Histomorphological analysis of the superficial musculoaponeurotic system in Macaca mulatta species.

INTRODUCTION: The superficial musculoaponeurotic system (SMAS) is a well described facial functional unit in humans. SMAS connects mimic musculature to the skin having many implication in facial mimic expression. One of the various morphological and physiological analogies in human and Macaca mulatta species is the facial mimic. The present study analyzed Macaca mulatta species SMAS morphology and its facial topographical differences and compared this with human SMAS tissue morphology. MATERIAL AND METHODS: Macaca mulatta full-graft tissue blocks of skin, subcutaneous tissue and mimic muscles from five topographical different facial regions (Regio Temporalis, Regio Buccalis, Regio Infraorbitalis, Regio Angulus Oris and Regio Mandibularis) were collected postmortem from eight individuals (n = 8) at the German Primate Center, Leibniz Institute for Primate Research in Göttingen (DPZ) and studied histologically. Haematoxylin-eosin and azan stained histological serial sections of full-graft tissue blocks were analyzed and SMAS topographical differences evaluated. RESULTS: SMAS typical tissue morphology was recognized in all Macaca mulatta histological serial sections (n = 780). Regio Infraorbitalis Macaca mulatta SMAS (MmSMAS) morphology was similar to human infraorbital SMAS morphology (type I SMAS). Suborbicularis oculi fat pad was recognized in Macaca mulatta samples. Human type I similar SMAS morphology was demonstrated over Macaca mulatta Regio Temporalis and Regio Buccalis. Regio Angulus Oris and the cranial area of the Regio Mandibularis presented human type II similar SMAS morphology. Type IV MmSMAS was closely related to the parotid gland tissue presence. The cervical area of the Regio Mandibularis presented human type V similar SMAS morphology. CONCLUSIONS: SMAS is a complex fibro-musculo-adipose tissue network and probably an important pivot in Macaca mulatta facial system supporting mimic expression. This study provided insights into MmSMAS typology and similarity with human SMAS tissue morphology.

Perception gap of aged facial appearance; self-perception is younger than actual status due to angle of viewing.

BACKGROUND: Facial morphology changes with aging, resulting in an aged appearance that is a great matter of concern for people. However, it is not clear whether people perceive their own facial appearance accurately, in part because there are few methods to evaluate this. AIM: The aim of this study is firstly to establish an evaluation system for the perception gap of aged facial appearance between the self-perceived status and the actual status, and then to use this evaluation system to quantify the perception gap and to clarify the mechanism of this gap METHOD: Thirty-six middle-aged female volunteers were first asked to rate their facial aging-related morphology according to a 6-grade set of photos taken at a 45° angle from the front showing progressive stages of sagging severity, without looking either in a mirror or at photos of themselves (self- or "subjective" perception). Then they were shown photos of their face taken at a 45° angle from the front, and asked again to rate their sagging grade based on these photos ("objective" rating). In addition, facial photos taken from several angles from the front to the side were evaluated for sagging severity by trained evaluators. RESULTS: This system for analyzing perception gap revealed that the self-perception of aged appearance was significantly younger than the actual situation in three facial areas, namely the cheek, around the eyes and the facial contour, and the gap corresponded to an age difference of as much as 8 years in middle-aged females. Trained evaluators found that the severity of sagging judged from photos taken from a frontal direction was significantly less than in photos of the same subject taken from side angles. This suggests that recognition of sagging is more difficult from the front, which is the direction from which people view their own face in daily life. Indeed, viewing photos taken from the side, a rare viewing angle of one's own face, increased the motivation to improve aged appearance in more than 70% of the subjects in a questionnaire survey. CONCLUSION: The results suggest that people perceive their own facial appearance as less aged than it actually is. The reason for this appears to be that viewing from the front, the usual viewing angle of one's own face in daily life, results in lower perceived sagging severity, likely due to reduced depth perception.

Mastering Midface Injections.

