Clinical Anatomy 27:11781184 (2014)

ORIGINAL COMMUNICATION

Anatomical Mapping of the Nasal Muscles

and Application to Cosmetic Surgery
MARKO KONSCHAKE*

AND

HELGA FRITSCH

Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Innsbruck
Medical University, Innsbruck, Austria

We present an anatomical mapping of the most important muscles inuencing the

nose, incorporating constant anatomical structures, and their spatial correlations.
At our disposal were the midfaces of 18 bodies of both sexes, obtained by informed
consent from body donors aged between 60 and 80 years. Macroscopically, we dissected the nasal regions of eight corpses, six midfaces were prepared according to
plastination histology, four by creating plastinated slices. On their way from their
periosteal origin to the edge of the skin, the muscles of the nose cross the subcutaneous adipose tissue, dividing it into supercial and deep layers. The individual
muscle bers insert into the skin directly at the reticular corium. Sometimes, they
reach the border of the epidermis which represents a special arrangement of corial
muscle attachments. The course of the anatomical bers of individual nasal
muscles presented macroscopically and microscopically in this study offers surgeons a detailed overview of the anatomically important muscular landmarks of
the midface. Clin. Anat. 27:11781184, 2014. VC 2014 Wiley Periodicals, Inc.
Key words: anatomical mapping; nasal muscles; nasal smas; smas; midface;
nose

INTRODUCTION
Modern plastic and esthetic surgery must aim to
avoid affecting structures not directly involved in the
surgical procedures. As early as 1944, Griesman (1944)
stated that a thorough knowledge of morphology, topography, and function is required to achieve this goal,
especially concerning the extremely ne muscles regulating facial expression, and the muscles on and around
the nose. Previous studies have demonstrated the
importance of knowing the muscles that inuence the
nose if optimal surgical results are to be achieved,
though there have been no detailed descriptions of their
origins, attachments, and topography (Daniel and
Letourneau, 1988; Saban et al., 2008) because none of
these former investigations could document the topographical relationships appropriately. The aim of our
present study was to establish an overview of the important muscles that functionally inuence the nose in the
form of an anatomical mapping:
 nasalis muscle
 levator labii superioris muscle (5levator lateralis
muscle)

C
V

2014 Wiley Periodicals, Inc.

 levator labii superioris alaeque nasi muscle (5 levator

medialis muscle)
For reasons of practical relevance, our investigations centered on the presentation of constant
anatomical structures and their topographical relationships, applying different anatomical techniques. We
thus obtained reliable data concerning the aforementioned muscles and their neighboring structures.

*Correspondence to: M. Konschake, Division of Clinical and

Functional Anatomy, Department of Anatomy, Histology and
llerstr. 59, 6020
Embryology, Innsbruck Medical University, Mu
Innsbruck, Austria. E-Mail: marko.konschake@i-med.ac.at
The work was presented at the 5th International Symposion of
Clinical and Applied Anatomy - 1st Paneuropean Meeting of Anatomists in Graz/ Austria in May 2013.
Received 21 March 2014; Revised 30 April 2014; Accepted 2
May 2014
Published online 26 May 2014 in Wiley Online
(wileyonlinelibrary.com). DOI: 10.1002/ca.22418

Library

Mapping of the Nasal Muscles and Application to Cosmetic Surgery 1179

MATERIALS AND METHODS

In this study, three anatomical techniques were
used:
1. Macroscopic preparation (eight corpses)
2. Plastination histology (six faces)
3. Plastinated slices (four faces)

