Keywords

6.1 The Role of Sonography in Cosmetic and Plastic Surgery

Several anatomical structures of the face may be critical for performing cosmetic or plastic surgery procedures. For example, the injection of Botulinum toxin type A in the wrong place may produce an unwanted effect such as an eyelid ptosis. Another example of an adverse reaction may follow the unintended intravascular injection of fillers in the glabellar or nasofold regions, which can cause skin necrosis and blindness [1]. Fortunately, in spite of the large and rising numbers of cosmetic procedures that are performed worldwide, reports of very severe adverse reactions seem to be infrequent; most adverse reactions are transitory and manageable. However, knowledge of the precise anatomical characteristics and location of these structures may support the prevention and/or early detection of these troublesome and sometimes devastating side effects [2, 3].

Sonography can show the location and thickness of muscles, arteries, veins, and glands, including the presence of anatomical variants. It provides non-invasive imaging of the eyelids, nose, and lips and can detect the presence and location of exogenous material such as fillers [4].

6.2 Main Anatomical Layers of the Face

The face is composed of several layers such as: [1,2,3]:

  1. 1.

    Skin : Epidermis, dermis, and hypodermis (also called subcutaneous tissue ), including superficial fat pads

  2. 2.

    Superficial muscular-aponeurotic system (SMAS) , defined as a network of connective tissue with fibrous and elastic components, which is located between the skin and the muscles

  3. 3.

    Muscles

  4. 4.

    Bones

Between these layers, there are deep fat pads, arteries, veins, nerves, glands, and cartilages. Figures 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, and 6.10 illustrate and describe the relevant facial anatomical structures. Moreover, the aging process produces changes in the anatomical layers of the face that are evidenced by common lines and wrinkles (Fig. 6.11).

Fig. 6.1
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Superficial fat pads of the face (front view).

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Fig. 6.2
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Muscles of the face (front view).

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Fig. 6.3
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Deep fat pads of the face (front view). ROOF—retro-orbicularis oculi fat ; SOOF—suborbicularis oculi fat.

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Fig. 6.4
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Vessels of the face (front view).

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Fig. 6.5
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Vessels of the face and scalp (lateral view).

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Fig. 6.6
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Classic path of the facial artery and its angular and labial branches (top), and some anatomical variants (I–III).

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Fig. 6.7
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Orbital fat pads and related structures.

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Fig. 6.8
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Upper eyelid (lateral view).

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Fig. 6.9
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Lower eyelid (lateral view). SOOF—suborbicularis oculi fat.

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Fig. 6.10
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Vessels of the orbit. The lateral aspect is located on the left and medial aspect on the right of the drawing.

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Fig. 6.11
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Frequent facial wrinkles and lines.

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6.2.1 Muscles of the Face

Most cosmetic procedures deal with the so-called facial expression muscles [5,6,7,8]. These include several muscles around the main cavities of the face, such as the orbit and the mouth. Interestingly, some of these muscles, such as the zygomaticus or risorius muscles, are very thin and may show prominent fibrous parts. Other muscles, such as the orbicularis oculi, present loose insertions into the fibrofatty hypodermal tissue, or they can end in a common muscular site such as the modiolus region of intersection of the peribuccal muscles. These muscles support the expression of emotions by playing agonist-antagonist roles and are mostly innervated by branch es of the facial nerve. Cosmetic procedures such as botulinum toxin injections are intended to decrease the strength of the muscles that generate unwanted lines or wrinkles by a powerful contraction.

An illustration of the muscles of the face is shown in Fig. 6.2. Table 6.1 summarizes the origin, insertion, and action of facial muscles, and the wrinkles derived from their actions [9,10,11,12,13,14,15,16,17,18].

Table 6.1 Muscles of the face
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6.2.2 Main Vessels of the Face

The location of some vessels produces danger regions in cosmetic and plastic surgery procedures. Among the most relevant are the facial artery and its branches, such as the angular and labial arteries. Illustrations of the distribution of the main vessels of the face and some anatomical variants of the facial and labial arteries [19,20,21,22] are shown in Figs. 6.4, 6.5, and 6.6.

6.2.3 Anatomy of the Eyelids and Periorbital Region

Several cosmetic and plastic surgery procedures are performed around the eyelids and periorbital regions [23, 24], so knowledge of the regional anatomy is of paramount importance. Figs. 6.7, 6.8, 6.9, and 6.10 illustrate the anatomy of these areas.

6.3 Sonographic Evaluation of Facial Structures

The ultrasound evaluation of facial structures can be relevant for the assessment of the regional anatomy, ruling out variants or a dystrophic presence of the components of the layers of the face. Additionally, the effects of facial nerve paralysis have been studied on ultrasound [25,26,27,28,29,30]. Sonography has proved useful in the evaluation of the masseter muscle in bruxism and its effects on the shape of the lower face [31]. These sonographic data may support more precise planning of the cosmetic or surgical procedures in this region.

Figures 6.12, 6.13, 6.14, 6.15, 6.16, 6.17, 6.18, 6.19, 6.20, 6.21, 6.22, 6.23, 6.24, 6.25, 6.26, 6.27, 6.28, 6.29, and 6.30 show a correlation of clinical and sonographic images. They include the recommended positions of the probe for faster tracking of the structures. Once a structure is detected in the suggested axis, the probe is rotated in order to study the perpendicular axis of the same structure.

Fig. 6.12
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Frontalis muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (transverse axis) demonstrates the hypoechoic structure of the frontalis muscle (asterisks). Notice the thin musculo-aponeurotic layer at the frontal region.

