Tái Tạo Thể Tích Khuôn Mặt: Một Tiếp Cận Theo Giải Phẫu học

(Trang không có chữ)

3
Chapter 3
The Perioral Area,
the Chin, and the Jowl
The Aging Characteristics of the Lip
and Perioral Region: Contemporary
Concepts
37
Deep Anatomy of the Chin and Jowl:
The Mandibular Osseocutaneous
Ligament and the Platysma Mandibular
Ligament
37
The Muscular and Compartment
Anatomy of the Perioral Region
40
Vascular Anatomy of the Lower
Perioral Region
44
Vascular Anatomy of the Upper Lip


Nasolabial Anatomy
48
The Authors’ Preferred Techniques
for Perioral Rejuvenation
50

(Trang không có chữ)

37

3 The Perioral Area, the Chin, and the Jowl
Jerome Paul Lamb, Christopher Chase Surek, and James D. Vargo
The Aging Characteristics of
the Lip and Perioral Region:
Contemporary Concepts
As far as we can tell, the perioral region is the one anatomical
-
cant role in aging characteristics and appearance. Studies such
as Iblher et al. and Penna et al. correlating radiographic change
-

lengthening of the prolabium and loss of visible vermillion
height are pathognomonic for an aging lip. Magnetic reso-
nance imaging (MRI) scans demonstrate a decrease in anterior-
posterior (A-P) dimension and increase in length without over-
all volume loss. Histomorphometric analysis demonstrates


The orbicularis oris muscle, which is composed of a pars
marginalis and a pars peripheralis, becomes thinner with age
(Fig. 3.1 -

present in the youthful lip. This forward curve in the youthful
-
quently as the muscle changes with age the vermillion becomes

of the anterior nasal spine and alveolus results in loss of ante-
rior upper lip support, resulting in alterations to SNA measure-
ments. Contrary to the upper lip, aging changes occurring in the

Deep Anatomy of the Chin
and Jowl: The Mandibular
Osseocutaneous Ligament and the
Platysma Mandibular Ligament
-

from the more caudal submandibular fat compartment by a

ligament (PML) or mandibular septum (Fig. 3.2). The PML is lo-

the mandibular border. It is postulated that this septum acts



In addition, the PML is a point of muscular stability for the pla-
tysma as it glides over the mandible during coordinated move-
ment, a function analogous to the orbital retaining ligament in
the midface.
Fig. 3.1 Illustration representing the cross-sectional anatomy in
the youthful and aged upper lip. Note the altered shape of the

forward curve (hockey stick) shape that it possesses in the youthful
lip. Adapted from Iblher N, Kloepper J, Penna V, Bartholomae JP, Stark
GB. Changes in the aging upper lip—a photomorphometric and MRI-

Plast Reconstr Aesthet Surg 2008;61(10):1170–1176, Iblher N, Stark
GB, Penna V. The aging perioral region—do we really know what is
happening? J Nutr Health Aging 2012;16(6):581–585, and Penna
V, Stark GB, Eisenhardt SU, Bannasch H, Iblher N. The aging lip: a
comparative histological analysis of age-related changes in the upper
lip complex. Plast Reconstr Surg 2009;124(2):624–628
Fig. 3.2 Cadaveric dissection demonstration of the platysma man-
dibular ligaments.

38
3 The Perioral Area, the Chin, and the Jowl
Cephalic to the PML lies the mandibular osseocutaneous lig-
ament (MOCL; Fig. 3.3). MOCL sits approximately 5.6 cm from
the gonial angle and 1 cm above the mandibular border. The lig-

with the depressor anguli oris (DAO), forming inferior quadrant
of the marionette lines. The MOCL can be palpated clinically as



In reference to the location of the mandibular ligament, recent
-

note, the PML and MOCL are not to be confused with the mas-
seteric cutaneous ligaments, which are nonosseous ligaments

As the marginal mandibular nerve exits the parotid masse-
-
neurotic system) crossing the facial vessels 2.3 cm distal to the
gonial angle. As the nerve crosses the vessels, it is 3 mm anterior

reaches the DAO. On average, the nerve will end as two branches
with the dominant terminal branch ending 1 cm superior to the
MOCL. Note that in accordance with traditional teaching, 81%
of the time the nerve travels cranial to the mandibular border.
Fig. 3.3 Cadaveric dissection demonstration of the mandibular os-
seocutaneous ligament.
Injection Pearl

Injection Pearl

a medial approach.
Fig. 3.4 -
ments of the perioral region.

