- Email: [email protected]
Treatment Alternatives for the Lip–Cheek Groove
477
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 15 (2007) 477–483
Treatment Alternatives for the Lip–Cheek Groove Lorne Segall, MD, FRCSCa,b,c, Naznin Karsan, David A.F. Ellis, MD, FRCSC, FACSb,c,* -
Anatomy Management The U-shaped lip–cheek groove The V-shaped lip–cheek groove
-
Much has been published on the lip–cheek fold with respect to anatomy and treatment options. However, the authors believe that the term lip–cheek fold, or melolabial fold, is somewhat of a misnomer, because the term lip–cheek fold does not correctly define this common abnormality in the aging face. By definition, a fold is a ‘‘doubling of something upon itself’’ [1]. However, a groove is a ‘‘furrow or long hollow that has side walls’’ [1]. The authors therefore prefer the term lip–cheek groove or melolabial groove. A more accurate use of terms is not merely an issue of semantics, but rather provides an avenue for correct communication of the components of the lip–cheek groove, hereby improving preoperative assessment and optimizing treatment of this important constituent of the aging face.
Anatomy The anatomy of the lip–cheek groove has been well described in recent literature [2,3]. At the level of
d
MD, FRCSC
,
Excessive cheek mound (lateral wall) involvement The skin crease in the lip–cheek groove Summary References
the skin crease of the lip–cheek groove, the skin adheres closely to the underlying muscle layer. Medial to the crease in the upper lip, a dense fascial layer is found close to orbicularis oris muscle with only a minimal subdermal fat layer. This anatomy allows the skin of the upper lip to remain adherent to the underlining muscular structure and makes it is resistant to the sagging process associated with aging. Lateral to the lip–cheek groove is the lateral cheek mound characterized by an abundance of fat in the subdermal layer. Therefore, the lateral wall of the lip–cheek groove is very mobile, hereby allowing for significant age-related sagging of the lateral cheek mound. As people age, the lateral wall of the groove gets displaced inferiorly and medially. Each patient has a unique lip–cheek groove, and a thorough analysis of each of its components will allow for an improved preoperative assessment and diagnosis of the underlying pathology. The authors’ classification system of the lip–cheek groove allows for a systematic analysis of the area, thereby
a
American Academy of Facial Plastic and Reconstructive Surgery, 310 S. Henry Street, Alexandria, VA 22314, USA b Department of Otolaryngology-Head and Neck Surgery, University of Toronto, 190 Elizabeth Street, Room 35438, Fraser Elliot Building, Toronto, Canada M5G 2N2 c Art of Facial Surgery, 167 Sheppard Avenue West, Toronto, Canada M2N 1M9 d Age-Less Clinic, Suite 114, 13311 Yonge Street, Richmond Hill, Canada, L4E 3L6 * Corresponding author. Department of Otolaryngology–Head and Neck Surgery, University of Toronto, 190 Elizabeth Street, Room 35438, Fraser Elliot Building, Toronto, Canada M5G 2N2. E-mail address: [email protected] (D.A.F. Ellis). 1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2007.07.004
478
Segall et al
facilitating an individualized treatment plan. Overall, superior results can be achieved if each component of the lip–cheek groove is managed effectively. This lip–cheek groove classification system is as follows: 1. 2. 3. 4. 5.
