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Background The efficacy of facial muscle exercises (FMEs) for facial rejuvenation is controversial. In the majority of previous studies, nonquantitative assessment tools were used to assess the benefits of FMEs. Objectives This study examined the effectiveness of FMEs using a Pao (MTG, Nagoya, Japan) device to quantify facial rejuvenation. Methods Fifty females were asked to perform FMEs using a Pao device for 30 seconds twice a day for 8 weeks. Facial muscle thickness and cross-sectional area were measured sonographically. Facial surface distance, surface area, and volumes were determined using a laser scanning system before and after FME. Facial muscle thickness, cross-sectional area, midfacial surface distances, jawline surface distance, and lower facial surface area and volume were compared bilaterally before and after FME using a paired Student t test. Results The cross-sectional areas of the zygomaticus major and digastric muscles increased significantly (right: P < 0.001, left: P = 0.015), while the midfacial surface distances in the middle (right: P = 0.005, left: P = 0.047) and lower (right: P = 0.028, left: P = 0.019) planes as well as the jawline surface distances (right: P = 0.004, left: P = 0.003) decreased significantly after FME using the Pao device. The lower facial surface areas (right: P = 0.005, left: P = 0.006) and volumes (right: P = 0.001, left: P = 0.002) were also significantly reduced after FME using the Pao device. Conclusions FME using the Pao device can increase facial muscle thickness and cross-sectional area, thus contributing to facial rejuvenation. Level of Evidence: 4
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Aesthetic Surgery Journal
2017, 1–14
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DOI: 10.1093/asj/sjx238
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Facial Surgery
Effect of a Facial Muscle Exercise Device on
Facial Rejuvenation
Ui-jae Hwang, PhD, PT; Oh-yun Kwon, PhD, PT;
Sung-hoon Jung, MS, PT; Sun-hee Ahn, MS, PT; and
Gyeong-tae Gwak, B.H.Sc, PT
Abstract
Background: The efficacy of facial muscle exercises (FMEs) for facial rejuvenation is controversial. In the majority of previous studies, nonquantitative
assessment tools were used to assess the benefits of FMEs.
Objectives: This study examined the effectiveness of FMEs using a Pao (MTG, Nagoya, Japan) device to quantify facial rejuvenation.
Methods: Fifty females were asked to perform FMEs using a Pao device for 30 seconds twice a day for 8 weeks. Facial muscle thickness and cross-
sectional area were measured sonographically. Facial surface distance, surface area, and volumes were determined using a laser scanning system before
and after FME. Facial muscle thickness, cross-sectional area, midfacial surface distances, jawline surface distance, and lower facial surface area and volume
were compared bilaterally before and after FME using a paired Student t test.
Results: The cross-sectional areas of the zygomaticus major and digastric muscles increased significantly (right: P < 0.001, left: P = 0.015), while the
midfacial surface distances in the middle (right: P = 0.005, left: P = 0.047) and lower (right: P = 0.028, left: P = 0.019) planes as well as the jawline surface
distances (right: P = 0.004, left: P = 0.003) decreased significantly after FME using the Pao device. The lower facial surface areas (right: P = 0.005, left:
P = 0.006) and volumes (right: P = 0.001, left: P = 0.002) were also significantly reduced after FME using the Pao device.
Conclusions: FME using the Pao device can increase facial muscle thickness and cross-sectional area, thus contributing to facial rejuvenation.
Level of Evidence: 4
Editorial Decision date: June 19, 2017.
An everlasting youthful appearance has been pursued by
humans of nearly all cultures for several centuries. Aging
is an inescapable part of human life that leaves traces on
the face in the form of wrinkles and sagging skin.1,2 As life
expectancy increases in many parts of the world, a youth-
ful appearance has become even more highly valued,3-5
and considerable efforts are being devoted to improving
and correcting facial aging.
From the Department of Physical Therapy, Yonsei University, Wonju,
South Korea.
Corresponding Author:
Dr Oh-yun Kwon, 234 Maeji-ri, Heungeop-Myeon, Wonju,
Kangwon-Do, 220-710, Laboratory of Kinetic Exercise based on
Movement Analysis, Department of Physical Therapy, Graduate
School, Yonsei University, Wonju, South Korea.
E-mail: kwonoy@yonsei.ac.kr
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As soft tissue ages, changes involving the nasolabial
region are closely associated with changes in the midface.
