Depressor Septi Research Articles

Anatomy and surgical treatment of the depressor septi nasi muscle: a systematic review.

Although the majority of nasal alterations in rhinoplasty result from either augmentation or reduction of bone and cartilaginous substructure, modifications of influential soft-tissue provide significant contribution to the final result. The depressor septi nasi muscle is a soft-tissue structure well known to influence the final result in rhinoplasty. The objective of this study was to perform a standardized, comprehensive review of relevant data published with regard to the depressor septi nasi muscle. A comprehensive search of the terms "depressor septi muscle" and "depressor septi nasi muscle" was performed using the PubMed, MEDLINE, and Cochrane databases. Articles were reviewed for relevancy and included if criteria were met. A secondary review was performed of all articles cited, to maximize diligence. Forty-three articles were identified in the initial search. Thirteen of the 43 were found to meet inclusion criteria. Secondary search revealed additional studies meeting inclusion criteria. Altogether, there were 175 cadaver specimens and 821 surgically treated patients for which data were available. Anatomical reports and nomenclature were found to vary. Surgical approach and muscle treatment diverged, with objective data showing no superior method. Although variation exists in anatomical reports regarding the depressor septi nasi muscle, the prevailing thought is that it originates from the maxilla and/or orbicularis oris muscle. More importantly, the muscle inserts on the medial crura and adjacent soft tissue. Disruption of this relationship provides the basis for surgical treatment of tip descent on animation.

Muscle tension line concept in nasolabial muscle complex--based on 3-dimensional reconstruction of nasolabial muscle fibers.

Plastic surgeons have attempted various ways to rebuild the aesthetic subunits of the upper lip in patients with cleft lip with less than perfect results in most cases. We propose that repairing the 3 muscle tension line groups in the nasolabial complex will have improved aesthetic results. Micro-computed tomographic scans were performed on the nasolabial tissues of 5 normal aborted fetuses and used to construct a 3-dimensional model to study the nasolabial muscle complex structure. The micro-computed tomographic (CT) scans showed the close relationship and interaction between the muscle fibers of nasalis, pars peripheralis, levator labii superioris, and pars marginalis. Based on the 2-dimensional images obtained from the micro-computed tomographic scans, we suggest the concept of nasolabial muscle complex and muscle tension line group theory: there is a close relationship among the alar part of the nasalis, depressor septi muscle, orbicularis oris muscle, and levator labii superioris alaeque nasi. The tension line groups are 3 tension line structures in the nasolabial muscle complex that interlock with each other at the intersections and maintain the specific shape and aesthetics of the lip and nose.

Multifactorial approaches for correction of the drooping tip of a long nose in East asians.

A long nose with a drooping tip is a major aesthetic problem. It creates a negative and aged appearance and looks worse when smiling. In order to rectify this problem, the underlying anatomical causes should be understood and corrected simultaneously to optimize surgical outcomes. The causes of a drooping tip of a long nose are generally classified into two mechanisms. Static causes usually result from malposition and incorrect innate shape of the nasal structure: the nasal septum, upper and lower lateral cartilages, and the ligaments in between. The dynamic causes result from the facial expression muscles, the depressor septi nasi muscle, and the levator labii superioris alaeque nasi muscle. The depressor septi nasi depresses the nasal tip and the levator labii superioris alaeque nasi pulls the alar base upwards. Many surgical methods have been introduced, but partial approaches to correct such deformities generally do not satisfy East Asians, making the problem more challenging to surgeons. Typically, East Asians have thick nasal tip soft tissue and skin, and a depressed columella and alar bases. The authors suggest that multifactorial approaches to static and dynamic factors along with ancillary causes should be considered for correcting the drooping tip of the long noses of East Asians.

The Role of Depressor Septi Nasi Manipulation in Rhinoplasty

The Role of Depressor Septi Nasi Manipulation in Rhinoplasty

Depressor septi nasi modifications in rhinoplasty: a review of anatomy and surgical techniques.

