Glabellar Skin Research Articles

Reconstructing the Glabella and Nasal Root.

Defects involving the glabella and nasal root require an optimal cosmetic outcome due to its critical position in the mid-face. Glabellar defects often involve multiple cosmetic subunits, hair variations, and various skin thicknesses (forehead superiorly, eyebrows / eyelids laterally, nasal root and dorsum inferiorly), further complicating the reconstruction. The eyebrows and natural concavity of this area must be preserved if possible. Repair options in this location vary by personal preference and experience rather than literature-based outcomes. Key considerations include the location of the defect (glabella vs nasal root +/- brow +/- medial canthus), the position of the defect (midline or off-center) and the texture/thickness of the skin (thick glabellar skin or thin skin of medial canthus). The rich blood supply in this area has made local flaps the preferred option for moderate to large defects. However, two pitfalls for local flaps are pincushioning resulting in a “bull nose” and the possibility of causing synophrys. Often, a combination of flaps, grafts, and/or primary closures are necessary to adequately close large glabellar/nasal root defects. There is a paucity of literature for reconstructive options of the glabella and nasal root, and in the authors’ experience, even experienced surgeons struggle to decide on these. We present a series of reconstructive approaches for the majority of moderate to large cutaneous glabellar and nasal root defects with excellent functional and aesthetic results. J Drugs Dermatol. 2022;21(9):983-988. doi:10.36849/JDD.6132.

The Use of a Hemi Glabellar Flap for Reconstruction of Medial Canthus Defects.

Background: Medial canthal reconstruction is a challenging task due to its complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum horizontal scarring, which is aesthetically displeasing, and possible injury of the supratrochlear artery. Multiple variations have been proposed in the literature, which is often complex. In this paper, the senior author (AK) has developed an intuitive, simple technique by utilising half of the glabellar skin in 12 patients with good clinical outcomes.Materials and methods: A rotational advancement flap involving the upper lateral nasal wall with the hemi glabellar was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients.Results: Reconstruction using the hemi glabellar technique was performed on 12 patients following resection of basal cell carcinoma (BCC) in or near the medial canthus area. Superficial cellulitis was noted in two patients; they were managed on oral antibiotics. Bruising was reported in seven patients which resolved spontaneously in 4-7 days. All patients had a good outcome at two months and six months follow up; there was no flap loss, and all patients were satisfied with the aesthetic outcome.Conclusion: The technique highlighted in this article can be performed quickly and applies to the reconstruction of medial canthus defects with excellent aesthetic outcomes, an inconspicuous scar and supple skin with matching colour.

Study of management of postburn flexion contracture of finger by glabrous versus nonglabrous split skin graft

Aims and Objectives: This prospective study was designed to determine the outcome of split-thickness glabellar and nonglabellar skin graft for the coverage of defects on palmar aspect of hand after release of postburn contracture in terms of graft take, complications, recurrence, and patient satisfaction for color and texture match. Materials and Methods: This prospective comparative study was carried out on patients from December 2018 to December 2020. Fifty patients were randomly divided into two groups by simple randomization method. Group A was offered treatment with split-thickness graft from glabellar region and other Group B was offered treatment with split-thickness graft from nonglabellar skin. Frequencies and percentages of both recipient and donor sites complications such as infection, hypertrophic scarring on the Vancouver scar assessment scale, recurrence, and difficulty in walking were noted. Patient satisfaction for colour and texture match to neighboring skin at recipient site were assessed 3 months after the operation using five points Likert scale. Results: At follow-up of the Group A, the donor areas were completely healed in all the cases 100%. The grafted area showed excellent color and texture match with the adjacent palmer skin. The graft was mobile, stable and without any pigmentation. There was also no hypertrophic scarring, hyperpigmentation or pain at the donor site as compared to ordinary skin graft. Walking and weight bearing were smooth and the instep curvature appeared normal. In Group B, 100% of patients had hyperpigmentation, 20% had marginal scarring and scar hypertrophy at hand. While 40% had scar hypertrophy at 80% had hyperpigmentation over the donor site. Recurrence was noted in 32% of patients in Group B as compared to 8% in Group A. Conclusions: Glabellar skin of the instep is the best replacement for the palmar skin of the digits and hand because of the similarities in their characteristics. Results are excellent in terms of color and texture match, no hyperpigmentation, less marginal scarring, scar hypertrophy, and less recurrence of contracture in patients with area grafted with glabellar skin. Donor site morbidity is very low and hardly any donor site scar is visible. So in conclusion for the management of postburn flexion contracture of the finger. An ideal skin substitute is glabellar skin grafts from the instep region of foot.