Type of groove: U- or V-shaped Depth of valley: mild, moderate, severe Width: mild, moderate, severe Skin crease depth: mild, moderate, severe Presence of a double groove
When analyzing the lip–cheek groove, the groove, width, and depth should be assessed in repose and while smiling. The skin crease, located at the bottom of the groove, is an intradermal problem and should be assessed separately (Fig. 1). The shape of the groove can be characterized as either a U or V shape if viewed in the plane perpendicular to the lip–cheek groove (Fig. 2). The Ushaped groove naturally resembles the letter U on cross-sectional analysis (when examined perpendicular to the lip cheek groove) because of its wide base. The V-shaped groove has a narrow base when assessed perpendicular to the plane of the groove. The V type of lip–cheek groove is more common. In these cases, the intradermal crease is
present at a younger age and is more common in women who have thinner skin. In general, the Vshaped groove usually starts to deepen more quickly than the U-shaped groove. The lip–cheek groove can be further conceptualized as the ‘‘valley’’ next to a ‘‘hill,’’ represented by the cheek mound. The depth of the groove, or valley, can be classified as mild, moderate, or deep (Fig. 3). The deeper the grooves, the larger the hill, or cheek mound (Fig. 4). The width of the groove is also an important characteristic. Some grooves are narrow, or stiletto style. Narrow grooves can be difficult to treat. In rare cases, a double groove can also be present. In most cases of double grooves, the grooves are narrow and not very deep (Fig. 5). The presence and corresponding depth of an intradermal skin crease at the bottom of the groove completes the preoperative assessment of the lip– cheek groove.
Management Based on the anatomy of the lip–cheek groove, treatment options can be divided into three categories that address its key anatomic components,
Fig. 1. Different styles of the lip–cheek groove in repose (left) and while smiling (right).
Treatment Alternatives for the Lip–Cheek Groove
Fig. 2. Width of the lip–cheek groove: narrow V-shaped (left) and wide U-shaped (right).
namely the intradermal crease, the lateral sidewall (cheek mound), and the groove itself. Depending on the anatomy, either one or a combination of techniques may be required to manage each of the components adequately. On physical examination, the height of the lateral sidewall can be evaluated by lifting the lateral wall laterally and upwards. If only a minimal lateral sidewall is present and no significant improvement of the lip–cheek groove is achieved through physically lifting the lateral sidewall, then the groove itself requires correction. If, however, a marked improvement is seen by lifting the lateral sidewall superolaterally on physical examination, then the lateral sidewall will require treatment. If some improvement is seen when shifting the lateral sidewall superolaterally but a wide U-shaped groove is still present, then the groove and lateral sidewall (cheek mound) require treatment. If a skin crease is still persistent after both the groove and lateral sidewall are addressed, then the skin itself requires attention. Any deficiency in the soft tissue or bony anatomy of the midface should be assessed. The patient and surgeon decide which techniques to perform. If filling the groove is selected, then either temporary or permanent treatment options are available. Temporary injectable fillers, such as collagen- or
hyaluronic-based fillers, are used for temporary treatment. Other longer-term temporary fillers include Radiesse and Sculptra. The permanent treatment options include permanent injectable fillers, such as Artecoll, Dermalive, and Bio-Alcamid. or nonautologous implants usually composed of expanded polytetrafluroethylene (ePTFE), such as the GORE-TEX and Advanta implants. Many of the permanent injectable fillers are not yet available in the United States. Overall, injectable filler injections can be easily performed and are effective in making the groove appear less deep. However, minimal lateral wall involvement is required to achieve an optimal result when filling the groove is chosen as the sole modality of treatment.
The U-shaped lip–cheek groove If the groove is wide, or U-shaped, then the authors recommend using an ePTFE implant. They prefer the ePTFE implant by Advanta (Fig. 6). Their technique is a slightly modified version of the Lassus [4] technique. The procedure can be performed under local anesthesia, with or without sedation. The lip–cheek groove is marked medial to the lip–cheek crease. The length of the lip–cheek groove is measured and an appropriate implant using oval ribbon ePTFE (3–5 mm in diameter) is fashioned. A stab
Fig. 3. Depth of the lip–cheek groove: mild (left), moderate (middle), and deep (right). The lateral wall contributes to the depth; therefore, as the lateral wall height increases, the depth of the groove increases.
