The Nasal Face. |
Elena Shchelokova
Founder and Medical Director
Face Clinic
Face Clinic
13, Prechistenka
119034, Moscow, Russia
Email for correspondence:
iamogu@yandex.ru
119034, Moscow, Russia
Email for correspondence:
iamogu@yandex.ru
Elena Shchelokova
Founder and Medical Director
Face Clinic
Face Clinic
13, Prechistenka
119034, Moscow, Russia
Email for correspondence:
iamogu@yandex.ru
119034, Moscow, Russia
Email for correspondence:
iamogu@yandex.ru
Nasal Face
If there is a pronounced problem with one of the facial systems, external manifestations of this malfunctioning will dominate 11the face. Based on my clinical observations, I have identified several facial types (the Ophthalmic Face, the Nasal Face, the Dental Face, the Neural Face, the Mixed Face, etc.) and developed the Smart Cosmetology approach, which allows us to correct undesirable facial changes caused by specific functional impairments.
The Role Of Facial Expression In Beauty Judgements
We talk a lot about the beauty of the face or ideal proportions, we look for standards that will accurately define the notion of beauty. However, again and again we come to the same conclusion that beauty is in the eye of the beholder.
Even the golden ratio, commonly recognized as the standard of harmony and perfection, does not necessarily mean that a face will be perceived as beautiful (Fig.1).
Even the golden ratio, commonly recognized as the standard of harmony and perfection, does not necessarily mean that a face will be perceived as beautiful (Fig.1).
Fig.1. The golden ratio mask may show whether a face is proportionate but not necessarily whether it is attractive.
Fashion for beauty is also changeable. However, there is one constant criterion that remains equally valid for everyone at all times. It is facial expression [2]. If the face is beautiful, but the expression is dissatisfied, angry or aggressive, its attractiveness decreases dramatically. By contrast, even a very ordinary face with a friendly expression will look significantly more attractive.
When we say “Have you seen his/ her face?”, we always have in mind facial expression, not facial features. But what is facial expression and what determines it?
Facial expression is formed by mimic muscles (Fig. 2). They are interconnected to perform the functions of the face. It is their joint work that creates facial expressions.
When we say “Have you seen his/ her face?”, we always have in mind facial expression, not facial features. But what is facial expression and what determines it?
Facial expression is formed by mimic muscles (Fig. 2). They are interconnected to perform the functions of the face. It is their joint work that creates facial expressions.
Fig. 2. Muscles of the face.
However, the same muscle groups can perform different tasks. For example, expressions of discontent and sadness are caused by the characteristic tension of the muscles in the central zone of the face. This tension results in the squinted eyes, wrinkled nose, drooping corners of the mouth, etc. But the muscles responsible for the expression of negative emotions are also responsible for the movement of air through the nasal passages (Fig. 3). This means that obstructed nasal breathing (due to nasal septum deviation, chronic rhinitis or frequent allergies) can lead to the same external manifestations on the face as the expression of dissatisfaction. In fact, as my experience shows, people with RBF [3] are often unaware that one of its causes is problems with nasal breathing.
Fig. 3. Facial muscles involved in pushing air through the nasal passages and forming an unhappy expression: m. frontalis, m. procerus, m. corrugator d. et s., m. orbicularis oculi, m. nasalis, m. levator labii sup. et prof., m. zygomaticus minor et major, m. dilatator nasi, m. depressor septi nasi, m. orbicularis oris, m. depressor anguli oris, m. mentalis, platysma.
I conducted a study which showed that in more than fifty percent of cases a dissatisfied facial expression was due to obstructed nasal breathing rather than bad character or negative emotions.
The Impact Of The Nasal System On The Face
The nose is a centrally located structure of the face, which by its shape, size and overall appearance obviously affects the beauty and harmony of the face. The main functions of the nose are:
- breathing (propelling, moisturizing and warming the passing air);
- sense of smell;
- protection (air disinfection, reflex sneezing).
The anatomical and physiological complexity of the nasal system is
determined by the multitude and variety of tasks it performs (Fig.4) [4, 5].
- breathing (propelling, moisturizing and warming the passing air);
- sense of smell;
- protection (air disinfection, reflex sneezing).
The anatomical and physiological complexity of the nasal system is
determined by the multitude and variety of tasks it performs (Fig.4) [4, 5].
