Ultrasonographic Evaluation of Facial Artery in the Nasolabial Fold for Gender Differences and Symmetry Between Hemifaces.

OBJECTIVES: The aim of this study was to establish the relationship of facial artery with nasolabial fold by color Doppler sonography and to determine facial artery variations and their relationship with age, gender, or hemifaces. METHODS: The study included 188 patients (94 women, 94 men) aged 18-60 years. Overall, 376 facial arteries in both hemifaces were evaluated for the course within nasolabial fold, symmetry, and relationship with gender. RESULTS: The mean age of the patients was 39.29 ± 12.81 years. Type A (55.7%) was the most common type in both hemifaces. There was no significant relationship between the course of facial artery and age (P > .05). Asymmetrical course of facial artery was more common in females (54.3%). In both genders, type A was the type with highest symmetry detected. CONCLUSIONS: Nasolabial fold is one of the important facial regions for filler injection. To prevent vascular injection, course of facial artery should be identified within the nasolabial fold. Type A was the most common type in both hemifaces and genders. Although the rates were close to each other, asymmetry in the course of the facial artery was observed in most of the patients. Ultrasonographic examination which is non-invasive and non-ionizing imaging method can be performed carefully before filler injection to determine vascular tissues.

Diffuse Large B-cell Lymphoma Presenting as an "Oops" Lesion in the Nasolabial Fold: A Case Report.

BACKGROUND: Diffuse large B-cell lymphomas are the most common type of non-Hodgkin lymphoma. Because cutaneous lymphomas predominantly originate from the T cells, primary cutaneous diffuse large B-cell lymphomas are considered a rare subtype of extranodal diffuse large B-cell lymphomas that commonly involve the subcutaneous tissues of the trunk and extremities. To date, only a single case of facial primary cutaneous diffuse large B-cell lymphoma has been reported in the literature. CASE REPORT: We present a case of primary cutaneous diffuse large B-cell lymphoma presented with a small painless nodule in the right nasolabial fold that had persisted for 10 days in a 67-year-old man. Ultrasonographic findings of this lesion mimicked the features of a complicated epidermal inclusion cyst. Primary cutaneous diffuse large B-cell lymphoma was confirmed by an excisional biopsy of the mass. CONCLUSION: The diagnosis of primary cutaneous diffuse large B-cell lymphomas presenting as "oops lesions" in daily clinical practice can be challenging due to their rarity and nonspecific clinical and radiological findings. Therefore, clinical suspicion and awareness are critical for the accurate diagnosis and management of patients with palpable soft tissue masses in the head and neck region.

Application of 3-Dimensional Technology for Evaluating Muscular Type and Muscle-Fat Pad Mixed-Type Nasolabial Folds With Botulinum Toxin-A Treatment.

BACKGROUND: Botulinum toxin-A (BTX-A) is used in the treatment of nasolabial folds (NLFs). However, lighting and clinician subjectivity play a major role in evaluating the efficacy of this treatment. OBJECTIVES: By applying 3-dimensional (3D) technology, this study aimed to quantitatively evaluate the effects of BTX-A injection on muscular (M) and muscle-fat pad mixed-type (MF) NLFs. METHODS: BTX-A was injected into bilateral marked points on the NLFs, where the levator labii alaeque nasi, zygomaticus minor, and zygomaticus major pull the skin to form the NLF (2 U at each injection site). Pretreatment and posttreatment 3D facial images were captured with static and laughing expressions. The curvature, width, depth, and lateral fat volume of the NLFs were measured to compare the therapeutic efficacy for type M and MF NLFs. RESULTS: Thirty-nine patients with type M and 37 with type MF NLFs completed the follow-up data. In these patients, the curvature, width, and depth of the NLF showed a significant reduction at 1 month and gradually recovered at 3 and 6 months after treatment, with more significant improvement when laughing than when static. Variations compared to the pretreatment values of type MF were greater than those of type M at each time point. The lateral fat volume of the type MF NLF was significantly reduced (P < .05). CONCLUSIONS: 3D technology can quantitatively evaluate the effects BTX-A injection for treating type M and type MF NLFs. BTX-A is more effective on type MF than on type M NLFs.

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.

Quantitative Evaluation of Nasolabial Fold by Three-Dimensional Imaging: A Comparison with WSRS Score.