479
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Segall et al
Fig. 5. A narrow lip–cheek groove. Fig. 4. A significant lateral cheek mound contributes to the groove. An implant alone will not address the problem.
incision is made intranasally at the lateral nasal skin vestibule anterior to the inferior turbinates. Scissors are inserted subdermally down the medial aspect of the lip–cheek groove and a tunnel is created just medial to the midline of the groove. A long straight 3-inch Keith needle is secured to the distal end of the ribbon with a gap of 3 cm between the end of the needle and the ePTFE. The needle is passed down the tunnel and out through the skin, allowing the ePTFE to enter the tunnel and fill the groove. Once the implant is in place and located at least 1 cm below the incision, the suture can be removed. The incision is then closed with a 4-0 chromic suture. An alternative treatment for the wide lip– cheek groove is either a temporary or permanent injectable filler. However, in cases involving a deep wide groove, a large amount of filler may be required. In these cases, using either a large-volume
filler, such as Bioalcamid, or an allogenic implant, such as the previously described ePTFE Advanta implants, may be preferable.
The V-shaped lip–cheek groove A narrow, or V-shaped, lip–cheek groove is a condition that cannot be adequately treated with an ePTFE implant because the implant is difficult to properly place exactly under the groove and may result in areas of unevenness. Occasionally double lip–cheek grooves are seen (Fig. 7). Therefore, injectable fillers are the preferred treatment in the management of a narrow, or V-shaped, lip–cheek groove. Depending on the depth of the groove, the filler can be placed subdermally or intradermally. Temporary fillers, such as Perlane, Restylane, or Juvederm, can be injected initially and, if the surgeon and patient are satisfied with the result of the temporary filler, the patient may choose to continue to undergo treatment using temporary fillers as needed or may elect to transition to a permanent
Fig. 6. The lip–cheek groove treated with a expanded polytetrafluroethylene implant. Preoperative (left) and postoperative (right) views.
Treatment Alternatives for the Lip–Cheek Groove
Fig. 7. Double lip–cheek groove corrected by injection
filler, such as Artecoll or Dermalive. However, four to six syringes of permanent filler may be required over several months so that the permanent filler is placed exactly at the bottom of the groove and not in the lateral wall of the groove. A permanent injectable filler may require up to 6 to 8 months to complete, because multiple treatments are required at 2- to 3-month intervals to achieve the final desired effect. An alternative for the management of the narrow, or V-shaped, groove is direct excision of the lip–cheek groove. Multiple techniques are described to completely excise the groove. Most of these techniques involve placing the incisions just medial to the skin crease in the groove with the lateral incision placed sufficiently lateral to include the entire groove. In all cases, a full thickness skin excision is performed and the medial and lateral
components are then reapproximated in a tension-free fashion.
Excessive cheek mound (lateral wall) involvement If the lateral cheek mound fullness is moderate to severe, the cheek mound should be elevated superolaterally. Many techniques have been described to accomplish this, including GORE-TEX sling insertion [4], the subperiosteal midface lift [5,6], the deep plane lift [7], the extended superficial musculoaponeurotic system facelift [8], malar fat pad elevation [9,10], direct excision with liposuction of lateral cheek mound [11,12], the midface sling [13], and most recently the thread-lift [14,15]. However, the lifting techniques often do not elevated the inferior part of the cheek mound sufficiently.
Fig. 8. Preoperative (left) and postoperative (right) views of a patient after the malar fad pad suspension to elevate the lateral wall of the lip–cheek groove.
481
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Segall et al
Fig. 9. The thread-lift technique to elevate the lateral wall of the lip–cheek groove. Preoperative (left) and 6week postoperative (right) views.