39
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.4 Medical illustration of key retaining ligaments of the perioral region: the platysma mandibular ligament and the mandibular osseocuta-
neous ligament.

40
3 The Perioral Area, the Chin, and the Jowl
The Muscular and Compartment
Anatomy of the Perioral Region
Muscular Anatomy
The three-dimensional (3D) muscular anatomy of the perioral

n -
ogy and not meant to represent a study of anatomic variability.
However, this 3D MRI isotopic study in vivo demonstrates that
the perioral musculature has a unique architecture.
The orbicularis oris muscle is more circular at its lateral ex-

-

with the lip elevators and lip depressors. The levator anguli oris
(LAO) inserts behind the buccinators. The levator labii superi-


of the orbicularis oris muscle. Of note, a lamina propria exists
within the lip sphincter located between the orbicularis muscle
and mucosa.
-
pressor labii inferioris (DLI), DAO, and mentalis muscle (Fig. 3.5).
The DLI muscle originates on the mandible between the sym-
physis and mental forearm and inserts on the orbicularis muscle

it is fused with the platysma and inserts onto the modiolus and
the angle of the mouth. Literature regarding mentalis muscle is
sparse. The mentalis muscle originates on the upper symphysis
-

of the lower lip. The mentalis muscle has a V -
tion. Added to the DLI, it forms an “M
the lower lip. Mentalis strain is largely the result of poor bony
support within individuals with Angle’s Class II occlusion or in
individuals with atrophy of the mental fat
Fig. 3.5 Illustration of cross-sectional anatomy of the lower lip and

(Adapted from a medical illustration by James Vargo, MD.)
Deep Lateral Chin Compartment
-
ment (Fig. 3.6

the DAO to facilitate muscle gliding with movement. This sub-
DAO fat has a thin gliding membrane along its anterior surface
and protects the mental nerve that has a superomedial course
and often accompanies the inferior labial artery. The diameter


this fat compartment via a cannula placed in the small triangle
bounded by the lateral border of the DLI, the medial border of
the DAO, and the caudal border of the orbicularis oris with an
-
nique (Fig. 3.7). Alternatively, the caudal half of this compart-
ment may be accessed via a paramedian chin pad approach,
passing caudal to the mental nerve foramen over periosteum of
the mandible, traversing in a medial to lateral direction.

41
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.7 The deep lateral chin compartment and the encapsulated space between the depressor labii inferioris (DLI) and depressor anguli oris

and DAO.
Fig. 3.6 Blue shading demonstrates origins and insertions of key perioral musculature. The mental fat pads are demonstrated.

42
3 The Perioral Area, the Chin, and the Jowl


-
tion. The anterior space extends across the entire w idth of the
lip and the posterior space ends at a midline partition.
The gross anatomy of the ROOrF is shown in Fig. 3.10, and
Fig. 3.11 -
oral region.
Retro-orbicularis Oris Fat

the orbicularis oris muscle, which appears to lose turgor with
age. This retro-orbicularis oris fat (ROOrF) compartment has
-
oral anatomy (Fig. 3.8). The caudal extent of the compartment
is roughly the midpoint of the upper central dentition. The




this compartment to be a useful augmentation target in patients
with upper alveolar collapse from previous bicuspid extraction,
as well as pyriform aperture retrusion. The consistency of the
-
eric dissection, the fat is unfused with the overlying muscle and
soft tissues and displays a sharp transition from its bordering
structures outside the perioral aperture.