Facial aging is most noticeable in the increased prominence
of the nasolabial folds, a function of thinning soft tissues
superficial to the levator labii superioris and zygomaticus
major muscles, loss of the malar fat, including the medial,
middle, and lateral temporal cheek fat, and secondarily,
sagging skin above the malar fold.6
Correction of these manifestations of facial aging has
long been the exclusive field of plastic surgeons and derma-
tologists, with interventions including injections with botu-
linum toxin, chemical peeling, dermal fillers, facelift, laser
treatment, browlift, and eyelid surgery.7,8 However, there is
increasing interest in reducing facial aging by alternative
approaches, such as facial acupressure, facial acupuncture,
and, especially, through exercises aimed at strengthening,
moving, and manipulating the facial muscles.7 These alter-
native approaches are less invasive and less expensive, and
they can usually be performed by nonmedical specialists.8
However, the efficacy of facial muscle exercises for facial
rejuvenation is controversial. Some researchers have con-
cluded that these exercises are an effective way to reduce
wrinkles and sagging skin.9,10 For example, van Lieshout
et al9 reported a direct correlation between improved
skin elasticity in weakened and sagging facial skin and
increased facial muscle exercise (FME). The skin may ben-
efit from FME through improved tissue regeneration and
enhanced drainage of waste materials via increased lymph
and blood circulation.10 Yet, other studies have reported
adverse effects of FME.11-14 According to Roizen and Oz,11
wrinkles result from repetitive movements of the skin,
specifically, repeated contraction of the facial muscles,
combined with the loss of elastin and collagen with aging.
FMEs that involve repeated folding of the facial skin might
therefore induce or aggravate, rather than lessen, the for-
mation of wrinkles.11 Excessive manipulation or massage
of the skin may increase the loss of elasticity, thereby also
promoting facial skin wrinkling and sagging.12-14
Previous studies suggested FME reduces vertical wrin-
kles above the upper lip by training the middle part of
the superior orbicularis oris muscle. Other exercises have
been aimed at reducing the depth of the nasolabial folds by
training the zygomaticus major muscle and at eliminating
a double chin while obtaining a more defined jawline by
training the suprahyoid muscles.9,10 However, the majority
of studies on FME have assessed the outcome nonquantita-
tively, such as by questionnaire15-17 visual observation,18,19
or self-reported patient satisfaction.20 In the absence of
studies showing that FME actually improves facial muscle
thickness (FMT), more precise investigation of the poten-
tial benefits of FME on the facial muscles are needed.
The Pao device (MTG, Nagoya, Japan) was designed to train
the muscles around the mouth (Figure 1). It involves simply
holding the device in the mouth and rocking it by nodding the
head, such that the bilateral balance weights begin to swing.
The Pao device was devised to simplify exercise requirements
and to offer a more standardized approach to FME.9 However,
very few studies have examined the effectiveness of FME
using the Pao device (FMEuP) for facial rejuvenation.
The purpose of this study was to evaluate effectiveness
of FMEuP on facial rejuvenation. FMT and cross-sectional
area (CSA) were measured by sonography; facial surface
distances, facial surface areas, and facial volumes using
a laser scanning system (LSS), and wrinkles and jawline
sagging by the Wrinkle Severity Rating Scale (WSRS) and
Face Visual Scale (FVS), respectively. We hypothesized
that, after FMEuP, FMT and facial muscle CSA would in-
crease, while facial surface distances, facial surface areas,
and lower face volumes would decrease.
METHODS
Subjects
Fifty women who met our inclusion and exclusion criteria
were recruited in Korea (Table 1) from those who filled out
AB
Figure 1. Facial muscle exercise using the Pao device demonstrated on a 30-year-old woman. (A) The mouthpiece of the Pao
device is held in the center of the mouth using the lips; (B) the oscillatory movement of the Pao device resulting from nodding.
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Hwang et al. 3
a questionnaire (Appendix A) and answered positively con-
cerning nasolabial folds or skin sagging around the mouth
or jawline. We advertised recruitment of this study for the
general public in Wonju city, Korea. We checked whether
or not the participants were concerned with nasolabial
folds or skin sagging around the mouth or jawline among
the general public in Wonju city who volunteered to par-
ticipate in answer to an advertisement. The exclusion cri-
teria were (1) history of dermatological interventions on or
around the mouth or jaw, such as laser treatment, chem-
ical peels, injection of botulinum toxin, and dermal fillers,
during the past 3 years; (2) history of plastic surgery on
or around the mouth or jaw during the past 3 years; (3)
history of cosmetic enhancement through FME; (4) history
of smoking; and (5) dimpled face. All participants signed
an informed consent form regarding the potential risks
and benefits of FMEuP. This study was approved by the
Yonsei University Wonju Institutional Review Board. The
study protocols were approved by the Yonsei University
Wonju Campus Human Studies Committee in February
2016 (1041849-201607-BM-036-02).
Instrumentation
Ultrasound Equipment
Ultrasound images of the facial muscles (levator labii superio-
ris, orbicularis oris, zygomaticus major, and, among the sup-
rahyoid muscles, the digastric muscle) were obtained using
a diagnostic ultrasound system (A35; Samsung Medison,
Seoul, Korea) that included a 3-16 MHZ probe (LA3-16A).