BACKGROUND: Nasolabial fold (NLF) reveals the aging of the face, and various treatments for NLF have been developed currently. However, most methods introduced to evaluate NLF are subjective and qualitative. OBJECTIVES: This study was aimed to establish and validate a quantitative evaluation method by three-dimensional imaging, and thus accordingly to determine the relationship between quantitative measurements and wrinkle severity rating scale (WSRS) score. METHODS: Seventy-five Asian female volunteers were enrolled for evaluating the severity of NLF based on both WSRS score and three-dimensional imaging. Three-dimensional imaging was used to collect the quantitative measurements of NLF, including length, width, and depth. The relationship between multiple WSRS scores and quantitative measurements was compared statistically. Besides, thirty patients with moderate or severe NLF were admitted to receive hyaluronic acid injection for NLF correction. All NLFs were evaluated quantitatively pre-injection and 3 months post-injection. RESULTS: The results revealed a statistically significant positive relationship between the WSRS score and the length, width, and depth of NLF, respectively. After 3 months of hyaluronic acid injection, the mean WSRS score, the length, width, and depth of NLF were significantly reduced. CONCLUSIONS: Three-dimensional imaging can be used to quantitatively assess the severity of the nasolabial folds, compensating for the deficiencies of traditional scales. This technique may help improve rejuvenation procedures for the aging nasolabial fold. 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 .

Three-Dimensional Description of the Angular Artery in the Nasolabial Fold.

BACKGROUND: Due to its arterial vasculature, the nasolabial sulcus is one of the most challenging facial regions to treat when trying to ameliorate the signs of facial aging. OBJECTIVES: The aim of the present study was to provide data on the 3-dimensional course of the angular artery within the nasolabial sulcus in relation to age, gender, and body mass index to increase safety during minimally invasive treatments. METHODS: Thee hundred nasolabial sulci from 75 males and 75 females of Russian Caucasian ethnic background (mean [standard deviation] age, 45.7 [18.7] years; mean body mass index, 25.14 [4.9] kg/m2) were analyzed. Bilateral multiplanar measurements were based on contrast-enhanced computed tomography cranial scans. RESULTS: Up to 3 arteries could be identified within the nasolabial sulcus: ~90% contained 1 arterial trunk, ~9% had 2 trunks, and ~1% had 3 trunks; females had more arteries than men. The artery is located at mean depths of 21.6 mm at the oral commissure and 8.9 mm at the nasal ala. The angular artery was lateral to the nasolabial sulcus in 100% of cases; the smallest distance between the artery and the nasolabial sulcus was at the oral commissure (11.91 [7.9] mm) and the greatest was at the nasal ala (13.73 [3.9] mm). CONCLUSIONS: In contrast to current concepts, the angular artery is not located strictly subdermal to the nasolabial sulcus but at a variable depth, and in 100% of the investigated cases lateral to the nasolabial sulcus. With increasing age, the depth and lateral distance between arteries and sulci reduces significantly, underscoring the need for special caution when injecting this site.

A Safe Doppler Ultrasound-Guided Method for Nasolabial Fold Correction With Hyaluronic Acid Filler.

BACKGROUND: Injection of hyaluronic acid filler, a common procedure for nasolabial fold correction, poses a risk of vascular compromise, which can result in skin necrosis and blindness. OBJECTIVES: The aim of this study was to examine the facial arterial pathway in real time by Doppler ultrasound to avoid arterial complications during filler injections. METHODS: The facial artery pathway of 40 patients (80 nasolabial folds; 2 men and 38 women; mean age, 46.5 years; range, 28-72 years) was examined by Doppler ultrasound before hyaluronic acid filler injection. On the basis of this ultrasound evaluation, the filler injection targeted the subdermal, subcutaneous, and deep to submuscular layers by bypassing the facial artery. The efficacy of the filler injection was evaluated for each patient. RESULTS: The facial artery was detected lateral to the nasolabial fold in 31% of patients; it was detected beneath the nasolabial fold in the other patients as follows: subdermal layer, 13%; subcutaneous layer, 29%; muscular layer, 24%; and submuscular layer, 4%. The mean [standard deviation] Wrinkle Severity Rating Scale score was 3.68 [0.76] before injection and 2.28 [0.78] at 3 months after injection. Two patients experienced unilateral bruising of the nasolabial fold, which resolved after 2 weeks without treatment. CONCLUSIONS: Doppler ultrasound can be considered as pretreatment tool for the prevention of vascular complications during filler injections to correct nasolabial folds.

