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The British Journal of Dermatology Sep 2014The skin of the nasal dorsum and bridge is more forgiving in terms of reconstructive options. Individual differences in skin laxity, nasal length and sebaceous...
The skin of the nasal dorsum and bridge is more forgiving in terms of reconstructive options. Individual differences in skin laxity, nasal length and sebaceous composition impact on reconstructive choice as do the size, depth and exact location of the surgical defect. For many, if not all, defects in this area there are multiple different reconstructive options available all of which can result in equivalent and excellent results. Oftentimes there is no clear advantage of one repair over another and the choice becomes one of personal preference based on experience. No proscriptive approach or algorithm can be usefully applied in this setting. Key considerations include the location of the defect (distal vs. proximal nasal dorsum), the position of the defect (midline or off-centre) and the texture of the skin involved (sebaceous vs. non-sebaceous). Defects may be considered complex if they border on, or cross onto adjacent cosmetic units. Examples include defects extending onto the nasal tip, tip-ala junction, sidewall, nasal root-glabella and medial canthus. The adjacent reservoirs of tissue redundancy that can be utilized in flap reconstruction include the nasal sidewall, the nasal dorsum itself, the glabella, the midline/paramedian forehead and the medial cheek. Nearly all flaps on the nasal dorsum require subnasalis muscle dissection to effect sufficient movement and to ensure adequate flap vascularity and viability. The nasal bridge and glabella have much thicker skin and it is usually sufficient to dissect in the subcutaneous plane rather than disrupting the deeper procerus and corrugator muscles. Thick sebaceous skin is generally stiffer, moves less easily and closures may result in greater wound tension. These factors together with a tendency for sutures to tear through easily potentially increases the risk of complications. Greater consideration should be given to the exact type of flap or graft chosen in these patients.
Topics: Humans; Nose; Nose Diseases; Rhinoplasty; Surgical Flaps
PubMed: 25124308
DOI: 10.1111/bjd.13238 -
The Journal of Craniofacial Surgery Jul 2014The aim of this review was to familiarize the reader with critical facial nerve anatomy relating to facial rejuvenation surgeries. The temporal branch to the upper... (Review)
Review
The aim of this review was to familiarize the reader with critical facial nerve anatomy relating to facial rejuvenation surgeries. The temporal branch to the upper orbicularis oculi muscle (OOM): The temporal branch was under the temporoparietal fascia above the zygomatic arch and divided into 2 to 4 branches. The highest level of the twigs that entered the OOM on the x axis and the y axis with the origin of the lateral canthus is +2.51 ± 0.23 cm and +2.70 ± 0.35 cm; and the lowest, 0 cm and +2.68 ± 0.32 cm, respectively. The zygomatic and the buccal branch to the lower OOM: All pretarsal and preseptal OOMs were innervated by 5 to 7 terminal twigs of the zygomatic branches of the facial nerve that approached the muscle at a right angle. The medial portion of the lower OOM was innervated by 1 to 2 terminal twigs of the buccal branch, and the middle portion was innervated with 2 to 3 twigs of the zygomatic branch. The lateral portion was supplied by the uppermost zygomatic branch, which split into 2 to 4 twigs. The temporal branch to the corrugator supercilii muscle: A plexus mainly from the inferior ramus partly from the middle ramus of the temporal branch of the facial nerve enters the corrugator supercilii muscle in the supraorbital area. The temporal branch has as many as 4 to 7 rami, with interconnection among them. The buccal branch to the procerus muscle: The buccal branch crosses the intercanthal line (the nasion to the medial canthus) at approximately one third laterally. The nerve entrance was within a circle with a diameter of 5 mm, and its center was located 9 mm lateral and 10 mm superior from the nasion. It was approximately at the midpoint of the lateral half of the intercanthal line and the lower one third between the intercanthal line and the tangential line of the supraorbital rim. The buccal branch, the buccal fat pad, and the parotid duct: The buccal branches and the parotid duct crossed each other within a semicircle with a 30-mm radius. The base (diameter) was parallel to a horizontal line passing the corner of the mouth and 12 mm above. Its center was located 53 mm lateral to it. The buccal branches of the facial nerve have 2 locations at the buccal fat pad: type I, branches crossing superficial to the buccal fat pad in 14 (73.7%) of 19 specimens, and type II, 2 twigs passing through the buccal extension of the buccal fat pad in 5 (26.3%) of 19 specimens. The buccal branch to the upper orbicularis oris muscle: Approximately 4 branches (4.06 ± 0.83) entering the pars marginalis were found. Most ramifying points (14/17, 82%) were located within a circle with a 5-mm radius, and the center was 12 mm lateral and 26 mm superior to the mouth corner. The mandibular branch according to the neck position: At the one-fourth point, the border-nerve distance decreased (4.32 ± 2.60 mm) with the neck in ipsilateral rotation and the border-nerve distance increased (5.97 ± 2.62 mm) with the neck in contralateral rotation. We hope that this knowledge will aid surgeons in achieving successful outcomes.