Injectable filler is one of the most common cosmetic procedures performed annually. An aging face shows a characteristic loss of volume in the deep fat pads of the midface. The goal of midfacial rejuvenation with injectable filler is to restore lost volume, with the suborbicularis fat pad and deep medial cheek fat being the most critical areas. Filler can be instilled here with a cannula or needle with successful outcomes. However, this procedure is not without complications if proper technique and underlying anatomy are not respected.

Quantification of Facial Fat Compartment Variations: A Three-Dimensional Morphometric Analysis of the Cheek.

BACKGROUND: Cheek contour is a main determinant of facial attractiveness. The aim of this study was to evaluate the relationship between age, sex, and body mass index (BMI) and cheek fat volume in a large cohort to better understand and treat facial aging. METHODS: The authors performed a retrospective review of the archives of the Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen. Epidemiologic data and medical history were assessed. Cheek superficial and deep fat compartment volumes were measured on magnetic resonance images. Statistical analyses were performed using SPSS and SAS statistical software. RESULTS: A total of 87 patients with a mean age of 46 years (range, 18 to 81 years) were included. The superficial and deep fat compartment volumes of the cheek increased with BMI ( P < 0.001 and P = 0.005), but there was no significant relationship between age and volume. The ratio of superficial versus deep fat did not change with age. No significant difference of the superficial or deep fat compartments was found between men and women in a regression analysis ( P = 0.931 and P = 0.057). CONCLUSIONS: Cheek fat volume measurements on magnetic resonance imaging scans using reconstruction software suggest that the fat volume of the cheek increases with BMI but does not change significantly with age. Further studies are needed to elucidate the role of age-related changes of bone structures or sagging of the fat compartments.

Defining the Cervical Line in Face-Lift Surgery: A Three-Dimensional Study of the Cervical and Marginal Mandibular Branches of the Facial Nerve.

BACKGROUND: Continuous sub-superficial musculoaponeurotic system (SMAS) dissection in the cheek with subplatysmal dissection in the neck is an important feature of many face-lift techniques, yet the neural anatomy in this area remains unclear, and recommendations regarding continuous dissection of these adjacent areas vary widely. The purpose of this study was to define the vulnerability of the facial nerve branches in this transitional area from the face-lift surgeon's perspective and to specifically identify the location of the cervical branch penetration through the deep cervical fascia. METHODS: Ten fresh and five preserved cadaveric facial halves were dissected under 4× loupe magnification. The skin was reflected, followed by elevation of a SMAS-platysma flap, with identification of the location of cervical branch penetration through the deep cervical fascia. The cervical and marginal mandibular branches were then dissected retrograde through the deep cervical fascia to the cervicofacial trunk to confirm identifications. RESULTS: Cervical and marginal mandibular branch anatomy was found to be similar to that of the other facial nerve branches, all of which initially course deep to the deep fascia in their postparotid course. The emergence of the terminal branch or branches of the cervical branch through the deep cervical fascia was consistently at or distal to a line from a point 5 cm below the mandibular angle on the anterior border of the sternocleidomastoid muscle to the point where the facial vessels course over the mandibular border (cervical line). CONCLUSIONS: Continuous dissection of the SMAS in the cheek, with subplatysmal dissection in the neck crossing over the mandibular border, is possible without jeopardizing the marginal mandibular or cervical branches if done proximal to the cervical line. This study serves as the anatomical justification for continuous SMAS-platysma dissection, and has implications for all types of SMAS flap manipulations.

Finesse Buccal Fat Pad Excision.

SUMMARY: The buccal fat pad has long been noted for its complex anatomy and its significance to facial aesthetics. Its bulk is mostly deep facial fat immediately superficial to the buccinator muscle. The buccal fat pad has a main body and four extensions: buccal, pterygoid, superficial temporal, and deep temporal. It can be removed in patients with round, heavy faces and anterior buccal fullness to slim the lower face and contour the jawline. This article describes the authors' technique for buccal fat pad removal, with a goal of conservative fat pad reduction.

