Dr. Sam Lam Plastic Surgery Forum

I remember from old anatomy classes that we have the orbicularis oris around the mouth, but the opening of the mouth and the movement of the nose are often linked. There are some "levator... not sure what" muscles close to the nose and linked to the mouth movement, right?

That makes me wonder: just the way botox, if wrongfully applied (place or dose) in the area can create problems with the movements of the mouth, can't the injection of fillers interfere with smiling?
In the case of the injection of fillers right underneath the nose, whether at the very center of it or at the sides, are the muscles of the mouth affected? In other words, can someone having a filler injected right underneath the nose affect the orbicularis oris or other muscle that would make him/her end up not being able to raise his/her lips as usual when smiling? I am talking of a problem that would the opposite of a gummy smile: not showing any gum or not fully showing teeth.
Is that a danger or do the muscles around the nose remain unharmed?
Or are the muscles linked to those movements that make the teeth and gums show more or less not affected by the injection of fillers?

On a sidenote, I only had once (because there was a "leftover" of my syringue) some resty injected in the nasolabial folds (although I don't have that done regularly, I don't think I need it), but I remember that for one day, I could not smile as "open". Which in my case was not bad because I tend to have a gummy smile. But it went away. Why did it happen? is it out of the inflammation response of the area resulting from having injected something?

Hope my questions are not too confusing. I have been watching anatomy documentaries, and then when reading the posts about non surgical nose jobs, this anatomy questions popped up in my head .

yes, all the muscles blend in. the levators you speak of include the levator alaque nasi (which extends around the nose and blends down to the mouth- it is the muscle that you botox to drop a gummy smile), levator labii between the mouth and nose, levator anguli oris that lifts the sides of the mouth. and of course, the depressors of the lower lip, etc.

in general, a firm product could physically obstruct movement like in your NLFs but they should not typically interfere with any muscle movements. for example, after a fat transfer, i tell my patients when there is swelling for the first week or 2 weeks, they can't smile because the swelling plus fat makes the area firm in feeling and hard to move until things soften.

so in short, fillers should not interfere with muscle function but a very thick product placed in large amounts (or if some swelling persists) can obstruct movement due to a physical obstacle but not one that actually impairs muscle function. hope that is clear.

Understanding the dynamics of a face and how x muscle affects y muscle truly marvels me. It reminds me of how complex and wonderful the human body is.

If people have some "hard" filler (whatever those might be) in the nasolabial lines in a relative large amount under the nose or around the mouth, relatively close to the mouth, then, would that fall into the potential "smile-messers"? (making up a word ).


I can imagine restylane falls into the soft products.
Would any of the currently used products for facial filling be cosidered firm? as in, among the FDA approved: perlane? artefill?
(I know you don't work with Artefill, I am wondering if it is the type of product that is "firm"/thick because of the particles it contains).
I know Artefill was approved in US for nasolabial folds, but isn't the product thick?

The more lasting the material, the more it tends to have ingredients that are firm? or are those variables not necessarily linked one to the other in any way?

>yes, all the muscles blend in. the levators you speak of include the levator alaque nasi (which extends around the nose and blends down to the mouth- it is the muscle that you botox to drop a gummy smile), levator labii between the mouth and nose, levator anguli oris that lifts the sides of the mouth. and of course, the depressors of the lower lip, etc.

Super clear!

> in general, a firm product could physically obstruct movement like in your NLFs but they should not typically interfere with any muscle movements.

Let's see if I understood it right.

Do you mean that the product would "normally", typically not interfere with any muscle. Should not, but can. Just the way anything applied the wrong way or wrong amount can have consequences unexpected and undesirable. Did I get that right?

When you say a firm product, do you mean an actual solid, hard product? like if the person had an imlant of as silastic, hydroxyapatite, polyethylene, gore-tex put in there?
I don't even know if there is any sort of implant of the type for the area, I am just wondering what those firmer products could be.

You totally got what I meant, when you brought up the fat transfer issue (even though I had not thought of it at first).

> for example, after a fat transfer, i tell my patients when there is swelling for the first week or 2 weeks, they can't smile because the swelling plus fat makes the area firm in feeling and hard to move until things soften.

