The surgical anatomy of the nasolabial fold

Why Do Nasolabial Folds Appear? Exploring the Anatomical Perspectives and the Role of Thread-Based Interventions

The classification of nasolabial folds into three types, each with distinct causative factors and mechanisms, is explored. Age-related changes in facial skin and connective tissues are examined in detail, revealing variations across different facial regions due to variances in tissue firmness and thickness. The innovative 'Reverse Technique,' involving cog threads to enhance tissue traction and effectiveness in thread-lifting procedures, is introduced. Detailed technical guidelines, anatomical considerations, and safety measures are provided, emphasizing the importance of identifying optimal vectors and fixing points to achieve maximum lifting effects while minimizing potential risks, particularly those associated with vascular structures. Additionally, the 'Cross Technique using volumizing thread' is discussed, designed to smooth tissue boundaries and rejuvenate sagging areas. Facial anatomy, including the positioning of arteries and ligaments, is underscored as essential for ensuring the safety and efficacy of procedures. In conclusion, this review stands as a comprehensive guide for practitioners, offering insights into innovative thread-lifting methods and their applications in addressing nasolabial folds. The primary focus is on achieving optimal aesthetic results while prioritizing patient safety.

Efficacy and Safety of Polycaprolactone in Treating Nasolabial Folds: A Prospective, Multicenter, and Randomized Controlled Trial

Nasolabial folds (NLFs) are the most pronounced sign of facial aging. This study explored the efficacy and safety of polycaprolactone gel in treating Chinese patients with moderate-to-severe NLFs. Patients with moderate-to-severe NLF who wished to be treated by dermal fillers were recruited from three centers between July 2017 and September 2019. The randomizing ratio was 1:1 in the polycaprolactone group (polycaprolactone injection) or control group (sodium hyaluronate gel injection). The primary endpoint was the effectiveness rate of Wrinkle Severity Rating Score (WSRS) scores at 12 months after injection. The full-analysis set (FAS) and safety sets had 80 patients in the polycaprolactone group and control group, respectively. In the FAS, the effectiveness rate at 12 months in the polycaprolactone group was 88.8% compared with 23.8% in controls (P < 0.001). The improvement in WSRS sustained during 12 months in the polycaprolactone group, while gradually vanished in the control group since 3 months after surgery. The global aesthetic improvement scale (GAIS) by investigator assessments was improved, much improved, or very much improved in all patients during follow-up, while the proportion of patients with a "no change" assessment gradually increased during follow-up after 6 months in the control group. The rates of injection-related adverse event (AE) and serve injection-related AE were 8.8 versus 11.3% and 0 versus 1.3% in the polycaprolactone group and control groups, respectively. Polycaprolactone gel injection is effective and safe to treat moderate-to-severe NLFs in Chinese patients.

Tissue Fillers for the Nasolabial Fold Area: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Abstract

Tissue fillers injections remain to be one of the most commonly performed cosmetic procedures. The aim of this meta-analysis was to systematize and present available data on the aesthetic outcomes and safety of treating the nasolabial fold area with tissue fillers. We conducted a systematic review of randomized clinical trials that report outcomes concerning treatment of nasolabial fold area with tissue fillers. We searched the MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, Cochrane Controlled Register of Trials, CNKI and Web of Science databases. Primary outcomes included aesthetic improvement measured using the Wrinkle Severity Rating Scale score and Global Aesthetic Improvement Scale. Secondary outcomes were incidence rates of complications occurring after the procedure. At baseline, the pooled mean WSRS score was 3.23 (95% CI: 3.20–3.26). One month after the procedure, the pooled WSRS score had reached 1.79 (95% CI: 1.74–1.83). After six months it was 2.02 (95% CI: 1.99–2.05) and after 12 months it was 2.46 (95% CI: 2.4–2.52). One month after the procedure, the pooled GAIS score had reached 2.21 (95% CI: 2.14–2.28). After six months, it was 2.32 (95% CI: 2.26–2.37), and after 12 months, it was 1.27 (95% CI: 1.12–1.42). Overall, the pooled incidence of all complications was 0.58 (95% CI: 0.46–0.7). Most common included lumpiness (43%), tenderness (41%), swelling (34%) and bruising (29%). Tissue fillers used for nasolabial fold area treatment allow achieving a satisfying and sustainable improvement. Most common complications include tenderness, lumpiness, swelling, and bruising.

Level of Evidence II

"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."

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02439-5.

J, Yang H, Kwon H, Lee S, Lim HS, Lim SY, Oh C. 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.

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.

The Versatility of Nasolabial Flaps in Maxillofacial Surgery

Introduction

The nasolabial flap can be used for reconstruction of the orofacial region. The procedure is of a short duration and treats orofacial soft tissue defects of small to moderate size, especially when microsurgical free flaps are less feasible due to lack of infrastructure, expertise or financial constraints.

Aims and Objectives

To study the effectiveness of the nasolabial flaps in reconstruction of orofacial defects of various origins.

Materials and Methods

In this prospective study, 10 patients (18 nasolabial flaps) were selected randomly regardless of age, sex and need for reconstruction-whether it being requirement of tissue coverage following traumatic loss of soft tissue, soft tissue coverage after resection of a benign or malignant tumor, or resection of soft tissue defects after excision of submucous fibrosis bands. Patients were treated under general anesthesia following routine investigations, using either inferiorly or superiorly based, unilateral or bilateral nasolabial flaps for local extraoral and intraoral reconstruction. Patients were evaluated for postoperative complications, flap uptake, donor site morbidity and postoperative extraoral scarring.

Results

In all cases, postoperative complications were relatively minor except in one flap where total flap loss was encountered. The average time taken for preparation of recipient site, flap elevation and closure was 72 min. The nasolabial flap proved itself to be extremely vascular and thus safe and suitable with satisfactory cosmetic outcomes.

