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Clinical Anatomy and Regional Approaches with Injectable Fillers

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Clinical Anatomy and Regional Approaches with Injectable Fillers lww 15/9/15 10:32 4 Color Fig(s): F1-22 Art: PRSJ-D-15-00632 LWW CLINICAL ANATOMY/REGIONAL APPROACHES November Supplement 2015 Lower Face: Clinical Anatomy and Regional Plastic and Reconstructive Surgery Approaches with Injectable Fillers 136 AQ3 André Braz, MD (Plast. Reconstr. Surg. XXX: 00, 2015.) Shannon Humphrey, MD, 5S FRCPC, FAAD Susan Weinkle, MD G. Jackie Yee, MD Use of Fillers in the Lower Face B. Kent Remington, MD, FRCP Z. Paul Lorenc, MD, FACS Steve Yoelin, MD Heidi A. Waldorf, MD Babak Azizzadeh, MD, FACS Kimberly J. Butterwick, MD Mauricio de Maio, MD, ScM, PhD Neil Sadick, MD, FAAD, FAACS, FACP, FACPh Patrick Trevidic, MD Gisella Criollo-Lamila, MD Philippe Garcia, MD Rio de Janeiro and São Paulo, Brazil; Vancouver, British Columbia, and Cal- gary, Alberta, Canada; Bradenton and Miami, Fla.; New York, N.Y.; Newport Beach, Beverly Hills, and San Diego, Calif.; and Paris, France he mandible (or inferior maxilla) consists Different mechanisms explain the aging of an inferior portion that has a horseshoe- process of the mandible contour:2,3 Tlike appearance, denominated body of the mandible, and 2 perpendicular parts, which are Atrophy of the superior and inferior mandibu- the mandibular ramus. The external surface is lar fat compartments, specially the subman- marked in the median line by a faint ridge, indi- dibular compartment; cating the symphysis or line of junction of the 2 Dehiscence of the mandibular septum causing pieces of which the bone is composed at an early the superior and inferior compartments to period of life. We name mandibular line the area move downward to the neck; between the mentum and the angle of the man- Bone resorption; F1 dible (Fig. 1).1 Skin laxity. From private practice; Carruthers & Humphrey Cosmetic AQ2 Medicine; Department of Dermatology & Skin Science, Uni- Fat Compartments and Ligaments versity of British Columbia; Remington Laser Dermatology 4 Centre; Laser & Cosmetic Dermatology, Mount Sinai Medi- Reece, Pessa, and Rohrich described 4 fat Plast. Reconstr. Surg. cal Center; Clínica Médica Dr. Maurício de Maio Ltda.; compartments in the mandibular region. Two and Expert2Expert Group. of them over the inferior mandibular border, Received for publication June 11, 2015; accepted August 7, named superior and inferior mandibular fat 00 2015. compartments; a submandibular fat compart- Copyright © 2015 by the American Society of Plastic Surgeons ment; and another covering the parotid-masse- Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001836 teric fascia. (See Video, Supplemental Digital 10.1097/PRS.0000000000001836 www.PRSJournal.com 1 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. lww 15/9/15 10:32 4 Color Fig(s): F1-22 Art: PRSJ-D-15-00632 Plastic and Reconstructive Surgery • November Supplement 2015 Disclosure: Dr. Braz reports financial disclosures with Allergan, Galderma, Loreal (La Roche-PO- SAY, Vichy, SkinCeuticals), and Palomar. Shannon Humphrey is a consultant and investigator for Al- lergan Pharmaceuticals, Galderma, and Kythera Biopharma. Susan Weinkle has received honoraria for her services as a speaker for Allergan, Bioform/ Merz, Dermik, Galderma, OrthoNeutrogena, and Proctor & Gamble. She declares having received no compensation for services as a consultant to Medi- cis. She has received honoraria for her services as an advisor for Allergan, Bioform/Merz, Dermik, Kythera, OrthoNeutrogena, Proctor & Gamble, and Stiefel. Dr. Weinkle is a stockholder in Derm Advance. Dr. Yee reports that no funds were used to support this work. Dr. Yee has associations with Al- lergan (consultant, trainer, speaker), Merz Aesthet- Fig. 1. Anatomical features of the mandible. ics (consultant, speaker), Galderma/Medicis (con- sultant, trainer, speaker), Valeant Pharmaceutical Corporation (consultant), Paradigm Medical Com- Content 1, which demonstrates lifting the fresh V1 munications, LLC (speaker), X-Medica (speaker), cadaver’s skin to show the superficial fat com- Revance Therapeutics (consultant), Sientra (con- partments of the face, available in the “Related sultant), and Medical Education Advocates, LLC Videos” section of the full-text article on PRS- (speaker). Dr. Remington has no financial interest Journal.com or, for Ovid users, at http://links. in any of the products, devices, or drugs mentioned lww.com/PRS/B468.) in this article. He also did not receive any finan- The lower face’s fat compartments have 2 lay- cial aid or reimbursement or honorariaum for the ers: the superficial fat compartment and the deep F3 5 project he submitted. Dr. Lorenc is a consultant for fat compartment (Figs. 2 and 3). F2 Galderma, Merz, Mentor, and La Lumiere. Dr. Mandibular septum is a membranous sep- Yoelin has associations with Allergan (consultant, tum that separates the 2 compartments located investigator) and Galderma (consultant). Dr. Wal- dorf has associations