A challenge to the undefeated nasolabial folds

Previous attempts to improve the nasolabial folds have been disappointing. By extending the face lift skin dissection to the nasolabial fold and up onto the malar prominence, reducing the fat of this fold by excision, and applying direct posterior retraction to the freed facial skin, rather dramatic improvement in the nasolabial folds have been achieved. This is a preliminary report with a follow-up of 8 months or less.     

Anatomic variations of the nasolabial fold.

The nasolabial fold varies considerably from person to person. Three main groups may be distinguished: convex, concave, and straight. It is the muscles of smiling that are directly responsible for the shape and depth of the fold, and in their absence of function, as in facial palsy, the nasolabial fold disappears. Cadavers were selected in accordance with the nasolabial fold they presented and were dissected to analyze the difference in underlying anatomy between one fold shape in one cadaver and another fold shape in another. The study demonstrates that the nasolabial fold is the result of a conflict between soft and dynamic tissues of the middle face or an interaction between the skin and fat envelope on one side and the underlying muscles on the other. The greater this conflict, the more excess there is of cheek skin and the more pronounced a nasolabial fold. The mechanism that creates the nasolabial fold and the anatomy of the fold are described in this paper.     

A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure

In 1990, the author reported on a series of 403 cases of deep plane face lifts, the first published technique describing the repositioning of the cheek fat, known as malar fat, in face lift surgery. This study examines the long-term results of 20 of the original series in an attempt to determine what areas of the rejuvenated face (specifically, the malar fat) showed long-term improvement. The results were judged by comparing the preoperative and long-term postoperative views in a half-and-half same-side hemiface photograph. The anatomy of the jawline (superficial musculoaponeurotic system [SMAS]), the nasolabial fold (malar fat), and the periorbital diameter were evaluated. The results confirmed that repositioning of the SMAS remained for longer than improvement in the nasolabial fold and that the vertical diameter of the periorbit did not change at all. The early results of malar fat repositioning shown at 1 to 2 years were successful, but the long-term results showed failure of the early improvement, manifested by recurrence of the nasolabial folds. There was, however, continuation of the improved results of the forehead lift and SMAS maneuvers of the original procedure. The conclusion is that only a direct excision will produce a permanent correction of the aging nasolabial fold.     

Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation.

The nasolabial fold has defied satisfactory correction with the face lift operation. This is despite variations of the SMAS technique over the last 20 years. In this study, the nasolabial fold is shown to be part of the overall aging deformity that affects the cheek and perioral region. The key to surgical correction, not previously appreciated, is the complete release of the anterior SMAS from the zygoma and zygomaticus major muscle. This allows a dramatic mobilization of the nasolabial fold without tension. The advanced SMAS is then reattached to the zygomatic periosteum by a series of permanent sutures. Each suture, by its location and direction of lift, corrects one of the four nasolabial regions including the jowl. The relevant anatomy is reviewed and the safety of the procedure is assessed in a personal series of 135 patients. It is concluded that the two principles of this technique, i.e., complete SMAS release and reattachment to the zygoma, safely and effectively achieve a natural-appearing rejuvenation of the cheek and nasolabial fold.     

The superiorly based nasolabial flap for simultaneous alar and cheek reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the epidemiology of skin cancer in a patient with preexisting skin cancer. 2. Understand the indications for the use of a nasolabial flap and nonanatomic alar strut graft. 3. Describe the blood supply to the nasolabial flap.The goals of reconstructing deformities of the face acquired secondary to skin tumors include optimizing donor-site aesthetics and reconstructing the area with similar types of tissue when possible. Multiple skin-cancer defects are often seen by the plastic surgeon and complicate the reconstruction, requiring more than one flap or skin graft. A case analysis of an innovative application of the nasolabial flap for reconstruction of a simultaneous medial cheek and alar-base nasal defect is presented. Concepts in nasal reconstruction are reviewed, and the authors' approach to alar reconstruction is presented.     

Rhytidectomy and the nasolabial fold.