New Insights into the Three-Dimensional Anatomy of the Facial Mimetic Muscles Related to the Nasolabial Fold: An Iodine Staining Technique Based on Nano-computed Tomography.

PURPOSE: This study aimed to introduce a novel approach to study the facial mimetic muscles (FMMs) in relation to the nasolabial fold (NLF) and realize the visualization of complex three-dimensional (3D) structures and spatial relationships of the FMMs. MATERIALS AND METHODS: Nano-computed tomography (nano-CT) and iodine staining techniques were used to obtain the two-dimensional (2D) radiographs of the FMMs. Materialise Mimics software was then used to reconstruct the 3D model of the FMMs. RESULTS: The zygomaticus major muscle (ZMM) was divided into trunk fibers and branch fibers. The trunk fibers of the ZMM were subdivided into branch fibers layer-by-layer. Adipose tissue in the cheek was not a mass of unorganized fat. It was separated and fixed by branch fibers. Moreover, the trunk fibers of the ZMM were directly connected to the levator anguli oris (LAO), not the skin. On the contrary, the ZMM was connected to the skin by its subdivided branch fibers indirectly. The muscle fibers in the modiolus were organized, rather than disorganized. In other words, the terminal of the trunk fibers of the ZMM was located in the LAO. Moreover, the terminal of the trunk fibers of the LAO was located at the terminal of the trunk fibers of the musculus depressor anguli oris at the corner of the mouth. Furthermore, the levator labii superioris alaeque nasi was not directly connected to the orbicularis oris muscle. It was connected to the combination of the LLS and the rhinaeus. CONCLUSIONS: Although nano-CT has many disadvantages, it enabled the 3D anatomical study of the FMMs in relation to the NLF when combined with iodine staining. We imported the 2D images obtained by nano-CT scanning into the Mimics software, successfully reconstructed the FMMs, and finally obtained images of complex 3D structures of the FMMs. The shapes, positions, and 3D spatial relationships of the FMMs were clearly visualized. The novel insights into the 3D anatomy of the FMMs may help understand the formation of the NLF. Finally, the results of this study may help improve the rejuvenation surgery of the NLF soon. 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.

Finite-Element Biomechanical-Simulated Analysis of the Nasolabial Fold.

BACKGROUND: Nasolabial fold (NLF) is an important anatomic sign of facial aging. However, the dynamic biomechanical relationships between the facial mimetic muscles (FMMs) and the NLF remain unclear. OBJECTIVE: This study aimed to investigate the dynamic biomechanical relationships between the FMM and various NLF by finite-element analysis (FEA). METHODS: The 3-dimentional computer-aided design (3D CAD) model of the skin-muscle-maxillofacial bone in the NLF was established by using the engineering design module of the Computer-Aided 3-dimensional Interactive Application (CATIA) software. This CAD model was then imported into the Hypermesh software to set element type, mesh, and material properties. Finally, the 3D FEA model of the skin-muscle-maxillofacial bone in the NLF was generated, and then exported and uploaded into the Abaqus software with HM format for mechanical force loading and biomechanical analysis. RESULTS: A 3D FEA model of the skin-muscle-maxillofacial bone in the NLF was successfully established by using the Mimics, Geomagic Studio, CATIA, Hypermesh, and Abaqus softwares. This FEA model had a good geometrical resemblance and good biomechanical properties. This provided an ideal biomechanical model for the study of deformation and the biomechanics of soft tissues, such as the NLF. The FEA was applied to the biomechanical simulation of the NLF. We established five effective FEA models to study the dynamic biomechanical relationships between the NLF and the FMM. The dynamic biomechanical relationships between the NLF and the FMM were preliminarily determined by computer simulating different types of mechanical force loadings. CONCLUSION: The FEA is an effective method to simulate the dynamic biomechanical relationships between the NLF and the FMM. Through the FEA simulation described in this study, we could preliminarily conclude that the formation of different types of NLF is mainly due to the coordinated contraction of various FMM. Moreover, not all FMM are involved in all types of NLF. According to the results of the FEA simulations in this study, it is worthwhile considering investigating the role of botulinum toxin in improving the morphology of the NLF in the near future.

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.

Analysis of age-related changes in midfacial fat compartments in Asian women using computed tomography.