The anatomy of the nasal muscles contributes a social harmony in aesthetic rhinoplasty because these muscles coordinate the nose and the upper lip while smiling. Sometimes this coordination can be interrupted by the hyperactivity or variations of these muscles and may result as a deformity because of their dynamic functions and relations with the nose. In our daily practice, we usually perform the rhinoplasty without considering the dynamic functions. When the patients recover the muscle functions after operation and start to use their mimics, such as smiling, the undamaged dynamic forces may start to rotate the tip of the nose inferiorly in a long-term period, correlated with their preoperative function. To avoid this unexpected rotation it is essential to remember preoperative examination of the smile patterns. To manage this functional part of rhinoplasty, we aimed to clarify the smiling patterns or deformities mainly focused on depressor septi nasi muscle in this article. This muscle creates downward movement of the nasal tip and shortens the upper lip during smiling. The overactivity of this muscle can aggravate the smiling deformity in some patients by a sharper nasolabial angle correlated with levator labii superioris alaeque nasi and orbicularis oris muscle activities. The article not only stresses the correction of this deformity, but also aims to guide their treatment alternatives for correlation of postoperative results and applicability in rhinoplasty.

Smile Analysis in Rhinoplasty

The depressor septi nasi muscle is responsible for smiling deformity. Its manipulation is beneficial in patients with muscle hypertrophy. In addition, it enhances the smile and tip-lip relationship. In this study, depressor septi nasi muscle excision through a transfixion incision is compared with its transposition through an upper labial sulcus incision. Two techniques of depressor septi nasi muscle treatment were performed randomly for rhinoplasty cases. Smile analysis in rhinoplasty, consisting of measurements of nasal length, nasal diagonal, tip projection, and upper lip height, and noting transverse upper labial crease in repose and full smile, was performed on preoperative and postoperative photographs. One hundred patients were studied in two equal groups. Preoperatively, tip projection and upper lip height were decreased significantly with smiling. Generally, the effect of smiling on all five parameters was decreased significantly following rhinoplasty. The two different techniques were not significantly different in decreasing the effects of smiling on nasal length, nasal diagonal, tip projection, upper lip height, or transverse crease. The two different techniques were the same in decreasing the effects of smiling. The authors recommend smile analysis in rhinoplasty, consisting of measurement of nasal length, nasal diagonal, tip projection, and upper lip height, and noting transverse upper labial crease in repose and during smiling, before rhinoplasty for preoperative evaluation and after the operation for outcome assessment. Depressor septi nasi muscle treatment should be considered if a decrease in tip projection or upper lip height with smiling or a transverse upper labial crease during smiling is extraordinary or unsightly. Therapeutic, II.

Modifying gummy smile: a minimally invasive approach.

Excessive gingival display is a problem that can be managed by variety of procedures. These procedures include non-surgical and surgical methods. The underlying cause of gummy smile can affect the type of procedure to be selected. Most patients prefer minimally invasive procedures with outstanding results. The authors describe a minimally invasive lip repositioning technique for management of gummy smile. Twelve patients (10 females, 2 males) with gingival display of 4 mm or more were operated under local anesthesia using a modified lip repositioning technique. Patients were followed up for 1, 3, 6 and 12 months and gingival display was measured at each follow up visit. The gingival mucosa was dissected and levator labii superioris and depressor septi muscles were freed and repositioned in a lower position. The levator labii superioris muscles were pulled in a lower position using circumdental sutures for 10 days. Both surgeon's and patient's satisfaction of surgical outcome was recorded at each follow-up visit. At early stage of follow-up the main complaints of patients were the feeling of tension in the upper lip and circum oral area, mild pain which was managed with analgesics. One month postoperatively, the gingival display in all patients was recorded to be between 2 and 4 mm with a mean of (2.6 mm). Patient satisfaction records after 1 month showed that 10 patients were satisfied with the results. Three months postoperatively, the gingival display in all patients was recorded and found to be between 2 and 5 mm with a mean of 3 mm. Patient satisfaction records showed that 8 patients were satisfied with the results as they gave scores between. Surgeon's satisfaction at three months follow up showed that the surgeons were satisfied in 8 patients. The same results were found in the 6 and 12 months follow-up periods without any changes. Complete relapse was recorded only in one case at the third postoperative month. This study showed that the proposed lip repositioning technique is an acceptable minimally invasive procedure in managing gummy smile. A non-invasive procedure to avoid other complicated surgical procedures.

