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Clinical Anatomic Considerations of the Zygomaticus Minor Muscle Based on the Morphology and Insertion Pattern

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The Doctor's 기획특집 성형임상 Clinical anatomic considerations of the zygomaticus minor muscle based on the morphology and insertion pattern Da-Yae Choi, BSDH1*, Jung-Suk Kim, DDS, MS1*, Kwan-Hyun Youn, PhD1, Mi-Sun Hur, PhD2, Jisoo Kim, MD3, Kyung-Seok Hu, DDS, PhD1, Hee-Jin Kim, DDS, PhD1 Introduction books and illustrations. The Zmi is described critical anatomic information required to elu- as inserting into the LLSAN4, blending with cidate the functional aspects related to human The zygomaticus minor muscle (Zmi) arises the orbicularis oris muscle (OOr) just lateral facial animation. from the lateral surface of the zygomatic bone to the alar of the nose5, or being nonexistent6. immediately behind the zygomaticomaxillary There is thus some confusion in the literature Materials and Methods suture, and passes downward and medially as to the actual anatomy of the Zmi. into the muscular substance of the upper lip. Some articles provide diverse descriptions of Materials Acting together, the levator labii superioris the morphology and insertion pattern of Zmi. Fifty-four embalmed adult hemifaces (48 bi- muscle, levator labii superioris alaque nasi Youn et al. reported a detailed description of lateral and 6 unilateral; 31 males, 23 females; (LLSAN), and Zmi raise the corner of the the Zmi that differed from those in general age range, 45–48 years; mean age, 67.4 years) mouth and upper lip, and expose the maxillary textbooks with regard to its origin. They re- from 30 cadavers were used in this study. teeth when expressing a smile1. ported that the Zmi and zygomaticus major Specimens with an impaired midface were ex- The Zmi is also involved with the formation of muscle (Zmj) look very similar, and could cluded. The study protocol was approved by negative expressions; it helps to curl the upper not be distinguished in 34.4% of cases7. The the Ethics Committee of Yonsei Medical Cen- lip when showing contempt, smugness, and prevalence of the Zmi was reported to be only ter, Korea. disdain. It also helps to deepen the nasolabial 36% (Pessa et al.8). sulcus when showing sadness2,3. The aim of this study was to clarify the mor- Insertion site of the Zmi While the Zmi is involved in the expression phology and insertion pattern of the Zmi The skin and subcutaneous tissues of the face of many different facial emotions, only poor through a topographic examination followed were removed. A detailed dissection was per- descriptions of it are available. The details of by a detailed dissection. In addition, the ana- formed on all specimens, with extreme care its insertion pattern and morphology are not tomical variations in the insertion of the Zmi being taken not to damage the underlying well described even in general anatomy text- are described herein, thereby providing the muscles, nerves, and blood vessels. Special at- 30 THE DOCTOR'S | APRIL 2015 tention was paid to the precise site of insertion insertion area of Zmi was marked and over- Discussion and the course of the Zmi. The dissection was lapped. In most cases the Zmi was inserted performed with the aid of a surgical micro- between 12.6 mm from the nose ala (point Facial expression muscles have been studied scope (OPMI pico, Carl Zeiss, Oberkochen, C) and the lateral two-thirds of line A–B. The from various perspectives due to their unique Germany). width of the Zmi was 11.9±4.4 mm. characteristics. The organization of the facial After dissection, the insertion region of the expression muscles differs from that of mus- Zmi was measured and analyzed with regard Morphology and insertion pattern of the cles in most other regions of the body because to the nose ala (point A in Fig. 1) and the Zmj Zmi there is no associated deep membranous fas- to clarify the location of its insertion point(s). The Zmi was classified into three types ac- cia beneath the skin of the face. Instead, many First, the point where the two muscles join was cording to its insertion area. In type A (63.0% small slips of muscle attached to the facial checked, the medial margin of the Zmj and the of cases, 34/54) the Zmi was attached only to skeleton insert directly into the skin2, which orbicularis oris (point B in Fig. 1) and the dis- the upper lip. This type could be further subdi- allows the facial muscles (especially the Zmi) tance between points A and B was measured. vided into two subtypes: straight, A-1 (31.5% to move the facial skin so as to reflect emo- The insertion area of the Zmi on this line was of cases, 17/54), and curved, A-2 (31.5% of tions. then examined. cases, 17/54). In type A-1 the muscle fibers of It is well known that the Zmi raises the up- Second, the insertion area of the Zmi was ex- the Zmi passed straight from the origin site to per lip in smiling; this muscle is also partly amined with the reference to point A, and fi- the upper lip, and in type A-2 the muscle fibers responsible for expressions such as contempt, nally the width of the Zmi was measured. of the Zmi curved while passing downward smugness, and disdain. However, since only and medially to the upper lip (Fig. 2). simple explanations exist regarding the origin Morphology and insertion pattern of the Type B, in which the Zmi was attached to both and insertion of the Zmi in textbooks, it has Zmi the upper lip and the alar portion, occurred in been difficult to elucidate its action—there has The Zmi was classified according to its mor- 27.8% of cases (15/54). The Zmi fibers could been no detailed description of how these ex- phology and course. All photographs and dia- be traced to their attachment at the nose ala, pressions are made. grams in this article are of structures viewed but could not be separated from those of the In the present study, the course of the Zmi was from the left side of the face. orbicularis oculi (OOc). In addition, the mus- classified into three types: A (including A-1 cle fibers of the Zmi blended with the inner and A-2), B, and C. The most commonly en- Direction and angular measurements of the lower part of the OOc. In type C (9.3% of countered (representing 63.0% of cases) was Zmi cases, 5/54) there was either no or only unde- type A, in which the Zmi was attached only The vector that represented the center of the veloped Zmi fibers (Fig. 2). to the upper lip. The straight (A-1) and curved Zmi fiber was defined on the photograph on (A-2) types were equally common (31.5%). It the basis of its origin and insertion. The angle Direction and angular measurements of the is anticipated that each type of Zmi plays a dif- between the muscle vector of each Zmi and Zmi ferent role in raising the upper lip, since each the facial midline was measured with image- The angles between the facial midline and the has a different vector. analysis software (Image-Pro Plus version 4.0, Zmi vector were 58.4±8.5°, 35.5±12.3°, and Five specimens (9.3%) had either no or only Media Cybernetics, Bethesda, MD, USA). 45.3±10.7° for types A-1, A-2, and B, respec- undeveloped Zmi fibers. In agreement with tively (Table 1). In type B it looked as if the this finding, in some articles it is noted that the Results muscle fibers were attached to the upper lip. Zmi does not exert great influence on function The symmetry of the Zmi with respect to its because it is usually a very poorly developed Insertion site of the Zmi morphology and vector was examined; sym- muscle9. The distance between the nose ala and the metry was accepted when the difference be- The angle between the facial midline and the point where the medial margin of the Zmj tween the vectors of both sides of the face was Zmi muscle vector was measured. The mean joined the orbicularis oris (line A–B in Fig. 1) less than 5°. Specimens with an impaired mid- angle was smallest in type A-1 and largest in was 35.3±3.9 mm (mean±SD). The distance face or type C were excluded from this analy- type A-2. In 6 of 18 specimens (33.3%), both between the nose ala and the point where the sis. Of the 18 specimens, the bilateral Zmi fi- faces had similar vectors (i.e., the difference Zmi joined the LLSAN (line A–C in Fig. 1) bers were symmetrical in 6 cases (33.3%) and was less than 5º) and were thus symmetrical. was 12.6±3.0 mm. asymmetrical in 12 (66.6%). Asymmetry was found in this regard in 12 In order to clarify the location of Zmi, the specimens (66.6%); this is one of the causes of THE DOCTOR'S | APRIL 2015 31 The Doctor's 기획특집 성형임상 2. Borley NR, Standring S, Gray H. Gray’s anatomy : the an asymmetric smile. Based on the present detailed dissection of anatomical basis of clinical practice. Edinburgh: Churchill According to the present findings, Zmi fibers the insertion of the Zmi, the insertion into the Livingstone; 2008. attached to the nose ala were observed in nose ala could play a role in the formation of a 3. Moore KL, Dalley AF. Clinically oriented anatomy. Philadelphia: Lippincott Williams & Wilkins; 1999.
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  • A Review of Facial Nerve Anatomy