Fig. 4. Projections of the nasal system on the face. The frontal sinus borders on the upper wall of the orbit, the maxillary sinus on its lower wall. The nasal cavity has a common border with the medial wall of the orbit. The nasal system and the periorbital area also have shared blood and lymph vessels.
Its functioning and connectedness to the adjacent structures of the face result in specific external patterns. Muscle hyperactivity of the nose aimed at increasing the airflow leads to the emergence of wrinkles and folds in the central zone of the face and the appearance of a negative facial expression. Chronic inflammation of the nasal system results in redness, telangiectasia or cuperosis in the central zone of the face. Owing to the common lymph and blood vessels shared with the periorbital zone, when inflammatory processes in the nasal system persist, edemas and hernias of the upper and lower eyelids may develop and the medial fat compartment may increase in size. In the framework of Smart Cosmetology, this characteristic facial pattern is labeled the Nasal Face (Fig.5)
Fig. 5. A characteristic Nasal Face pattern: pronounced nasolabial (1) and melomental folds (2), cheek grooves (3), flaring nostrils (4), increased medial fat compartment (5), hernias of the lower eyelids (6), and a raised upper lip (7).
If problems with the nasal system appear in childhood, the shape of the facial skeleton may change, as can be seen, for instance, in the ‘adenoid face’ with its characteristic facial expression (Fig.6) [6].
Fig. 6. A child’s face with nasal problems which resulted in a sad facial expression and gave him what we would typically call an ‘aged’ appearance in an adult person: a sagging face, tear troughs, nasolabial folds, drooping corners of the mouth and unclear face contours (a boy statue from the Montserrat Monastery, Spain). This is a typical Nasal Face, which can be found both in children and adults, suggesting that age is not the only factor behind this type of appearance.
Cosmetological Signs Of Nasal System Disorders
External manifestations of nasal problems include:
Problems with the nasal system result in very similar facial patterns regardless of patients’ age (Fig. 7).
- nasal flaring;
- deepened nasolabial folds;
- marionette lines;
- pronounced cheek grooves;
- glabella wrinkles ;
- raised upper lip with a vertical line across it;
- platysma cords;
- increased medial fat compartment;
- edema of the face;
- edema and hernia of the eyelids;
- pore dilation;
- telangiectasia around the nose, etc.
Problems with the nasal system result in very similar facial patterns regardless of patients’ age (Fig. 7).
Fig. 7 (A-D). Examples of Nasal Face patients.
Causes of nasal system disorders include:
Improved air passage when the nose tip is raised can be considered as a diagnostic criterion for nasal system disorders (Fig. 8).
- chronic rhinitis;
- sinusitis;
- allergic rhinitis;
- nasal septum deviation;
- polyposis;
- adenoids, etc.
- frequent nasal congestion;
- snoring;
- nasal voice;
- headaches;
- regular use of vasoconstrictors, etc.
Improved air passage when the nose tip is raised can be considered as a diagnostic criterion for nasal system disorders (Fig. 8).
Fig. 8. A simple but effective test for nasal problems: when the tip of the nose is raised, the patient experiences an increase in the airflow and thus improved breathing.
Standard Cosmetological Treatment Options For Patients With Nasal System Disorders
Standardly, cosmetological treatment does not take into account functional problems of the nasal system, which reduces its effectiveness and may lead to patient dissatisfaction.
Case 1
Patient S (46 y.o.) presented with complaints about tired appearance and pronounced nasolabial folds (Fig. 9A). The anamnesis revealed that for many years the patient had been suffering from obstructed nasal breathing caused by nasal septum deviation. Examination showed facial asymmetry, pronounced glabella wrinkles, medial hernias of the lower eyelids, cheek grooves, increased medial fat compartments, nasolabial folds, drooping corners of the mouth, nasal flaring, a raised upper lip and marionette lines. Considering the anamnesis, these facial changes were clearly a consequence of a nasal system pathology.
Case 1
Patient S (46 y.o.) presented with complaints about tired appearance and pronounced nasolabial folds (Fig. 9A). The anamnesis revealed that for many years the patient had been suffering from obstructed nasal breathing caused by nasal septum deviation. Examination showed facial asymmetry, pronounced glabella wrinkles, medial hernias of the lower eyelids, cheek grooves, increased medial fat compartments, nasolabial folds, drooping corners of the mouth, nasal flaring, a raised upper lip and marionette lines. Considering the anamnesis, these facial changes were clearly a consequence of a nasal system pathology.