Effect of the Depressor Septi Nasi Muscle on Nasal Lengthening Over Time

Effect of the Depressor Septi Nasi Muscle on Nasal Lengthening Over Time

Effect of Depressor Septi Nasi Muscle Activity on Nasal Lengthening With Time

The depressor septi nasi (DSN) muscle is an important muscle in nose dynamics. Its hyperactivity causes smile deformity including nasal tip depression. The nasal tip of individuals with a hyperactive DSN muscle depresses repeatedly while they are speaking and smiling. This may result in nasal lengthening as they age. Pairs of cases consisting of a child and one of his or her parents were studied in two groups: case group (with DSN muscle hyperactivity) and the control group (with DSN muscle inactivity in both child and parent). Nasal length from nasion to tip and facial length from nasion to menton were measured during repose and during smiling. This study investigated 80 pairs of children and parents. In both groups, a significant linear correlation between the nasal length of the parent and the child was found. In both groups (case and control), the nasal length of the child differed significantly from that of the parent. The increase in the nasal length of the parents compared with the children was greater in the control group. This study demonstrated that nasal length increases with age and that DSN muscle hyperactivity is not an effective factor in this increase. This unpredictable result may affect the presumption that patients with DSN muscle hyperactivity will have longer noses in the future. Long-term prospective studies investigating cohort groups are required to clarify the variables affecting nasal lengthening with aging, and interventional studies are needed to examine the effects of DSN muscle resection on this phenomenon.

Anatomy of the depressor septi nasi muscle: The basis for correction of deformities of the nose/lip junction

The purpose of this study was to analyse the macroscopic aspect of the depressor septi nasi muscle in cadavers according to its relations with the nasolabial region, and to describe a surgical technique developed out of the knowledge gained from its study to take care of nasal tip drooping and gummy smile. Twenty fresh adult cadavers were studied. All of them were men. A transverse incision was done at the gingivo-labial sulcus, through the frenulum, to expose the orbicularis oris and the depressor nasi muscles. These muscles were isolated and their anatomical aspect, localisation, origin, and insertion were registered. Sixteen of the cadavers presented the muscle. From these, 14 were bilateral and two were unilateral. Four cadavers did not present the muscle. Muscular fibres were vertically disposed and presented oblique direction towards the midline, in a quadrangular shape. From the 16 cadavers of the subgroup in whom the muscle was present, 14 originated in the orbicularis oris and its insertion was in the maxilla. Two of the cadavers presented the origin and insertion at the maxilla. According to these findings, a surgical approach of the muscles was proposed to treat the gummy smile deformity during rhinoplasty and two clinical cases are presented. The depressor nasi muscles presented an anatomical variation. In most cases it is intimately related with the orbicularis oris and the maxilla, being a relatively thick structure. We suggest its treatment simultaneously during rhinoplasty for a better result of the nasal tip and it benefits the “tense nose” aspect and the smiling deformity.

The Lower Nasal Base: An Anatomical Study

Currently, most rhinoplasty surgeons focus their analysis and operative techniques on the upper nasal base, with its alar cartilages. They tend to minimize the lower nasal base, composed of the columellar base, nostril sills, and alar lobules. The requisite operative techniques are often considered ancillary techniques. In this article, the authors describe anatomical composition of the columellar base, nostril sill, and alar lobule; discuss the presence of a distinct lower nasal base; and reevaluate the nasal musculature and the nasal superficial muscular aponeurotic system in an anatomical cadaver model. They also discuss the results of both a detailed literature review (for articles related to the levator labii superioris alaeque nasalis, orbicularis oris, depressor septi nasalis, myrtiformis, and dilator naris) and the results of their own dissection of 45 fresh cadavers.