In the senior author’s opinion, the malar fat pad elevation described by Keller [9] is the most substantial way to move the lateral wall superolaterally, hereby making the lip–cheek groove appear less deep (Fig. 8). Another technique, involving either the Endotine midface ST or midface B suspension devices (Coapt Systems, Palo Alto, California), for midface lifting and malar fat pad suspension may offer similar results [10]. The thread-lift technique [14,15] can be performed under local anesthetic with or without section. It involves using specially designed 2-0 polypropylene sutures (Contour threads, Surgical Specialties Corp., Reading, Pennsylvania), which have unidirectional ‘‘barbs’’ or cogs at each end. The threads are double-armed with a 7-inch straight needle at each end. Two to four threads are passed subcutaneously down to the lateral wall of the lip–cheek groove through a 1-cm incision in the hairline just superior to the attachment of the helical rim. Given that the threads are double-armed, they should be placed proximally at least 1 cm apart to provide a sufficient bridge of temporal fascia to secure the common end of the threads. If singlearmed threads are used, then the two sutures are sewn together and the threads pulled inferiorly to bury the knot. The skin is then contoured or massaged superiorly and posteriorly, thereby lifting the lateral wall of the groove and decreasing the depth of the lip–cheek groove. In general, the longevity of results of thread-lift procedures has been disappointing, and at best, this procedure should be considered a very temporary solution. The thread-lift pictured in Fig. 9 lasted 3 months.
The skin crease in the lip–cheek groove Finally, the intradermal crease at the depth of the groove requires skin treatment. Temporary fillers,
such as Restylane, Restylane Fine Line, or Juvederm Ultra, can be injected into the dermis to fill the skin crease. This treatment is ideal in patients who want a minimally invasive approach with little downtime. In most cases, a very fine skin crease will still remain even after optimal filler injections. Ablative laser resurfacing using a carbon dioxide or erbium laser is a more permanent treatment option to manage the skin crease, although it involves more downtime with the added risk of pigmentation changes. As a result, this procedure cannot be offered to every patient.
Summary Through understanding the anatomy of the lip– cheek groove and properly assessing its individual components, a thorough treatment plan can be devised. Ultimately, by addressing each component of the lip–cheek groove, improved aesthetic results are achieved with optimal rejuvenation of this historically challenging sign of facial aging.
References [1] Webster’s Dictionary. 1986 Edition. [2] Millard DR Jr, Yuan RTW, Devine JW Jr. A challenge to the undefeated nasolabial folds. Plast Reconstr Surg 1987;80:37. [3] Youssif NJ, Gosain A, Matloub HS, et al. The nasolabial fold: an anatomic and histologic reappraisal. Plast Reconstr Surg 1994;93:60. [4] Lassus C. A surgical solution to the deep nasolabial fold. Plast Reconstr Surg 1996;97(7). [5] Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation. Plast Reconstr Surg 1992;89:822.
Treatment Alternatives for the Lip–Cheek Groove
[6] Anderson RD, Lo MW. Endoscopic malar/midface suspension procedure. Plast Reconstr Surg 1998;102:2196. [7] Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: shortterm success but long-term failure. Plast Reconstr Surg 2002;110:940. [8] Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg 1992;90:601. [9] Keller GS, Namzie A, Blackwell K, et al. Elevation of the malar fat pad with a percutaneous technique. Arch Facial Plast Surg 2002;4(1):20. [10] Heffelfinger RN, Blackwell KE, Rawnsley J, et al. A simplified approach to midface aging. Arch Facial Plast Surg 2007;9(1):48–55.
[11] Guyuron B, Michelow B. The nasolabial fold: a challenge, a solution. Plast Reconstr Surg 1994;93:522. [12] Millard DR, Mullin WR, Hunsaker RH. Evaluation of a technique designed to correct nasolabial folds. Plast Reconstr Surg 1992;89(2):356. [13] Yousif NJ, Matloub H, Summers AN. The midface sling: a new technique to rejuvenate the midface. Plast Reconstr Surg 2002;110:1541. [14] Lee S, Isse N. Barbed polypropylene sutures for midface elevation: early results. Arch Facial Plast Surg 2005;7:55–61. [15] Sulamanidze MA, Paikidze TG, Sulamanidze GM, et al. Facial lifting with ‘‘APTOS’’ threads: featherlift. Otolaryngol Clin North Am 2005;38: 1109–17.
