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Romanian Journal of Morphology and Embryology logoLink to Romanian Journal of Morphology and Embryology
. 2023 Jun 30;64(2):199–206. doi: 10.47162/RJME.64.2.10

Clinical and morphofunctional identity of the nasal SMAS

Marius Valeriu Hînganu 1, Delia Hînganu 1, Octavian Dragoş Palade 2, Iuliana Eva 3, Simona Ruxandra Volovăţ 4, Ramona Paula Cucu 5,6, Victor Vlad Costan 5
PMCID: PMC10520399  PMID: 37518877

Abstract

The fascial system of the face (superficial musculo-aponeurotic system, SMAS) in the nasal part is a sustained layer that connects the nearby regions. In this paper, we aimed to emphasize the presence of SMAS in different areas of the nasal region: ala nasi, nasolabial fold, nasal dorsum and radix. We performed three studies (anatomical, histological, and radiological) to demonstrate the existence of nasal SMAS. The study group consisted of cadaveric analyses and retrospective analysis of the patient radiological data. The nasal SMAS was identified as a superficial fascia and a subcutaneous adipose layer. The anatomical dissection study together with histological and radiological evaluations demonstrated the presence of SMAS in the nasal region. We identified peculiarities of the nasal SMAS in two areas: in the ala nasi where it is thinner, and the deep part of the dermis does not adhere to the underlying structures and at the radix and dorsum nasi, where the adipose layer is very thin. The results of our research define nasal SMAS as a unit of great value in facial surgeries, such as facial rejuvenation, the resolution of malformations, or tumor removal.

Keywords: SMAS , nasal region , nasal surgery , radix , dorsum nasi , ala nasi

Introduction

Superficial musculo-aponeurotic system (SMAS) is an anatomical and surgical concept [1, 2] that is not yet completely understood or accepted by researchers. Several authors have previously reported their evaluations of the morphofunctional features of the SMAS, particularly the parotid, masseteric, and labial regions [3, 4, 5]. Soft tissue of the face is topographically formed by the following layers: skin, subcutaneous adipose tissue, superficial fascia, facial muscles, parotidomasseteric fascia, and the parotid duct, facial nerve, and buccal fat tissue [6]. It has been demonstrated that the nasal SMAS unites similar structures of nearby regions [7]. In the nasal region, adipose trabeculae forms and provides antigravitational support of the superficial soft tissues. It provides fixation and elevation of the SMAS of the upper lip [5]. From an anatomical and surgical perspective, the nasal region comprises the following parts: (i) The nasal root, which is the upper part of the nose that joins with the forehead [8]. It is located under the glabella, forming a prominence known as the nasion. (ii) The nasal dorsum, which is the boundary between the root and the tip of the nose; this has a different appearance in different profiles [9]. (iii) The ala nasi, which is the inferior lateral surface of the outer nose, is mostly made up of cartilage. (iv) The nasolabial groove. The SMAS layer is the central part of the nose, which is accompanied by a superficial adipose layer. The main function of this layer is to allow the movement of the superficial layers of the nasal region, to form laminae carrying vessels and nerves, to maintain the thickness of the skin, and to transmit the contractile force of the nasal muscles to the skin [10]. The SMAS layer mainly consists of procerus, anomalous nasi and the transverse nasal crease [11]. The superficial, conventional limits of this region are: (i) superior – the horizontal plane through the infraglabellar notch, corresponding to the frontonasal suture and the cephalometric landmark called the nasion; (ii) inferior – the transversal plane between the posterior part of the nasal septum and nasolabial groove; and (iii) lateral – the two planes that unite the nasolabial groove with the nasogenian groove on each side [12, 13]. The nasal region can be subdivided into the proper nasal region (regio nasalis – RN) and the nasal wing (ala nasi – AN). There are major differences between these two regions from morphological and visual points of view. The nasolabial groove (sulcus nasolabialis – SNL) connects the AN, the infraorbital and oral regions, through the SMAS. The superficial fascia of the nose inserts to the periosteum, because of skin attachment of the levator anguli oris muscles, zygomaticus, and levator labii superioris [14, 15, 16, 17, 18, 19]. Multiple anatomical relationships between the facial muscles and the surrounding bones, structures, and skin can be visualized on magnetic resonance imaging (MRI). In this study, we only used MRI because it does not produce Roentgen radiation and provides the same results as computed tomography (CT) [20, 21]. The nasal muscles (procerus, and the compressor naris major and minor) are considered part of the SMAS in this region. The SMAS in the nasal region communicates with surrounding SMAS through the levator labii alaeque nasi and the dilator nasi muscles [22]. The transverse segment of the nasalis muscle is of major importance for the surgical SMAS flap which attaches to the maxilla and ascends to the dorsum of the nose [23].