Topics: Cosmetic Techniques; Face; Facial Nerve; Humans; Plastic Surgery Procedures; Rejuvenation
PubMed: 24926717
DOI: 10.1097/SCS.0000000000000577 -
Journal of Clinical Movement Disorders 2014To provide a systematic description of component movements of upper facial chorea in Huntington disease, consecutive videos of 25 active patients with confirmed...
To provide a systematic description of component movements of upper facial chorea in Huntington disease, consecutive videos of 25 active patients with confirmed diagnosis were scored on eye opening, eye closing, and procerus/corrugator contractions. Of the 25 patients evaluated, 76% exhibited intermittently widened palpebral fissures associated with frontalis contractions. Brief periods of repetitive but irregular blinking were observed in 16%. 8% had brief spasms of the orbital portion of the orbicularis oculi muscles. In addition, brief contractions of procerus and corrugator supercilii muscles were noted in 52%.
PubMed: 26788333
DOI: 10.1186/2054-7072-1-7 -
Journal of Psychiatric Research May 2014Converging lines of evidence suggest a role for facial expressions in the pathophysiology and treatment of mood disorders. To determine the antidepressant effect of... (Randomized Controlled Trial)
Randomized Controlled Trial
UNLABELLED
Converging lines of evidence suggest a role for facial expressions in the pathophysiology and treatment of mood disorders. To determine the antidepressant effect of onabotulinumtoxinA (OBA) treatment of corrugator and procerus muscles in people with major depressive disorder, we conducted a double blind, randomized, placebo-controlled trial. In an outpatient clinical research center, eighty-five subjects with DSM-IV major depression were randomized to receive either OBA (29 units for females and 40 units for males) or saline injections into corrugator and procerus frown muscles (74 subjects were entered into the analysis). Subjects were rated at screening, and 3 and 6 weeks after OBA treatment. The primary outcome measure was the response rate, as defined by ≥ 50% decrease in score on the Montgomery-Asberg Depression Rating Scale (MADRS). Response rates at 6 weeks from the date of injection were 52% and 15% in the OBA and placebo groups, respectively (Chi-Square (1) = 11.2, p < 0.001, Fisher p < 0.001). The secondary outcome measure of remission rate (MADRS score of 10 or less) was 27% with OBA and 7% with placebo (Chi-square (1) = 5.1, p < 0.02, Fisher p < 0.03). Six weeks after a single treatment, MADRS scores of subjects were reduced on average by 47% in those given OBA, and by 21% in those given placebo (Mann-Whitney U, p < 0.0005). In conclusion, a single treatment with OBA to the corrugator and procerus muscles appears to induce a significant and sustained antidepressant effect in patients with major depression.
TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT01556971.
Topics: Acetylcholine Release Inhibitors; Adult; Botulinum Toxins, Type A; Depressive Disorder, Major; Double-Blind Method; Female; Follow-Up Studies; Humans; Logistic Models; Male; Middle Aged; Outcome Assessment, Health Care; Psychiatric Status Rating Scales; Statistics, Nonparametric
PubMed: 24345483
DOI: 10.1016/j.jpsychires.2013.11.006 -
Cutis Jul 2013To assess the feasibility, safety, and lack of inferiority of reconstituting botulinum toxin type A (BTX-A) in 1% lidocaine hydrochloride with epinephrine 1:100,000, 181...
To assess the feasibility, safety, and lack of inferiority of reconstituting botulinum toxin type A (BTX-A) in 1% lidocaine hydrochloride with epinephrine 1:100,000, 181 participants were asked to complete a satisfaction survey 3 to 6 months after treatment with the reconstituted formulation for facial rejuvenation. The addition of lidocaine was believed to achieve an immediate paralyzing effect on the injected muscles, and the addition of epinephrine was hypothesized to minimize diffusion to adjacent muscles. Participants were treated in the areas of the forehead and glabella, as well as the orbicularis oculi, orbicularis oris, and procerus muscles, in varying doses (10-60 U). Fifty-eight percent (91/157) of participants reported being more satisfied with BTX-A reconstituted in 1% lidocaine with epinephrine 1:100,000, with 85.7% (78/91) of these participants reporting that the immediate results made the formulation superior; 35.7% (56/157) were indifferent and 6.4% (10/157) reported that the modified formulation did not work better. The injection of BTX-A reconstituted in 1% lidocaine with epinephrine 1:100,000 presented no increased adverse effects (AEs), no decrease in pharmacologic potency, immediate feedback to the clinician, and higher satisfaction for the participants who previously had been treated with BTX-A reconstituted in unpreserved saline. Botulinum toxin type A reconstituted in 1% lidocaine with epinephrine 1:100,000 may increase the duration and efficacy of this widely used toxin.