According to Pessa et al, the upper lip contains a series of super-
Fig. 3.9). These compartments are sep-

the outside diameter of 30-gauge needles, with the exception of

columns: the superior upper lip compartment, lateral upper lip
compartment, inferior lateral upper lip compartment, and the
central upper lip compartment. The central upper lip compart-
ment contains an inferior and a superior quadrant. Clinically,
these subcutaneous compartments are thin and compartmen-
tal division corresponds with vascular septation similar to other
regions of the face. These septations are manifested as vertical
perioral rhytids.
According to Pessa et al, the lower lip contains a trio of super-

lateral lip compartment, and the inferior chin compartment.
The medial boundary of the lateral lip compartment is the sep-
tum containing the inferior labial artery. The arteries cephalic




Perioral Potential Spaces

white roll. Arterial vasculature immediately deep to this space
is intimate with the SMAS of the lower lip orbicularis oris. Can-
nula passage from commissure directed medially can easily
traverse the entire lower lip. Cannula passage from a parame-
-
nous barrier at the commissure and extending caudally a short
distance.
Potential spaces also exist within the subvermillion of both
the upper and lower lips. The upper lip has a potential space
that is frequently medially partitioned posterior to the wet dry
Fig. 3.8

shape of this structure.
Fig. 3.9 -
partment. Note the transition of loosely organized fat into a more

with age.

43
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.10 Demonstration of the retro-orbicularis oris fat compartment.
Fig. 3.11

44
3 The Perioral Area, the Chin, and the Jowl
-

-
luses in the oral commissure. To date, studies are inconsistent
in the depth of the ILA; as a general rule, the vessel is 4.7 mm
deep at its origin and will transcend to 2.3 mm in depth upon
reaching the midline.
Fig. 3.14 illustrates the vascular and fat compartment anato-
my of the perioral region.
Vascular Anatomy of the Lower
Perioral Region
Understanding the architecture and blood supply in the lip and
nasolabial region is critical to avoid unwanted complications.
-
dible deep to the platysma muscle branching into an inferior
labial artery, superior labial artery (SLA), and continuing past
the corner of the mouth toward the nose as the angular artery.
However, the variation in the patterns and locations of the
facial artery branches has proven to be the rule and not the

-
mography angiography (CTA) studies have correlated the domi-
nance of the facial artery at this bifurcation with the presence
or absence of an angular system on the ipsilateral side. At this
level, the average diameter of the vessel is approximately 2.3


done from commissure to nasolabial crease (Fig. 3.12).
Injection Pearl
-
sure and nasolabial crease are safe.
Studies have shown that often the inferior labial artery is ip-
silaterally present and/or dominant, more commonly on the
right than on the left side. The inferior labial artery passes deep

labiomental artery (Fig. 3.13). The labiomental artery has pre-
viously been referred to as the sublabial artery. The origin of
the inferior labial artery lies within an area 2.4 cm from the
labial commissure and 2.4 cm superior to the inferior edge of
the mandible. The average vessel diameter at the ILA origin is
1.3 mm; the vessel traverses submucosal on the anterior wall
-
veolar border. Some authors advocate the inferior border of the
buccinator as an estimate of the level at which the ILA courses
toward the midline. For topographic comparison, the ILA has
predominately been shown to run as low as the labiomental

to run within the orbicularis muscle or between the orbicularis
and lip depressors.
-
tal nerve and the vessel will send small perpendicular perfo-
rators to the lower lip. As note of caution, a small percentage

bifurcating; when this occurs, the ILA will run along the vermil-
Fig. 3.12
in the oral commissure.
Fig. 3.13 Cadaveric dissection demonstration of the inferior labial
artery.

45
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.14
region.