The mechanical index was set to 0.73 for the LA3-16A trans-
ducer. Sonography was performed at 95 dB using constant
time gain compensation, and transmission gel applied to the
facial area of interest. The transducer was always held verti-
cally to the skin surface. The ultrasound equipment settings
were held constant during the measurements.
Facial Surface Scanning
Facial surface distance, facial surface area, and facial
volume were determined by facial surface scanning using
the FastSCAN LSS (Polhemus, Colchester, VT), which
probe is manually swept over the object by the operator
in a manner analogous to spray painting. In this study, a
Class A laser line scanner was swept repeatedly over the
participant’s face. The FastSCAN laser scanning software
system collects data from the hand-held laser scanner and
a 3-dimensional position reference transmitter to produce
digital surface maps in real time. FastSCAN uses two cam-
eras arranged symmetrically at an offset angle on either
side of a centrally mounted laser generator. An electromag-
netic tracker measures the position and orientation of the
scanner in space, thus removing the need for a rigid mech-
anical scanning gantry.
Assessment
Quantitative Measurements of Facial Muscle Thickness
and CSA
Ultrasonography scans were made of four mimic muscles
on each side of the face: the levator labii superioris, orbicu-
laris oris, zygomaticus major, and digastric (suprahyoid)
muscles (Figures 2 and 3). Studies have shown that these
facial muscles can be identified reliably.21-24 FMT and CSA
were quantified using the calculation system of the A35
application (A35; Samsung Medison, Seoul, Korea). The
levator labii superioris muscle was scanned by holding the
probe in the middle of a line between the corner of the
mouth and the medial corner of the eye, beside the alar
cartilage of the nose.24 The probe was tilted slightly lat-
erally, and the FMT of the muscle was calculated.24 The
orbicularis oris muscle was scanned by holding the probe
between the columella and philtrum ridges and on the
upper lip.21 It was then positioned sagittally within the
philtrum ridges,21 and the FMT of was calculated.22 The
zygomaticus major muscle was scanned by holding the
probe perpendicular to a line between the corner of the
mouth and the zygomatic bone and against the zygomatic
bone,24 a position that allowed calculation of the CSA of
the zygomaticus major muscle.22 The digastric muscle, one
of the suprahyoid muscles, was scanned by holding the
probe perpendicular to a line midway between the man-
dible and the hyoid bone.23 The CSA was then calculated.23
Quantitative Measurements of Facial Surface
Distances, Surface Areas, and Volumes
The data collected by laser scanning were viewed and
analyzed using Delta software (FarField Technology,
Christchurch, New Zealand). Because of differences in
the axis and location of the measured structures between
before and after FME, both were determined using land-
marks based on three points (center of Cupid’s bow of the
upper lip, contact spots under the ear lobe on both sides)
in the registration process (Figure 4).
The midfacial surface distances between the sagittal
axis of the center of Cupid’s bow of the upper lip and
the sagittal axis contact spots with the ear lobe and chin
were measured in the upper, middle, and lower transverse
Table1. Characteristics of the Study Participants
Characteristic Mean±SD (N=50) Range
Age, years 40.0±10.0 30-63
Body height, cm 160.3±14.6 153-170
Body mass, kg 59.5±8.3 44.1-75.7
BMI, kg/m222.21±2.83 1.53-1.7
BMI, body mass index; SD, standard deviation.
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4 Aesthetic Surgery Journal
planes (upper: contact spot between the columella and
philtrum; lower: center of Cupid’s bow of the upper lip;
middle: middle of two planes) (Figure 5). The midfacial
surface distances were measured bilaterally to confirm
improvement of the nasolabial folds. The Delta software
could target participants’ facial surfaces with customized
axis points using the Contours mode. In addition, a dot
was placed at the meeting point between the sagittal axis
along the center of Cupid’s bow of the upper lip and the
chin in frontal view. The jawline surface distance was
measured between the meeting point of the sagittal axis in
the center of Cupid’s bow of the upper lip, the chin in fron-
tal view, and the contact spots on the ear lobe and chin
to confirm the improvement of jawline sagging (distance
measurement of intrareliability: ICC = 0.894) (Figure 6).
Facial surface area and volume were measured using
the quadrants mode to assess changes in jawline sagging
(Figure 7). The Delta software divided the laser-scanned
face into four quadrants, measuring surface area and volume
within each one, based on the corner of the mouth on the
right and left sides (intra-reliability of the surface area and
volume measurements: ICC = 0.998 and 0.998, respectively).