Fig.9. Case 1. Patient S (A) before and (B) after standard treatment, which did not correct the negative facial expression.
Treatment was given in accordance with the standard protocol, without taking into account the fact that the patient had all the typical manifestations of the Nasal Face, and included the introduction of botulinum toxin type A only in the upper and lower thirds of the face; correction of the middle zone with Restylane Sub-Q 2.0 ml using a cannula; and correction of nasolabial folds and marionette lines with Restylane Perlane 2.0 ml. However, botulinum toxin was not applied to the central zone of the face. Following complex correction (Fig. 9B), the patient's face became more youthful, but the negative facial expression remained unchanged. Thus, failure to take into consideration the impact of the nasal system on the patient’s facial image, together with the unresolved underlying problems of nasal breathing, resulted in a limited aesthetic effect.
Case 2
Patient B (60 y.o.) came to our clinic complaining of pronounced facial wrinkles and visible blood vessels under the nose (Fig.10 A). The anamnesis revealed obstructed nasal breathing caused by chronic sinusitis and nasal septum deviation. Examination showed pronounced glabella wrinkles, medial hernias of the lower eyelids, cheek grooves, increased medial fat compartments, nasolabial folds, drooping corners of the mouth, nasal flaring, pronounced telangiectasia around the nose, a raised upper lip and marionette lines. Considering the anamnesis and the results of the physical examination, it is obvious that this is a typical Nasal Face.
Case 2
Patient B (60 y.o.) came to our clinic complaining of pronounced facial wrinkles and visible blood vessels under the nose (Fig.10 A). The anamnesis revealed obstructed nasal breathing caused by chronic sinusitis and nasal septum deviation. Examination showed pronounced glabella wrinkles, medial hernias of the lower eyelids, cheek grooves, increased medial fat compartments, nasolabial folds, drooping corners of the mouth, nasal flaring, pronounced telangiectasia around the nose, a raised upper lip and marionette lines. Considering the anamnesis and the results of the physical examination, it is obvious that this is a typical Nasal Face.
Fig. 10. Case 2. Patient B (A) before and (B) after standard treatment applied simultaneously with rhynological treatment, which did not correct the negative facial expression.
Standard cosmetological treatment was applied simultaneously with the treatment of nasal disorders and included the introduction of botulinum toxin type A only in the upper and lower thirds of the face; correction of the middle zone with Restylane Sub-Q 2.0 ml using a cannula; correction of nasolabial folds and marionette lines with Restylane Perlane 2.0 ml; and blood vessel electrocoagulation. Like in the previous case, botulinum toxin was not injected in the central zone of the face.
The patient received rhynological treatment for two weeks (as a result of which nasal flaring was reduced). But, although the patient's appearance improved (Fig. 10B), the dissatisfied facial expression remained unchanged.
The patient received rhynological treatment for two weeks (as a result of which nasal flaring was reduced). But, although the patient's appearance improved (Fig. 10B), the dissatisfied facial expression remained unchanged.
Smart Cosmetology For The Nasal Face
Smart cosmetology identifies the pathogenetic causes of the problem and offers correction of facial changes taking into account the patient’s anatomy and physiology. This allows us to change the patient’s facial appearance and eliminate not only wrinkles and folds but also the negative expression, thus significantly enhancing the aesthetic result. Based on a correct understanding of the underlying causes of facial changes, we can choose an optimal recovery algorithm.
Case 3
Patient L (42 y.o.) complained of age-related facial changes (Fig.11 A, B). The anamnesis revealed chronic polysinusitis, nasal septum deviation, and obstruction of nasal breathing. Examination showed glabella wrinkles, medial hernias of the lower eyelids, cheek grooves, a pronounced medial fat compartment, nasolabial folds, nasal flaring, a raised upper lip and marionette lines. These external manifestations on the face typically result from nasal problems. The patient was referred for surgical treatment of nasal septum deviation, which significantly improved nasal breathing. Then the following treatment was applied: the introduction of botulinum toxin type A in the central area of the face and correction of the lacrimal groove with Restylane Perlane 1.0 ml. As a result of the combined treatment, the patient’s facial expression became much calmer, visibly enhancing the aesthetic effect of cosmetological rejuvenation (Fig.11 C, D).