The use of botulinum toxin in the treatment of plunging nose: cosmetic results and a functional serendipity.

Muscles of the nose are active in facial movements both with the other facial muscles. An active depressor septi muscle (DSN) can accentuate a drooping nasal tip and shorten the upper lip on animation, especially during smiling. Paralysis of the DSN allows the tip of the nose to be lifted up. Between January and June 2011 a double blinded, randomized study was performed on 40 patients for nasal defects as "plunging" tip. 20 patients underwent to Botulinum toxin injection (B), 20 patients were treated with placebo such as saline solution (S). Both aesthetic and functional results were evaluated using objective and subjective parameters at time 0, after 7, 15 and 30 days and values were compared using t Student test. S group results were not significant from an objective point of view. In botulinum group, patients showed an increase in columellar-lip distance. Satisfaction of the Group B patients was an average of 6.3 on VAS (range from 4 to 9). VAS mean values were studied with t-Student test and were found significant. Several authors recommend the incision of DSN muscle during rhinoplasty to correct the plunging tip. In patients with no needs for rhinoplasty this procedure is unnecessary and a quick and targeted injection of Botulinum toxin is the most convenient choice to improve aesthetic of the plunging tip.

Estudio anatómico y clínico del músculo depresor de la punta nasal

The relationship between the rhino-gingivolabial syndrome and the hypertrophy of the depressor septi nasi muscle was investigated. We identified and dissecte...

Intraoral Approach for Nasal Tip Upturning

The nose is an important landmark in facial beauty, and slight modifications lead to dramatic changes. The authors describe their surgical technique to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi. There were 14 patients (5 male and 9 female patients) in this study. All patients complained of nasal tip ptosis. The surgical procedure was explained to the patients, and the informed consent was obtained; preoperative frontal and lateral photographs were taken. The same surgical procedure was performed in all patients. No complications were observed. Tip upturning, with satisfaction of the patients, was observed in all cases and was confirmed comparing preoperative and 6-month postoperative photographs. From the outcomes of this short case series, the surgical technique described to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi and with the skeletization of the premaxilla is an easy, safe, and inexpensive technique that can be easily performed at the office.

Treatment of Hyperdynamic Nasal Tip Ptosis in Open Rhinoplasty: Using the Anatomic Relationship Between the Depressor Septi Nasi Muscle and the Dermocartilaginous Ligament

Smiling causes a deformity in some rhinoplasty patients that includes drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show. The depressor septi muscle leads this deformity. The dermocartilaginous ligament originates from the fascia of the upper third of the nose and extends down to the medial crus, merging into the depressor septi muscle. In this study, 100 primary rhinoplasty patients were studied for hyperdynamic nasal tip ptosis. Of these patients, 36 had hyperdynamic nasal tip ptosis due to hyperactive depressor septi nasi muscle. The dermocartilaginous ligament was used as a guide to reach the depressor septi muscle in open rhinoplasty. Muscle excision was performed just below the footplates of the medial crura. A strong columellar strut graft was placed between the medial crura to avoid narrowing of the columellar width resulting from tissue excision and to withstand activation of depressor septi muscle remnants. No complications such as infection or hematoma occurred in the early postoperative period. The technique corrected the hyperdynamic nasal tip ptosis, increased upper lip length, and decreased gingival show when patients smiled. There was no narrowing of the columellar width. No depression in the columellar-labial junction due to distal resection of the depressor septi muscle was observed. The dermocartilaginous ligament can be used as a reliable guide to reach the depressor septi muscle in open rhinoplasty. Therefore, the hyperactive depressor septi muscle can be definitively identified and treated without an intraoral approach. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Intranasal Approach for Manipulating the Depressor Septi Nasi