A
E
B
F
C
D
GH
Figure 2. Measurement of the thickness of the levator labii superioris and orbicularis oris muscles using ultrasound images
of a 30-year-old woman. (A) Anatomical position of the levator labii superioris muscle, (B) probe position for the levator labii
superioris and muscle thickness of the levator labii superioris (C) initially and (D) after the sessions; (E) anatomical position
of the orbicularis oris muscle, (F) probe position for the orbicularis oris and muscle thickness of orbicularis oris (G) initially,
and (H) after the sessions.
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Hwang et al. 5
Wrinkle Severity Rating Scale
The wrinkle severity rating scale (WSRS) is a validated
5-point scale where 1 = absent, 2 = mild, 3 = moderate, 4
= severe, and 5 = extreme wrinkling of the skin (intra-re-
liability of the WSRS: ICC = 0.840). This scale is based
on the current assessment rather than on a comparison
with the pretreatment appearance determined from a facial
photograph. Scoring is based on visual assessment of the
length and apparent depth of the nasolabial folds, with-
out reference to a baseline or to the pretreatment appear-
ance. In the present study, the WSRS was determined by
a blinded independent observer asked to judge randomly
ordered facial photographs. The independent observer is
an office staff member and researcher for facial muscle
rehabilitation. The order in which the facial photographs
were shown to the independent observer was randomized
using a random number table created using a randomiza-
tion generator (www.randomization.com).
Face Visual Scale: Wrinkles and Jawline Sagging
The face visual scale (FVS) is a subjective instrument
measuring patient satisfaction. Six selected studies have
A
EF
HG
BC
D
Figure 3. Measurement of the cross-sectional area of the zygomaticus major and digastric muscles using ultrasound images of
a 30-year-old woman. (A) Anatomical position of the zygomaticus major muscle, (B) probe position for the digastric muscle,
cross-sectional area of the digastric muscle, (C) cross-sectional area of the zygomaticus major initially, and (D) after the
sessions, (E) anatomical position of the digastric muscle, (F) probe position for the zygomaticus major, (G) initially, and (H)
after the sessions.
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shown a significant mean improvement based on a 0 to 10
scale in participants receiving skin treatment such as hya-
luronic acid, fractional YAG laser, and intense-pulsed light
treatment.25-29 Evaluations in the present study included
two self-assessments (jawline sagging and wrinkle satis-
faction) and self-rating of jawline sagging and wrinkles.
(0 = very good, 10 = very poor) before and after FME.
Procedures
This study was performed as follows for 3 months from
June to September 2016. First, during a presession, all
participants were asked to assess themselves in front of
a mirror, using the FVS to assign a score for wrinkles
and jawline sagging. Second, all participants were pho-
tographed in a standardized manner in the frontal plane.
Illumination was from artificial light and the built-in flash
of the Canon 750D camera only. The distance from the
tip of the participant’s nose to the lens of the camera was
150 cm. The height of the tripod was adapted to the par-
ticipant’s height. All participants sat in the same chair in
front of the same white background and wore no make-up.
They were asked to sit upright with a straight back and
to maintain a neutral facial expression. Third, the faces
of all participants were scanned using the LSS to meas-
ure facial surface distance, surface area, and volume.
A standard protocol was implemented to reduce variation
and unwanted scan artifacts during laser scanning of the
face. During scanning, all overhead lights in the vicinity
were turned off to reduce light artifacts (Supplemental
Figure 1). Participants were asked to sit on a wooden chair,
using its attached wooden plate to support their head and
back, and to remain motionless in the sitting position with
eyes closed during laser scanning. The LSS transmitter was
placed on the wooden plate within 10 cm of the individ-
ual’s head. Laser scanning was performed by sweeping
the face with the hand piece. Completion of the surface
laser scan was confirmed based on the real-time raw facial
A
B
Figure 4. Calibration of the pre- and postsession axes and placement of the face scan data based on three landmark points in
the facial registration process (A) before and (B) after calibration, demonstrated on a 44-year-old woman.
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Hwang et al. 7
surface image displayed on the system’s laptop. The laser
scan data were saved on the laptop and processed using
the Delta software. Fourth, FMT and CSA were measured
ultrasonographically. All participants were examined in the
supine position and were completely relaxed. During the
examination, directed contraction of facial muscles was
used to confirm the correct position of the transducer. To
reduce systematic error arising from muscle compression,
the pressure between the probe and skin was minimized
prior to image acquisition. Fifth, the participants were
educated about the FMEs, including their correct perfor-
mance. The participants also received written instructions
and a video for each exercise, along with advice on how
to incorporate training into their daily routine. Participants
were instructed to form an “O” with their mouth and hold
the mouthpiece of the Pao device, located in its center,
with their lips, making sure that force was evenly applied
by the involved facial muscles. Nodding the head up and
down causes the weighted ends of the Pao bar to swing.
The weights were regulated to 23 g. FMEuP was performed
twice a day for 30 seconds for 8 weeks. Adherence to this
schedule was confirmed by telephone two times a week
and the participants were encouraged to perform FMEuP
at least 6 days a week.