The Deep Fascia of the Infraorbital Region, Deep Plane, and Suprafibromuscular Facelift: New Anatomy for Safer Facelifting.

Deep-plane rhytidectomy, first described by Skoog, has had a resurgence in popularity and is in high demand today. We describe anatomical findings that establish the presence of a true deep fascia in the midface, we named as Chiara's fascia, like the first author's first name, which helps to form the facial ligaments and is contiguous with the superficial layer of the deep temporal fascia. This fascia inserts on the periosteum of the inferior orbital rim at the arcus marginalis and separates the suborbicularis oculi fat (SOOF) from the preperiosteal fat. This distinct fascial layer lies under the superficial fascia or superficial musculoaponeurotic system (SMAS) and represents the floor of what is commonly termed the "deep plane." When this fascial highway is identified intraoperatively, blunt dissection immediately superficial to this layer will protect facial nerve branches overlying the muscles lifting the upper lip such as the zygomaticus. Subsequent dissection over the middle and lower face can usually be performed bluntly. Over a 10-year period, a total of 100 hemifaces were dissected with a 100% success rate of identifying this fascia in all specimens. This work was further validated by examining histologic specimens that clearly demonstrate this unique fibrofatty fascial layer. These dissections and new anatomical findings were then correlated to over 300 intraoperative deep-plane facelift cases by the primary and senior authors. We term this operative technique as the suprafibromuscular facelift. Dissection in this plane allows for safe release of facial retaining ligaments with protection of facial nerve branches.

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.

Mastering Midface Injections.

Injectable filler is one of the most common cosmetic procedures performed annually. An aging face shows a characteristic loss of volume in the deep fat pads of the midface. The goal of midfacial rejuvenation with injectable filler is to restore lost volume, with the suborbicularis fat pad and deep medial cheek fat being the most critical areas. Filler can be instilled here with a cannula or needle with successful outcomes. However, this procedure is not without complications if proper technique and underlying anatomy are not respected.

Tear Trough and Lid-Cheek Junction Anatomy: Current Understanding and Nonsurgical Treatment.

The tear trough and lower eyelid are sentinel sites of facial aging and are increasingly the target of nonsurgical aesthetic procedures. This article will review the advances that have led to our current understanding of tear trough anatomy. We propose a new functional classification of the lid-cheek junction for soft tissue filler treatment, and suggest simpler stratification of patients seeking lower eyelid treatment based on the etiology of their tear trough depression. We aim to describe a stepwise approach to management, with specific technical considerations targeting the underlying causes of lower eyelid pathology. The common complications and pitfalls of nonsurgical tear trough management will be discussed.

Relaciones anatómicas del cuerpo adiposo de la mejilla asociadas a complicaciones de bichectomía: a propósito de un caso / Anatomical relationships of the adipose buccal fat pad associated with bichectomy complications: about a case

RESUMEN: El presente estudio busca entregar conocimientos y aspectos importantes de las estructuras anatómicas asociadas al cuerpo adiposo de la mejilla (CAM), a consecuencia del reporte de un caso de complicación posterior a una bichectomía. Conocer los elementos anatómicos y sus relaciones con el CAM es de vital importancia, ya que en la actualidad son muchos los cursos y pasadas que se realizan para odontólogos generales y especialistas para el retiro del CAM, esto producto de la creciente demanda estética de las personas por presentar un perfil más fino y estilizado. El caso presentado corresponde a una mujer que consultó al servicio de urgencia por aumento de volumen facial posterior a la extracción del CAM, el cual se diagnosticó como sialocele, consecutivo a daño del conduc- to parotídeo. Al revisar la literatura y observar en nuestros preparados anatómicos se aprecia la cercanía de elementos de importancia, como son el conducto parotídeo, los ramos cigomático y bucal del nervio facial, vasos faciales como la arteria facial, vena facial y arteria transversa facial, es por esto que es necesario conocer en detalle la zona a intervenir y considerar las posibles variaciones anatómicas de estos elementos, para así evitar dañarlos durante el procedimiento, tomando una actitud preventiva. Apuntado entonces al objetivo de este estudio, fue lograr entregar información anatómica precisa y concisa de los elementos de importancia próximos o inmersos en el CAM, para prevenir la iatrogenia de estos.