Clinical effects of nasal glabellar flap on reconstruction of nasal dorsal and tip

Objective To introduce an excellent one-stage procedure for repairing defects of the middle and distal part of the nose: nasal dorsal glabellar flap. Methods According to the size, shape and location of nasal defect, homologous nasal dorsal glabellar flap was selected to cover the nasal defect in 17 cases. Among 17 cases, there were 7 men and 10 women, with age of 38 to 76 years. The locations were nasal tip in 9 cases and dorsum of nose in 8 cases, The area of the defect ranged from 15 mm×15 mm to 30 mm×26 mm. The nasal dorsal glabellar flap, which received a versatile axial blood supply from branches of the facial artery and ophthalmic artery, took tissue from the lax glabellar skin and might appear to be too aggressive for closure of a distal nasal or mid-nasal defect. However, because its design was primarily that of a rotation flap with a back-cut in the glabella region, it was greater than the primary defect in order to maximize tissue movement and decreased wound closure tension at the flap donor site. The secondary defect of donor site was directly sutured. Results The nasal defect was successfully repaired in all patients, and the all flaps survived. The patients were available for follow-up of 1 to 6 months, no tumor recurrence occurred, and the repaired tissue were good match with surrounding tissue in color, thickness and texture, good nasal contour was obtained and no secondary deformity occurred, and therefore the cosmetic results were satisfactory. Conclusions The nasal glabellar flap has evolved into a choice flap for nasal defects of cover since it provides local skin with an exact color, thickness, and texture match for the nasal skin. It allows large reconstructions for up to 30 mm defects leaving minimal scars. It represents an interesting alternative for the reconstruction of defects of the nasal tip or supra tip of the nose. Key words: Nose; Skin; Reconstructive surgical procedures; Surgical flaps; Nasal glabellar flap; Defects

Management of the aging forehead and brow.

The appearance of the forehead and brow conveys both a state of aging as well as the dynamic status of human emotion. Maintaining a youthful and pleasant appearance of this region is often integral to facial rejuvenation. Conditions that are often addressed include transverse rhytids and glabellar frown lines, ptotic eyebrows, skin deterioration, and volume loss. Surgical treatments to improve the forehead/brow might be open, endoscopic or combined. Common nonsurgical methods used to improve the region include neuromodulation, volume replacement, ablative and nonablative skin resurfacing, as well as phototherapy. Whatever treatments might be indicated, aim is to achieve optimum and natural-looking results.

Midface swelling reveals nasofrontal dermal sinus

Nasofrontal dermal sinuses are very rare and generally occur in children. This congenital malformation can be revealed by midface swelling, which can be complicated by local infection or neuromeningitis. Such complications make the dermal sinus a life-threatening disease. Two cases of nasofrontal dermal sinuses are reported in this work. The first case is an 11-month-old girl who presented with left orbitonasal soft tissue swelling accompanied by inflammation. Physical examination found fever, left orbitonasal thickening, and a puncture hole letting out pus. Computed tomography revealed microabscesses located at the left orbitonasal soft tissues, a frontal bone defect, and an intracranial cyst. Magnetic resonance imaging showed the transosseous tract between the glabella and the brain and affirmed the epidermoid nature of the intracranial cyst. The second case is a 7-year-old girl who presented with a nasofrontal non-progressive mass that intermittently secreted a yellow liquid through an external orifice located at the glabella. MRI revealed a cystic mass located in the deep layer of the glabellar skin related to an epidermoid cyst with a nasofrontal dermal sinus tract. In both cases, surgical excision was performed, and pathological confirmation was made for the diagnoses of dermal sinuses. The postoperative course was favorable. Through these cases, the authors stress the role of imaging methods in confirming the diagnosis and looking for associated cysts (dermoid and epidermoid) to improve recognition of this rare disease. Knowledge of the typical clinical presentations, imaging manifestations, and most common sites of occurrence of this malformation are needed to formulate a differential diagnosis.