Aim

We aimed to investigate and describe the settlement of the SMAS in various parts of the nasal region: the radix, the nasal dorsum, nasolabial fold, and ala nasi. We also evaluated the morphological and topographical features of the nasal subregional area and attempted to configure the functional anatomy of this structure and the related implications for nasal surgery [24]. However, the distribution, morphology, and functionality of the SMAS at the nasal level have yet to be determined by the literature. Our study presents new and relevant data about the nasal SMAS cytoarchitecture and its extensions and places the functionality of this anatomical structure in the context of the entire facies. We make this statement because the present study is an integral part of our research team’s project on the morphofunctional and clinical characteristics of SMAS at the level of the entire face, which began in 2004 and is still ongoing.

Materials and Methods

Anatomical study

The anatomical study was performed on 24 cadaveric specimens from Ion Iancu Institute of Anatomy, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania. Through dissection, we identified the overlapping layers: the dermoepidermal layer, the adipose subcutaneous layer, the superficial fascia layer, the superficial muscular layer, and the deep fascia, perichondrium, and periosteum, which were dissected in the coronal plane, from the superficial to the third plane, as demonstrated by the schematic illustration in Figure 1. Of the donors, three were male and nine were female (age range: 63–90 years).

Figure 1.

Figure 1

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Spatial disposition in the anterior regions of the face. 1: The skin layer, epidermis, and dermis, with the denser deep part, serving as the insertion for the muscles of facial expressions; 2: The subcutaneous fat layer; 3: The superficial plane of the facial muscles, which differs according to the studied region; 4: The plane of the branches of the facial nerve – dissection plane medial to the nasolabial groove; 5: The deep plane of the facial muscles, which differs from one region to another – dissection plane lateral to nasolabial groove

An incision was made by following the medial edge of the nasolabial groove over its entire length, up to the periosteum. Then, we removed the superficial layers from the entire surface of the heminose from root to tip. We continued the dissection to the lateral part by separating the SMAS from the deep periosteum.

The macroscopic study was performed using the SOM 62 Kaps microscope made by Karl Kaps Germany (zoom adjustment: 5×–8×–12.8×; objective lens: f=250), from the Laboratory of Quantitative Microanatomy of the Ion Iancu Institute of Anatomy, Grigore T. Popa University of Medicine and Pharmacy, Iaşi.

Histological study

For the histological study, we collected tissue fragments from the skin to the deep layers, from 4% formalin-embalmed cadaver specimen, which can be used reliably for histopathological investigation if cellular morphology is the major criteria for diagnosis. These layers were processed using a paraffin technique and stained using special Verhoeff’s and Szekely techniques [25, 26, 27, 28] to highlight collagen, elastin, and muscle fibers. These fragments were collected from the lateral side of the nasolabial groove at the junction with the infraorbital region (NLIO), the jugal region (NLJ), the angle of the mouth (NLAO), and the upper lip (NLLS).

Quantitative measurements were performed on microscopical pictures using an image acquisition system, after which the Prodit 5.2 professional software (BMA, Amsterdam, The Netherlands) was used. The results were processed. Stereology used the standard grid with Weibel parallels to quantify the percentage volumes of the main parietal structures of the blood vessels. This procedure allows estimation of the percentage volumes of the tumor’s component structures (tumor cells, stroma, and blood vessels). The digital overlay of the standard grid over the acquired video image from the histology slide is used. The grid corresponded to the parameters of the structures to be studied to meet the optimal quantification conditions.

