Both skin and structural aging are significant components

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1 Treatment of Depressor nguli Oris Weakening The authors have created a strategy for rejuvenation of the peribuccal region based on the concept that the repeated contraction of certain fascicles of the mimetic muscles, and not gravity, is the primary cause of structural aging. Treatment is based on a 4-stage strategy, with interventions including botulinum toxin, hyaluronic acid, autologous fat transfer, and surgery of the depressor anguli oris. (esthetic Surg J 2006;26: ) oth skin and structural aging are significant components of the aging face. Structural aging is characterised by the hollowing of paramedian folds (ie, tear trough, nasolabial grooves), resulting from movement of the fatty volumes. For a long time, gravity was considered to be the main cause of structural aging. However, recent clinical studies 1 demonstrate that structural aging can be attributed primarily to the repeated contraction of certain fascicles of the mimetic muscles. ccordingly, gravity has only a secondary effect on tissues that are already damaged by movement of the mimetic muscles. Over time, the mimetic muscles shorten and change from a curved to a rectilinear shape (Figure 1). Consequently, the deep fat lying beneath the muscle is expelled and pushed toward the superficial fat. Certain fascicles of the mimetic muscles (that have an insignificant or nonexistent functional role), called age marker fascicles, are specifically involved in this mechanism. These age marker fascicles are responsible for the paramedian folds. range of innovative medical and surgical techniques has arisen from these findings. These new techniques, which we have named Face Recurve, target the age marker fascicles and fatty transfers. Stages in Peribuccal Rejuvenation The application of this concept to the depressor anguli oris (DO) has given rise to a new 4-stage strategy for rejuvenation of the peribuccal region: Prevention Stage (otulinum Toxin Recurve): In patients aged 20 through 25 years, botulinum toxin is injected to prevent muscular shortening and fatty transfer. s a result, the tone of the young person at rest is maintained at a low level for a longer time without modifying the maximum traction force (Figure 2). ging Stage 1 (otulinum Toxin-Filler Recurve): In patients aged 30 through 35 years, the early stages of aging are treated by injecting botulinum toxin into the DO to block its contraction force, as well as filling the buccal commissure, vermillion line of the upper and lower lips, marionette fold, and mandibular rim in front of the marionette fold with hyaluronic acid (Figure 3). ging Stage 2 (Face Recurve): In patients aged 40 through 45 years, treatment involves sectioning the DO (if necessary) under local anesthesia, along with the lateral platysma (LP) muscle. Fat is suctioned from the jowl and then reinjected into the marionette fold (Figure 4). ging Stage 3 (Face Recurve Lift): In patients 50 years and older, treatment includes a cutaneous lift combined with age marker fascicles sectioning and fat transfer. y using this treatment, high lateral skin traction is no longer required to correct the signs of aging arising from the action of the age marker fasciculus (Figure 5). natomic Considerations Claude Le Louarn, MD, Paris, France, is a plastic surgeon. Coauthors: Jacques uis, MD; Didier uthiau, MD, Paris, France. It is important to distinguish between the action of the DO at the corner of the mouth (vertical traction) and that of the LP (rear oblique traction) (Figure 6). The fatty transfer toward the jowl during the contraction of the DO and LP is complemented by the associated contraction of the mentalis or the depressor labii inferioris (DLI). ecause of the support offered by the bone, the muscular curtain, thus created, favors the transfer of the deep fat toward the superficial fat and contributes to jowl formation (Figure 7). ESTHETIC S URGERY J OURNL ~ SEPTEMER/OCTOER on 19 ugust 2018

2 YOUTHFUL Deep fat Long, curved, thin muscle Superficial muscle GING Superficial fat Transfer of deep fat towards superficial fat Short, thick, straight muscle Illustrations by William M. Winn, tlanta, G Figure 1. In the aging person, the deep fat is transferred toward the superficial fat due to the shortening of the youthful, curved muscle. Figure 2. Prevention Stage of the Face Recurve concept., Preoperative view of a 25-year-old woman shows the injection location; 2 units of otox are injected into the subcutaneous fat in front of the DO., Postoperative view demonstrates lifting of the corner of the mouth at rest with a reduction of the tone at rest, which formerly was too high. 604 esthetic Surgery Journal ~ September/October 2006 Volume 26, Number 5 on 19 ugust 2018

3 Figure 3. ging Stage 1 of Face Recurve., Preoperative view of a 34-year-old woman with increased resting tone of the DO, source of an early-stage marionette fold. The upper lip corner (DO dependent) overlaps the lower lip corner (zygomaticus major dependent). The modiolus stays stable with time., Postoperative view after botulinum toxin injection to block the maximum power of DO contraction and to decrease the resting tone of the levator alaquae nasi. She was also injected with hyaluronic acid in the vermillion border, the mucosa of the corner of her mouth, the marionette fold, and the mandibular line in front of her jowl. C D Figure 4. ging Stage 2 of Face Recurve.,C, Preoperative views of a 45-year-old woman. In () the patient is at rest and in (C) she is turning down the corners of her mouth, contracting her DO.,D, Postoperative views 4 months after section of the DO under local anaesthesia. In () the patient is at rest and in (D) she is attempting to turn down the corners of her mouth, but is unable to contract her DO. Treatment of Depressor nguli Oris Weakening ESTHETIC S URGERY J OURNL ~ September/october on 19 ugust 2018