3 The Perioral Area, the Chin, and the Jowl
-


Fig. 3.18 -
oral region.
Vascular Anatomy of the Upper

Compartments
The SMAS of the lip has been previously described by Pensler et
al. The facial nerve innervation of the orbicularis oris muscle of
the upper lip enters superior laterally on the underside of the
muscle and has numerous small branches. Recent studies have
delineated the topographic location of the SLA. Lee et al catego-

to this cadaver study, approximately 22% of superior labial ar-
teries will provide the ipsilateral alar branch. Presumably in the
remaining 78% of specimens, the angular or infraorbital vessels
supply the alar branch. In addition, this study found that the su-
perior labial vessel is absent on one side in 7% of specimens.
Computed tomography studies have reported an incidence of


2 area from
the oral commissure with a depth location of approximately
3.5 mm (Figs. 3.15, 3.16
her thumbnail at the oral commissure to estimate vessel loca-
tion. The SLA pierces the orbicularis oris muscle and then travels
cephalically to the vermillion cutaneous border until it reaches
a relative midpoint between the oral commissure and the ipsi-

white roll and continue to the sagittal midline. This transition


SLA is approximately 1 mm inferior to the cutaneous vermillion
border. During its entire course, the SLA maintains a depth of at
least 3 mm. Upon approaching the midline, 85% of SLA systems
-
cend to the nose in a suborbicularis plane; however, up to 25%
-


Injection Pearl

the intraoral mucosa, at least 4 mm deep to the skin, and is 5
mm in depth centrally at the lower lip margin.

As previously mentioned, Pessa et al describe a series of super-
Fig. 3.17): the superior upper
lip compartment, lateral upper lip compartment, inferior lat-
eral upper lip compartment, and the central upper lip compart-
ment. The central upper lip compartment contains an inferior
and a superior quadrant. Clinically, these subcutaneous com-
partments are thin and compartmental division corresponds
with vascular septation similar to other regions of the face.
These septations are manifested as vertical perioral rhytids.

the central lower lip fat compartment, lateral lip compartment,
and the inferior chin compartment. The medial boundary of the
lateral lip compartment is the septum containing the inferior
labial artery. The arteries cephalic to the inferior labial–buccal
Fig. 3.15 Cadaver dissection demonstration of the superior labial
artery.
Fig. 3.16 A 27-gauge cannula comparison to the superior labial
artery in a cadaveric specimen.
Fig. 3.17 -
partment. Note the transition of loosely organized fat into a more

with age.

47
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.18
corresponds with vascular septation similar to other regions of the face. These septations are manifested as vertical perioral rhytids.

48
3 The Perioral Area, the Chin, and the Jowl
Nasolabial Anatomy
Moving cephalically into the nasolabial fold, studies indicate
an intimate relationship of the facial artery to the nasolabial
fold approaching 93%. Given the tortuous nature of the artery,

-
vided data on location of depth of the artery relative to the fold.
The artery more commonly travels medial to the fold, starting
1.7 mm medial from the fold in the lower portion and crossing
beneath the fold at a depth of 5 mm at the superior third of the
fold, eventually reaching a point 3.2 cm lateral to the nasal ala.
Cadaveric dissection has revealed insertion of the LLSAN,





(Fig. 3.19). Release of the dermal attachments of the mimetic
muscles in the nasolabial fold is a well-established tenant in


-
crum lift of the lip elevators resulting in a softening of the na-
solabial fold restoring youthful appearance to the face (Videos
3.1, 3.2).
Injection Pearl

placement in the reticular dermis or immediate subcutis. Be
cognizant of the depth of the angular artery (~ 5 mm) and the


white color of blanching skin, but NOT the gray color of the


recommend gentle needle subcision of the fold followed by

As discussed earlier in this chapter, the ROOrF lies immediately
deep to the orbicularis oris muscle overlying the canine fossa
(Fig. 3.20). This compartment is an excellent target for upper
lip volume replenishment, particularly in patients with upper
alveolar collapse from prior bicuspid extractions incidental
to orthodontic manipulation (see section “Authors’ Preferred

Fig. 3.21 shows the gross anatomy of the structures that lie

Fig. 3.19 Medical illustration demonstrating proper depth of the

medical illustration by James Vargo, MD.)
Fig. 3.20 Cadaveric dissection demonstration of the retro-orbicularis
-

prior to dissection.