SUMMARY: The present study seeks to provide knowledge and important aspects of the anatomical structures associated with the buccal fat pad (BFP), as consequence of the report of a case of complication after bichectomy. Knowing the anatomical elements and their relationships with BFP is of vital importance, because nowadays there are too many BFP removal courses and internships, for general dentists and specialists, due to the increasing aesthetic demands of individuals seeking a finer and more stylized profile. The case presented is a female patient who consults the emergency department for an increase in facial volume after BFP extraction, which was diagnosed as sialocele, following damage to the parotid duct. When reviewing the literature and observing our anatomical preparations, the proximity of important elements is appreciated, such as the parotid duct, the zygomatic and buccal branches of the facial nerve, facial vessels such as the facial artery, facial vein and facial transverse artery. It is essential to know in detail the area in order to intervene and consider the possible anatomical variations of these elements to avoid injury during the procedure. The aimed objective of this study, is to provide accurate and concise anatomical information of important elements near or immersed in BFP, to prevent iatrogenesis.

Anatomic Characteristics and Treatment of the Midcheek Groove by Deep Filling.

BACKGROUND: Because the anatomic mechanisms underlying the formation of the midcheek groove are unclear, treatments to date have resulted in unsatisfactory outcomes. OBJECTIVE: This study investigated the anatomical foundation of the midcheek groove and evaluated appropriate treatment methods. MATERIALS AND METHODS: Six cadaver hemifacial specimens were subjected to gross anatomic dissection and 6 to P45 sheet plastination. Based on the anatomic results, the area under the orbicularis oculi muscle (OOM) was selected for deep filling. Patients were evaluated by measuring 3D depth, regrading, and self-assessment. RESULTS: The medial band was observed to be an important structure of the OOM, with the facial projection overlapping the midcheek groove trace. Two of the 6 P45 specimens were found to have compact fibroelastic bundles (CFBs) between the medial band and the dermis. Deep filling of the area under the OOM significantly reduced the depth of each section in all 34 patients (p < .001). Grades 3 and 4 midcheek grooves were downgraded distinctively. Most subjects expressed satisfaction with outcomes. CONCLUSION: Formation of the midcheek groove is associated with the passage of CFBs. Deep filling of the area under the OOM effectively improves the midcheek grooves.

A Cadaveric Study of the Buccal Fat Pad: Implications for Closure of Palatal Fistulae and Donor-Site Morbidity.

BACKGROUND: For the cleft surgeon, palatal fistulae after cleft palate repair remain a difficult problem, with a paucity of local tissue options to aid closure. Small clinical series have described the use of the buccal fat pad flap to repair palatal fistulae; however, there is no literature detailing the anatomical coverage of the flap. This study delineates the anatomy of the buccal fat pad flap to guide surgeons in patient selection and examines the residual buccal fat after flap harvest to provide new information with regard to possible effects on the donor site. METHODS: Buccal fat pad flaps were raised in 30 hemicadavers. The reach of the flap across the midline, anteriorly and posteriorly, was recorded. In 18 hemicadavers, the entire buccal fat pad was then exposed to determine the effects of flap harvest on movement and volume of the residual fat. RESULTS: All buccal fat pad flaps provided coverage from the soft palate to the posterior third of the hard palate and all across the midline. Approximately three-fourths of flaps would cover the mid hard palate. The flap constitutes 36 percent of the total buccal fat pad on average, and a series of retaining ligaments were identified that may prevent overresection. CONCLUSIONS: The buccal fat pad flap is a useful tool for coverage of fistulae in the soft palate to the posterior third of the hard palate. In most cases, it will also reach the middle third; however, it is not suitable for more anterior defects. On average, two-thirds of the buccal fat pad remains within the cheek after flap harvest, which may protect against unwanted alteration in aesthetics.