External Macroscopic Preparation

Nasalis muscle. To prepare and demonstrate the
nasalis muscle, we chose the following approaches,
using a monocular op-microscope (Zeiss) and microsurgical tools.
First, the skin of the forehead and the muscular
plate of the frontalis muscle were cut through at about
three ngers breadth cranially from the bridge of the
nose and lifted off. Within this layer, we prepared
toward the orbita and bridge of the nose, respectively,
to reach the origins of the procerus muscles near the
nasal bones (ossa nasalia). The connective tissue on
the underside of the muscles was removed to make it
possible to trace the muscle bers from their origins
to their attachments.
The removed musculocutaneous layer was then
sliced medially, the origins of the procerus muscles
were cut off and the muscle aps thus obtained folded
aside, and we continued the vertical incision as far as
the cranial border of the cartilage of the nasal wings.
The muscular noose of the nasalis muscle over the
cartilaginous side and septum was also severed, and
we examined the extent of the antimere muscle ber
linkage by removing the skin insertions in the area of
the nasal bridge. The coat of soft tissue covering the
bone or the cartilaginous nasal structure was also
removed en bloc laterally from the midline.
To follow the course of the nasalis muscle bers,
we removed the adherent layer of connective tissue
on the underside. When we prepared the alae of the
nose, we observed many short muscles bers. However, we could not establish exact topographical connections. Only when the area around the mucous
membranes was prepared, were we able to reveal the
bers of the nasalis muscle near the base of the nasal
wings. Having cleaved the upper lip on the midline
horizontally, we succeeded in preparing the bers of
the nasalis muscle reaching out to the posterior circumference of the nares. We prepared its origin from
enoral.
To achieve a wider preparation area, we rst cut
both labial angles, extending the oral ssure, and
folded the upper lip cranially. Then, we split the oral
mucosa along this fold from the gingiva to the upper lip,
thus directly exposing the origins of the nasalis muscle.
We subsequently removed them from the orbicularis
oris muscle from the cranial to the caudal end to gauge
the course of the bers from the dorsal aspect.
Levator labii superioris muscle (5 levator lateralis muscle). Levator labii superioris alaeque
nasi muscle (5 levator medialis muscle). When
the skin and subcutis were removed, it was easy to

reveal the proximal parts of the levator medialis and

lateralis muscles. The levator medialis muscle was
prepared from the base of the nose on the level of the
right medial corner of the eye caudad, heading toward
the nasal wings and into the skin-insertion area, and
the levator lateralis and orbicularis oculi muscles were
prepared by detaching the skin and subcutis caudally
from the lower lid margin.
The bers of the orbicularis oculi muscle covering
the levator lateralis muscle were then removed
together with the fat layers between them. Because
they were closely interlaced we could not separate the
muscle bers of the nasalis, levator medialis, and lateralis muscles precisely enough to dene the extent
of their insertion area clearly or their interconnections
around the base of the nasal wings.

Macroscopic and Magnied Anatomical

Preparation from Inside
We then fashioned a musculocutaneous mask by
removing the bony elements forming the viscerocranium. All the periosteal structures were lifted and the
origins of the muscles were severed. The adherent
retromuscular connective tissue was removed, but no
attempt was made to preserve the neurovascular
structures.

Plastination Histology
Six midface regions were treated according to the
method of plastination histology developed by Fritsch
(Fritsch, 1989; Fritsch and Hegemann, 1991). The
samples were xed in formalin, rinsed in water for 24
hr, and then dehydrated in acetone by freeze substitution at 225 C for 5 weeks until the residual water content amounted to less than 1%. Two weeks of
degreasing with methylene chloride at room temperature was followed by forced impregnation with epoxy
resin (BIODURV E12). When the samples had hardened completely, they were cut into 500-mm thick
transverse, frontal, and sagittal slices with a diamond
saw (WellV, Ebner, Mannheim, Germany), put on
slides, wet-sanded and polished, and then immersed
in AzureII//Methylene Blue in sodium bicarbonate to
be investigated microscopically according to the pro and Levai (1975) and by
tocols developed by Lazko
Fritsch (1989; Fritsch and Hegemann, 1991), and
afterwards counterstained with basic fuchsin.
The sections were then examined microscopically
(Wild-Heerburg, Switzerland) and photographed. The
method we used stained connective tissue violet-blue,
muscles greenish-blue, adipose tissue bright-pink,
bones blackish-brown, and cartilage violet.
R

Plastination of Slices
For this technique (Hagens et al., 1987), the
formalin-xed heads of four body donors were frozen
at 280 C, cut into 35 mm thick sagittal and frontal
slices with a band saw, dehydrated in acetone at
225 C, and degreased with methylene chloride. The
slices were then force-impregnated with epoxy resin

1180 Konschake and Fritsch

R

(BIODURV E12) for 1 day and nally put between two

panels of glass in an incubator and cured at 150 C for
23 days. When the glass panels were removed, the
transparent slices could be viewed and photographed
from both sides.