I describe a technical modification in the Skoog face lift procedure that releases the deep attachments of the SMAS to the muscles of facial expression for maximal mobility of the medial cheek yet elevates the cheek flap as a composite of skin, subcutaneous tissue, and SMAS to enhance skin perfusion. My results with the procedure in 100 patients are analyzed by using functional zones of the nasolabial fold corresponding to underlying musculature and a simple grading system based on preoperative and postoperative photographs. Marked improvement in the nasolabial fold was noted in over 80 percent of patients by 6 and 12 months postoperatively. This effect seemed to last up to 4 years.     

Review of long-term results in supportive treatment of facial paralysis.

We have reviewed approximately 150 patients who were treated with supportive measures for facial paralysis. We found that in the patient's view an adequate result requires establishment of a proper lip sphincter--either by restoring muscular tone, or by creating an anatomical framework to which can be added either a motor unit or stabilization to aid the opposite intact muscle. We also found lasting value from dampening contralateral spasticity, and from the use of such ancillary procedures as the face lift, the brow lift, and the creation of a nasolabial fold. It is important for the physician to help the patient acquire a tranquil face during speech and emotion by persevering in mirror training and mimetic gymnastics.     

The SMAS and the nasolabial fold.

In a series of histologic sections and clinical and cadaver dissections, the superficial musculoaponeurotic system (SMAS) is seen to become the investing fascia of the zygomaticus major and minor muscles in the medial cheek. The pull on the cheek flap during rhytidectomy is diffused by the attachment of the SMAS to these muscles. I believe that this attachment accounts for the minimal change in the nasolabial crease after a Skoog-type sub-SMAS face lift.     

Subperiosteal approach as an improved concept for correction of the aging face

A harmonious facial appearance is determined by a balanced relationship among all tissues of the face. With advancing age, balance is lost among the bone, muscle, fat, and skin as progressive changes occur in their volume, shape, position, and consistency. Study of clinical cases and fresh cadaver dissections has led to better understanding of the superficial musculoaponeurotic system (SMAS) and its relationship with the facial muscles and their bony insertions. From these anatomic studies we have developed an improved concept of rhytidectomy with the subperiosteal detachment of all soft tissues from the orbit, upper maxilla, malar bone, and nose. Following this detachment, the soft tissues of the cheek, forehead, jowls, nasolabial folds, lateral canthus, and eyebrows can be lifted to reestablish their youthful relationship with the underlying skeleton. Our 4-year experience includes 105 patients. Sixty percent of these patients were admitted to the hospital and had their procedure under general anesthesia; forty percent, however, had their procedure in an outpatient setting requiring only local anesthesia (lidocaine hydrochloride 1% plus epinephrine) and intravenous sedation (midazolam, ketamine). Complications have been minimal except for temporary paralysis of the frontal nerve in seven patients; guidelines for prevention have subsequently been developed. The subperiosteal rhytidectomy is excellent and appears more natural for rejuvenation of the upper and central face, eyebrows, periorbita, external canthus, cheeks, and nasolabial fold.     

Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning

Aesthetic analysis in facial rejuvenation has traditionally been subordinate to technical solutions. While concerns regarding correction of facial laxity, a reduction in the depth of the nasolabial fold, and improvement of both the jowl and the jawline are worthy goals in rhytidectomy, the aesthetic concept of restoring facial shape to a more youthful appearance is equally important. Restoring facial shape in face lifting requires an understanding of how the face ages and then the formulation of a treatment plan that is individualized for the patient. Re-establishment of facial contour is significantly influenced by the re-elevation of descended facial fat through superficial musculoaponeurotic system manipulation; it can be approached through a variety of technical solutions. Underlying skeletal support affects not only the appearance of the face in youth but also how the face ages and influences the operative plan in terms of the requirements for fat repositioning. Formulating a treatment plan that is patient specific and based on the artistic goals as influenced by skeletal support is the key element for consistency in restoring facial shape in face lifting.     

A simple method for alar rim reconstruction

A one-stage repair procedure is described for the reconstruction of small to medium-sized full-thickness alar rim defects with a hinged medially based nasolabial island flap. The operation is performed under local anesthesia as an office procedure and is indicated particularly in older patients. The hinged flap provides both the inner and outer layers of the alar rim. The donor site is closed primarily with no need to mobilize a large skin flap. The procedure leaves no conspicuous scars on the face. This method was found to be simple and safe, providing excellent tissue viability and yielding good color and texture match.     