Quantitative study

We used stereology to evaluate the percentage volumes of the studied structures. The main stages of the measurement are: (i) determining the reference structures: collagen fibers, elastic fibers, muscle fibers, interstitium; (ii) defining the Weibel geometric grid superimposed on the microscopic image; (iii) determining the total number of points to be counted and counting them by pressing the keys corresponding to the intersections with the reference structures; (iv) automatic calculation of the stereological ratio; (v) statistical evaluation of the calculated parameters; (vi) graphic representation of the observed changes; (vii) formulating conclusions.

In each case, a test surface corresponding to 540 points on the test grid with Weibel parallels, with a distance between two points of d=15.07 μm, was studied with the 40× objective. The orientation of the test lines was changed during quantifications to ensure random intersection of all structures.

The statistical report assessed the percentage volumes of the reference structures in each case, then on the topography of the veins. The results of the quantifications were then represented graphically.

Radiological study

The radiological study was conducted on a group of 11 people (eight males and three females) using MRI at the Arcadia Medical Imaging Center, Iaşi. All subjects were adults aged between 27 and 51 years, and MRI investigations and 3D reconstructions had been performed previously for reasons related to oromaxillofacial or plastic surgery pathology. We highlighted the continuity of the SMAS in the nasal region on the acquired images.

The group of patients investigated using the MRI technique were subjected to this examination due to their basic pathology: facial aesthetics issues (wrinkles, facial prolapse) as well as parotid and submandibular tumors. They were meticulously selected so that the underlying disease would not affect the quality of the acquired images, nor their interpretation. The following MRI sequences were used: T2-weighted (T2W)–turbo spin echo (TSE) axial, T1-weighted (T1W)–fast field echo (FFE) axial native, and T1W–FFE axial with contrast agent.

Ethical considerations

This study followed the principles outlined in the Declaration of Helsinki. The Ethics Committee Approval of Grigore T. Popa University of Medicine and Pharmacy, Iaşi (Approval No. 195/June 3, 2022) and the Ethics Committee Approval of St. Spiridon Emergency County Clinical Hospital, Iaşi (Approval No. 13/February 25, 2022) are attached to this manuscript.

Results

Our study demonstrated the continuity of the SMAS in the nasal region. The SMAS had a different morphofunctional structure in the nasal wings compared to the nasolabial groove. We also demonstrated the continuity of the nasal SMAS with the surrounding regions.

Anatomical study

We identified the buccinator muscle in the deep plane of the nasolabial groove. Laterally (nasal wing), this plane was no longer found, and the superficial layer between the skin and nose muscles showed a thin layer of adipose tissue (Figures 2 and 3; Figure 4A and 4B).

Figure 2.

Figure 2

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Perioral muscles and nasal region. The levator anguli oris alae nasi (LAON) muscle, SMAS at the ala nasi (ANSMAS), orbicularis oris (OO) muscle, and SMAS in the nasolabial fold (NLFSMAS). Dissection specimen (SOM 62 Kaps microscope, ×20 oculars), 10/1 scale. SMAS: Superficial musculo-aponeurotic system.

Figure 3.

Figure 3

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Inferior part of the nasolabial groove with the terminal part of the facial artery. Dissection specimen (SOM 62 Kaps microscope, ×20 oculars), 10/1 scale

Figure 4.

Figure 4

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(a) Skin insertion of the zygomaticus, levator labii superioris, and levator anguli oris muscles – the border area between the zygomatic region (RZ) and cheek (RO); image taken with the operating microscope; (b) Perioral muscles and nasal region; the levator anguli oris alae nasi (LAON) muscle, SMAS at the level of the wing of nose (SN), orbicularis oris (OO) muscle, SMAS at the level of the lower and upper lips (SBIS)

The existence of a deep adipose layer of SMAS at this level allowed a block dissection of the superficial layers in the axial plane between a line that followed the medial edge of the nasolabial groove and the dorsum nasi. The same resectable area extended craniocaudally between the skin insertion of the procerus muscle and the parallel plane to the anterior edge of the homolateral nostril, about 3 mm above it.

The medial to the nasolabial groove, the levator anguli oris, levator labii superioris, and zygomaticus muscles showed skin insertion. At the same time, the orbicularis oris muscle adhered tightly to the deep surface of the skin (Figure 4A and 4B; Figure 5A and 5B). These insertions made dissection at this level difficult (Figure 6A and 6B).