The subjects did not undergo dermatological interven-
tions, and plastic surgery on or around the mouth or jaw in
the time between when the pre-and postfacial muscle exer-
cise. Before experimental procedures, we notified the sub-
jects to refrain from dermatological interventions and plastic
surgery on or around the mouth or jaw. Also, we recruited
the subjects who have not experienced dermatological inter-
ventions and plastic surgery on or around the mouth or jaw.
After 8 weeks, the measurements performed as
described above were repeated. For each participant, the
instrument settings remained the same as during the pre-
session (Figures 8 and 9).
Statistical Analysis
All statistical analyses were conducted using SPSS ver. 18.0
software (SPSS, Chicago, IL). A P-value of 0.05 was consid-
ered to indicate statistical significance. The Kolmogorov-
Smirnov Z-test was used to verify the assumption of
distribution normality. Descriptive statistics were used to
analyze the sonography and facial laser scanning data,
which were normally distributed. The ICC (3, 2) model
was used to test intrarater reliability for measurements
of surface distance, area, and volume. The WSRS scores
A
B
C
Figure 5. Measurement of midfacial surface distances in the (A) upper, (B) middle, and (C) lower transverse plane using Delta
software, demonstrated on a 44-year-old woman.
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based on photos and the FVS (wrinkle and jawline sag-
ging) for self-assessments before and after FME were com-
pared using Wilcoxon signed-rank tests. The quantitative
data on levator labii superioris and orbicularis oris mus-
cle thickness and the CSA of the zygomaticus major and
digastric muscle values pre- and post-FME were compared
for both sides using paired Student t tests. The quantitative
data on the midfacial surface distances in a 3-directional
transverse plane, consisting of jawline distance, quad-
rant surface area, and volume based on the corner of the
mouth, were compared in paired Student t tests for both
sides of the face before and after FME.
RESULTS
The 50 women (mean age, 40.0 ± 10.0 years; range,
30-63 years) completed the protocol and provided data for
analysis.
Quantitative Measurements of FMT
and CSA
Table 2 shows the mean (standard deviation) of FMT pre-
and post-FME. The CSA of the zygomaticus major muscle
increased significantly on both sides (right: P < 0.001, left:
AB
C
Figure 6. Measurement of the jawline surface distance using Delta software demonstrated on a 44-year-old man. (A) Frontal,
(B) oblique, and (C) side views.
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Hwang et al. 9
P = 0.015) after, compared with before, FMEuP. The bilat-
eral increase in the CSA of the digastric muscle was also
significant (right: P = 0.003, left: P = 0.001). The FMT of
the levator labii superioris increased significantly on the
right side (from 0.126 to 0.136cm; P = 0.006) compared
with before FME, but not on the left side (from 0.125 to
0.128cm; P = 0.230). The pre- vs post-FMEuP values for
the FMT differed significantly on the left (from 0.212 to
0.228 cm; P = 0.019) but not on the right (from 0.227 to
0.235cm; P = 0.183) side of the orbicularis oris muscle.
A
B
Figure 7. Measurement of facial surface area and volume in of the lower quadrants using Delta software demonstrated on a
44-year-old man. (A) Right and (B) left sides.
AB
Figure 8. A 44-year-old woman (A) before and (B) 8 weeks after facial muscle exercise using the Pao device.
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Quantitative Measurements of Facial
Surface Distances, Facial Surface Areas,
and Volumes
Tables 3 and 4 show the mean (standard deviation) facial
surface distance, surface area, and volume pre- and post-
FME. The midfacial surface distance in the midtransverse
plane (midpoint between the contact between the colu-
mella and philtrum and the center of Cupid’s bow of the
upper lip) was significantly lower on both sides (right:
P = 0.005, left: P = 0.047), as were the midfacial surface
distance in the lower transverse plane (center of Cupid’s
bow of the upper lip; right: P = 0.028, left: P = 0.019)
and the jawline surface distance (right: P = 0.004, left:
P = 0.003). However, the difference between the pre- and
post-FMEuP measurements of the midfacial surface dis-
tance in the upper transverse plane (contact spot between
the columella and philtrum) was not significant, bilaterally.
The surface areas of the lower quadrants based on
the corner of the mouth were significantly lower on both
sides (right: P = 0.005, left: P = 0.006), as were the vol-
umes of the same lower quadrants (right: P = 0.001, left:
P = 0.002).
Wrinkle Severity Rating Scale
As shown in Table 5, the mean (standard deviation) of
the WSRS pre- and post-FME was 2.582 ± 0.629 and
2.370 ± 0.708, respectively. The decrease was significant
(P = 0.025).