Does the fat applied in the cheek around the nose / buccal area during graft transfer OR the filler create immediate swelling? Have either the property to cause as soon as they are injected/grafted exert a pulldown force over the mouth, and make the "line of the smile" (the upper one) lower?
But if I understand correctly, that would go away, right?

The day I will have a fat graft with you (counting the days LOLOL), you will see me and decide what is ok for me, but I will assume (from watching myself LOL) that I might need it in the area around the nose myself (in the cheeks/sides of the narines) even below the nose if you think I need it, and/or to lift the nose. So IF you put fat there or a filler or whatever you decided (or nothig LOL), would I have to be prepared to right away want to smile and get a half smile? LOL or not even open my mouth?
But that would go away as the swelling would go away, right?

I know we are talking out of suppositions, of course. You should have to see me and evaluate everything.

How fast does the body respond with inflammation to an aggression of the type? (injection of filler or fat).

> so in short, fillers should not interfere with muscle function but a very thick product placed in large amounts (or if some swelling persists) can obstruct movement due to a physical obstacle but not one that actually impairs muscle function. hope that is clear.

So it would not impair muscle function but obstruct it enough as to make the movement weird looking, or not "normal"?

Well, I guess I must stop bothering you. But I looooooooooove understanding the anatomy and physiology of our body and how and why substances work one way or the other, and how it could work if I or someone I know got fillers or a fat graft (for me I will say WHEN, I will find the way to travel there and meet you sooner or later!)

I must have bored you to tears.
I am su courious! Well, I told you my parents called me "whywhyhowhow" as a kid.

PS... wait... wouldn't anything, anything applied to the area of "the levator alaque nasi" that you say "extends around the nose and blends down to the mouth- it is the muscle that you botox to drop a gummy smile" necessarily make the lips fall lower and modify the smile?
I read that it is not so uncommon to put botox on the levator alaque nasali and end up with someone with a gummy smile with a way too NON gummy smile and a weird, half-smile (I paid attention because I always care for what is said for gummy smiles). Would not, then, the product applied at the levator alaque nasali achieve the same negative effect? especially in someone without a gummy smile?

here i think are the big answers to your questions:
1. never used artefill. i have no idea.
2. perlane is firmer than restylane but restylane is firmer than fat. so depending on firmness, you get a better lifting potential on a fold (hence that is why fat does not work well for folds), but more resistance to motion. typically, people are not bothered by perlane in the folds. i prefer perlane there because first it requires more lifting potential to fill a fold and also that area tends to dissipate more quickly due to motion so i prefer a harder product there.
3. no, fillers should not compromise the muscle movement in the way you are thinking. it does not interfere with the muscle moving, i.e., not stop a muscle's dynamic abilities. it just can be like a physical obstruction against which a muscle moves. typically this is quite minor.
4. yes, botox into the LAN can drop the lip unfavorably even in repose. that is why only the most skilled injector that understands the anatomy and its consequences should be doing perioral botox. botox not fillers truly blocks muscle movements.

How can you can so fantastic at explaning these things? Haven't you thought of teaching in medical schools? of course there are your books already, though. Even thought I am a lay person, I think I will buy some of your books some time soon!
Absolutely clear!

>yes, botox into the LAN can drop the lip unfavorably even in repose.

Understood. I saw pics of that result in a paper and wow, scary.
When you said the effect of fillers should be minimal if any (totally understood that the barrier would be physical against the muscle, but they would not affect the muscle), they would never be like those of botox in the situations you described, right?

Besides, the strenght of our perioral muscles might counteract whatever effect the fillers might have, right? we have quite some strong muscles there!

Final question (really ), the muscles can't be affected because both fillers and fat are injected into the dermis or subdermis but not into the muscle, is that correct?


Hugs a ton and loved learning!!!!!!!!!!

answer to the first 2 questions, yes you are correct.

fat is injected into the fat and above bone and in and around muscle with no consequence to the muscle. even a guy who has passed on Roger Amar who injected it into the muscle (FAMI-fat autografting muscle injection) would not say the muscle is compromised.

best,
sml

Makes sense!
Thanks for all you taught me these two days!!!

my pleasure!
best,
sml