Case 3
Patient L (42 y.o.) complained of age-related facial changes (Fig.11 A, B). The anamnesis revealed chronic polysinusitis, nasal septum deviation, and obstruction of nasal breathing. Examination showed glabella wrinkles, medial hernias of the lower eyelids, cheek grooves, a pronounced medial fat compartment, nasolabial folds, nasal flaring, a raised upper lip and marionette lines. These external manifestations on the face typically result from nasal problems. The patient was referred for surgical treatment of nasal septum deviation, which significantly improved nasal breathing. Then the following treatment was applied: the introduction of botulinum toxin type A in the central area of the face and correction of the lacrimal groove with Restylane Perlane 1.0 ml. As a result of the combined treatment, the patient’s facial expression became much calmer, visibly enhancing the aesthetic effect of cosmetological rejuvenation (Fig.11 C, D).
Fig.11. Case 3. Patient L (A, B) before and (C, D) after combined surgical and smart cosmetological treatment.
Case 4
Patient A (50 y.o.), complained of deep nasolabial folds, which persisted even after multiple cosmetological treatments over a course of several years, involving the application of hyaluronic acid fillers to the nasolabial folds and the middle zone of the face for their effacement (Fig. 12 A). The anamnesis revealed nasal septum deviation and obstruction of nasal breathing. Examination showed pronounced medial hernias of the lower eyelids, a pronounced medial fat compartment, glabella wrinkles, cheek grooves, pronounced nasolabial folds, nasal flaring, a raised upper lip and marionette lines. These external manifestations on the face resulted from obstructed nasal breathing, explaining the limited effectiveness of previous treatments, which had failed to achieve a stable, aesthetically pleasing effect. The patient was referred for surgical treatment of nasal septum deviation, which significantly improved nasal breathing. Then the following treatment was applied: the introduction of botulinum toxin type A in the central area of the face; correction of the middle area of the face with Restylane Sub Q 2.0 ml with a cannula; and correction of nasolabial folds and marionette lines with Restylane Perlane 2.0 ml. Only after surgical restoration of nasal breathing and administration of botulinum toxin in the central area of the face was a stable positive result achieved, with a significant reduction of the nasolabial folds and the appearance of a visibly more relaxed facial expression (Fig. 12 B).
Patient A (50 y.o.), complained of deep nasolabial folds, which persisted even after multiple cosmetological treatments over a course of several years, involving the application of hyaluronic acid fillers to the nasolabial folds and the middle zone of the face for their effacement (Fig. 12 A). The anamnesis revealed nasal septum deviation and obstruction of nasal breathing. Examination showed pronounced medial hernias of the lower eyelids, a pronounced medial fat compartment, glabella wrinkles, cheek grooves, pronounced nasolabial folds, nasal flaring, a raised upper lip and marionette lines. These external manifestations on the face resulted from obstructed nasal breathing, explaining the limited effectiveness of previous treatments, which had failed to achieve a stable, aesthetically pleasing effect. The patient was referred for surgical treatment of nasal septum deviation, which significantly improved nasal breathing. Then the following treatment was applied: the introduction of botulinum toxin type A in the central area of the face; correction of the middle area of the face with Restylane Sub Q 2.0 ml with a cannula; and correction of nasolabial folds and marionette lines with Restylane Perlane 2.0 ml. Only after surgical restoration of nasal breathing and administration of botulinum toxin in the central area of the face was a stable positive result achieved, with a significant reduction of the nasolabial folds and the appearance of a visibly more relaxed facial expression (Fig. 12 B).
Fig.12. Case 4. Patient A (A) after multiple standard nasolabial fold treatments and (B) after combined surgical and smart cosmetological treatment.