483
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 15 (2007) 477–483
Treatment Alternatives for the Lip–Cheek Groove Lorne Segall, MD, FRCSCa,b,c, Naznin Karsan, David A.F. Ellis, MD, FRCSC, FACSb,c,* -
Anatomy Management The U-shaped lip–cheek groove The V-shaped lip–cheek groove
-
Much has been published on the lip–cheek fold with respect to anatomy and treatment options. However, the authors believe that the term lip–cheek fold, or melolabial fold, is somewhat of a misnomer, because the term lip–cheek fold does not correctly define this common abnormality in the aging face. By definition, a fold is a ‘‘doubling of something upon itself’’ [1]. However, a groove is a ‘‘furrow or long hollow that has side walls’’ [1]. The authors therefore prefer the term lip–cheek groove or melolabial groove. A more accurate use of terms is not merely an issue of semantics, but rather provides an avenue for correct communication of the components of the lip–cheek groove, hereby improving preoperative assessment and optimizing treatment of this important constituent of the aging face.
Anatomy The anatomy of the lip–cheek groove has been well described in recent literature [2,3]. At the level of
d
MD, FRCSC
,
Excessive cheek mound (lateral wall) involvement The skin crease in the lip–cheek groove Summary References
the skin crease of the lip–cheek groove, the skin adheres closely to the underlying muscle layer. Medial to the crease in the upper lip, a dense fascial layer is found close to orbicularis oris muscle with only a minimal subdermal fat layer. This anatomy allows the skin of the upper lip to remain adherent to the underlining muscular structure and makes it is resistant to the sagging process associated with aging. Lateral to the lip–cheek groove is the lateral cheek mound characterized by an abundance of fat in the subdermal layer. Therefore, the lateral wall of the lip–cheek groove is very mobile, hereby allowing for significant age-related sagging of the lateral cheek mound. As people age, the lateral wall of the groove gets displaced inferiorly and medially. Each patient has a unique lip–cheek groove, and a thorough analysis of each of its components will allow for an improved preoperative assessment and diagnosis of the underlying pathology. The authors’ classification system of the lip–cheek groove allows for a systematic analysis of the area, thereby
a
American Academy of Facial Plastic and Reconstructive Surgery, 310 S. Henry Street, Alexandria, VA 22314, USA b Department of Otolaryngology-Head and Neck Surgery, University of Toronto, 190 Elizabeth Street, Room 35438, Fraser Elliot Building, Toronto, Canada M5G 2N2 c Art of Facial Surgery, 167 Sheppard Avenue West, Toronto, Canada M2N 1M9 d Age-Less Clinic, Suite 114, 13311 Yonge Street, Richmond Hill, Canada, L4E 3L6 * Corresponding author. Department of Otolaryngology–Head and Neck Surgery, University of Toronto, 190 Elizabeth Street, Room 35438, Fraser Elliot Building, Toronto, Canada M5G 2N2. E-mail address: [email protected] (D.A.F. Ellis). 1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2007.07.004
478
Segall et al
facilitating an individualized treatment plan. Overall, superior results can be achieved if each component of the lip–cheek groove is managed effectively. This lip–cheek groove classification system is as follows: 1. 2. 3. 4. 5.