RESULTS
Topographical mapping of the nasal muscles and
their positional relationships:

Nasalis Muscle
This muscle takes its origin from the periosteum of
the juga alveolaria maxillae of the equilateral incisor
teeth, from the indentation between them and the
hollow between the lateral incisor tooth and the cuspid
(Figs. 1a1d).
The bers originating from these hollows are situated directly above the fold of the mucous membrane
of the oral cavity (Fig. 1e).
The area of origin of the nasalis muscle ascends
along the upper jaw from the medial to the lateral
aspect. As far as the direction of its course and the
insertion areas of the different muscle ber bundles
are concerned, the nasalis muscle can be divided
macroscopically into three portions (Figs. 1a1c),
which are named topographically as follows:
1. Pars ostii posterioris (POP)ventromedial
bers: These ascend steeply cephalad to double
over across the bers of the orbicularis muscle
ventrally (Fig. 1e) and nally insert into the
corium of the back perimeter of the nares (Fig.
1f), with a possible extension medially into the
columella. There they attach caudally and laterally to the equilateral medial crus of the alar
cartilage (Fig. 1g), closely proceeding along and
intermingling with the steeply ascending bers
of the orbicularis oris muscle that crosses the
midline here (Fig. 1g).
2. Pars alaris basalis (PAB)dorsolateral bers: In
almost fan-shaped form, they run laterocranially and insert laterally into the corium from the
base of the nasal wings and medially from the
neighboring nasolabial fold (Fig. 1h). The insertion areas of the PAB and POB merge into each
other, the PAB-bers being closely intermingled
with those of the levator medialis and lateralis
muscles, which also insert here (Fig. 1h).
3. Pars nasi intermediae (PNI)dorsolateral of the
PAB-bers: Closely adjacent to the maxilla, this
portion follows the piriform aperture forming an
arc (Figs. 1h and 1i) and moves forward divergently to the bridge of the nose, where most of
its bers form a loop with the antimere muscle
(Fig. 1j). Another part radiates into the skin
above the lateral cartilage and forward and
downward into the skin of the nasal wing (Fig.
1i). In its course along the maxilla, the exterior
surface of this portion cannot be separated denitely from the laterally adjoining bers of the
levator medialis and lateralis muscles (Fig. 3c).

The nasalis muscle is situated directly below the

skin only near the bridge of the nose; everywhere else, it is always covered by the bers of
the levator medialis and lateralis muscles and
those of the orbicularis oris muscle (Fig. 1d). At
its beginning, the nasalis muscle is a homogenous muscle without segmentation by connective or fatty tissue (Fig. 1d). The gap between
the two antimere nasal muscles from the fold of
the mucous membrane of the oral cavity to the
spina nasalis anterior is lled with fatty tissue
(Figs. 1d and 1h), bordered ventrally by the
orbicularis oris muscle and dorsally by the maxillary alveolar processes. Moreover, this fat pad
contains accessory salivary glands, branches of
the superior labial artery, and concomitant
nerves. Cranially, it peters out in the area of
the lateral cartilage (Fig. 1h). After crossing the
osseous barrier constituting the brink of
the nasal entrance, the fatty tissue borders on
the strongly vascularized submucosal tissue of
the nasal mucosa, itself streaked by numerous
veins.

Levator Labii Superioris Muscle (5 Levator

Lateralis Muscle)
This muscle has its origin at a rough bony area or
crista of the zygomatic process of the maxilla below
the margo infraorbitalis, the line of its origin varying
in width (Figs. 2a2c). The infraorbital foramen is consistently covered by the medial part of the levator labii
superioris muscle; further lateral, the line slants caudad, passing the infraorbital foramen laterally. In all
specimens, the cranial part of the levator lateralis
muscle was supercially covered by the orbicularis
oculi muscle and crossed by the facial vein. Cranially,
its insertion area begins at the medial half of the
nasooptic furrow and the base of the nasal wings and
ends at the skin of the upper lip laterally from the
edge of the philtrum, sometimes reaching as far as
the labial angle (Fig. 1h). With its medial part, the
muscle is located behind the rear face of the levator
medialis muscle and laterally from the PNI-bers of
the nasalis muscle (Fig. 2c). In the area between the
nasolabial fold and the base of the nasal wings in the
direct vicinity of the skin the bers of the levator lateralis intermingle inextricably with those of the levator
medialis and the PAB-portion of the nasalis muscle
(Fig. 1h). The infraorbital vessels and nerves lie dorsal
of the muscle, that is, between its periosteum and
main part (Fig. 2c).