49
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.21 Medical illustration of demonstrating the nasolabial fold and perioral skin with demonstration of underlying anatomic structures.

50
3 The Perioral Area, the Chin, and the Jowl
muscle. The cannula encounters very little restriction in this


-

of the ROOrF through this central cannula approach with hyal-

in the upper outer triangle of the upper lip bordering the alar
Fig. 3.22; Video 3.4). When grafting autologous
fat, the fat is placed in numerous passes, while the cannula is

these suborbicularis oris structures broadens the dental arch
and often lifts the upper lip.
Vertical Perioral Rhytids
Vertical perioral rhytids within the lower third of the upper lip
are generally not the purview of autologous fat grafting proce-
dures. When present, the authors prefer primarily crosshatch-
ing in an intradermal level with particulate HA products (Video
3.5



subcutaneous fat of the upper lip over the course of the orbicu-
laris oris muscle.
The Authors’ Preferred Techniques
for Perioral Rejuvenation
Columella–Lip Interface
Retro-Orbicularis Oris Fat
-
ing dental occlusion. In individuals who have undergone orth-

level of upper lip collapse will be present. The ROOrF represents



lip and extends medially to the entrance of the deep-pyriform
space. This fat compartment is devoid of arteries large enough
to be cannulated readily. The authors’ preferred technique is
to approach this compartment with a port placed centrally in


-
Video 3.3). A cannula is passed
through the port in an anterior to posterior direction; the can-
nula is then angulated laterally and easily runs on the ante-
rior side of the upper lip mucosa, deep to the orbicularis oris

51
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.22 Medical illustration demonstrating cannula volumization of the retro-orbicularis oris fat.

52
3 The Perioral Area, the Chin, and the Jowl
rection immediately deep to the dry vermillion mucosa. Paral-

central three-quarters of the upper lip vermilion are performed
from commissure to commissure. This method will result in
maximal vermilion convexity and improved anteroposterior



An alternative method to augment the red vermilion is via
cannula (Videos 3.8). Two potential spaces exist within the up-

and the second lies posterior. The anterior space extends the
entire width of the upper lip in most individuals, whereas the
posterior space is partitioned at the midline in most individu-

-


vermillion and increased height of the wet vermillion, respec-


gingival show.
The anatomical shape of the orbicularis oris has a vertical

transverse to vertical leaves an area of poor soft-tissue sup-
port, resulting in oral incompetence, in both the upper and the
lower lips. The superior and inferior labial arteries are not in


posterior to the white roll of the upper and lower lip commis-
sure (Video 3.9).
Upper Lip Enhancement
The Philtrum and the White Roll

white roll approach (Fig. 3.23; Video 3.6). The philtrum is gen-
-

branches of the SLA. The white roll is enhanced from commis-
sure to commissure including the philtral component with HA
-

A very sharp and unexaggerated white roll can be achieved in
this fashion. Enhancement of the white roll should precede any
vermillion enhancements.
The Oral Commissure
Although it has not been studied photomicrographically, the
-

misshapen. Depressed lateral commissures are addressed by an

orbicularis oris muscle approximately 5 mm lateral to the com-
missure creating a downward curvature at this 5-mm point. The
-
terior and caudal to the course of the SLA. By proxy, this maneu-
ver results in the illusion of an upturned commissure (Video
3.7).
The Red Vermillion
One method for enhancement of the dry vermilion is accom-

-

53
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.23

54
3 The Perioral Area, the Chin, and the Jowl
For lower lip vermillion enhancement with cannula, the in-

upper lip. The cannula can be angulated caudally into a space
beneath the anterior vermilion of the lower lip. This space
transverses the entire lower lip.
The lower lip contribution to the commissure is addressed

lip, which in many individuals is a tightly bound compartment.
-

-
ments medially. Crosshatching with immediate subdermal in-

-

should be done conservatively; however, as all vascularity runs

this region.
-

the lower lip are safe and easy to perform with a cannula with
either a midline chin port or a port at the lateral extent of the
labiomental crease.
Lower Lip Enhancement

the white roll: cannula or needle. Our preferred method is to

the white roll (Videos 3.10, 3.11). Using an oral commissure in-





Needle enhancement of the dry vermilion is accomplished

-
mediately deep to the dry vermillion mucosa (Fig. 3.24). Paral-

central three-quarters of the lower lip vermilion are performed
from commissure to commissure. This method will result in
maximal vermilion convexity and improved anteroposterior



labial artery.

