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Orbicularis Oris

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121. Facial Nerve Paralysis, Static Reconstruction

be aesthetically and functionally problematic. Static suspension of the commissure can reestablish symmetry and enhance oral competence. The sling involves suspension of autologous or alloplastic materials from the orbicularis oris muscle to either the zygomatic arch or the orbital rim. [ ] Sundry surgical approaches and incisions are used in facial suspension. A standard rhytidectomy incision and dissection provide excellent exposure to the entire hemiface. Moreover, exposure of the oral commissure can (...) for normal orbicularis oris and lip from the contralateral unaffected side. The lip resection should be achieved with a full-thickness V or W wedge. As much as one third of both the upper and lower lip can be excised and closed primarily. The goal of this rotation and transfer of normal tissue is to reestablish a dynamic sphincter. Cheiloplasty can improve speech, eating, commissure competence, and appearance. Illustrative case The case illustrated below depicts a patient with facial nerve paralysis

2014 eMedicine Surgery

122. Facial Nerve Anatomy

Elevates corners of mouth Buccal Zygomaticus minor Elevates upper lip Levator labii superioris Elevates upper lip and midportion nasolabial fold Levator labii superioris alaeque nasi Elevates medial nasolabial fold and nasal ala Risorius Aids smile with lateral pull Buccinator Pulls corner of mouth backward and compresses cheek Levator anguli oris Pulls angles of mouth upward and toward midline Orbicularis Closes and compresses lips Nasalis, dilator naris Flares nostrils Nasalis, compressor naris (...) nasolabial fold and nasal ala Risorius Aids smile with lateral pull Buccinator Pulls corner of mouth backward and compresses cheek Levator anguli oris Pulls angles of mouth upward and toward midline Orbicularis Closes and compresses lips Nasalis, dilator naris Flares nostrils Nasalis, compressor naris Compresses nostrils Buccal and marginal mandibular Depressor anguli oris Pulls corner of mouth downward Depressor labii inferioris Pulls lower lip downward Marginal mandibular Mentalis Pulls skin of chin

2014 eMedicine Surgery

123. Facelift, Subperiosteal

penetrate the fibers of the orbicularis oculi muscle. The frontalis muscle has multiple dermal attachments in the forehead area. The procerus muscle takes origin from the junction of the nasal bones and the upper lateral cartilages and inserts into the forehead skin. This muscle is directly beneath the skin and may cause a transverse crease at the junction of the nose and the forehead. The corrugator supercilii muscle arises from the medial end of the orbit. It runs laterally and superiorly (...) , interdigitating with the fibers of the orbicularis muscle. It has multiple insertions into the skin of the supraorbital region. This muscle causes vertical glabellar lines. The muscle lies deep to the frontalis muscle. The zygomaticus major muscle originates from the lateral part of the zygomatic body and inserts into the modiolus. The zygomaticus minor originates just medial to this. The zygomatic branch of the facial nerve runs superficial to the zygomaticus minor and deep to the zygomaticus major muscle

2014 eMedicine Surgery

124. Facial Alloplastic Implants, Chin

to the labiomental fold, the groove that separates the lower lip from the chin. Several muscles cover the bony mandibular symphysis or chin. These include the mentalis, quadratus labii inferioris, triangularis, orbicularis oris, and some platysma fibers. Branches of the facial nerve innervate these muscles. The geniohyoid, genioglossus, and anterior bellies of the digastric muscle attach along the posterior and inferior surfaces of the mandibular symphysis (chin). The sensory innervation of the chin area is from

2014 eMedicine Surgery

125. Facial Nerve Paralysis

Pyramidalis The zygomatic division innervates the following muscles: Zygomaticus major [ ] Zygomaticus minor Elevator ala nasi Levator labii superioris Caninus Depressor septi Compressor nasi Dilatator naris muscles The buccal division gives off fibers to innervate the buccinator and superior part of the orbicularis oris muscle. Mandibular division innervations are found in the following muscles: Risorius Quadratus labii inferioris Triangularis Mentalis Lower parts of the orbicularis oris The cervical (...) , with occasional use of tests for salivation, tearing, and taste; these are the first steps in determining the site of injury. Physical examination findings reveal affected facial musculature movement. Tests for facial innervation include the following: Forehead wrinkling (frontalis muscle) Eye closure (orbicularis oculi muscle) Wide smile Whistling Blowing (eg, buccinator muscle, orbicularis oris muscle, zygomatic muscle) During the patient's initial consultation, evaluate general muscle status (latissimus