with Allergan (consultant, ad- visory board member, speaker’s bureau), Caudalie Valeant (consultant), Galderma (consultant, advi- (advisory board member), Ferndale (consultant, sory board), and Suneva (advisory board). Dr. de AQ16 advisory board member), Galderma (consultant, Maio has no financial interest in any of the prod- advisory board member), Kythera (consultant, advi- ucts, devices, or drugs mentioned in this article. Dr. sory board member, investigator, speaker’s bureau), de Maio is a consultant and speaker for Allergan. L’Oreal (speaker’s bureau), Merz Aesthetics (con- Dr. Sadick has associations with Allergan (grants/ sultant, advisory board member, speaker’s bureau), research funding, honoraria), Galderma Laborato- Neostrata (consultant, advisory board member, ries, L.P. (honoraria), and Valeant Pharmaceuticals speaker’s bureau), Proctor & Gamble (speaker’s International (grants/research funding, honoraria). bureau), Revance (consultant, advisory board Drs. Trevidic, Criollo-Lamilla, and Garcia have no member), Sunvea (consultant, advisory board mem- financial interest in any of the products, devices, or ber), Unilever (consultant, advisory board member, drugs mentioned in this article. speaker’s bureau), and Valeant (consultant, advi- sory board member, speaker’s bureau). Dr. Waldorf reports receiving honoraria from all of the aforemen- Supplemental digital content is available for tioned entities, and additionally has received re- this article. Direct URL citations appear in the search support from Kythera. Dr. Azizzadeh reports text; simply type the URL address into any Web no relevant disclosures for his portion of the article. browser to access this content. Clickable links Dr. Butterwick has associations with Allergan (con- to the material are provided in the HTML text sultant, advisory board, investigator, stockholder), of this article on the Journal’s website (www. Merz (consultant, advisory board, speaker bureau), PRSJournal.com). 2 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. lww 15/9/15 10:32 4 Color Fig(s): F1-22 Art: PRSJ-D-15-00632 lww 15/9/15 10:32 4 Color Fig(s): F1-22 Art: PRSJ-D-15-00632 Volume 136, Number 5S • Use of Fillers in the Lower Face AQ1 Video 1. Supplemental Digital Content 1, demonstrating lifting of the fresh cadaver’s skin to show the superficial fat compart- ments of the face, is available in the “Related Videos” section Fig. 3. The midface and lower face of a cadaver show the deep of the full-text article on PRSJournal.com or, for Ovid users, at layer of fat compartments. The tip of the tool shows the deep http://links.lww.com/PRS/B468. portion the buccal fat pad. over the mandibular edge from the submandibu- lar fat compartment. Fibers from the platysma intermingle with the mandibular septum and are inserted at the anterior border of the mandible. Behind the depressor anguli oris (DAO) muscle, inserting the skin, is the mandibular ligament (Fig. 4).4 F4 MUSCLES The mental area is composed of 3 muscles: DAO muscle, depressor labii inferioris (DLI) muscle, and mental muscle. These muscles merge inferiorly with the platysma.6 It is important to Fig. 2. The lower face of a cadaver shows the superficial layer of remember the relation of these muscles with the fat compartments. orbicularis oris muscle (Fig. 5). F5 Fig. 4. The marionette fold and the jowl, in this female patient, are explained by the mandibular ligament in the cadaver’s picture. The latter still shows the DAO muscle and the masseter muscle. 3 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. lww 15/9/15 10:32 4 Color Fig(s): F1-22 Art: PRSJ-D-15-00632 Plastic and Reconstructive Surgery • November Supplement 2015 Fig. 5. The lower face of a cadaver shows the orbicularis oris muscle and the DLI muscle. Orbicularis Oris Muscle Origin and insertion: It is not merely a sphinc- ter muscle like the orbicularis oculi. It consists of Fig. 6. The lower face of a cadaver shows the DLI muscle and the numerous strata of muscular fibers surrounding DAO muscle. the mouth orifice with different directions. It con- sists partly of fibers derived from the other facial Function: It helps to depress the lower lip. muscles, which are inserted into the lips, and Innervation: Mandibular branch of the facial partly of fibers proper to the lips. Of the former, nerve. a considerable number are derived from the buc- cinator muscle and form the deeper stratum of Depressor Anguli Oris Muscle the orbicularis. The medial fibers decussate at the angle of the mouth: those arising from the max- Origin and insertion: It arises from the illa passing to the lower lip, and those from the oblique line of the jaw where its fibers converge mandible to the upper lip. The uppermost and to be inserted into the angle of the mouth. At its lowermost fibers of the buccinator pass across the origin, it fuses with the platysma, and at its inser- tion with the orbicularis oris and risorius muscle lips from side to side without decussation. Super- 10,11 ficial to this stratum is a second one, formed on (Fig.
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