Topics: Adult; Aged; Botulinum Toxins, Type A; Epinephrine; Facial Muscles; Feasibility Studies; Female; Follow-Up Studies; Humans; Lidocaine; Male; Middle Aged; Neuromuscular Agents; Patient Satisfaction; Rejuvenation; Skin Aging; Time Factors; Young Adult
PubMed: 24308152
DOI: No ID Found -
The Journal of Craniofacial Surgery Nov 2013The aim of this study was to introduce a technique of dividing forehead depressor muscles with a subbrow excision for improvement of brow ptosis or redundant upper...
The aim of this study was to introduce a technique of dividing forehead depressor muscles with a subbrow excision for improvement of brow ptosis or redundant upper eyelid skin and glabella wrinkles. Upper incisions were designed at the lower limit of the eyebrow with a lateral extension along the eyebrow curvature. After measuring the redundant upper eyelid skin, the excess skin was excised. The orbital part of the orbicularis oculi muscle was identified and split longitudinally. The forehead depressor muscles (depressor supercilii, oblique and transverse head of corrugator, and medial part of orbicularis oculi) in the brow fat pad were identified and avulsed. In the patients who have a lowered brow, the brow was elevated and fixed to the underlying periosteum about 1 cm above the superior orbital rim after subgaleal dissection. During the dissection, the supraorbital nerve was preserved. Preaponeurotic fat was transferred and sutured between the cut stumps of the corrugator and procerus. The 78 patients (19 men, 60 women; age range, 41-72 years [mean, 52.0 ± 7.1 years]) were operated on. The follow-up periods ranged from 3 to 48 months. Preoperative and postoperative photographs were taken, and the following evaluations were conducted by 1 surgeon via a Likert scale (1 = not improved, 2 = slightly improved, 3 = somewhat improved, 4 = much improved, 5 = markedly improved). The mean score for improvement of the glabella frowns in contraction was 3.7 ± 1.6. The mean score for the improvement of the glabella frowns in relaxation was 4.1 ± 1.3. The mean score for improvement of drooping eyelids was 4.7 ± 0.5. The mean score for the improvement of forehead wrinkles was 4.8 ± 0.7. We improved brow ptosis, redundant upper eyelid skin, and glabella wrinkles simultaneously using a subbrow excision and depressor muscle division while preserving the superficial branch of the supraorbital nerve.
Topics: Adult; Aged; Blepharoptosis; Cosmetic Techniques; Eyebrows; Facial Muscles; Female; Forehead; Humans; Male; Middle Aged
PubMed: 24220387
DOI: 10.1097/SCS.0b013e3182a28bc8 -
Muscle & Nerve Sep 2013In this study we describe a protocol for quantitative ultrasound of facial muscles (procerus, zygomaticus major, levator labii superior, depressor anguli oris, mentalis,...
INTRODUCTION
In this study we describe a protocol for quantitative ultrasound of facial muscles (procerus, zygomaticus major, levator labii superior, depressor anguli oris, mentalis, orbicularis oris pars labialis, orbicularis oris pars marginalis).
METHODS
Muscle thickness (MT) and echo intensity (EI) were measured in 12 healthy subjects and a myotonic dystrophy type 1 patient.
RESULTS
MTs ranged from 0.15 to 0.30 mm, except for the procerus muscle (0.06 mm). EIs ranged from 1 to 34, except for the procerus muscle. MT reproducibility was fair for the orbicularis oris pars labialis, excellent for the procerus and levator labii, and good for the other muscles. The myotonic dystrophy type 1 patient showed high EIs, outside the range in healthy subjects in 6 of the 7 muscles. MT was lower than the range seen in healthy subjects in 4 muscles.
CONCLUSION
Quantitative muscle ultrasound of the facial muscles is feasible and shows moderate to excellent reproducibility.