BACKGROUND: Volume restoration is no more a fresh theory for midfacial rejuvenation. However, lack of knowledge regarding the natural ageing process of fat compartments often leads to an insufficient or excessive clinical result. The aim of this study is to reveal the age-related changes in midfacial fat compartments and the correlation between midfacial grooves and the related fat compartments. METHODS: This study included 60 Asian females in defined age-based categories. The thickness of the infraorbital fat compartment, the nasolabial fat compartment, and the cheek fat compartments were measured using computed tomography (CT) images. Analysis of correlations between midfacial grooves and the related fat compartments was performed using the SPSS software. RESULTS: A tendency of thickening in the infraorbital fat and nasolabial fat compartments with age was observed. The superficial layer of cheek fat compartments was found to be thinner, and a similar tendency was observed in the medial part of deep medial cheek fat. However, it was thicker in the lateral part of deep medial cheek fat. There was a negative correlation between the fat thickness of deep medial cheek fat and both the severity of tear trough deformity and the nasolabial fold. A positive correlation between the lower third of the nasolabial fat compartment and the severity of the nasolabial fold was found as well. CONCLUSION: Different midfacial fat compartments tended to undergo selective hypertrophy or atrophy with ageing. The findings of this study suggested that augmentation of the deflated fat compartment and liposuction of the hypertrophic fat compartment can provide a more natural effect in facial rejuvenation.

Complejo esclerosis tuberosa en población aymara: relato de un caso / Tuberous sclerosis complex in the Aymara population: a case report

El Complejo Esclerosis Tuberosa (CET) es una enfermedad de origen genético, multisistémica de transmisión autosómica dominante, se debe a la mutación de los genes TSC1 (Tuberose Sclerosis Complex 1) y TSC2 de los cromosomas 9 y 16 respectivamente. Las manifestaciones clínicas se deben a la presencia de lesiones tumorales benignas (harmatomas) en diferentes órganos lo que genera un amplio espectro de signos y síntomas. El caso que se presenta es de una adolescente de origen aymara con epilepsia, retraso mental y lesiones dérmicas típicas. Es una enfermedad poco frecuente en nuestro medio y rara en personas de origen indígena, no encontrándose ninguna descripción en la literatura nacional. Por la multiplicidad de las manifestaciones clínicas, se hace necesario divulgar la información para que que las diferentes especialidades médicas reconozcan y diagnostiquen esta patología tempranamente para un tratamiento adecuado, oportuno y interdisciplinar.

The Tuberose Sclerosis Complex (TSC) is a genetic, multisystemic disease of autosomal dominant transmission, due to the mutation of the TSC1 and TSC2 genes of chromosomes 9 and 16 respectively. The clinical manifestations are due to the presence of benign tumor lesions (harmatomas) in different organs, which generates a wide spectrum of signs and symptoms. The case presented is that of a teenager of Aymara origin with epilepsy, mental retardation and typical skin lesions. It is a rare disease in our environment and rare in people of indigenous origin, no description found in the national literature. Due to the multiplicity of the clinical manifestations, it is necessary to disseminate the information so that the different medical specialties recognize and diagnose this pathology early for an adequate, timely and interdisciplinary treatment.

Using three-dimensional average facial meshes to determine nasolabial soft tissue deformity in adult UCLP patients.

BACKGROUND AND PURPOSE: There is limited literature discussing the residual nasolabial deformity of adult patients prior to undergoing orthognathic surgery. The purpose of this study is to determine the site and severity of the residual nasolabial soft tissue deformity between adult unilateral cleft lip and palate (UCLP) patients and a non-cleft reference group, prior to orthognathic surgery. MATERIAL AND METHODS: Sixteen adult male UCLP patients, who all received primary lip and palate surgery according to a standardised Hong Kong protocol were recruited for this study. Facial images of each individual were captured using three-dimensional (3D) stereophotogrammetry and compared to a previous published Hong Kong non-cleft reference group of 48 male adults. Using two-sample t-tests differences in linear and angular measurements and asymmetry scores were evaluated between the two groups. In addition a "conformed" average UCLP facial template was superimposed and compared to conformed average non-cleft reference group facial template. Reproducibility of the measurements were assessed using Students paired t-tests and coefficients of reliability. MAIN FINDINGS: Significant differences in linear and angular measurements and asymmetry scores were observed between the two groups (p < 0.05). Adult UCLP patients showed significantly narrower nostril floor widths, longer columella length on the unaffected side, a wider nose, shorter cutaneous lip height, shorter upper lip length and shorter philtrum length. Prior to orthognathic surgery adult UCLP patients showed significantly more facial asymmetry. Superimposition of the average facial meshes clearly showed the site and severity of the deficiency in the x, y and z-directions. CONCLUSIONS: Many of the nasolabial characteristics reported to be present in children following primary UCLP repair continue into adulthood. The detrimental soft tissue effects of orthognathic surgery for UCLP patients may be different to non-cleft individuals; and as such the site and severity of the residual deformity should be assessed prior to surgery.