The juxta-oral organ of Chievitz (organum yuxtaorale) updated: Embryology, anatomy, function and pathology.

BACKGROUND: The Chievitz's organ or juxta-oral organ is a mysterious bilateral structure, phylogenetically preserved, which develops from the mouth epithelium as an invagination that loses connection to it in the prenatal period. It is located laterally to the walls of the oral cavity in an imprecise anatomical location and receives abundant innervation from the buccal nerve. Structurally it consists of non-keratinizing squamous-like neuroepithelial cells surrounded by two layers of connective tissue with nerve fibers and different morphotypes of sensory corpuscles. Its function is completely unknown although based on its rich innervation it is assumed that works as a mechanoreceptor. METHODS: We have performed immunohistochemistry for axonal and Schwann cells, and the putative mechanoproteins ASIC2, TRPV4 and Piezo2 in sections of fetal juxta-oral organ. RESULTS: Intraparenchymatous nerve fibers and sensory corpuscles were observed as well as immunoreactivity for Piezo2 in both nerve fibers and epithelial parenchymatous cells. CONCLUSIONS: We add indirect evidence that the juxtaoral organ is a mechanoreceptor because in addition to its dense innervation, the epithelial cells and sensory nerve fibers display immunoreactivity for the mechanogated ion channel Piezo2. Based on current knowledge, the functional and clinical importance of the juxta-oral organ should be further investigated.

The bicycle wheel analogy for linear closures of small suborbital cheek defects.

Primary closure of suborbital skin defects can cause tension along the closure resulting in ectropion. The bicycle wheel analogy is a simple yet effective guide to aid in reducing tension vectors resulting in ectropion.

Relação anatômica da Bola de Bichat com ramos terminais do nervo facial / Anatomical Correlation among Bichat's fat pad with the Facial Nerve Terminal Branches

Introdução: A cirurgia de Bichectomia está sendo muito procurada por pessoas que visam diminuir o volume facial. O corpo adiposo da bochecha, ou bola de Bichat, possui uma complexa relação anatômica com estruturas faciais. Uma das complicações que o procedimento pode causar é a paralisia facial temporária ou permanente, em decorrência de injúrias causadas aos ramos terminais do nervo facial, devido à proximidade dessas duas estruturas anatômicas. Metodologia: O objetivo do presente artigo é enfatizar a relação anatômica da bola de Bichat com alguns ramos terminais do nervo facial através da dissecação de cadáveres. Foram feitas dissecações em três hemifaces de cadáveres humanos para a exposição do corpo adiposo da bochecha e dos ramos extracranianos do nervo facial. Resultados: A anatomia dos ramos terminais zigomáticos e bucais do nervo facial se mostrou variável em cada hemiface dissecada, mas sempre intimamente relacionados a bola de Bichat. Conclusões: O profissional que realiza a Bichectomia deve ter pleno conhecimento não só da técnica cirúrgica, mas também da variabilidade anatômica da região... (AU)

Introduction: The Buccal Fat Extraction surgery has been sought by people who aim to reduce facial volume. The Buccal fat pad has a complex anatomical correlation among the facial structures. The facial nerve paralysis is one of Bichat's fat extraction complications which might be temporary or permanent, due to the proximity of those anatomical structures. Methodology: The present article aims to emphasize the anatomical correlation between the Buccal fat pad and a few terminal branches of the facial nerve through the human cadaveric dissection. The dissection was performed on three human cadaveric hemifacial to expose the buccal fat pad body and the facial nerve extracranial branches. Results: The zygomatic and buccal terminal branches anatomy of the facial nerve has shown variables in each dissected hemifacial part. However, it has always presented closely related to Bichat's fat pad. Conclusions: The professional that performs the Buccal Fat Removal surgery must have to have the full knowledge not only about the surgical technique but the anatomical variability of the region, as well... (AU)

Simple procedure to evaluate mid-face sagging: A pilot study from Taiwan.