55
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.24 Medical illustration demonstrating volumization techniques for the lower lip. Cannula volumization of the vermillion is depicted.

preferred.

3 The Perioral Area, the Chin, and the Jowl
A cannula port along the inferior border of the mandible at
the parasagittal midline facilitates cannula passage cephalically

the deep lateral chin compartment and provide support deep
and medial to the lower lip commissure. The cannula can be

will meet very little resistance as it enters the deep lateral chin
compartment; this potential space is formed by the investing
capsule on the posterior surface of the DAO and volume can be
placed in this space to provide support beneath the DAO. This
-
Video 3.12). Autologous fat and high G-

these approaches.
-



Lip–Chin Interface
Support for the lower lip and chin interface is achieved by re-
storing volume within the area of the labiomental crease (Fig.
3.25). The inferior labial artery runs in close proximity to the

-
ural plane. Volume is added over the cephalic insertion of the
mentalis muscle along the posterior aspect of the orbicularis


intravascular complications.
When mentalis strain is present, volume should be placed
in the mentalis fat pad, which is septated at the midline. A
midline port at the point of maximal chin convexity can be uti-


cannula enters the fat pad.

57
3 The Perioral Area, the Chin, and the Jowl
Fig. 3.25 Medical illustration demonstrating volumization techniques for the lip–chin interface. Cannula volumization the mental fat compart-
ments and labiomental crease is demonstrated. Cannula volumization of the deep lateral chin compartment from a midline ports is demonstrat-
ed; the cannula is advanced on the backside of the depressor anguli oris.

58
3 The Perioral Area, the Chin, and the Jowl
changes in the upper lip complex. Plast Reconstr Surg
2009;124(2):624–628
-
neurotic system in the upper lip: an anatomic study in
cadavers. Plast Reconstr Surg 1985;75(4):488–494

of perioral region. Clin Anat 2005;18(5):330–339

technique for lip enhancement. Plast Reconstr Surg
2016;138(4):603e–613e
Lower Lip

Arterial anatomy of the lower lip: a cadaveric study. Plast
Reconstr Surg 2003;111(7):2176–2181
Tansatit T, Apinuntrum P, Phetudom T. A typical pattern of the
labial arteries with implication for lip augmentation with

1089
Nasolabial Fold
Barton FE Jr, Gyimesi IM. Anatomy of the nasolabial fold. Plast
Reconstr Surg 1997;100(5):1276–1280
Beer GM, Manestar M, Mihic-Probst D. The causes of the
nasolabial crease: a histomorphological study. Clin Anat
2013;26(2):196–203
-
metic muscles on the nasolabial fold. Aesthetic Plast Surg
1992;16(2):167–171


1989;83(1):1–10

the course and branching patterns of the facial artery:


2014;133(5):1077–1082
Complication Management

complications. Dermatol Surg 2008;34(Suppl 1):S92–S99
-

Facial Plast Surg 2013;15(3):226–231

Surg J 2013;33(4):561–575
-
lar complications. Aesthet Surg J 2014;34(4):584–600


Pathol 2013;7(3):241–249


Surg 2011;64(7):892–896

complications. Dermatol Surg 2009;35(Suppl 2):1672–1680
Suggested Reading
Chin and Jowl Anatomy


Plast Reconstr Surg 2015; 136(5, Suppl):235S–257S
-
bial sulcus: a histologic study. Int J Oral Maxillofac Surg
1995;24(2):145–147
de Castro CC. The anatomy of the platysma muscle. Plast Re-
constr Surg 1980;66(5):680–683