Levator Labii Superioris Alaeque Nasi

Muscle (5 Levator Medialis Muscle)
This muscle originates from the medial palpebral
ligament and from the periosteum of the nasofrontal
process of the maxilla (Figs. 3a and 3b) from which it
is, during its course, separated only by some fatty tissue, with PNI-bers of the nasalis and levator lateralis
muscles interposing caudally, so that their bers cross

Mapping of the Nasal Muscles and Application to Cosmetic Surgery 1181

Fig. 1.

1182 Konschake and Fritsch

in the contact area of the muscles (Fig. 3c). Most of its
bers insert in the skin area of the nasolabial fold and
the furrow of the nasal wings (Fig. 1). Fewer bers
reach the upper lip in a medially concave arc, where
they adjoin those of the levator labialis muscle and
become indistinguishable and indiscernible from them
in the process. The path of the infraorbital vessels and
nerves runs dorsally from the muscles or between
them and the nasalis muscle (Figs. 2b and 2c).

DISCUSSION
Previous studies have described the anatomy of the
nasal prole including soft tissue structures overlying
the cartilaginous skeleton of the nose and their relationship to the dorsum shape (Anderson et al., 2008)
or have given details of the effects of the nasal
muscles on the nasal airway (Kienstra et al., 2005).
The muscular dynamics and their anatomical terminology (nomina anatomica) have also been discussed
(Figallo and Acosta, 2001). None of these studies
gave a detailed description of the origins, attachments, and topography of the nasal muscles because
none of them could document the topographical relationships in true form, applying different anatomical
techniques.
With the detailed ndings described in our study,
we demonstrated that all bers of the muscles inuencing the nose originate directly at the corium without regard to their respective areas, and in some
cases they can be traced to the border of the epidermis. However, it must be conceded that even in the
plastinated histological slices a considerable number
of muscle bers could not denitely be traced to their
starting points.
No general supercial musculo-aponeurotic system (SMAS) consistent with the denitions of Mitz
and Peyronie, a bro-muscular network including all
nig, 1997)
face muscles (Mitz and Peyronie, 1976; Ho
Fig. 1. (a, b) Lateral, frontal: Nasalis portions at the
cranial bone: 1a PNI violet, 1b PAB green, 1c POP blue
originattachmentcourse, and black 5 orbicularis oris
muscle. (c) Mask with the course of the different nasalis
portions (1a PNI violet, 1b PAB green, 1c POP blue) and
the course of the levator medialis (2 orange), and lateralis
muscle (3 red). Black 5 orbicularis oris muscle. (d) Transverse section (plastination histology). Origin of the nasalis muscle at the maxilla close to the orbicularis oris
muscle and median fat pad. OR 5 orbicularis oris,
M. 5 maxilla, N. 5 nasalis muscle, and FP 5 fat pad(s). (e)
Sagittal section (plastination histology) through the upper
lip and maxilla. Origin of the nasalis muscle. N 5 nasalis
muscle, OR 5 orbicularis oris muscle, M 5 maxilla, and
NL 5 nostrils. (f) Transverse section (plastination histology) at the level of the spina nasalis anterior maxillae.
OR 5 orbicularis oris muscle, POP 5 pars ostii posterioris
mm. nasalis, N 5 nasalis muscle, SNA 5 spina nasalis
anterior. (g) Sagittal section (plastinated slices) through
the upper lip and maxilla with the course of the bers of
the POP-portion of the nasalis muscle. N 5 nasalis muscle,
OR 5 orbicularis oris muscle, Di 5 dens incisivus,