Quantitative and perceived visual changes of the nasolabial fold following orthodontic retraction of lip protrusion.

OBJECTIVES: The objectives of this study were to evaluate the quantitative and perceived visual changes of the nasolabial fold (NLF) after maximum retraction in adults and to determine its contributing factors. MATERIALS AND METHODS: A total of 39 adult women's cone-beam computed tomography images were collected retrospectively and divided into the retraction group (age 26.9 ± 8.80) that underwent maximum retraction following 4 premolar extraction and the control group (age 24.6 ± 5.36) with minor changes of the incisors. Three-dimensional morphologic changes of hard and soft tissue including NLF were measured by pre- and posttreatment cone-beam computed tomography. In addition, perceived visual change of the NLF was monitored using the modified Global Aesthetic Improvement Scale. The influence of age, initial severity of NLF, and initial soft tissue thickness was evaluated. RESULTS: Anterior retraction induced significant changes of the facial soft tissue including the lips, perioral, and the NLF when compared with the controls ( P < .01). Perceived visual changes of the NLF was noted only in women younger than age 30 ( P < .05), with the odds ratio (95% confidence interval) of 2.44 (1.3461-4.4226), indicating greater possibility for improvement of NLF esthetics in young women of the retraction group when compared with the controls. CONCLUSIONS: Orthodontic retraction induced quantitative and perceived visual changes of the NLF. For adult women younger than age 30, the appearance of the NLF improved after maximum retraction despite the greater posterior change of the NLF.

Cheek Volumization and the Nasolabial Fold.

BACKGROUND: The impression that cheek filling results in longitudinal shortening ("lift") of the skin and elevation of the nasolabial crease or nasolabial fold has become common within the facial injection community but remains unsubstantiated. METHODS: In this study, 77 patients were evaluated before and after injection of the cheeks with a hyaluronic acid filler using a three-dimensional camera system. RESULTS: A constant pattern of skin expansion away from the center of the injection and perpendicular to the surface of the skin was observed. A subgroup of 37 patients without differences in their preinjection and postinjection facial expression were analyzed by direct comparison and failed to demonstrate lateral traction (or "pull") on the intervening skin from the cheek injection site to the nasolabial crease. Furthermore, there was no photographic difference in the nasolabial fold or nasolabial crease. The only patients who demonstrated photographic improvement of the medial face were those who had filler placed directly in the transition between the lateral nasolabial fold and cheek (nasojugal crease). CONCLUSIONS: Filling the cheek with 3 cc of volume does not create traction forces or move the skin between the site of injection and the nasolabial crease. It is likely that expanding the nasojugal crease is the direct visual cue that leads to perceived improvement in the nasolabial fold.

Bilateral nasolabial cyst.

Nasolabial cyst is an uncommon non-odontogenic extraosseous cyst located in the nasolabial fold. Bilateral nasolabial cysts are rarer and only few cases have been reported. We describe a case of two asymptomatic masses of the nasal ala areas, which prove to be nasolabial cysts in a 30-year-old Moroccan woman.

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.

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.

The External Nose: The Nasal Arteries and Their Course in Relation to the Nasolabial Fold and Groove.

BACKGROUND: The blood supply to the external nose is poorly described. The aim of this study was to identify the different types of blood supply to the external nose and the course of the arteries in relation to the nasolabial fold and groove and to the facial muscles. METHODS: With 96 facial halves of 48 adult specimens, the arteries of the outer nose were dissected, and three-dimensional computed tomographic reconstructions and horizontal sections were made. RESULTS: Three main types of blood supply to the external nose were identified, associated with the different types of facial arteries. Moreover, a deep course of the nasal arteries in relation to the nasolabial fold and a very superficial course in relation to the nasolabial groove were found. CONCLUSION: Knowledge regarding the nasal arteries is clinically relevant for filler injection for aesthetic improvements of the nose and nasolabial fold and for planning local flaps in facial reconstructions and also for rhinoplasty.