Inc.; 2006:107
-
str Surg 1989;83(1):11–16

marginal mandibular nerve to the mandibular osseocutane-
ous ligament and lesser ligaments of the lower face. Aesthet
Surg J 2015;35(2):111–120



2002;110(3):885–896, discussion 897–911
Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: ana-


1420
Upper Lip


Radiol Anat 1998;20(4):273–278
-
tery on computed tomographic angiography using 64-slice
multidetector computed tomography: implications for
facial reconstruction in plastic surgery. Plast Reconstr Surg
2013;131(3):526–535

Changes in the aging upper lip—a photomorphometric and

approach). J Plast Reconstr Aesthet Surg 2008;61(10):1170–
1176


2012;16(6):581–585

-
tion. Plast Reconstr Surg 2015;135(2):445–450

variations of the facial artery, with emphasis on the supe-
rior labial artery. Surg Radiol Anat 2006;28(3):316–324

and nose: anatomy and a clinical application. Plast Reconstr
Surg 2002;109(3):855–861, discussion 862–863

dimensional appearance of the lips muscles with three-
dimensional isotropic MRI: in vivo study. Int J CARS
2009;4(4):349–352

aging lip: a comparative histological analysis of age-related

4
Chapter 4
The Temple and the Brow
The Temporal Fascia Layers, the Upper
and Lower Temporal Compartments,
and the Inferior Temporal Septum
61

the Sentinel Vein, the Brow Partition,

Components
64

for Temporal Volumization
66

(Trang không có chữ)

61

4 The Temple and the Brow
Jerome Paul Lamb and Christopher Chase Surek
The Temporal Fascia Layers,
the Upper and Lower Temporal
Compartments, and the Inferior
Temporal Septum
Temple hallowing is a common problem in the aging face, and
nomenclature can be confusing. Volume lost with aging in the
temple may be the result of atrophy of the temple fat pad, su-

coined term temporal hollow ing -
poral adipose and/or muscle. In accordance with this aging


the temple. As a general rule, authors advocate undercorrection
compared to overcorrection for temporal contour (Video 4.1).
As the scalp layers converge into the temple, the galea apo-

with the temporoparietal fascia [TPF]); in contrast, the perios-
teum becomes synonymous with the deep temporal fascia. The
deep temporal fascia is composed of separately named lamina


one layer at the temporal line of fusion. A reproducible method
to understanding the temporal anatomy is to divide the tem-
poral into upper and lower temporal compartments. This has

colleagues.
The upper temporal compartment is bordered superiorly by
the superior temporal septum. This septum is the upper limit
of the temple region. It is at this point that the periosteum con-
verts to deep temporal fascia. The septum traverses anteriorly
to the triangular temporal ligamentous adhesion (TLA). The TLA

and inferior temporal septa. No vital structures exist in the su-
perior temporal compartment and it is within the bounds of
-
dling of the temporal fat compartment by the two laminae of
deep temporal fascia.
The lower temporal compartment cephalic border is the in-


-
gomaticocutaneous ligaments and forming the relative inferior
border of the compartment.
The deep fat compartment of the upper periorbital region
is the retro-orbicularis oculi fat (ROOF) compartment. The fat

of this fat results in deep upper eyelid sulci and descent of the
tail of the eyebrow.

62
4 The Temple and the Brow
A thorough understanding of temple vascular anatomy is
important to avoid undesirable complications. Three separate
branches of the external carotid artery provide vascular supply


with the temporal rami of the facial nerve and often commu-
nicates with the supraorbital artery (Fig. 4.1). Intravascular in-

ophthalmic system and subsequent central retinal artery occlu-

region should be performed with caution. Within the deep tem-
poral fascia lie the middle temporal and deep temporal arter-
ies. Of note, the deep temporal artery arises from the internal
-
-

inferior medial quadrant of the temporal fossa (see section “The

the remainder of the temple, we recommend cannulas either in
the upper temporal compartment, which is an avascular plane,

Fig. 4.2 presents the gross anatomy of the neurovasculature
and the upper temporal space.
Fig. 4.1 Illustration of the intersection of the frontal branch of the