Face Visual Scale: Wrinkle and Jawline
Sagging
Table 5 also shows the mean (standard deviation) FVS
values (wrinkle and jawline sagging) as self-reported by
the study participants pre- and post-FME (3.855 ± 1.715
and 5.130 ± 1.493 for wrinkles and 4.000 ± 2.082 and
5.407 ± 1.666 for jawline sagging, respectively). The dif-
ferences in both were significant (both P < 0.001).
DISCUSSION
This study is the first to demonstrate changes in facial sur-
face distances, surface areas, and volumes, as well as in the
WSRS and FVS for wrinkle and jawline sagging in women
Table2. Comparison of the Thickness and Cross-Sectional Area of the
Facial Muscles Before and After Facial Muscle Exercise Using the Pao
Device
Muscle Side Before After P
Mean±SD Mean±SD
Levator labii superioris, cm Right 0.126±0.023 0.136±0.026 0.006
Left 0.125±0.019 0.128±0.021 0.230
Orbicularis oris, cm Right 0.227±0.041 0.235±0.041 0.183
Left 0.212±0.042 0.228±0.036 0.019
Zygomaticus major, cm2Right 0.772±0.058 0.822±0.063 0.000
Left 0.773±0.052 0.802±0.064 0.015
Digastric muscle, cm2Right 0.750±0.126 0.799±0.130 0.003
Left 0.740±0.123 0.797±0.126 0.001
SD, standard deviation.
AB
Figure 9. A 51-year-old woman (A) before and (B) 8 weeks after the facial muscle exercise using the Pao device.
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Hwang et al. 11
who used the Pao device for 8 weeks by performing FMEuP
on at least 6 days a week. Moreover, after FME, the FMT
and CSA of the facial muscles increased, while facial surface
distances, surface areas, and volumes decreased compared
to the pre-FME values. Only the FMT of the left side of the
levator labii superioris, the right side of the orbicularis oris,
and the midfacial surface distances in the upper transverse
plane had not changed significantly by the end of the study.
Previous studies suggested that FME lessens the
nasolabial folds and thus contributes to facial rejuvena-
tion.8,17,30,31 The mean baseline length of a straight line
measured by caliper between the nasolabial fold and the
tragus was reduced after daily isotonic, isometric, and
isokinetic FMEs and weekly facial massage and manipu-
lation for 8 weeks, from 92.2 mm to 88.3 mm (P = 0.023)
on the right and from 94.1 mm to 88.5 mm (P = 0.001) on
the left.31 Our data similarly showed significant bilateral
reductions of the midfacial surface distance in the mid-
dle (right: P = 0.005, left: P = 0.047) and lower (right:
P = 0.028, left: P = 0.019) transverse planes. The reduc-
tion in the facial surface distance along the nasolabial
folds may reflect flattening of the surface or a decrease in
the depth of the nasolabial folds. An increase in zygomat-
icus major muscle tension may result from the increasing
CSA. The lack of a significant reduction of the midfacial
surface distance in the upper plane (right: P = 0.358, left:
P = 0.344) may have been due to the increased volume
of the zygomaticus major, which may have increased the
surface distance.
Table3. Comparison of Facial Surface Distance, Determined Using the Laser Scanning System, Before and After Facial Muscle Exercise Using the Pao
Device
Distance, mm Side Before After P
Mean±SD Mean±SD
Midfacial surface distances in the upper transverse plane Right 130.103±7.040 129.564±7.031 0.358
Left 130.131±7.175 130.676±7.957 0.344
Midfacial surface distances in the middle transverse plane Right 126.717±7.609 126.302±7.553 0.005
Left 126.525±7.875 126.129±8.000 0.047
Midfacial surface distances in the lower transverse plane Right 126.357±6.984 125.942±6.947 0.028
Left 125.822±7.510 125.323±7.551 0.019
Jawline surface distance Right 130.892±7.637 129.544±8.404 0.004
Left 130.046±8.242 128.671±8.499 0.003
SD, standard deviation.
Table4. Comparison of Facial Surface Area and Volume, Determined Using the Laser Scanning System, Before and After Facial Muscle Exercise Using
the Pao Device
Surface area and volume in the lower facial
quadrantsa
Side Before After P
Mean±SD Mean±SD
Surface area, cm2Right 22.615±7.446 22.144±6.756 0.005
Left 21.249±8.012 20.491±8.011 0.006
Volume, cm3Right 29.887±16.230 28.992±16.487 0.001
Left 27.127±15.111 26.533±14.760 0.002
aWith respect to the corner of the mouth. SD, standard deviation.
Table5. Wrinkle Severity Rating Scale, and Facial Visual Scale Scores
Assessing Wrinkles and Jawline Sagging Before and After Facial Muscle
Exercise Using the Pao Device
Assessment tool Before After P
Mean±SD Mean±SD
Wrinkle Severity Rating Scale 2.582±0.629 2.370±0.708 0.025
Facial Visual Scale: wrinkles 3.855±1.715 5.130±1.493 <0.001
Facial Visual Scale: jawline
sagging
4.000±2.082 5.407±1.666 <0.001
SD, standard deviation.