Re ‘Isolated eyelid edema in Melkersson–Rosenthal syndrome: a case series’

Sir, Rawlings et al1 have reported on a series of five patients with isolated eyelid edema and have made the diagnosis of Melkersson–Rosenthal syndrome on the basis of granulomatous inflammation. Melkersson–Rosenthal syndrome is described as a granulomatous disease with the triad of facial palsy, facial edema, and a fissured tongue, although the complete triad is reported to be seen in only 25% of cases.2 We have recently reported on a series of 15 patients with chronic eyelid edema, and in 9 of these cases (60%) there was an associated diagnosis of acne rosacea.3 Granulomatous inflammation was present in some of these patients, and this has been reported before in the presence of acne rosacea.4 Indeed, acne rosacea and Melkersson–Rosenthal syndrome have some overlap in their clinical and pathological features and both are classified as granulomatous dermopathies. The illustrations of Cases 1 and 2 in the series of Rawlings et al1 show facial features that would be consistent with acne rosacea, with rhinophymatous change and thickened glabellar skin. I suspect these two illustrated patients do indeed have acne rosacea rather than Melkersson–Rosenthal syndrome, and it would be of interest to know whether any of the other three patients in the series also showed features of rosacea. It is likely that Melkersson–Rosenthal syndrome is over diagnosed when the other features of the syndrome are absent, and many of the reported cases of eyelid edema as the only feature of the syndrome are more likely to have acne rosacea as the underlying cause of their eyelid edema. Such phymatous change in the eyelid was certainly the commonest cause in our series, which to date is the largest published series of chronic eyelid lymphedema.

Commentary on: Percutaneous Selective Radiofrequency Nerve Ablation for Glabellar Frown Lines

Ablation of nerve tissue with radiofrequency-generated (RF-generated) heat is an established technique for treating patients with cardiac arrhythmias.1,2 The application of this concept to the ablation of motor nerve function in the face was introduced by Gregorio Hernandez-Zendejas and Jose Guerrerosantos3 in 1994, when they were attempting to find a less invasive treatment to provide forehead symmetry in patients with unilateral frontalis muscle paralysis from Bells palsy or iatrogenic causes by ablating the function of the temporal branch of the facial nerve on the opposite side. During their study, they found that they could soften glabellar “frown” lines by ablating motor nerves to the muscles that act on the glabellar skin to produce creasing in that area. Subsequently, other authors—as referenced by Dr. Kim and his coauthors in “Percutaneous Selective Radiofrequency Nerve Ablation for Glabellar Frown Lines”—reported with varying success their attempts to similarly apply RF technology to soften glabellar skin lines. My experience with motor nerve ablation through RF-generated heat began in 2006. The technique my colleagues and I applied has been published by Newman.4 Except for some minor differences, our technique was remarkably similar to that described by Kim et al. Dr. Kim and his coauthors obtained a significant improvement in glabellar skin lines for at least 12 months postoperatively in 21 of 27 patients (87%). This is interesting, considering that the same technique was applied in all 27 patients. One might expect that the six patients who did not maintain their good clinical result for at least 12 months were treated at the beginning of the study, but those six …

Mechanisms of cutaneous vasodilation during the postmenopausal hot flash

Menopausal hot flashes can seriously disrupt the lives of symptomatic women. The physiological mechanisms of the hot flash efferent responses, particularly in the cutaneous circulation, are not completely understood. The aim of this study was to examine the mechanisms of increases in skin blood flow during the postmenopausal hot flash in symptomatic women. Healthy postmenopausal women rested in a temperature-controlled laboratory while responses before and during hot flashes were recorded for three unique protocols. In protocols 1 and 2, women were locally pretreated with an intradermal injection of botulinum toxin A (BTX; blocks the release of neurotransmitters from sympathetic cholinergic nerves) in the forearm (protocol 1) and in the glabellar region (protocol 2). In protocol 3, skin sympathetic nerve activity from the peroneal nerve was recorded, along with skin blood flow and sweating within the region innervated by that neural signal. Skin blood flow was indexed using laser-Doppler flowmetry at the BTX-treated and adjacent untreated control sites. The onset of a hot flash was objectively identified as a transient and pronounced increase in sternal sweat rate. The increases in forearm (protocol 1) and glabellar skin (protocol 2) blood flow during hot flashes were attenuated at the BTX sites relative to the adjacent untreated sites (P<0.05 for both protocols). In protocol 3, skin sympathetic nerve activity significantly increased during hot flashes and returned to pre-hot flash levels after the hot flashes. Increases in skin blood flow during postmenopausal hot flashes are neurally mediated primarily through BTX-sensitive nerves, presumably sympathetic cholinergic.