63
4 The Temple and the Brow
Fig. 4.2

64
4 The Temple and the Brow
The cephalic border of this fat compartment is the temporal
crest and the superior temporal septum; the compartment is a

resistance at the caudal and cephalic boundaries of the com-
partment corresponding with the temporal septa as they insert
-
cated caudal to the inferior temporal septum.
The vasculature of the upper brow has been described three-


run along a septum contiguous with the membranous bound-




The sentinel vein drains into the middle temporal vein,
which resides within the temporal fat pad straddled by the deep
temporal fascia. The location of the supraorbital and supra-
trochlear neurovascular bundles is well described and familiar
-



-


Injection Pearl


Fig. 4.3

the Sentinel Vein, the Brow

Temporal Components
The inferior temporal septum is a bilaminar ligamentous struc-

of the facial nerve. This branch is synonymous with the fron-
tal branch of the facial nerve. The frontal branch courses near

and inferior to the infratemporal septum. The nerve becomes

the ceiling of the inferior temporal compartment. The frontal

-
ately beneath the subcutaneous fat. These rami will continue
their course into the forehead and ROOF. It is important to note

within the inferior temporal compartment. Cannula-based

-
cal augmentation with implants or other synthetic composites
-
muscular and supramusclar planes in this compartment.
An additional anatomic structure of note is the temporal


orbicularis retaining ligament (medially), and TPF (laterally).
-
gomatic space.
There are two fat compartments in the temple region. The

65
4 The Temple and the Brow
Fig. 4.3

66
4 The Temple and the Brow


the sideburn. The cannula will travel on the anterior-inferior
-
graphically correlates with Pitanguy’s line. The cannula will
meet resistance along the cephalad border of the space at the
temporal crest. Caudally, the bounds will be the anterior two-

Fig. 4.4 -


for Temporal Volumization

The insertion site for the cannula is located along the anterior
border of the sideburn, 2 to 3 cm superior to the helical root.
-

amount of resistance as the cannula traverses within the fat
compartment. Cannula depositions can be performed in a retro-

67
4 The Temple and the Brow
Fig. 4.4

68
4 The Temple and the Brow

topography of the temple fusion line along with the scaphoid
temporal fossa. The target area is 1 cm superior to supraorbital
rim along the temporal fusion line and 1 cm lateral from the
fusion line within the temporal fossa. This location is medial



-



to spread between deep temporal fascia and the temporalis




visible portions of the temporal fossa.
Fig. 4.5.
Deep Periorbital

improve periorbital shape and appearance (Video 4.2). Prior
-


-
praorbital and supratrochlear vessels is recommended prior to

the eyebrow tissues. The needle or cannula is inserted lateral to
the tail of the eyebrow and advanced medially in a deep plane
-


-
Video 4.3
anterior branch of the deep temporal it is no more anterior than

69
4 The Temple and the Brow
Fig. 4.5

70
4 The Temple and the Brow










-





Suggested Reading

-





-
mentous attachments in the temple and periorbital regions.




New perspectives on the surgical anatomy and nomencla-
ture of the temporal region: literature review and dis-

71

Index
Note: Page numbers followed by f or t
A
f f
f
f
B

t
f
f
C
f
f
D
f
f f
f f
f f

f
f f
E
see
F
f

f f
t
f f
f

f f
I

f
f
f
f
f
f
f f
f

J
f
L




f
f
f
f
f




f
f
f

f
f
f
M

f
f f
f f
f
see
f f
f
f f
f f
f
f f
f

f
f
f
f
f
f
N


f
f
f f

72
Index
S
f

f f

f
f
f
f
f f f
f f
f f
f
f
f
T
f
f f
f

f
f f

f
f f
f f f
f
f
U
f
V
f
Z
f
f f f f f
f f
f
O
f

f f

f f f f
P



f
f
f
f
f
see

f
f

f
f
f

f

f

f
f

f
f f f
f
f
f f
f f f
R
f

f f f f
f f
f