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12 Aesthetic Surgery Journal
The reduction in the WSRS was significant (P = 0.025),
as was the increase in the FVS for wrinkles (P < 0.001).
Recently, Shin et al32 and Ascher et al33 had blinded investi-
gators to assess the effect of a dextran filler (mean improve-
ment in WSRS from baseline: 1.50 ± 0.51) and different
forms of hyaluronic acid (mean improvement in WSRS from
baseline: 1.58 ± 0.89) on the correction of nasolabial folds.
In our study, although the WSRS decreased significantly, the
difference was small (from 2.592 ± 0.629 to 2.370 ± 0.708).
Compared with the previous results, the change in the WSRS
score in our study was relatively small. It might be difficult
for the independent observer to detect a pronounced differ-
ence between the before vs after photographs of a 2-dimen-
sional frontal plane view. There was a significant difference
between the before and after LSS data in the 3-dimensional
analysis, suggesting that the independent observer did find
it hard to detect a difference between the before and after
photographs. Improvement in the latter was visually appar-
ent to both the study participants and the independent
observer. A direct comparison of the results of our study with
those of previous studies is difficult because of the different
methods used to measure facial distance with respect to an
improvement of the nasolabial folds and the fact that most
other studies relied on subjective (mostly descriptive), not
quantitative, assessments provided by the study participants
themselves.15-20 Therefore, a quantitative measurement is rec-
ommended, using more objective methods, to minimize the
interrater variability compared with the WSRS.
The present study measured jawline surface distance
and the lower quadrant surface area and volume bilaterally
based on the corner of the mouth to confirm improvement
in jawline sagging after FMEuP. A previous study demon-
strated reduced sagging following 10 treatment sessions that
included changing posture-lengthening muscles and reducing
tension, cervical stretching, relaxation of the muscles, facial
stretching, heat, manipulation maneuvers, facial exercises,
and general tips related to bilateral chewing and hydration.18
In another study, isotonic and isometric exercises, stretching,
and facial and cervical manipulation were performed daily
(at home) and in weekly 1 h sessions for 10 weeks; infor-
mation on facial care was provided as well.16 The improve-
ment in sagging was assessed by the authors (pre- and
posttherapy) based on visual observation aided by clinical
photographs and videos; thus, the results cannot be read-
ily compared to our own. In the present study, the jawline
surface distance (right: P = 0.004, left: P = 0.003), surface
areas of the lower facial quadrants (right: P = 0.005, left:
P = 0.006), and the volume of these areas (right: P = 0.001,
left: P = 0.002) decreased significantly after FME. These
changes typically manifested as a reduction in and straight-
ening of the jawline curve compared to before FME. Changes
in jowl surface area can be achieved by treatments such as
radiofrequency34 and CO2 laser,28 both of which have been
used in an attempt to quantify posttherapy differences in the
lower part of the face. However, the calculations made use
of a photograph and not the actual contour of the jowl. The
decrease in 2-dimensional jowl surface area demonstrated in
this study is highly consistent with other clinical grading stud-
ies showing improvements in the lower part of the face.34-39
By scanning the actual contour of the jowl using LSS, both
the surface area and the volume could be quantified. The
results showed a reduction in the surface area and volume of
the lower part of the face after FMEuP. However, the differ-
ences in the surface area and volume of the lower part of the
face, before vs after FMEuP, were in the negative range in 15
cases. The variation in individual body fat percentage or total
body water, before and after, may have contributed to dif-
ferences in the surface area and volume of the lower part of
the face in response to FME, possibly affecting the results.40
There was no way to know whether the subjects complied
with the instructions to perform FMEuP on at least 6 days a
week. This might explain the negative range, which could be
due to failure to perform FMEuP on at least 6 days a week.
The decreases in facial surface distances, facial surface
area, and lower face volumes after FMEuP can be explained
as follows. First, increases in the FMT and CSA of the facial
muscles after FMEuP contribute to firmer and more elastic
facial skin. In our study, increases in the FMT and CSA
of tested facial muscles were either significant or showed
increasing trends bilaterally following the prescribed exer-
cises, except the levator labii superioris on the left side
and the orbicularis oris on the right side (P = 0.183). The
levator labii superioris raises and pushes out the upper
lip, while the orbicularis oris closes and holds the lip. The
zygomaticus major draws the ends of the mouth upward
and laterally. Among the suprahyoid muscles, the digastric
muscle depresses the mandible and elevates the hyoid bone.