Figure 5.

Figure 5

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(a) Dissection area lateral and medial to the nasolabial fold; (b) Facial vessels, connective tissue, fat, and fibers of the muscles of the nose. Dissection specimen.

Figure 6.

Figure 6

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Adhesions and perioral muscles of the nasal region: (a) Ligamentary adhesions that secure the SMAS to the deep fascia; dissection specimen (SOM 62 Kaps microscope, ×20 oculars), 10/1 scale; (b) Conjunctival adipose tissue in the cheek, prebuccinator, and perioral region; dissection specimen

Histological study

The deep adipose layer was thin, crossed by collagen septa, and the superficial fibroadipose layer was very well represented. The histological study identified the SMAS on the nasolabial groove in the form of a thick concentration of medium-sized collagen fibers. For the lateral to the nasolabial groove, there were numerous elastic fibers of various sizes (Figure 7A, 7B, 7C, 7D). The fragments from the lateral side of the groove were collected from the boundary with the adjacent regions: infraorbital, cheek, mouth angle, and upper lip.

Figure 7.

Figure 7

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Fibers of the SMAS: (a) SMAS medial to the nasolabial groove, with longitudinal collagen fibers; (b) Thinner collagen fibers and numerous elastic fibers, along with muscle fibers longitudinally arranged in the superior lip of the SMAS; (c) SMAS structure in the angle of the mouth, with numerous interlaced collagen fibers with elastic fibers almost absent; (d) Fibrous attachments that cross the infraSMAS adipose layer in the infraorbital region. Verhoeff’s staining: (a and b) ×400; (c) ×600. Szekely staining: (d) ×400

The SMAS structure in this region also contained isolated muscle fibers or small fascicles, most of which came from the cutaneous muscles that passed through the superficial area to the deep face of the skin (Figure 8A, 8B).

Figure 8.

Figure 8

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Various fibers of the SMAS: (a) Elastic fibers of various sizes in the SMAS structure, more numerous on the side of the nasal region; (b) Isolated muscle fibers or small bundles, most of which come from cutaneous muscles that pass through the superficial fascia, medial to the nasolabial groove. Verhoeff’s staining: (a and b) ×400

Quantitative study

To determine the proportions of the SMAS, we considered the proximity of the nasolabial groove. Thus, we determined the percentage of fibrous connective tissue in relation to the elastic and muscular tissue at the level of the nasolabial groove, and we also determined the morphological and functional aspects that continued into the neighboring regions.

Connective tissue had the highest percentage volume in the nasolabial groove, then in the infraorbital region and the cheek region and the lowest percentage volume in the upper lip. Muscular fibers had the higher percentage volume in the upper lip, then in the cheek and at the infraorbital level, and the lowest percentage volume in the parotid region.

The SMAS from the NLJ region showed the following quantified percentage volumes: connective tissue – 59.07%, muscular fibers – 27.22%, and interstitium – 13.70%. The stereological quantification from the SMAS in the NLIO showed the following percentage volumes: connective tissue – 67.59%, muscular fibers – 16.11%, and interstitium – 16.30%. The SMAS from the NLLS showed the following quantified percentage volumes: most of it was conjunctive tissue approx. 50%, muscular fibers approx. 40%, and interstitium approx. 20%. The SMAS from the NLAO showed the following percentage volumes: connective tissue – 79.07%, muscular fibers – 1.11%, and interstitium – 19.81%.

Figure 9 shows the significance of these findings, highlighting the regional variability of the SMAS at the facial level.

Figure 9.

Figure 9

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Graphical representation of quantified percentage volumes in the SMAS in the studied regions.

Radiological study

The results of the MRI study showed that the SMAS in the nasal region continued cranially with the procerus muscle fascia and then with the frontal fascia. The SMAS was laterally continuous with the SMAS from the jugal and infraorbital regions (Figure 10A and 10B; Figure 11A, 11B, 11C, 11D).

Figure 10.