2014 eMedicine Surgery

126. Facelift, Platysmaplasty

to posterior, the muscle is anchored to the mentum and the inferior mandibular border and meets the orbicularis oris laterally and then the depressor anguli oris. Platysmal meshing with the depressor anguli oris contributes to the superficial muscular aponeurotic system (SMAS), highlighting its importance when attempting to reverse facial aging. Ventral rami of cervical nerves II-IV provide the tactile sense of the anterior neck. Tracking along the posterior surface of the sternocleidomastoid muscle

2014 eMedicine Surgery

127. Face Embryology

) Muscles - Muscles of mastication (ie, temporalis, masseter, pterygoids), mylohyoid, anterior belly of digastric, tensor tympani, and tensor veli palatini Skeleton - Maxillary cartilage (incus, alisphenoid), mandibular or Meckel cartilage (malleus), and arch dermal mesenchyme (maxilla, zygomatic, squamous portion of temporal bone, mandible) Pharyngeal arch II (hyoid) Facial nerve - Cranial nerve VII Artery - Stapedial Muscles - Muscles of facial expression (ie, orbicularis oculi, orbicularis oris

2014 eMedicine Surgery

128. Facelift, Composite

and, in contrast to muscles of the lower face, have direct bony insertions. Thus, the zygomaticus minor muscle arises from the region of the zygomaticomaxillary suture and passes downward and medial into the orbicularis oris muscle. The zygomaticus major arises further lateral on the zygomatic bone and runs to the angle of the mouth, blending with the orbicularis oris in the region of the modiolus. Freilinger et al described 4 layers of the facial musculature. [ ] The superficial layer is composed (...) of the depressor anguli oris, zygomaticus minor, and orbicularis oculi. The depressor labii inferioris, risorius, platysma, zygomaticus major, and levator labii superioris alaeque nasi constitute the second layer. The third layer is composed of the orbicularis oris and levator labii superioris. The mentalis, levator anguli oris, and buccinator constitute the fourth or deep layer. The first 3 layers are superficial to the plane of the facial nerve and therefore receive motor innervation from their deep surfaces

2014 eMedicine Surgery

129. Facelift, Extended SMAS

the surface of the orbicularis oculi, the superficial temporal fascia, the frontalis muscle, and the superficial cervical fascia. When the SMAP is part of the surgical strategy, the pattern of the skin excision is particularly important to the effectiveness of a facelift. Once the facial integument has been released from its retaining ligaments [ ] and fusion planes, the force generated in the approximation of the edges of the excisional defect is an important determinant of the new facial contours (...) to the corner of the mouth that is excluded from dissection. It is a mobile 4 X 4-cm full-thickness section of the cheek. The inferior border of this patch is just above the mandibular ligament; the medial border is at the anguli oris. The modiolar peninsula is in a highly mobile area of the masticatory part of the face; dissection is unnecessary. The intact peninsula is more efficient in transmitting forces to the lower face and it captures extra blood supply from the facial and labial vessels

2014 eMedicine Surgery

130. Flaps, Muscle and Musculocutaneous Flaps

in Plastic Surgery. III. Two dominant pedicles (eg, gluteus maximus; see the image below) Type III, vascular patterns of the muscle and musculocutaneous flaps. Two vascular pedicles, each arising from a separate regional artery (except orbicularis oris). Gluteus maximus, rectus abdominis, serratus anterior, semimembranosus, orbicularis oris. Image courtesy of Selected Reading in Plastic Surgery. IV. Segmental vascular pedicles (eg, sartorius; see the image below) Type IV, vascular patterns of the muscle (...) . Image courtesy of Selected Reading in Plastic Surgery. Type III, vascular patterns of the muscle and musculocutaneous flaps. Two vascular pedicles, each arising from a separate regional artery (except orbicularis oris). Gluteus maximus, rectus abdominis, serratus anterior, semimembranosus, orbicularis oris. Image courtesy of Selected Reading in Plastic Surgery. Type IV, vascular patterns of the muscle and musculocutaneous flaps. Multiple pedicles of similar size. Flexor digitorum longus, extensor