Topics: Adult; Facial Muscles; Female; Humans; Male; Middle Aged; Myotonic Dystrophy; Reproducibility of Results; Ultrasonography; Young Adult
PubMed: 23893891
DOI: 10.1002/mus.23769 -
Aesthetic Plastic Surgery Oct 2013Botulinum neurotoxin type A (BoNTA) is approved for the treatment of glabellar lines and also is commonly injected in an off-label fashion in the frontalis (i.e.,... (Review)
Review
BACKGROUND
Botulinum neurotoxin type A (BoNTA) is approved for the treatment of glabellar lines and also is commonly injected in an off-label fashion in the frontalis (i.e., frontalis epicranius) muscle to improve the appearance of horizontal forehead lines. This study aimed to review and discuss both the anatomy and physiology of the frontalis muscle and its relationship with antagonist muscles in the upper face and to provide a guide for the use of BoNTA to treat forehead rhytides while minimizing the occurrence of complications such as brow ptosis.
METHODS
A PubMed search was conducted to identify practitioner opinion and clinical publications on the efficacy and safety of BoNTA for aesthetic treatment of the upper face.
RESULTS
The use of BoNTA produces durable improvement in the appearance of moderate to severe horizontal forehead lines. Dose and injection technique must be adjusted and individualized based on the variable anatomy and function/mass of muscles in the forehead and upper face as well as on patient goals. Optimal aesthetic outcomes can be achieved by skillfully balancing the opposing effects of the frontalis muscle and its intricate interactions with the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi muscles.
CONCLUSIONS
The use of BoNTA to improve the aesthetic appearance of horizontal forehead lines is optimized when clinicians take into account variations in frontalis muscle function and position, anatomy of the brow, and proper injection technique when they devise individualized treatment regimens.
Topics: Adult; Botulinum Toxins, Type A; Cosmetic Techniques; Facial Muscles; Female; Humans; Neuromuscular Agents; Skin Aging
PubMed: 23846022
DOI: 10.1007/s00266-013-0178-1 -
JAMA Facial Plastic Surgery 2013To review the single-stage forehead flap for patient selection, technique, and main outcome measures.
OBJECTIVE
To review the single-stage forehead flap for patient selection, technique, and main outcome measures.
METHODS
Patients undergoing nasal reconstruction between January 1, 1995, and June 30, 2000, were reviewed from medical records, photographs, and personal communication. All work was performed in an academic medical center.
RESULTS
Fifty-one patients had a forehead flap for nasal reconstruction, of which 10 (20%) were repaired in a single stage. All patients had no evidence of small vessel disease, eg, hypertension, diabetes mellitus, or tobacco use. Nasal defects were limited to the upper two-thirds of the nose. The technique is modified from the original description by creating a unilateral, subcutaneous pedicle, wide undermining, and partial resection of the procerus muscle. One patient had superficial epidermolysis at the distal tip of the flap. The remaining 9 patients maintained complete viability with satisfactory outcomes. One debulking procedure was performed to the glabellar area for aesthetic reasons. The average interval for returning to work was 6.6 days compared with the minimal 3 weeks for conventional interpolated flaps.
CONCLUSION
In select cases, a single-stage, island midline forehead flap can be used safely as an advantageous alternative to the conventional interpolated forehead flap.
Topics: Forehead; Humans; Outcome Assessment, Health Care; Rhinoplasty; Surgical Flaps
PubMed: 23787760
DOI: 10.1001/jamafacial.2013.1 -
Dermatologic Surgery : Official... May 2013Botulinum toxin is a powerful and often used agent to treat dynamic rhytides. Focal and reversible neurogenic atrophy is considered to be the relevant mechanism of...
BACKGROUND
Botulinum toxin is a powerful and often used agent to treat dynamic rhytides. Focal and reversible neurogenic atrophy is considered to be the relevant mechanism of action.
OBJECTIVE
To investigate the loss and regain of muscular volume in relation to clinical wrinkle severity as assessed using standardized scales.
METHODS
The facial procerus and corrugator supercilii muscles were injected in two drug-naïve men with 20 U of onabotulinumtoxinA at five injection points (onA). Two men served as controls (one with the same volume of placebo injection using saline solution, one without any intervention). All subjects underwent 3 Tesla magnetic resonance imaging before and after the injection and 1, 4, 6, 10, and 12 months after the injection. Standardized photographs were taken at each test point.
RESULTS
Volumetric muscle analysis revealed a 46% to 48% reduction in procerus muscle volume lasting for 12 months after a single dose of onA; glabellar line severity returned to the drug-naïve status after 6 to 10 months.
CONCLUSION
The gap between long-term focal muscular atrophy and regained function remains to be elucidated. Future studies will be needed to investigate the complex interaction between focal neurogenic atrophy and potential compensatory functional muscle changes.
Topics: Adult; Botulinum Toxins, Type A; Facial Muscles; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Muscular Atrophy; Neuromuscular Agents; Skin Aging
PubMed: 23379599
DOI: 10.1111/dsu.12125