4 Figure 5. ging Stage 3 of Face Recurve., Preoperative view of a 65-year-old woman., Postoperative view 2 years after undergoing a face lift that included the DO section and fat transfer from the jowl to the marionette fold. Figure 6. natomy linked to botulinum toxin administration., natomic view delineating the areas of the DO and LP muscles., Downward vertical traction of the DO associated with the highly visible mentalis elevation. C, ackward and downward oblique traction of the LP associated with highly visible traction of the DLI. C 606 esthetic Surgery Journal ~ September/October 2006 Volume 26, Number 5 on 19 ugust 2018

5 Figure 7. xial magnetic resonance imaging studies at half-mandible level demonstrate the changes affecting the fat under the DO in a young person compared with an aged person., In a 21-year-old patient, the DO muscle is delineated in a darker shade of grey on the right, and the thickness of the deep fat is marked by the orange line (positioned between the muscle and the mandibular bone)., In a 54-year-old patient, the deep fat is not as thick. The orange line is shorter and the thickness of fat in the jowl has increased both in absolute terms (thickness) and relative terms (compared with the fatty thickness of the chin). Figure 8., Preoperative view of a 53-year-old woman demonstrates contraction of the DO., Postoperative view following injection of botulinum toxin. When the patient turns her mouth down, she can no longer contract the DO but compensates for this by contracting her LP. Experience has shown that frequently the blocking of the DO is compensated for by the contraction of the LP (Figure 8). otulinum toxin must be injected as close as possible to the motor endplate of the muscle, since an injection performed at a distance of 5 mm is 50% less effective than an injection performed into the motor endplate itself. 2 The motor innervation of the DO muscle comes from the marginalis mandibulae ramus, and in the LP, from the cervical branch of the facial nerve. The DO has one motor endplate 3 located at mid-muscle height in the marionette fold (Figures 2, and 6, ). The LP motor endplates stage along its muscular cord (Figure 6, C). The DO muscle starts on the linea obliqua mandibulae and ends in the skin of the upper lip commissure. The LP starts on the skin at the clavicle level and ends in the modiulus (Figure 6, ). Of utmost concern is avoiding injury to the marginalis mandibulae ramus, which is also responsible for the innervation of the DLI (Figure 9). The projected course of this nerve branch is along the lower half of the DO. 4,5 section performed parallel to the Treatment of Depressor nguli Oris Weakening ESTHETIC S URGERY J OURNL ~ September/october on 19 ugust 2018

6 Insertion, at the commissure, into the skin of the upper lip Marginal mandibular N. Insertion of lateral platysma M. Origin of depressor anguli oris M. (D..O.) Depressor labii inferioris M. (D.L.I.) Figure 9. The marginalis mandibulae ramus passes behind the platysma and the DO, but above the DLI. free rim of the lower lip, lying in the upper quarter of the muscle close to the lower rim of the orbicularis oris, cannot injure this branch (Figure 10). s demonstrated by the 4-stage breakdown of Face Recurve, the concept of the weakening of the DO and the transfer of volume can be applied to a wide range of patients, from those who exhibit the very first signs of aging to those with significant aging. It is always worthwhile to offer patients a trial of botulinum toxin before performing a muscular section, since this gives them time to experience the results and make a more informed decision. otulinum Toxin Injections Injection must be superficial in the subcutaneous fatty tissue at mid-muscle height. This makes it possible to avoid any effect on the buccinator muscle, which lies against the mucosa, and on the DLI with motor endplates lying deep down along the mandibular rim. Using a concentrated solution of botulinum toxin further minimizes this risk. 6.7 Dilute a 50-unit bottle of otox (llergan, Irvine, C) with 0.5 ml of saline. Then use a syringe of 0.5 ml graduated into 50 units. Consequently, one syringe unit (1/100 ml) corresponds to one otox unit. For the DO, to block the maximum contraction force, inject 3 to 4 units of otox into the motor endplate. One unit of otox is necessary to reduce the tone at rest without reducing the maximum contraction force. For the LP, tier the injections along the muscular band (Figure 6, C). Two units of otox are used per injection point, with a total of 4 to 8 units. Surgical Procedure The markings (with the patient in a vertical position) are the marionette fold and a horizontal line drawn on the upper quarter of the marionette fold parallel to the lower lip (Figure 11, ). transcuta- Figure 10. The location of the mucus section on the upper quarter of the muscle avoids the area of the marginalis mandibulae ramus (red transparent). 608 esthetic Surgery Journal ~ September/October 2006 Volume 26, Number 5 on 19 ugust 2018