2014 eMedicine Surgery

131. Facial Nerve Paralysis, Dynamic Reconstruction

as to expressions of sadness, anger, and sorrow. The lower lip is animated by interactions of the orbicularis oris, depressor labii inferioris, depressor anguli oris, mentalis, and platysma. Terzis described a technique to improve this type of smile by transfer either of the anterior belly of the digastric tenor or of the platysma. [ ] Other authors argue that this symmetrical smile could be achieved with less invasive approaches, including or myectomy of the depressor labii inferioris. Regional muscle (...) , spontaneous facial movements Oral competence and eyelid closure with corneal protection Absence or limitation of synkinesis and mass movement Limitations of surgery The facial nerve innervates a total of 23 paired muscles and the orbicular oris, but only 18 of these muscles, working in a delicate balance, produce facial animation and expression. No current reconstructive stratagem can reproduce every facial expression and movement. The patient and the surgeon should thoroughly discuss the patient's

2014 eMedicine Surgery

132. Bell Palsy

. The facial nerve passes through the stylomastoid foramen in the skull and terminates into the zygomatic, buccal, mandibular, and cervical branches. These nerves serve the muscles of facial expression, which include the frontalis, orbicularis oculi, orbicularis oris, buccinator, and platysma muscles. Other muscles innervated by the facial nerve include the stapedius, stylohyoid, posterior belly of the digastric, occipitalis, and anterior and posterior auricular muscles. All muscles innervated

2014 eMedicine Surgery

133. BOTOX&reg

on the galea aponeurotica near the coronal suture and inserts on the superciliary ridge of the frontal bone and skin of the brow, interdigitating with fibers of the brow depressors (ie, procerus, corrugator supercilii, orbicularis oculi muscle). See the image below. Anatomy of frontalis, corrugator supercilii, procerus muscles, and other facial muscles. The medial fibers usually are more fibrous than the lateral fibers, thus requiring less toxin for paralysis. Avoid total paralysis of the frontalis, since (...) frown lines in a woman with a more horizontal-type brow. Anatomy Facial rhytides and folds in this area result from action of the depressor muscles (ie, corrugator supercilii, depressor supercilii, orbicularis oculi, procerus). See the image below. Anatomy of frontalis, corrugator supercilii, procerus muscles, and other facial muscles. The corrugator superciliaris, medial orbital portion of the orbicularis oculi, and more vertically oriented fibers of the depressor supercilii produce the vertical

2014 eMedicine Surgery

134. Monitors, Facial Nerve

constant at this level. The threshold setting may be altered if prognostic information about facial nerve recovery is sought at the end of the procedure. Previous Next: Electrode Placement Paired electrodes are placed in 2 facial muscle groups. (Two separate muscles are usually monitored, principally to assure redundancy.) The orbicularis oris and the orbicularis oculi are usually selected. They are relatively large facial muscles and are easily identified. The portion of the electrode not within (...) the facial nerve in the absence of the nerve's visual identification is unreliable and fraught with hazard. Ashram et al pointed out that stimulation of the nervus intermedius can result in a long-latency, low-altitude response recorded only in the orbicularis oris channel. [ ] The nervus intermedius lies in an entirely different position from the main trunk of the facial nerve. The operating surgeon must be aware of this potential pitfall in intraoperative facial nerve monitoring and should be aware