An easy and objective way to evaluate mid-face sagging is marking straight lines between the nasal alar and the mandibular angle, one in the supine and the other in an upright position. The maximal distance between the two lines drawn is measured. Statistic analyses shows that this maximum distance demonstrates positive correlation with age and body mass index that reflects the level of mid-face sagging. This simple method may be utilised to evaluate the effect of anti-ageing treatment on the face in the context of mid-face sagging.

Morphological investigations on the lips and cheeks of the goat (Capra hircus): A scanning electron and light microscopic study.

The current study was done to provide comprehensive information on the anatomical features of the lips and cheeks of the goat by gross examination and morphometric analysis in addition to scanning electron microscope (SEM). Samples from 12 normal healthy adult goat's heads of both sexes were collected directly after slaughtering. The lips and cheeks were dissected, and specimens were collected for both light and SEM. The lips of goat were soft and mobile. The free border of both lips was characterized rostrally by the presence of labial projections. The number, size, and arrangement of labial projections differed in the upper and lower lips. On the other hand, the buccal papillae were arranged into 6-8 longitudinal rows parallel to the cheek teeth. The length of these papillae decreased caudally while they were absent on the most caudal part of the cheek. Presence of several types and shapes of labial projections and papillae, and buccal papillae suggest a high degree of mechanical adaptation of the lips and cheeks of the goat. This study provides baseline data for clinical studies. This study is the first report to shed light on the morphology of the lips and cheeks of the goat by gross and scanning electron microscopy.

Nasolabial fold correction through cheek volume loss restoration versus thread lifting: a comparative study.

Nasolabial folds are caused by loss of deep fat and subsequent loss of muscle contour in the midface, leading to sagging which forms cosmetic issues in some cases when they are otherwise overly pronounced. Various treatment procedures have been developed to reduce their appearance. The objective of this study is to compare the efficacy of hyaluronic acid (HA) cheek fillers injection and thread lifting in improving the nasolabail folds. Twenty cases presenting with prominent nasolabial folds were randomly divided into two groups; group A underwent HA fillers for cheek lifting and group B underwent thread lifting for the cheek. Only one session was done for each case, and then they were followed up after 1 and 2 months. Statistical significant difference after treatment for both groups was detected using the wrinkle severity rating scale (WSRS) and the modified Fitzpatrick wrinkle scale (MFWS). The average global aesthetic improvement scale (GAIS) was 2.2 ± 0.79 for the fillers group and 3.2 ± 0.92 for the threads group, showing a statistical significant improvement with a p value less than 0.05 favoring the fillers group. 70% of fillers cases were satisfied and only 30% of threads cases. Fillers cheek injection is recommended for patients with sagged thin face to improve the nasolabial folds as well as giving volume and contour. Threads would do better for patients desiring an oval, less wide face shape. Combining threads with other cosmetic procedure would give a better holistic appearance.

Facial Nerve Danger Zones.

Facial nerve injury is one of the most feared complications in surgical rejuvenation of the aging face. Understanding the three-dimensional architecture of the facial soft tissue, the fascial planes that exist within this architectural arrangement, and the danger zones where the facial nerve is situated superficial and adjacent to the planes of dissection commonly used in face-lift techniques, are the keys to safety in preventing motor branch injury. The two-dimensional branching patterns of the marginal and cervical branches of the facial nerve are variable, making it difficult to ascertain exact nerve location when dissecting within the cheek and neck. On a three-dimensional basis, the position and depth of the marginal and cervical branches are constant and predictable. Understanding the three-dimensional anatomy in terms of planes of dissection, and the danger zones where these nerve branches are vulnerable to injury, provides protection against iatrogenic injury when performing surgical rejuvenation of the aging face. These video vignettes provide an overview of the fascial anatomy of the cheek in relation to the facial nerve branches and delineate the regions of the face in which nerve branches are most likely to be injured. Methods to prevent injury are discussed. Furthermore, the vignette defines these danger zones and delineates methods to protect the nerve branches.