Multiplane face lift with the subperiosteal dissection for orientals

A subperiosteal face lift rejuvenates the midface and periorbital region by restoring facial muscle tone. Since 1993, the authors have performed this procedure on Oriental patients who have their own distinct facial contours: the brachycephalic cranium and a prominent zygoma and mandibular angle. Although it was thought that these protuberances might disturb the subperiosteal procedure, especially in the anterior midface, the procedure could be performed easily by adopting the ancillary upper buccovestibular and subciliary incisions; the authors found that the protuberances actually act as fulcrums to keep up the lifting vectors reliably. For older patients, the procedure was combined with a deep subcutaneous dissection. A simple lift of the periosteum would not improve a severe nasolabial fold deformity and prominent wrinkles adequately because of "lag-lifting" of the superficial layer. It was concluded that the multiplane face lift, consisting of the subperiosteal and the deep subcutaneous approaches, achieves a natural-appearing rejuvenation of the Oriental aging face.     

The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update

The medical charts of 267 patients who had primary high-superficial musculoaponeurotic system (SMAS) rhytidectomies were reviewed. The depth of the nasolabial fold was used as an indicator of the degree of descent of the subcutaneous cheek mass, as a guide in procedure selection, and as a method of judging the operative results. Fold depth was assigned a score of 0 to 3, with 3 being most severe. According to their preoperative fold depth, patients were operated on using one of three variants of the high-SMAS technique: sub-SMAS dissection up to the nasolabial fold, sub-SMAS dissection up to the nasolabial fold plus transnasal SMAS graft, or sub-SMAS dissection across the nasolabial fold. An independent trained observer rated the postoperative fold depth in each case from photographs taken at the 6-month follow-up visit. Of patients with fold scores of 2 or 3, 97 percent (183 of 189 patients) showed visible improvement in nasolabial crease depth after the operation.     

The nasolabial fold: an attempt at synthesis

There is now enough information on the nasolabial fold to try to synthesize it with other well-known structures, such as the dermal terminations of the facial muscles, the superficial musculoaponeurotic system, and the fat pad. Rest dynamic equilibrium is a good concept to use to understand the nasolabial fold, because the nasolabial fold is not a passive, definitive structure, but an evolutive border whose limits depend on the absence or presence of fibromuscular terminations crossing the superficial musculoaponeurotic system of the cheek. A simple photograph of two men will help illustrate the difference between the convex and the concave nasolabial fold.     

Histochemistry of glycoconjugates in the goat nasolabial skin with special reference to eccrine glands

The histochemistry of glycoconjugates in the nasolabial skin of the goat has been studied by means of a series of selected methods of light microscopy. The epidermis of the nasolabial skin was found to contain neutral and acid glycoconjugates with different saccharide residues. The secretory epithelial cells and secretory substances of the sebaceous glands contained primarily neutral glycoconjugates, whereas those of the apocrine glands involved largely strongly acidic and neutral glycoconjugates. In the epithelial cells and secretory substances of the nasolabial eccrine glands, glycoconjugates involved were characteristically strongly neutral but weakly acidic in nature. From the present results, the histophysiological significance of glycoconjugates in the particular histologic structures of the nasolabial skin has been discussed with special reference to the functions of this particular skin type in the goat.     

Chemical access to the vomeronasal organs of a plethodontid salamander

Plethodontid salamanders have unique nasolabial grooves that may function as “capillary tubes” to convey chemicals to the vomeronasal organ when these animals nose-tap. ³H-proline was placed at the base of these grooves in Plethodon cinereus, and autoradiography revealed large concentrations of radioactive material in the vomeronasal organs. There was no significant accumulation of radioactive material in the main olfactory epithelium. Salamanders with blocked nasolabial grooves lacked significant accumulation of material in their nasolabial grooves or vomeronasal epithelia, although some salamanders had radioactive material in the posterior portion of their vomeronasal organ that had entered through the internal nares. Anteriorly placed vomeronasal organs situated adjacent to the posterior limits of the nasolabial grooves may insure that nose-tapping primarily stimulates the vomeronasal sensory epithelium.     