7 Mucosal incision Marionette fold Mark in the upper quarter of fold Transcutaneous needle Vertical fibers of the D..O. uccinator fibers Posterior border of D..O. Facial vessels Retracted edge of D..O. Subcutaneous fat C D Figure 11. Surgical technique., Needle to determine the mucosal incision level., The mucosal incision is parallel to the lower lip rim. C, Retraction of the horizontal fibers of the DO. D, The 2 edges of the DO have to be widely separated. Figure 11 (continued) neous needle perpendicular to the skin marks the location of the horizontal mucosal incision (Figure 11, ). retractor is helpful in visualizing the horizontal fibers of the buccinator muscle. Retract these fibers, using a vertical movement of the tip of the scissors until the deeper lying vertical fibers of the DO appear (Figure 11, C). t this point it is important to mark the posterior border of the DO. The fat and the facial vessels behind the DO are clearly visible. The anterior border is sometimes more difficult to determine since it can be close to the posterior border of the DLI. However, the anterior border of the DO Treatment of Depressor nguli Oris Weakening ESTHETIC S URGERY J OURNL ~ September/october on 19 ugust 2018

8 Figure 11. E, Transfer of the fat harvested from the jowl to the area around the marionette fold. is near the skin, whereas the posterior border of the DLI is deeper. Perform the section under direct vision (Figure 11, D) until the subcutaneous fat appears. To block muscle regeneration, otox is injected in the two sectioned parts of the DO. pproximate the mucosa with a few sutures of Vicryl 4-0 Rapide (Ethicon Inc., Somerville, NJ). Perform lipoplasty of the jowl via a 1-mm incision in the buccal commissure, using a 1- to 2-mm cannula and a 10-mL syringe. Reinject the fat that is removed vertically in the marionette fold and along the underlying hollow of the mandibular rim (Figure 11, E). Discussion We usually treat cutaneous aging with a face lift, skin resurfacing, or local cutaneous excision. However, we no longer use a cervicofacial lift to improve the marionette fold with preauricular cutaneous tension. The improvement of the jowl and marionette fold is local and the face lift serves only to remove the cutaneous excess, requiring only normal skin tension. When performing a face lift (ging Stage 3), we often observe a descent of the submaxillary gland that, if not treated, causes a bulge that is as bothersome to the patient as the jowl. However, one of the underlying principles of Face Recurve is that there is a reduction in the hammock effect of the LP to support the submaxillary gland due to an increase in its tone at rest between its origin and insertions. Thus, to reposition the ptotic submaxillary gland, instead of performing a glandular resection, it is necessary to carry out a horizontal plication of the fibers of the LP (Figure 12). Since neither the DO nor the LP is involved in the smile mechanism, it is in no way affected. No other functional problems have been reported. Many doctors claim to have sectioned the DO and witnessed a significant recovery of function. limited section that does not include the immediate anterior border of the DO (its most powerful segment) leads to continued activity once the posttraumatic paresis effect disappears. Using the Face Recurve concept, the weakening of the DO and fat transfer, with or without the weakening of 610 esthetic Surgery Journal ~ September/October 2006 Volume 26, Number 5 on 19 ugust 2018

9 Figure 12., Lack of support of the lateral platysma inducing submaxillary gland ptosis, which is demonstrated by a visible bulging., Horizontal plication sutures restore the concave young cervicomandibular angle. the LP, makes it possible to slow down the structural and cutaneous aging of the oval of the face in a young person and to stabilize structural aging in an older person. References 1. Le Louarn C, uthiau D, uis J. Facial rejuvenation and concentric malar lift: the FCE RECURVE concept. nn Chir Plast Esthet 2006;51: Shaari CM, Sanders I. Quantifying how location and dose of botulinum toxin injections affect muscle paralysis. Muscle Nerve 1993;16: Lapatki G, Oostenveld R, Van Dijk JP, Jonas IE, Zwarts MJ, Stegeman DF. Topographical characteristics of motor units of the lower facial musculature revealed by means of high-density surface EMG. J Neurophysiol 2006:95: Rodel R, Lang J. Peripheral branches of the facial nerve in the cheek and chin area. natomy and clinical consequences. Hals Nasen Ohren 1996;44(10): German. 5. Savary V, Robert R, Rogez JM, rmstrong O, Leborgne J. The mandibular marginal ramus of the facial nerve: an anatomic and clinical study. Surg Radiol nat 1997;19: Le Louarn C. otulinum toxin and facial lines: the variable concentration. esth Plast Surg 2001;25: Shaari CM, George E, Wu L, iller HF, Sanders I. Quantifying the spread of botulinum toxin through muscle fascia. Laryngoscope 1991;101: Reprint requests: Claude Le Louarn, MD, 59 Rue Spontin, Paris France. Copyright 2006 by The merican Society for esthetic Plastic Surgery, Inc X/$32.00 doi: /j.asj Treatment of Depressor nguli Oris Weakening ESTHETIC S URGERY J OURNL ~ September/october on 19 ugust 2018