A hyperactivated depressor septi nasi is an important factor contributing to nasal tip drooping. Although many studies have examined this, its treatment remains controversial. This study presents a surgical intervention based on an anatomic study.Ten fresh cadavers with large noses were used for the anatomic study. Between April 2008 and September 2010, 20 patients underwent surgical intervention for hyperactivated depressor septi nasi.In all of the cadaver dissections, the depressor septi nasi was present, although it was difficult to identify the muscle clearly in 6 of the cadavers. We found that the depressor septi nasi in the other 4 cadavers consisted of 3 fascicles. The medial fascicles were divided into superficial and deep fibers. Both the deep and superficial fibers were inserted into the dermocartilaginous ligament in the nearby nasal tip. After the superficial fibers were interdigitated with the orbicularis oris, they originated from the alveolar bone. The deep fibers originated at the anterior nasal spine. The intermediate fascicles inserted to the footplates of the medial crus and caudal septum. After interdigitating with the medial fascicles and orbicularis oris, they also originated from the alveolar bone. The drooping nasal tips were improved in all cases using an intranasal approach to manipulate the depressor septi nasi. No specific complication was seen. Surgical intervention of a hyperactivated depressor septi nasi using an intranasal approach was a useful method for correcting a drooping nasal tip.

Anatomic Variations Found on Dissection of Depressor Septi Nasi Muscles in Cadavers

To define variations of the depressor septi muscle in Iranians; to provide guidance for modification of this muscle during rhinoplasty in patients with an active muscle and short upper lip; and to correlate our findings with our clinical experience to develop the applied algorithms. This study was conducted by dissecting 82 depressor septi nasi muscles in 41 Iranian cadavers. Origin and insertion points of each muscle were studied. Three variations were found in muscle insertion points: periosteal, orbicularis oris, and floating. Forty-four percent of the muscles were inserted into the periosteum of the maxilla (n = 36); 39% of muscles were inserted into the orbicularis oris muscle (n = 32); and 17% were diminutive or floating (n = 14). Periosteal insertion was thicker and stronger than the other variations. In all cadavers, the origin of the muscle was medial crus of alar cartilage and caudal of the nasal septum. This cadaveric dissection showed that the percentage of depressor septi muscle insertions is not similar to that found in other surveys. In this study, periosteal insertion of the depressor septi muscle was the most common variation.

Tratamento cirúrgico da columela retraída em narizes primários

Background: Retracted columella may be present in primary noses as well as in patients who have undergone aesthetic or functional rhinoplasty. This study aims to demonstrate the use of the labial portion of the depressor septi nasi (the depressive muscle of the nasal tip) and upper lip orbicularis muscle for retracted columella correction. Methods: The subjects included 20 patients between 20 and 35 years old (4 males and 16 females) who underwent primary aesthetic rhinoplasty. Results: Moderate edema was observed postoperatively in all patients and was resolved within 1 to 3 months. V-shaped scars at the base of the columella presented excellent aesthetic aspects. Conclusions: The surgical technique is easy and the learning curve is fast. Columella correction with the presented technique provides natural and predictable results.

The Effect of Depressor Septi Nasi Cutting on the Nasal Tip

Objective: The nasal tip is an important aesthetic feature of the face and its surgery is the most interesting and challenging part of a rhinoplasty. The aim of this study was to evaluate the effect of cutting the depressor septi nasi muscle on the nasal tip rotation and projection. Method: This clinical trial was carried out from 2008 to 2010 in Imam Reza hospital of Tabriz. Forty primary rhinoplasty patients who required nasal tip modifications underwent rhinoplasty including cutting of depressor septi nasi. The nasal tip rotation and projection and patient satisfaction were evaluated before and 6 months after the operation. Results: The mean age of patients was 24.10 ± 5.37 years with male to female ratio of 13/27. Following rhinoplasty including depressor septi nasi muscle cutting, nasal tip rotation and projection, and patient satisfaction were improved in 58%, 70%, and 85% of patients, respectively ( P < .001 for all). Conclusion: Rhinoplasty by cutting and repositioning of depressor septi nasi muscle has effectively improved the nasal tip rotation and projection and patient satisfaction.