SMAS graft of the nasolabial area during deep plane rhytidectomy

The extensive list of treatments for the nasolabial area illustrates that the problem is not solved yet. Although a better understanding of the anatomy and physiology of the nasolabial area has been developed, the ideal treatment has not been found. It seems that a combined approach based on summation of partially effective modalities is the best option. The authors present their experience with combined deep plane rhytidectomy, malar fat lift, and superficial musculoaponeurotic system graft in the treatment of the aging nasolabial area. Results in 70 consecutive patients are presented with this simple, nonscarring, inexpensive technique.     

Nasolabial cyst. Case report.

We present a case of nasolabial cyst. The clinical and histological aspects are discussed and a new concept of the embryology of the nasolabial cyst in described.     

Analysis of the African American female nose

The African American nose has been broadly classified as ethnic yet it differs significantly in morphology from that of other ethnic groups with which it is categorized. The objectives of this study were to (1) establish an objective protocol for analysis of the African American female nose using anthropometric measurements, and (2) determine whether subjective subcategorization schemes are a reliable replacement for anthropometry. African American women (n = 107) between the ages of 18 and 30 years consented to participate in this study. Photographs and 14 standard anthropometric measurements were taken of the face and nasal region, including nose length, nose width, special upper face height, intercanthal distance, mouth width, nasal bridge inclination, nasal tip protrusion, ala thickness, nasal root width, nasal bridge length, tangential length of ala, length of columella, nasofrontal angle, and nasolabial angle. Nasal indices including nose width-nose height index, nasal tip protrusion-nose height index, and nasal tip protrusion-nasal width index were calculated. In addition, photographic analysis was performed to evaluate nostril shape, nasal base shape, and nasal dorsal height. Proportional relationships and subcategorization schemes were evaluated. A new method of nasal analysis for the African American woman uses the proportional relationships of the anthropometric measurements. Proportional relationships included a columellar to lobule ratio of 1.5:1, a nasolabial angle of 86 degrees, and an alar width to intercanthal distance ratio of 5:4. The nasal dorsal height classification scheme was the most reliable for subjective analysis. The degree of variability found within this group of young African American women is illustrated by the following indices and their respective ranges: nose width-nose height index mean, 79.7 (range, 57 to 102); nasal tip protrusion-nose height index mean, 33.8 (range, 23 to 46); and nasal tip protrusion-nose width index mean, 42.8 (range, 32 to 61). The guidelines provided are a baseline from which to begin analysis and evaluation.     

The lower muscular balance of the face used to lift labial commissures

One of the weak points in face lifts is their failure to fully correct the ptosis of the labial commissures. This article illustrates a new technique to optimize this commissural repositioning in face lifts by using the muscular balances of the lower half of the face. There is, in effect, a third type of muscular balance, which acts on the commissural modiolus and is created by the opposing forces of the levator muscles (notably the zygomaticus major and the levator anguli oris) and the depressor muscles (principally the depressor anguli oris). Rarely a purely cutaneous problem, labial commissural ptosis is more a part of mediofacial ptosis affecting the entire soft tissue. I have used the malar subperiosteal face lift technique, the only approach that allows the centrofacial features to be lifted as a whole block, since late 1996 and have treated a series of more than 30 patients affected with mediofacial ptoses involving the malar eminences, the nasolabial folds, and the labial commissures. Retensioning the levator muscles was combined with wholesale subperiosteal release of the depressor muscles, notably the depressor anguli oris. Patient follow-up has lasted between 6 and 20 months. In all instances, this use of the lower facial muscular balances allowed optimal repositioning of the labial commissure. In particularly outstanding cases, unilateral release of the depressor muscles was used to correct facial asymmetry at the level of the lip commissures and thereby restore harmony and alignment. In 10 of our cases, this slackening of the depressor muscles was also used in conjunction with a peripheral face lift; the resulting heightening of the commissures was, in these cases, perhaps less spectacular, but it invariably contributed to the rejuvenation of the face.