Avulsion of the Corrugator Supercilii Muscle through a Closed Rhinoplasty Approach

Sir: Patients presenting for rhinoplasty are generally young and do not need standard procedures for elimination of glabellar skin furrowing. Treatment of muscles responsible for frowning (corrugator supercilii, procerus, and depressor supercilii) through routine rhinoplasty approaches can be the most ideal approach for reduction, or prevention, of glabellar skin furrowing in these patients. Avulsion of corrugator supercilii and procerus muscles through a closed rhinoplasty approach was initially performed by the first author (A.J.K.-H.) on patients complaining of frown lines. It was performed by continuing subperiosteal dissection of nasal bones over the frontal bone up to 25 mm superior to the nasion and up to 16 mm lateral to the midline on each side. Since 2004, it has been performed on all patients undergoing closed rhinoplasty because of its feasibility, excellent results, and satisfaction of patients. During a 3-year period, the severity of frown lines of 250 patients was rated before surgery and at the follow-up visit 1 year after the operation. Rating was performed on a scale from 1 to 5 by the patient and by the second and third authors, with 5 being the most severe. Fifty-four men and 196 women were studied. The mean age was 24.52 ± 3.836 years (range, 18 to 36 years). The mean preoperative and postoperative scales of severity of frown lines are listed in Table 1. The mean scale was decreased significantly (by 0.6454) after the operation (t = 17.351, df = 249, p < 0.001) (Fig. 1). In the postoperative period, nearly all patients had some degree of hematoma in the glabellar region that was resolved by 2 weeks. There was no ecchymosis, no depression in the area of avulsion, and no dyskinesia of the muscles.Table 1: Mean Preoperative and Postoperative Scales of Severity of Frown LinesFig. 1.: (Above) Preoperative and (below) postoperative views of frown lines.In the study by Janis et al.,1 the most lateral and superior extent of the origin of the corrugator muscle was 14.0 ± 2.8 mm and 18.7 ± 2.42 mm from the nasion, respectively. Miller et al.2 demonstrated that all supratrochlear branches are located more than 1.6 cm from the midline. Thus, our extent of dissection had no risk of nerve injury and avulsed most of the origin fibers. The transpalpebral approach to the corrugator supercilii and procerus muscles has become a standard procedure for the treatment of glabellar frown lines after its description by Knize3 and Guyuron et al.4 Although complete resection of the corrugator muscle is advocated for a long-lasting and complete improvement in frown lines, its weakening through avulsion of its origin can be all that is needed in young rhinoplasty patients. Kalantar-Hormozi and Beiraghi-Toosi5 have proposed “rhinometry” for outcome assessment after rhinoplasty using actual measurements of the nose, but an objective yet simple and practical method for evaluating frown lines is not available. We used a scaling method similar to what Guyuron et al.4 used for evaluation of results of corrugator supercilii muscle resection through blepharoplasty incision. This method demonstrated a significant decrease of the scale of severity of frown lines following the operation. Avulsion of corrugator supercilii and procerus muscles through a closed rhinoplasty approach is a simple and valuable adjunct to rhinoplasty for treatment of minimal frown lines or, potentially, prevention of their progression. ACKNOWLEDGMENT The authors gratefully acknowledge the invaluable assistance of Alireza Chitsazan in taking photographs and managing photographic analyses. Abdoljalil Kalantar-Hormozi, M.D. Arash Beiraghi-Toosi, M.D. Elham Azarnoosh, M.D. 15 Khordad Hospital Tehran, Iran

Use of a Glabellar Skin Graft for the Repair of Nasal Tip and Alar Defects

All excisions were performed under local anesthesia with an adequate safety margin of normal skin. The donor site was selected according to tissue quality, color, texture, and thickness that could match the surrounding nose skin. Because nose skin tends to be thick and heavily populated with sebaceous glands, not all conventional donor sites for nose grafts are a good option, hence the suitability of the glabella. It is also important to consider the presence of glabellar hyperdynamic furrows at rest and redundant tissue that provides an adequate bank of loose tissue. If severe actinic keratosis or seborrheic dermatitis is present, another site must be sought.