Type of groove: U- or V-shaped Depth of valley: mild, moderate, severe Width: mild, moderate, severe Skin crease depth: mild, moderate, severe Presence of a double groove
When analyzing the lip–cheek groove, the groove, width, and depth should be assessed in repose and while smiling. The skin crease, located at the bottom of the groove, is an intradermal problem and should be assessed separately (Fig. 1). The shape of the groove can be characterized as either a U or V shape if viewed in the plane perpendicular to the lip–cheek groove (Fig. 2). The Ushaped groove naturally resembles the letter U on cross-sectional analysis (when examined perpendicular to the lip cheek groove) because of its wide base. The V-shaped groove has a narrow base when assessed perpendicular to the plane of the groove. The V type of lip–cheek groove is more common. In these cases, the intradermal crease is
present at a younger age and is more common in women who have thinner skin. In general, the Vshaped groove usually starts to deepen more quickly than the U-shaped groove. The lip–cheek groove can be further conceptualized as the ‘‘valley’’ next to a ‘‘hill,’’ represented by the cheek mound. The depth of the groove, or valley, can be classified as mild, moderate, or deep (Fig. 3). The deeper the grooves, the larger the hill, or cheek mound (Fig. 4). The width of the groove is also an important characteristic. Some grooves are narrow, or stiletto style. Narrow grooves can be difficult to treat. In rare cases, a double groove can also be present. In most cases of double grooves, the grooves are narrow and not very deep (Fig. 5). The presence and corresponding depth of an intradermal skin crease at the bottom of the groove completes the preoperative assessment of the lip– cheek groove.
Management Based on the anatomy of the lip–cheek groove, treatment options can be divided into three categories that address its key anatomic components,
Fig. 1. Different styles of the lip–cheek groove in repose (left) and while smiling (right).
Treatment Alternatives for the Lip–Cheek Groove
Fig. 2. Width of the lip–cheek groove: narrow V-shaped (left) and wide U-shaped (right).
namely the intradermal crease, the lateral sidewall (cheek mound), and the groove itself. Depending on the anatomy, either one or a combination of techniques may be required to manage each of the components adequately. On physical examination, the height of the lateral sidewall can be evaluated by lifting the lateral wall laterally and upwards. If only a minimal lateral sidewall is present and no significant improvement of the lip–cheek groove is achieved through physically lifting the lateral sidewall, then the groove itself requires correction. If, however, a marked improvement is seen by lifting the lateral sidewall superolaterally on physical examination, then the lateral sidewall will require treatment. If some improvement is seen when shifting the lateral sidewall superolaterally but a wide U-shaped groove is still present, then the groove and lateral sidewall (cheek mound) require treatment. If a skin crease is still persistent after both the groove and lateral sidewall are addressed, then the skin itself requires attention. Any deficiency in the soft tissue or bony anatomy of the midface should be assessed. The patient and surgeon decide which techniques to perform. If filling the groove is selected, then either temporary or permanent treatment options are available. Temporary injectable fillers, such as collagen- or
hyaluronic-based fillers, are used for temporary treatment. Other longer-term temporary fillers include Radiesse and Sculptra. The permanent treatment options include permanent injectable fillers, such as Artecoll, Dermalive, and Bio-Alcamid. or nonautologous implants usually composed of expanded polytetrafluroethylene (ePTFE), such as the GORE-TEX and Advanta implants. Many of the permanent injectable fillers are not yet available in the United States. Overall, injectable filler injections can be easily performed and are effective in making the groove appear less deep. However, minimal lateral wall involvement is required to achieve an optimal result when filling the groove is chosen as the sole modality of treatment.
The U-shaped lip–cheek groove If the groove is wide, or U-shaped, then the authors recommend using an ePTFE implant. They prefer the ePTFE implant by Advanta (Fig. 6). Their technique is a slightly modified version of the Lassus [4] technique. The procedure can be performed under local anesthesia, with or without sedation. The lip–cheek groove is marked medial to the lip–cheek crease. The length of the lip–cheek groove is measured and an appropriate implant using oval ribbon ePTFE (3–5 mm in diameter) is fashioned. A stab
Fig. 3. Depth of the lip–cheek groove: mild (left), moderate (middle), and deep (right). The lateral wall contributes to the depth; therefore, as the lateral wall height increases, the depth of the groove increases.