    A Review of Facial Nerve Anatomy

    A Review of Facial Nerve Anatomy Terence M. Myckatyn, M.D.1 and Susan E. Mackinnon, M.D.1 ABSTRACT An intimate knowledge of facial nerve anatomy is critical to avoid its inadvertent injury during rhytidectomy, parotidectomy, maxillofacial fracture reduction, and almost any surgery of the head and neck. Injury to the frontal and marginal mandibular branches of the facial nerve in particular can lead to obvious clinical deficits, and areas where these nerves are particularly susceptible to injury have been designated danger zones by previous authors. Assessment of facial nerve function is not limited to its extratemporal anatomy, however, as many clinical deficits originate within its intratemporal and intracranial components. Similarly, the facial nerve cannot be considered an exclusively motor nerve given its contributions to taste, auricular sensation, sympathetic input to the middle meningeal artery, and parasympathetic innervation to the lacrimal, submandibular, and sublingual glands. The constellation of deficits resulting from facial nerve injury is correlated with its complex anatomy to help establish the level of injury, predict recovery, and guide surgical management. KEYWORDS: Extratemporal, intratemporal, facial nerve, frontal nerve, marginal mandibular nerve The anatomy of the facial nerve is among the components of the facial nerve reminds the surgeon that most complex of the cranial nerves. In his initial descrip- the facial nerve is composed not exclusively of voluntary tion of the cranial nerves, Galen described the facial motor fibers but also of parasympathetics to the lacrimal, nerve as part of a distinct facial-vestibulocochlear nerve submandibular, and sublingual glands; sensory innerva- complex.1,2 Although the anatomy of the other cranial tion to part of the external ear; and contributions to taste nerves was accurately described shortly after Galen’s at the anterior two thirds of the tongue.