Figure 10

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Axial MRI: (a) Infraorbital insertion and transSMAS of the major zygomatic muscle (ZMI); (b) TransSMAS insertion of the levator labii superioris muscle (TIL). MRI: Magnetic resonance imaging

Figure 11.

Figure 11

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Specimen sections: (a and c) Sagittal section (SS) through the wing of the nose; SMAS continues to the frontal fascia; (b and d) Axial section (AS) highlighting the jugal SMAS and the insertions into the skin of the nasal muscles, marked with red arrows. A: Anterior insertion of the SMAS on the dorsum nasi.

In MRI exploration, the SMAS behaved just as we had seen during dissections, facilitating the insertion of nasal mimic muscles into the deep surface of the skin (Figure 10A, 10B; Figure 11A, 11B, 11C, 11D). The MRI showed the same strong periosteal and perichondral insertions of the SMAS at the radix, dorsum nasi, and nasolabial groove. The area between these inserts mediated the transfascial attachments of the nasal and adjacent muscles into the deep surface of the skin.

The results of our histological, quantitative, and qualitative studies are correlated with our radiological study and demonstrated that our findings based on classical anatomical dissection are reliable and sustainable.

Discussions

The nasal SMAS was identified as a superficial fascia and a subcutaneous adipose layer. The anatomical dissection study together with histological and radiological evaluations demonstrated the presence of SMAS in the nasal region. We identified peculiarities of nasal SMAS in two areas: in the ala nasi where it is thinner, and the deep part of the dermis does not adhere to the underlying structures and at the root and dorsum nasi, where the fatty plane is very thin. Through anatomical study, we confirmed the presence of a superficial musculoaponeurotic layer in the nasal region in all explored cadavers.

In the nasal region, we identified the following layers (from superficial to deep): (i) the skin, epidermis, and dermis, with a deep thinner part, which support mimic muscles; (ii) the subcutaneous fat layer; (iii) the superficial fascia; (iv) the superficial plane of the facial muscles.

The results of this study support the findings of other authors [29, 30] who reported five layers of the nasal region, which are: the subcutaneous fatty layer, the fibromuscular layer, the profound fatty layer, the fibrous longitudinal layer, and a layer that contains interdomal ligaments. We consider that, at this level, the SMAS is represented by a second layer: a fibromuscular one, which interconnects with the alar muscles and distributes power to the dermis.

The superficial fascia is gradually thinned to the modiolus but remains visible as a net layer both on the MRI and in the dissected specimens. In the upper part of the region, towards the radix base, the two fasciae (superficial and deep) join in a dense connective structure. This structure is the dermocartilaginous ligament [31, 32, 33, 34]. Medial to the nasolabial groove, the superficial fascia is more obvious and protects the upper branch of the angular artery, the homonymous vein, and the superficial branches from the facial nerve.

Through histological, quantitative, and qualitative studies, we have demonstrated that the nasal SMAS differs both macroscopically and microscopically in the AN compared to the radix, dorsum, or nasolabial groove. On one hand, at the AN level, the muscles at this level are inserted into the dermis transfascially, clearly delineating the SMAS line, while in the nasal dorsum the superficial fascia has no muscular fascicles.

The results of the stereological and histological study showed that the structure and architecture of the SMAS from the nasal region, especially from the nasolabial groove, allow the traction of conjunctive and fibroadipose structures underlying the skin. Together with the superficial muscles, it also allows them to return to a repose state.

Medial to the nasolabial groove, the SMAS shows a longitudinal disposition of the collagen fibers. A similar structure is found where it continues with the SMAS from the mouth angle and infraorbital region. In contrast with this structure, the nasal SMAS becomes more elastic at its continuity with the superior labial region of the SMAS [35, 36, 37]. At this level, collagen fibers become scarce and muscular fibers predominate. Collagen fibers are disposed on successive longitudinal and transverse planes and gradually, as we descend, they lose their proper structure, arranging themselves in different types of lamellae, especially at the level of the modiolus.

These findings can be applied to modern surgical practice, particularly in various facial rejuvenation techniques, such as injectable filler treatment [38, 39, 40, 41, 42].