Preventing Tip Modifications and Alar Retractions: The “Joy-Ride” Stitch

Sir: We congratulate Gruber et al. on their article1 that describes a new technique for correcting tip bulbosity without resecting the cephalic component of the lateral crus. In that technique, the cephalic part of the lateral crus is used as a lateral crural strut and effectively avoids alar retractions. Tip stabilization is an open issue in rhinoplasty, and several techniques have been described over time. At present, the most popular options are medial crural-septal sutures, interdomal-septal sutures, and columellar struts. These techniques are widely used to stabilize the medial crura and to contour tip projection. In primary or secondary rhinoplasty, columellar struts are also evaluated when the nasal tip is underprojected and/or the nasal tip skin is thick. Nevertheless, strut malposition, problems with graft visibility, and unnatural appearance have been described.2 Moreover, tip instability and retraction could occur, especially in tension noses or where the nasal lobule is subject to strain forces, both absolute (where strain forces are applied on the lobule by other nasal structures) and relative (produced by the interface of tip components with different rheologic properties). In fact, the excessive length of triangular cartilages could stress the cranial portion of lateral crura while the overburden size of septal cartilage acts on medial crura. These forces could be magnified by the excessive function of the depressor septi nasi. Tip stabilization and projection have been addressed by several authors who reported different solutions with graft struts, such as the columellar strut-tip graft3 and the dorsal columellar strut.4 Classically, tip stabilization and contouring are performed with a columella-septal suture that affects both tip projection and rotation. This suture could correct an existing hanging columella and provide a small amount of tip projection, whereas greater corrections require columellar struts5 with interdomal-septum or crural-septum sutures. Nevertheless, these sutures could alter the shape of the previously modeled nasal tip, especially where the columella is weak. We propose a different technique for fixing columellar struts to achieve durable tip projection and stabilization without interfering with tip contour. A pocket is dissected between the alar cartilages and the strut graft is placed anterior to the caudal septum (Fig. 1). The strut is sandwiched between the alar cartilages and fixed with a 5-0 Prolene suture. At this point, the graft is secured to the caudal septum with a so-called joy-ride stitch. The joy-ride stitch consists of a simple stitch performed between the columellar strut and the caudal septum (Fig. 2). Strut, alar cartilages, and septum are then fixed together without interdomal-septum or crural-septum sutures, which could alter tip contour in tightening the knot. The placement of the strut is symmetric and precise.Fig. 1.: The columellar strut graft is placed anterior to the septum, thus avoiding alterations in tip symmetry and profile.Fig. 2.: The joy-ride stitch secures the strut graft directly to the septum. The stitch is performed with 5-0 Prolene suture between the lateral edge of the columellar strut and the caudal septum. The placement of the strut is then symmetric and precise, avoiding interdomal-septum or crural-septum sutures that could alter tip contour.In fact, use of the joy-ride stitch, which fixes the strut to the caudal septum, avoids unintended further distortions and gives the surgeon greater control in securing columellar strut grafts. The surgeon is free to model the tip after having placed the strut graft, thus giving predictable, stable, and durable results. DISCLOSURE The authors have no financial interest to declare. Luciano Ariel Lanfranchi, M.D. Riccardo Gazzola, M.D. Franz Wilhelm Baruffaldi Preis, M.D. Unit of Plastic and Reconstructive Surgery IRCCS San Raffaele Hospital, and Unit of Plastic and Reconstructive Surgery IRCCS Istituto Ortopedico Galeazzi Milano, Italy