2014 eMedicine Surgery

135. Congenital Malformations, Mouth and Pharynx

detachment of musculature from atypical locations and realignment in a more anatomically functional position. [ ] Cleft lip The orbicularis oris muscle is the primary muscle of the lip and can be divided functionally and anatomically into 2 parts (see the image below). [ ] The deep component, in concert with other oropharyngeal muscles, works in swallowing and serves as a sphincter. The superficial component is a muscle of facial expression and inserts into the anterior nasal spine, sill, alar base (...) , and skin to form the philtral ridges. Muscular defects in unilateral deformity. In a complete cleft lip (CL), the deep fibers of the orbicularis oris muscle are interrupted by the cleft and end on either side of the defect instead of making their way around the mouth. In addition, the superficial component of the orbicularis oris turns upward, along the margins of the cleft and ends beneath the ala or columella. [ ] Incomplete cleft lip behaves in a similar manner, except when the cleft is less than

2014 eMedicine Surgery

136. Cleft Lip

is characteristically deformed, and the medial crus is displaced posteriorly. The dome is separated from that of the noncleft side, and the lateral crus is flattened and stretched across the cleft. The axis of the nostril on the cleft side is characteristically oriented in the horizontal plane. This position is in contrast to the normal vertical axis of the nostril on the opposite side. The muscular fibers of the orbicularis oris do not decussate transversely as in the normal lip; rather, they course obliquely

2014 eMedicine Surgery

137. Chin Implants

. Projection of the chin is dependent on the mental protuberance and tubercles. The chin is separate from the lip at the labiomental angle. However, the chin and lip have an intimate relationship. The depressor muscles insert on the mental tubercles and interdigitate with the orbicularis oris muscle. Any intervention on the chin can affect the lips. Previous Next: Contraindications Severe microgenia is a contraindication to augmentation mentoplasty. Other contraindications include labial incompetence, lip

2014 eMedicine Surgery

138. Cheek Reconstruction

gland, where it branches at the pes anserinus into upper (zygomaticofacial) and lower (cervicofacial) divisions. The upper division forms the temporal and zygomatic branches, which primarily supply the frontalis and orbicularis oculi, zygomaticus major and minor, and levator labii superioris muscles. The lower division forms the buccal, marginal mandibular, and cervical branches, which primarily supply the buccinator, orbicularis oris, and platysma muscles. A great deal of arborization is present (...) between the zygomatic and buccal branches. Indeed, variations in individual anatomy, exact patterns of branching, and patterns of innervation are common. The zygomaticus major, orbicularis oculi, and risorius muscles are of particular clinical relevance because they are innervated via the deep surface of their muscle bellies. See for moreinformation. The muscles of facial expression, which are anatomically associated with the cheek, include the zygomaticus major and minor, orbicularis oculi

2014 eMedicine Surgery

139. Static Suspension for Facial Paralysis

the zygomatic, buccal, and marginal branches lie in deeper layers. The muscles that comprise the 4 layers are as follows: First layer - Depressor anguli oris, superficial portion of zygomaticus minor, orbicularis oculi Second layer - Platysma, risorius, zygomaticus major, deep portion of zygomaticus minor, levator labii superioris alaeque nasi Third layer - Levator labii superioris, orbicularis oris Fourth layer - Levator anguli oris, mentalis, buccinator Anatomic classification of facial paralysis See

2014 eMedicine Surgery

140. Skin Flaps, Design

occurred with one out of 23 V-Y flaps (4%), compared with 2 out of 11 cervicofacial flaps (18%). [ ] Lip The upper and lower lips are the focal points of the lower part of the face. Goals of lip reconstruction include maintenance of oral competence, including both motor and sensory innervation and preservation of an adequate gingival-labial sulcus without distortion of surrounding structures. The first step in reconstruction is consideration of the complete sphincter formed by the orbicularis oris (...) of the donor site. Full-thickness defects involving more than 40% of either the upper or the lower lip generally require a 2-staged lip flap, namely, a Karapandzic, Abbe, or Estlander flap. All 3 flaps transfer functional orbicularis oris muscle. The Abbe and Estlander flaps are pedicled lip-switch flaps in which the pedicle must be divided, usually 3 weeks after interpolation. The Karapandzic flap is an advancement rotation flap with arterial and nervous supplies. The incisions are created to produce

2014 eMedicine Surgery

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