developed and presentable in the area of the cheek

and the retromandibular fossa, was found in the
course of our examinations. It is remarkable that in
the meshes of this connective tissue network and
among the muscle bers originating there, there are
small clusters of adipose cells that constitute a specic
arrangement of corial muscle attachments. In agreement with Ghassemi et al. (2003) and the investigations of Har-Shai et al. (1996), one might speak of a
constant, organized bro-muscular network of the
face in this area, consisting of collagen bers, muscle
bers and adipose cells connecting the face muscles
to the dermis.
It was not possible to differentiate the separately
prepared layers in the midface regions clearly. This is
consistent with earlier investigations by Gardetto
et al. (2003) and by Figallo and Acosta (2001).
However, according to our results, a topographicalhistological differentiation between a laterally positioned type I and a medially positioned type II
SMAS (Har-Shai et al., 1996; Ghassemi et al., 2003)
appears to make sense. The nasolabial fold serves as
the border of this medial or lateral compartment. The
lateral (5 type I) SMAS is a brous, septated network
enveloping lobules consisting of adipose tissue, which
are afxed to the periosteum or the facial muscles. The
medial (5 type II) SMAS contains mixed and disseminated elastic collagen bers, muscle bers, and adipose
cells, guaranteeing that the musculature is solidly
afxed to or embedded in the dermis.
Our observations therefore resulted in the following
clinical consequence: To spare the ne skin insertions
of the facial muscles, surgeons can try (if circumstances allow) to operate on a submuscular preparation
level, though admittedly there is a danger of injuring
the nerves and vessels running dorsally of the muscles.
The exact topographical neurovascular supply pattern to these muscles inuencing the nose must therefore be the subject of further anatomical investigations.

M 5 maxilla, Cm 5 Crus mediale cartilaginis alaris, and

Cn 5 cavitas nasi. (h) Transverse section (plastination
histology) at the level of the spina nasalis anterior maxillae with insertion of the POP- and PAB-portions. The PNIportion is separated from the levator muscles by infraorbital nerve branches. OR 5 orbicularis oris muscle,
VNB 5 vessel-nerve-branches,
L 5 levator
muscles,
M 5 maxilla, and FP 5 fatty tissue parts. PAB- 1 PNI1 POP-portions. (i) Sagittal section (plastinated slices)
through the base of the nasal wings with the origin and
course of the nasal wings of the PNI-portion and intermingling with the bers of the M levator medialis. X 5 brous
attachments of the levator and nasalis muscle (PAB),
OR 5 orbicularis oris muscle, Lm 5 levator medialis muscle (PNI-portion), M 5 Maxilla, and FNW 5 furrow of the
nasal wings. (j) Transverse section (plastination histology). Muscle loop of the antimere nasalis muscles.
ML 5 muscle loop, LC 5 lateral cartilage, S 5 septum,
Cn 5 cavitas nasi, PNI 5 PNI-portion, and FP 5 fat pad.
[Color gure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]

Mapping of the Nasal Muscles and Application to Cosmetic Surgery 1183

Fig. 2. (a, b) Levator lateralis muscle at the cranial

bone and the mask preparation sample. Red, 3 5 levator
lateralis muscle and Black 5 orbicularis oris muscle. (c)
Transverse section (plastination histology) at the level of
the concha nasalis inferior with description of the relationships between the levator muscles and the infraorbital

nerves and vessels. Ll 5 levator lateralis muscle, Lm 5 levator medialis muscle, M 5 maxilla, VNB 5 vessel-nervebranches, Cn 5 cavitas nasi, and Sm 5 sinus maxillaries.
[Color gure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]

Fig. 3. (a, b) Origin, attachment, and course of the

levator medialis muscle at the cranial bone and the mask
preparation. Orange, 2 5 levator medialis muscle, Black5 orbicularis oris muscle. (c) Transverse section (plastination histology) cephalad of the concha nasalis inferior.

Lm 5 levator
medialis
muscle,
PNI 5 PNI-portion,
VNB 5 vessel-nerve-branches, and M 5 maxilla. [Color
gure can be viewed in the online issue, which is available
at wileyonlinelibrary.com.]

CONCLUSIONS

ACKNOWLEDGMENTS

The course of the anatomical bers of individual

nasal muscles presented macroscopically and microscopically in this study offers surgeons a detailed
overview of the anatomically important muscular
landmarks of the midface.

The authors thank Andreas V. Criegern, Claudia

rmann for their assistance, proSimon, and Romed Ho
ducing the photographs, and help in graphically processing them. The authors also wish to thank the
individuals who donated their bodies and tissues for the
advancement of education and research.

CONFLICT OF INTEREST STATEMENT:

The authors have no nancial interest to declare in
relation to the content of this article. No outside funding was received.

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