479
480
Segall et al
Fig. 5. A narrow lip–cheek groove. Fig. 4. A significant lateral cheek mound contributes to the groove. An implant alone will not address the problem.
incision is made intranasally at the lateral nasal skin vestibule anterior to the inferior turbinates. Scissors are inserted subdermally down the medial aspect of the lip–cheek groove and a tunnel is created just medial to the midline of the groove. A long straight 3-inch Keith needle is secured to the distal end of the ribbon with a gap of 3 cm between the end of the needle and the ePTFE. The needle is passed down the tunnel and out through the skin, allowing the ePTFE to enter the tunnel and fill the groove. Once the implant is in place and located at least 1 cm below the incision, the suture can be removed. The incision is then closed with a 4-0 chromic suture. An alternative treatment for the wide lip– cheek groove is either a temporary or permanent injectable filler. However, in cases involving a deep wide groove, a large amount of filler may be required. In these cases, using either a large-volume
filler, such as Bioalcamid, or an allogenic implant, such as the previously described ePTFE Advanta implants, may be preferable.
The V-shaped lip–cheek groove A narrow, or V-shaped, lip–cheek groove is a condition that cannot be adequately treated with an ePTFE implant because the implant is difficult to properly place exactly under the groove and may result in areas of unevenness. Occasionally double lip–cheek grooves are seen (Fig. 7). Therefore, injectable fillers are the preferred treatment in the management of a narrow, or V-shaped, lip–cheek groove. Depending on the depth of the groove, the filler can be placed subdermally or intradermally. Temporary fillers, such as Perlane, Restylane, or Juvederm, can be injected initially and, if the surgeon and patient are satisfied with the result of the temporary filler, the patient may choose to continue to undergo treatment using temporary fillers as needed or may elect to transition to a permanent
Fig. 6. The lip–cheek groove treated with a expanded polytetrafluroethylene implant. Preoperative (left) and postoperative (right) views.
Treatment Alternatives for the Lip–Cheek Groove
Fig. 7. Double lip–cheek groove corrected by injection
filler, such as Artecoll or Dermalive. However, four to six syringes of permanent filler may be required over several months so that the permanent filler is placed exactly at the bottom of the groove and not in the lateral wall of the groove. A permanent injectable filler may require up to 6 to 8 months to complete, because multiple treatments are required at 2- to 3-month intervals to achieve the final desired effect. An alternative for the management of the narrow, or V-shaped, groove is direct excision of the lip–cheek groove. Multiple techniques are described to completely excise the groove. Most of these techniques involve placing the incisions just medial to the skin crease in the groove with the lateral incision placed sufficiently lateral to include the entire groove. In all cases, a full thickness skin excision is performed and the medial and lateral
components are then reapproximated in a tension-free fashion.
Excessive cheek mound (lateral wall) involvement If the lateral cheek mound fullness is moderate to severe, the cheek mound should be elevated superolaterally. Many techniques have been described to accomplish this, including GORE-TEX sling insertion [4], the subperiosteal midface lift [5,6], the deep plane lift [7], the extended superficial musculoaponeurotic system facelift [8], malar fat pad elevation [9,10], direct excision with liposuction of lateral cheek mound [11,12], the midface sling [13], and most recently the thread-lift [14,15]. However, the lifting techniques often do not elevated the inferior part of the cheek mound sufficiently.
Fig. 8. Preoperative (left) and postoperative (right) views of a patient after the malar fad pad suspension to elevate the lateral wall of the lip–cheek groove.
481
482
Segall et al
Fig. 9. The thread-lift technique to elevate the lateral wall of the lip–cheek groove. Preoperative (left) and 6week postoperative (right) views.
