into the arterial and venous systems, respectively. A total of 30 hemifacial specimens were radiographed stereoscopically and observed microscopically. In all the cadavers, a distinct vein (termed as the "transverse nasal root vein") connected the bilateral angular veins. One or two large ascending veins branched from the transverse nasal root or angular vein, coursing toward the forehead skin. Numerous small veins branched out from the large ascending vein(s), forming a subdermal polygonal venous network. Small ascending veins arose from this network and coursed toward the dermis, draining venous flow from the dermis. Three different-sized valves prevented the reflux of blood in the venous pathway. The large ascending vein(s) and supratrochlear artery ran parallel only in the medial canthal area. Tiny venous vasa vasorum surrounded the adventitia of the supratrochlear artery and anastomosed with the polygonal venous network, while a few small veins from the vasa vasorum ascended toward the dermis. Understanding the venous architecture of this region is expected to facilitate the safe elevation of various flaps in the area.

Discovery of a new waveform for intraoperative monitoring of hemifacial spasms.

BACKGROUND: Surgeons often rely on intraoperative electrophysiological monitoring to determine whether decompression is sufficient during microvascular decompression surgery for hemifacial spasms. A new monitoring method is needed when an abnormal muscle response is occasionally not available or is unreliable. This study was an observational clinical trial exploring a new waveform recorded from the facial muscles while the offending artery wall was electrically stimulated. METHODS: Thirty-two patients with typical hemifacial spasm and 12 with trigeminal neuralgia as a control were included. The facial muscle response was recorded during microvascular decompression surgery while the offending artery wall was stimulated (2 mA × 0.2 ms). The latency, amplitude, and effective refractory period were analyzed. RESULTS: A waveform was recorded from the facial muscles of patients with hemifacial spasm when the offending artery wall was stimulated and was named the "Z-L response." The latency was 7.3 ± 0.8 ms, the amplitude was 0.08 ± 0.02 mV, and the effective refractory period was 3.5-4 ms. The Z-L response disappeared immediately after microvascular decompression. No waveform was recorded from the facial muscles of patients with trigeminal neuralgia while the anterior inferior cerebellar artery, which adheres to the facial nerve, was stimulated (2 mA × 0.2 ms). CONCLUSION: We found a new waveform for intraoperative monitoring of hemifacial spasm. The Z-L response was useful when the abnormal muscle response was absent before decompression or persisted after all vascular compressions were properly treated. Particularly, the Z-L response may help neurosurgeons determine the real culprit when multiple offending vessels exist.

Microvascular decompression for hemifacial spasm.

OBJECTIVE: Although microvascular decompression (MVD) has been accepted as effective therapy for hemifacial spasm, failed surgery has been reported frequently. For a sophisticated neurosurgeon, an apparent offending artery is seldom missed. However, it is still an embarrassed situation when the neurovascular conflict site could not be approached. METHODS: Clinical data were collected from consecutive 211 MVDs in 2010. Intraoperative abnormal muscle response was recorded. Among them, the neurovascular conflict was not finally discovered in 3 patients, whom were then focused on. All patients were followed up for 6 to 15 months. RESULTS: In 17 of the 211 MVDs, the cerebellum was hard to be retracted because of adhesions. After careful dissection, a working space was finally created in the cerebellopontine angle. However, there still were 3 cases, whose neurovascular conflict site was unable to be discovered at last because of a branch of an artery embedded in the petrous bone and made the cerebellum unmovable. With navigation of real-time abnormal muscle response, the offending artery was moved away eventually even without exposing the conflict site. Postoperatively, all the patients were completely spasm-free immediately. No recurrence was noticed in the last follow-up period. CONCLUSIONS: The most important thing for a successful MVD operation is to remove the offending artery off the nerve. However, if the conflict site failed to be approached after endeavors, a successful MVD can still be achieved by relocating the offending artery with the guidance of real-time electromyography even without visualization of the confliction.

Facial composite tissue allograft.

Despite complex facial anatomy, transplantation of soft tissues of the entire face, including the maxilla and mandibular segment anterior to the masseter muscle insertion, can be safely performed based on facial vessels alone. Inclusion of hair-bearing scalp requires dissection of the superficial temporal vessels. Unlike other groups, we advocate for supercharging dissected superficial temporal vessels in the preauricular area avoiding difficult dissections in the depth of external auditory canal that presents significant challenges associated with lengthy dissection and bleeding. Neurorrhaphy at the trunk of the facial nerve leads to less targeted postoperative reinnervation, with potential for synkinesis, and whenever possible, individual peripheral facial nerve branches should be reconnected. Adequate planning for integration of the facial allograft requires both complete sensory and motor nerve connection and should be part of each operation. Bilateral external carotid anastomosis may cause a variety of functional problems including oropharyngeal dysfunction and ocular ischemia and hence is not recommended.

The rehabilitation of facial involvement in systemic sclerosis: efficacy of the combination of connective tissue massage, Kabat's technique and kinesitherapy: a randomized controlled trial.

In Systemic Sclerosis (SSc), face involvement causes functional loss as well as aesthetic changes and loss of the self-image. The aim of the work is to evaluate the efficacy of a rehabilitation program based on the combination of Kabat's technique, connective massage and kinesitherapy specifically conceived for the face of SSc patients. Forty SSc patients were enrolled: 20 patients (interventional group) were treated for 9 weeks (twice a week, 1 h per session) with a combined connective tissue massage, Kabat's technique, kinesitherapy and home exercise program, and 20 patients (control group) were assigned only home exercise program. All patients were assessed at baseline (T0), at the end of the treatment (T1) and after 9 weeks of follow-up (T2). They were evaluated with SF-36, HAQ, modified Rodnan skin score, mouth opening in centimeters and Mouth Handicap in Systemic Sclerosis (MHISS) scale. At T1, both groups improved in mouth opening (P < 0.05), but the improvement was maintained at T2 only in interventional group. In interventional group, facial skin score ameliorated at T1 and maintained at T2 (P < 0.05 vs. T0), while no change was observed in controls. In both groups, SF-36 and HAQ were not affected by the treatment. MHISS scale improved significantly in interventional group at T1 (P < 0.001), while no change was found in controls. The combination of connective tissue massage, Kabat's technique, kinesitherapy and home-based exercises is more effective than a home exercise program alone in the rehabilitative treatment of SSc facial involvement.

[Surgical planes of the head and neck]. / Planos quirúrgicos en cabeza y cuello.

The surgical plane is a plane of dissection that can be used to excise a tumor while preserving most of the neurovascular structures. The majority of skin tumors are situated on the head and neck, and dermatologic surgeons should therefore have detailed knowledge of the surgical anatomy of this region. Fear of damaging important structures may result in insufficient efficacy of the surgical treatment, with consequent risk of persistence or recurrence of the tumor. Knowledge of the superficial musculoaponeurotic system and its relationship to key neurovascular structures enables the operation to be planned and will help us to locate the appropriate plane and minimize postoperative complications. The objective of this article is to review the key anatomical features defining suitable planes of dissection in the head and neck, the use of which will ensure survival of flaps and grafts.