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Fig. 6.13
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Corrugator muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (oblique axis) demonstrates the deep location of the corrugator muscle (asterisks).

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Fig. 6.14
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Orbicularis muscle upper part (orbital and palpebral). (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal axis) shows the thin hypoechoic band of the upper palpebral part of the orbicularis muscle (om). (c) Ultrasound panoramic longitudinal view demonstrates the upper orbicularis muscle orbital part (omo) and palpebral part (omue), as well as the lower palpebral part of the orbicularis muscle (omle). fm frontalis muscle, t tarsal plate.

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Fig. 6.15
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Orbicularis muscle lower part (orbital and palpebral). (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal axis) demonstrates the hypoechoic thin band of the palpebral and orbital part of the orbicularis muscle (om). Notice the distal insertion of the orbicularis muscle in the superficial fibrofatty hypodermal tissue and the eyelashes (arrow). B bony margin, ofp orbital fat pad.

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Fig. 6.16
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Procerus muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal axis) shows the hypoechoic thin structure of the procerus (p) muscle attached to the bony margin (b) of the nasal bones.

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Fig. 6.17
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Zygomaticus major muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal oblique axis at the proximal part) and (c) Ultrasound (longitudinal oblique panoramic view) present the hypoechoic thin structure of the zygomaticus muscle (zm) at the proximal part and the thin, hyperechoic band at the distal part close to the distal insertion at the modiolus (m).

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Fig. 6.18
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Levator labii superioris and levator labii superioris alaeque nasi muscles . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal axis) demonstrates the hypoechoic band of the levator labii superioris. Notice that the levator labii superioris muscle is thicker at the distal part (arrow) and the close and superficial location of the levator labii superioris alaeque nasi muscle.

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Fig. 6.19
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Risorius muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal axis) demonstrates the hypoechoic band of the risorius muscle close to the modiolus.

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Fig. 6.20
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Upper and lower parts of the orbicularis oris muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal axis) shows the hypoechoic bands of the upper and lower parts of the orbicularis muscle at the lips.

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Fig. 6.21
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Depressor anguli oris muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal panoramic view) shows the hypoechoic structure of the depressor anguli oris muscle. Notice that the muscle (asterisks) is wider in the upper part (left part of the image) close to the modiolus region. (c) Ultrasound (longitudinal closer view) demonstrates the presence of minor salival glands (gl) beneath the muscle, which should not be confused with the location of the depressor. (d) Ultrasound (transverse view) shows the wide oval shape of the depressor anguli oris muscle (asterisk) at the proximal region close to the modiolus region. gl minor salival gland, m mandible, t tooth.

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Fig. 6.22
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Depressor labii inferioris muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal oblique view) demonstrates the mostly hyperechoic band of the depressor labii inferioris muscle (depr lab) underneath and medial to the depressor anguli oris muscle (depr angl or). Note that the location of the depressor anguli oris and depressor labii inferioris muscle forms a letter V.

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Fig. 6.23
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Mentalis muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (longitudinal oblique view) shows the hypoechoic band of the left band of the mentalis muscle (m) attached to the anterior aspect of the mandible.

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Fig. 6.24
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Masseter muscle . (a) Clinical image shows the location of the probe. (b) Ultrasound (transverse axis) shows the hypoechoic structure of the masseter muscle, which also contains hyperechoic septa between the muscle fibers.

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Fig. 6.25
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Buccal fat pad . (a) Clinical image shows the location of the probe. (b) Ultrasound (transverse oblique axis) demonstrates the hypoechoic structure of the buccal fat pad attached to the anterior aspect of the masseter muscle. Notice the facial artery (fa) running anteriorly to the buccal fat pad.

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Fig. 6.26
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Facial surface anatomy of the nasal and nasolabial regions . (a) Clinical image shows the names of the superficial structures and the level of the location of the probe for detecting the upper and alar nasal cartilages (horizontal lines). (b) Ultrasound (transverse view) demonstrates the hypoechoic and homogenous structure of both upper nasal cartilages (c). (c) Ultrasound (transverse view) shows the hypoechoic structure of the alar nasal cartilages.

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Fig. 6.27
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Nasalis muscle . (a) Clinical image shows the location of the probe for detecting the nasalis muscle. (b) Ultrasound (transverse view) demonstrates the hypoechoic structure of the left nasalis muscle.

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Fig. 6.28
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Facial artery . (a) Clinical image shows the location of the probe for tracking the facial artery. It is recommended to start in transverse axis and then turn to the longitudinal axis. (b, c) Color Doppler ultrasound of the facial artery. (b) Transverse view. Notice the location of the artery (red color) passing anterior to the buccal fat pad. (c) Longitudinal view. The facial artery (in colors) may present a tortuous path; therefore, observation of the artery can require angulation of the probe to follow the axis of the artery.

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Fig. 6.29
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Superior labial and angular arteries . (a) Clinical image shows the recommended positions of the probe for tracking the labial and angular arteries. (b, c) Color Doppler ultrasound. (b), Superior labial artery (transverse view) at the left border of the upper lip. Notice the location of the labial artery (color) running close to the surface of the teeth (t). (c) Angular artery (longitudinal view) at the paranasal region.

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Fig. 6.30
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Superficial temporal vessels . (a) Clinical image shows the recommended positions of the probe for tracking the temporal vessels. (b) Color Doppler ultrasound (transverse view) demonstrates the location of the vein (tv) and artery (ta) at the preauricular region. Notice that three branches of the auriculotemporal nerve (tan) can be seen as oval-shaped, hypoechoic structures (arrows) in cross-sectional view, running on top of the superficial temporal vessels.

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