Conclusion

The nasolabial flap proves to be a versatile flap with a proven blood supply from the facial, transverse facial and infraorbital vessels. It establishes itself as a simple procedure to execute to reconstruct the various defects of the anterior orofacial region. It is considered to be a safe flap with a low complication rate, and most importantly it offers a cosmetically pleasing and functionally satisfactory solution.

A diagnostic model for impending death in cancer patients: Preliminary report

BACKGROUND

Several highly specific bedside physical signs associated with impending death within 3 days for patients with advanced cancer were recently identified. A diagnostic model for impending death based on these physical signs was developed and assessed.

METHODS

Sixty-two physical signs were systematically documented every 12 hours from admission to death or discharge for 357 patients with advanced cancer who were admitted to acute palliative care units (APCUs) at 2 tertiary care cancer centers. Recursive partitioning analysis was used to develop a prediction model for impending death within 3 days with admission data. The model was validated with 5 iterations of 10-fold cross-validation, and the model was also applied to APCU days 2 to 6.

RESULTS

For the 322 of 357 patients (90%) with complete data for all signs, the 3-day mortality rate was 24% on admission. The final model was based on 2 variables (Palliative Performance Scale [PPS] and drooping of nasolabial folds) and had 4 terminal leaves: PPS score ≤ 20% and drooping of nasolabial folds present, PPS score ≤ 20% and drooping of nasolabial folds absent, PPS score of 30% to 60%, and PPS score ≥ 70%. The 3-day mortality rates were 94%, 42%, 16%, and 3%, respectively. The diagnostic accuracy was 81% for the original tree, 80% for cross-validation, and 79% to 84% for subsequent APCU days.

CONCLUSIONS

Based on 2 objective bedside physical signs, a diagnostic model was developed for impending death within 3 days. This model was applicable to both APCU admission and subsequent days. Upon further external validation, this model may help clinicians to formulate the diagnosis of impending death.

[Correction of the deep nasolabial fold using a temporalis superficialis fascia graft]

SUBJECT

The deep nasolabial fold (NLF) due to age is a frequent complaint from patients in plastic surgery. Various surgical and medical management solutions have been described in literature and are often based on different concepts to justify their interest. We present a new surgical treatment of this region using a temporalis superficialis fascia graft in order to fill the NLF. We also propose a review of the literature about the anatomy and the physiology of this major fold of the face.

PATIENTS AND METHODS

From 1990 to 2010, we practiced the replenishing of the NLF using a temporalis superficialis fascia graft on 24 female patients. They all were presenting NLF of great or mild importance due to ageing. We also performed on patients with a great importance NLF a lipofilling of the cheek and the lips in order to recover the volumes lost with ageing. The evaluation items were the quality of the filling (importance and symmetry), quality of the scars and complications occurring on the donor and receiving sites.

RESULTS

Objective and subjective results were good. Projection of the NLF was in most of cases strongly and durably restored.

CONCLUSION

Filling of the deep nasolabial fold using a temporalis superficialis fascia graft is a simple and reliable technique. Depending on the patients this method can be associated with a lipostructure of the cheek and the lips in order to optimize the facial rejuvenation. According to us this tissular implant allows a long lasting and important correction of the NLF.

Surgical softening of the nasolabial folds by liposuction and severing of the cutaneous insertions of the mimetic muscles

BACKGROUND

A surgical technique was developed to soften the nasolabial folds by liposuction and severing of the cutaneous insertions of the mimetic muscles. This procedure was used for 11 patients from September 2006 to June 2009.

METHODS

With the patients under local tumescent anesthesia, extraoral incisions were made in nine cases and intraoral incisions in two cases. Liposuction was performed superior and lateral to the nasolabial fold using an order-made one-hole 2.5-mm cannula. After liposuction, the fibrae septa and the cutaneous insertions of the mimetic muscles in the nasolabial region were severed by a sharp-edge eye scissors. Compressive dressings were maintained for 3 days.

RESULTS

All the patients, followed up from 3 months to 3 years, were satisfied with the aesthetic results. Both the depth and the length of the nasolabial folds were decreased conspicuously. The most obvious change was improvement in the lateral part of the nasolabial folds. The extraoral scars were almost imperceptible. Severe complications were not observed in this series.

CONCLUSION

Surgical softening of the nasolabial folds by liposuction and severing of the cutaneous insertions of the mimetic muscles is especially suitable for 40- to 60-year-old women with aging faces who are unwilling to undergo a face-lift. The procedure is simple, and the anatomic causes for deepening of the nasolabial folds can be corrected. Patients usually are satisfied with the final postoperative results.

The Undesirable Influence of Reconstructive Procedures on the Symmetry of the Nasolabial Folds

BACKGROUND AND OBJECTIVES

Although considerable attention has been directed toward the nasolabial fold in the esthetic surgery literature, there are infrequent discussions of the fold's importance in reconstructive surgery of the face. Because the use of common reconstructive techniques for wounds of the central face often introduces undesirable asymmetry to the nasolabial folds, reconstructive surgeons should be more aware of the esthetic consequences of manipulating the nasolabial folds.

METHODS

The influence of selected reconstructive procedures of the central face on the form and symmetry of the nasolabial folds is analyzed through the examination of multiple clinical examples of reconstructive successes and failures in this area.

RESULTS

Many commonly performed reconstructive procedures of the face introduce changes in the nasolabial fold's depth, slope, and location. The inherent asymmetries that such procedures introduce frequently detract from their overall esthetic results.

CONCLUSIONS

The nasolabial fold is a visually distinct unit of the face that deserves more attention from reconstructive surgeons. When possible, surgical alterations of the fold should be minimized to preserve facial symmetry.