Case 5
Patient K (33 y.o.) complained of age-related facial changes. The anamnesis revealed obstructed nasal breathing caused by chronic vasomotor rhinitis. Examination showed a typical Nasal Face pattern: medial hernias of the lower eyelids, glabella wrinkles, cheek grooves, a pronounced medial fat compartment, nasolabial folds, nasal flaring, a raised upper lip and marionette lines. These external manifestations on the face typically result from obstructed nasal breathing. Simultaneously with therapeutic treatment of vasomotor rhinitis, the following smart cosmetological treatment was applied: the introduction of botulinum toxin type A in the central area of the face and correction of the middle zone of the face with Restylane Sub-Q 2.0 ml using a cannula. The result was a significant improvement in the patient’s appearance (Fig.13).
Patient K (33 y.o.) complained of age-related facial changes. The anamnesis revealed obstructed nasal breathing caused by chronic vasomotor rhinitis. Examination showed a typical Nasal Face pattern: medial hernias of the lower eyelids, glabella wrinkles, cheek grooves, a pronounced medial fat compartment, nasolabial folds, nasal flaring, a raised upper lip and marionette lines. These external manifestations on the face typically result from obstructed nasal breathing. Simultaneously with therapeutic treatment of vasomotor rhinitis, the following smart cosmetological treatment was applied: the introduction of botulinum toxin type A in the central area of the face and correction of the middle zone of the face with Restylane Sub-Q 2.0 ml using a cannula. The result was a significant improvement in the patient’s appearance (Fig.13).
Fig.13. Case 5. Patient K (A) before treatment, (B) after the application of hyaluronic acid to the middle and botulinum toxin to the central zone of the face, (C) two weeks after the combined treatment.
Thus, in Nasal Face patients, injections of botulinum toxin in the central zone may not only reduce wrinkles and folds but also globally improve their overall facial expression, as demonstrated in Fig.11, 12 and 13.
Conclusion
We have seen that constant muscle hypertension in the central area of the face due to obstructed nasal breathing contributes to the formation of wrinkles and folds as well as a dissatisfied facial expression. Only the introduction of botulinum toxin in the central area of the face allows us to radically change facial expression, making it calmer and more satisfied, and, at the same time, to significantly enhance the aesthetic effect in Nasal Face patients. Fig.14 shows the treatment scheme I developed specifically for this group of patients.
Fig.14. Recommended zones and doses for botulinum toxin (100 units) correction in Nasal Face patients.
To conclude, a clear understanding of the processes that underlie specific changes in the face enables us to manage and prevent them more successfully by taking into account the patient’s anatomical and physiological peculiarities. In this article I have discussed the Nasal Face, in the next article I will focus on the Dental Face.
Patient Consent
Patients provided written consent for the use of their images.
References
[1] Shchelokova, E. Structural facial aging resulting from muscle activity.
[2] Mueser, K., Grau, B., Sussman, S. and Rosen, A. You're only as pretty as you feel: Facial expression as a determinant of physical attractiveness. Journal of Personality and Social Psychology. 46 (1984), 469-478.
[3] Bennett, J. I’m not mad. That’s just my RBF. The New York Times, 02.08.2015.
[4] Ivanova E.A. The nose. From function to form. Aesthetic aspects of the anatomy of the external nose. Metamorphoses. 13 (2016), 6-17.
[5] Ivanova E.A. Features of lymph outflow from the soft tissues of the head and neck. Metamorphoses. 17 (2017), 6-14.
[6] Koca, C. F., Erdem, T. and Bayındır, T. (2016). The effect of adenoid hypertrophy on maxillofacial development: an objective photographic analysis. Journal of otolaryngology: head and neck surgery. 45 (2016), 48.
[2] Mueser, K., Grau, B., Sussman, S. and Rosen, A. You're only as pretty as you feel: Facial expression as a determinant of physical attractiveness. Journal of Personality and Social Psychology. 46 (1984), 469-478.
[3] Bennett, J. I’m not mad. That’s just my RBF. The New York Times, 02.08.2015.
[4] Ivanova E.A. The nose. From function to form. Aesthetic aspects of the anatomy of the external nose. Metamorphoses. 13 (2016), 6-17.
[5] Ivanova E.A. Features of lymph outflow from the soft tissues of the head and neck. Metamorphoses. 17 (2017), 6-14.
[6] Koca, C. F., Erdem, T. and Bayındır, T. (2016). The effect of adenoid hypertrophy on maxillofacial development: an objective photographic analysis. Journal of otolaryngology: head and neck surgery. 45 (2016), 48.
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