The buccinator muscle forms the profound muscular plane of the nasolabial groove, except for the ala nasi. Under the dermis, we found collagen fibers, fat cells, and muscle fibers mixed with nasal muscle fibers, which form a distinctive layer between the dermis and the nasal muscles.

Quantitative CT measurements performed by Macchi et al. [43], at the nasolabial fold, showed that the superficial fibroadipose layer was low represented and the profound adipose layer had an increased thickness. Meanwhile, where the SMAS continued to the facial expression muscles, this layer had an average thickness of 2.41±0.05 mm. Our previous studies showed that the SMAS structure at the level of the nasolabial groove was similar to that of the parotidomasseteric region [3, 4]. Under the same structural shape, the SMAS continues to the infraorbital, jugal, and angle of the mouth areas.

Unlike classical anatomy, where it is considered that subcutaneous adipose tissue is missing from the superficial fascia where the skin adheres to the subjacent layers, our study demonstrated its continuity into the nasal region without subdivision, which is already deemed clinically relevant [11, 44]. This correlates with the results obtained by other researchers in the field and has implications for injectable filling procedures performed at this level. The filling will be gravitationally dispersed in the nasal regions compared to areas in which the fat layer is compartmentalized, which ensures the fluid remains in the desired position [19, 45, 46].

Another important clinical application of the notion of the SMAS is facial rejuvenation surgery, especially rhytidectomy. In the nasal region, the SMAS is used as nasolabial flaps for deep plane rhytidectomy surgery [41, 47, 48]. This is preferable to other interventional methods due to the special structure of the nasolabial SMAS collagen matrix, which delivers remarkable results at a distance. The nasal skin has lack of mobility; this is why the repair of nasal skin defect with a local flap is challenging to plastic surgeons [49].

From a functional perspective, the manner of attachment of the SMAS to the viscerocranium is of utmost importance. This provides facial skin firmness and acts as a fixed point in facial muscle contraction.

Even though the superficial fascia gradually narrows to the modiolus, its thickness remains and appears as a net layer on MRI. This was also observed during the dissection of specimens. At the base of the nasal pyramid, it appears that the superficial and deep fascia are joined in a dense connective structure, most likely the dermocartilaginous ligament [29, 50]. To the medial side of the nasolabial groove, the superficial fascia becomes more obvious and mediates the cutaneous insertion of the zygomatic muscles. The strong insertion of the SMAS into the periosteum of the nasolabial groove makes this region a hinge and suspension mechanism for the soft tissues of the upper lip, and for the perioral muscular apparatuses [5]. At the same time, these insertions act as a barrier to possible infections at or from this level.

It is clearly important for cosmetic surgeons who perform rhytidectomy procedures to have a good understanding of the SMAS, given that the SMAS is dissected and mobilized during these procedures. Our findings have applications in many other medical fields. Firstly, knowing the anatomy of this region is crucial to understanding the evolutionary particularities of tumors that develop at this level, the principles of tumor excision, and for the selection of appropriate reconstructive techniques for soft tissue defects located in the nasal pyramid. In addition, palatine cleft surgery is based on studies of anatomy and embryology, which are absolutely indispensable for achieving the best aesthetic and functional results. Several previous articles have reported that preoperative MRI evaluation of facial anatomy is useful for surgical planning and postoperative follow-up in patients with a cleft palate [51, 52, 53]. Tumor and traumatic lesions that affect the nasal region also require interventional techniques based on the concept of the unique cervicofacial layer [54, 55].

Conclusions

Our study presents the cytoarchitecture, morphology, and topography of the nasal SMAS from an integrative, functional, anatomical, and clinical perspective. During the study, we faced several limitations. Firstly, dissections were performed on hemifacial that had been fixed in formalin; had such dissections taken place on hemifacial that had not been fixed in formalin, the results may have been different. Secondly, a greater MRI magnetic field strength may have produced different results. Despite these limitations, we demonstrated that the SMAS is a continuous layer of the nasal region between two adipose layers. Understanding nasolabial groove anatomy and adjacent areas allows a surgeon to achieve much more accurate results. The results of our research define nasal SMAS as a unit of great value in facial surgeries, such as facial rejuvenation, the resolution of malformations, or tumor removal.

Conflict of interests

The authors declare no conflict of interests.

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