In the senior author’s opinion, the malar fat pad elevation described by Keller [9] is the most substantial way to move the lateral wall superolaterally, hereby making the lip–cheek groove appear less deep (Fig. 8). Another technique, involving either the Endotine midface ST or midface B suspension devices (Coapt Systems, Palo Alto, California), for midface lifting and malar fat pad suspension may offer similar results [10]. The thread-lift technique [14,15] can be performed under local anesthetic with or without section. It involves using specially designed 2-0 polypropylene sutures (Contour threads, Surgical Specialties Corp., Reading, Pennsylvania), which have unidirectional ‘‘barbs’’ or cogs at each end. The threads are double-armed with a 7-inch straight needle at each end. Two to four threads are passed subcutaneously down to the lateral wall of the lip–cheek groove through a 1-cm incision in the hairline just superior to the attachment of the helical rim. Given that the threads are double-armed, they should be placed proximally at least 1 cm apart to provide a sufficient bridge of temporal fascia to secure the common end of the threads. If singlearmed threads are used, then the two sutures are sewn together and the threads pulled inferiorly to bury the knot. The skin is then contoured or massaged superiorly and posteriorly, thereby lifting the lateral wall of the groove and decreasing the depth of the lip–cheek groove. In general, the longevity of results of thread-lift procedures has been disappointing, and at best, this procedure should be considered a very temporary solution. The thread-lift pictured in Fig. 9 lasted 3 months.
The skin crease in the lip–cheek groove Finally, the intradermal crease at the depth of the groove requires skin treatment. Temporary fillers,
such as Restylane, Restylane Fine Line, or Juvederm Ultra, can be injected into the dermis to fill the skin crease. This treatment is ideal in patients who want a minimally invasive approach with little downtime. In most cases, a very fine skin crease will still remain even after optimal filler injections. Ablative laser resurfacing using a carbon dioxide or erbium laser is a more permanent treatment option to manage the skin crease, although it involves more downtime with the added risk of pigmentation changes. As a result, this procedure cannot be offered to every patient.
Summary Through understanding the anatomy of the lip– cheek groove and properly assessing its individual components, a thorough treatment plan can be devised. Ultimately, by addressing each component of the lip–cheek groove, improved aesthetic results are achieved with optimal rejuvenation of this historically challenging sign of facial aging.
References [1] Webster’s Dictionary. 1986 Edition. [2] Millard DR Jr, Yuan RTW, Devine JW Jr. A challenge to the undefeated nasolabial folds. Plast Reconstr Surg 1987;80:37. [3] Youssif NJ, Gosain A, Matloub HS, et al. The nasolabial fold: an anatomic and histologic reappraisal. Plast Reconstr Surg 1994;93:60. [4] Lassus C. A surgical solution to the deep nasolabial fold. Plast Reconstr Surg 1996;97(7). [5] Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation. Plast Reconstr Surg 1992;89:822.
Treatment Alternatives for the Lip–Cheek Groove
[6] Anderson RD, Lo MW. Endoscopic malar/midface suspension procedure. Plast Reconstr Surg 1998;102:2196. [7] Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: shortterm success but long-term failure. Plast Reconstr Surg 2002;110:940. [8] Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg 1992;90:601. [9] Keller GS, Namzie A, Blackwell K, et al. Elevation of the malar fat pad with a percutaneous technique. Arch Facial Plast Surg 2002;4(1):20. [10] Heffelfinger RN, Blackwell KE, Rawnsley J, et al. A simplified approach to midface aging. Arch Facial Plast Surg 2007;9(1):48–55.
[11] Guyuron B, Michelow B. The nasolabial fold: a challenge, a solution. Plast Reconstr Surg 1994;93:522. [12] Millard DR, Mullin WR, Hunsaker RH. Evaluation of a technique designed to correct nasolabial folds. Plast Reconstr Surg 1992;89(2):356. [13] Yousif NJ, Matloub H, Summers AN. The midface sling: a new technique to rejuvenate the midface. Plast Reconstr Surg 2002;110:1541. [14] Lee S, Isse N. Barbed polypropylene sutures for midface elevation: early results. Arch Facial Plast Surg 2005;7:55–61. [15] Sulamanidze MA, Paikidze TG, Sulamanidze GM, et al. Facial lifting with ‘‘APTOS’’ threads: featherlift. Otolaryngol Clin North Am 2005;38: 1109–17.
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