Medial Canthal Reconstruction by a Modified Glabellar Flap

Aims: To present a modified technique for the preparation of glabellar skin flaps to reconstruct medial canthal defects. Methods: Ten consecutively treated patients were included who had skin defects after resection of skin tumours like basal cell carcinomas in the medial canthal area of a medium vertical diameter of 2.5 cm. The defects were closed by preparation of a modified glabellar flap. The pedicle of the flap was guided through a skin tunnel prepared diagonally at the root of the nose. The pedicle was resected 4 weeks after the initial surgery. Results: In all 10 cases, the procedure was adequate for reconstruction of the defect. There were no flap necroses and the cosmetic results were favourable in all cases. The resection of the pedicle could be performed easily in an out-patient procedure 4 weeks after the operation. Conclusion: Glabellar flaps are established procedures to reconstruct medium to large defects of the medial canthus. Skin distortion in the area of the flap pedicle leading to a skin bulge and visible scars at the root of the nose and medial transposition of the eye brows can be reduced by a modification of the surgical technique preparing a skin tunnel for the flap pedicle. In our hands, the cosmetic results are better with the modified technique in comparison to the original procedure.

La greffe de peau totale glabellaire pour la reconstruction de la pointe du nez

The use of glabellar skin as full thickness skin graft is a good alternative to the common techniques, which are essentially represented by local flaps for repair of the nasal tip defects. Three cases out of 25 patients are reported. This technique provides no dyschromia unlike skin graft or composite graft commonly used. The glabellar scar remains remarkably discrete on a patient with previous glabellar wrinkles. The limits of this technique are represented by the surface of the donor skin its use on young patients without glabellar wrinkles.

Muscles that Act on Glabellar Skin: A Closer Look

Muscles that Act on Glabellar Skin: A Closer Look

Muscles that act on glabellar skin: a closer look.

The coronal incision forehead lift became a component of the face-lift procedure 35 years ago and increased the cosmetic benefit for the facial aesthetic surgery patient. Later, this enhanced cosmetic effect achieved from eyebrow resuspension was complemented by treatment of the glabellar skin lines by modifying corrugator supercilii and procerus muscle function through the same coronal incision. In recent years, newer procedures for treating the corrugator supercilii and procerus muscles by using endoscopy or limited incision techniques have eliminated the need for the coronal incision. With these newer techniques has come a renewed interest in the surgical anatomy of the muscle complex that acts on glabellar skin. This study was designed to examine the current understanding of the anatomy of these muscles and to resolve misconceptions and controversy concerning them. Fresh cadaver dissections and simulated muscle action studies done on the glabellar musculature of four specimens were correlated with nerve blockade studies performed in 10 subjects on the temporal and zygomatic branches of the facial nerve. The presence of the depressor supercilii muscle as a distinct entity was confirmed. The little-appreciated oblique head of the corrugator supercilii muscle was identified. The conclusions from this study suggest that the transverse head of the corrugator supercilii muscle produces the vertical component of the glabellar skin line and also contributes to the formation of the oblique component of the glabellar skin line. The oblique head of the corrugator supercilii muscle, the depressor supercilii muscle, and the medial head of the orbital portion of the orbicularis oculi muscle all appear to depress the medial head of the eyebrow and contribute to the formation of the oblique glabellar skin line. The nerve block study provided evidence that the zygomatic branch of the facial nerve supplies the three medial eyebrow depressor muscles, which opens the possibility for future nerve ablation techniques to control the action of the medial eyebrow depressor muscle group. This nerve block study also supports the concept of "physiologic" elevation of the medial eyebrow as an effective component of foreheadplasty.

Transpalpebral Approach to the Corrugator Supercilii and Procerus Muscles

The most effective method for treating glabellar area skin contour irregularities produced by hyperactive corrugator supercilii and/or procerus muscles is resection of the former and at least transection of the latter. The usual surgical approach is a coronal incision, which produces recognized sequelae of scalp or prefrontal hairline scarring and scalp dysesthesia; potential complications include injury to the frontal branch of the facial nerve, postoperative alopecia, and excessive recession of the frontal hairline. Hyperactive corrugator supercilii muscles may be excised and procerus muscles transected without a coronal incision. These muscles can be treated through an upper blepharoplasty incision without compromise to the blepharoplasty procedure

The use of a bipedicled flap for defects on the bridge of the nose.

Use of a bipedicled flap with advancement of glabellar skin is an excellent method to close defects on the bridge of the nose. The technique is illustrated by photographs selected from several cases.