The work by van Lieshout et al9 reported that FME for 8
weeks increased facial muscle strength, as measured using
the Facial-Flex device with fixed resistance, and decreased
the biomechanical extensibility of the facial skin. They also
showed that increased facial muscle strength was directly
related to improved skin elasticity, as the facial muscles
become stronger and shorten, causing the attached skin to
become firmer and more elastic.41 A reduction in the func-
tion of the mimetic facial muscles was shown to influence
sagging.42 Second, FMEuP may confer the proper inten-
sity to the facial muscles through isometric contraction.
Repetitive facial movements based on repeated facial mus-
cle contraction with repeated folding of the facial skin leads
to the appearance of wrinkles, which become prominent as
the skin loses elastin and collagen with aging.11 Isometric
contraction of the mouth, as achieved by forming an “O”
to hold the mouthpiece of the Pao device, may reduce
the adverse effects of FME by regulated, repetitive facial
movements. Fourth, the oscillatory movement achieved
by nodding the head while holding the Pao device with
the mouth may contribute to an increase in the number
of motor units of the facial muscles. Previous studies sug-
gested that oscillatory movements increase muscle spindle
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Hwang et al. 13
activity such that there is less muscle fiber disruption of
excitation-contraction coupling43 whereas muscle preacti-
vation is enhanced, increasing the number of motor units
and muscle fibers recruited.44
FMEuP was performed for 8 weeks. Generally, strength
increases are mostly due to neural adaptation that synchro-
nizes firing and increases the recruitment of motor units
before the onset of muscle hypertrophy, usually over a
period of 8 weeks, or in 2 to 3 weeks with very high-inten-
sity resistance exercise.45-47 Hypertrophy is an increasingly
important adaptation that explains the strength increase in
muscle.45 Because FMEuP would not be of sufficiently high
intensity to produce hypertrophy of the facial muscles, we
chose 8 weeks as the duration of the FMEuP regimen.
Previous studies reported that the detraining effect
begins within 2 weeks.48,49 Because of the reversibility prin-
ciple, detraining could begin within 1 to 2 weeks after the
cessation of exercise and continue until the training effects
disappear.45,49 A further study should examine the detrain-
ing effect in facial muscle, which we postulate would show
a detraining effect. Therefore, a follow-up session is neces-
sary to determine how long the effect of FMEuP lasts.
Although our study confirmed that FME was effective
for reducing the signs of aging, it had several limitations.
First, a control group is needed, with random patient assign-
ment, to allow comparison of the results between control
and experimental groups. Second, although we confirmed
the effect of FMEuP for 8 weeks, by increasing and extend-
ing the checkup session, expeditious FME, and retention of
the effect of the FMEuP could be detected more precisely.
Third, all of the participants were women. Whether the
benefits of FME extend to men remains to be determined.
Third, we did not measure facial hyaluronic acid levels,
facial skin mechanical properties, or facial muscle strength.
These are important factors in facial rejuvenation and their
evaluation should be included in future studies.
CONCLUSION
We investigated whether FMEuP using the Pao device
influenced the FMT and CSA of the facial muscles, facial
surface distances, facial surface areas and volumes, and
the WSRS and FVS for wrinkles and a sagging jawline. Our
results demonstrated beneficial effects of FMEuP on facial
rejuvenation.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Acknowledgments
The authors would like to thank David Lee, CEO of
KOREATECH, for providing complimentary Pao devices for
this study.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this article.
Funding
The authors received financial and administrative support
provided by KOREATECH (grant number: 2016-51-0122). Also,
this work was supported by the Yonsei University Research
Fund of 2017-51-0018.
REFERENCES
1. Baumann L. Skin ageing and its treatment. J Pathol.
2007;211(2):241-251.
2. Guinot C, Malvy DJ, Ambroisine L, et al. Relative con-
tribution of intrinsic vs extrinsic factors to skin aging as
determined by a validated skin age score. Arch Dermatol.
2002;138(11):1454-1460.
3. Atiyeh BS, Rubeiz MT, Hayek SN. Aesthetic/Cosmetic
surgery and ethical challenges. Aesthetic Plast Surg.
2008;32(6):829-839; discussion 840.
4. Haboush A, Warren CS, Benuto L. Beauty, ethnicity,
and age: does internalization of mainstream media ide-
als influence attitudes towards older adults? Sex Roles.
2012;66(9-10):668-676.
5. Noale M, Limongi F, Scafato E, Maggi S, Crepaldi G.
Longevity and health expectancy in an ageing society:
implications for public health in Italy. Ann Ist Super
Sanita. 2012;48(3):292-299.
6. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119(7):2219-2227; discussion
2228.
7. Van Borsel J, De Vos MC, Bastiaansen K, Welvaert J,
Lambert J. The effectiveness of facial exercises for
facial rejuvenation: a systematic review. Aesthet Surg J.
2014;34(1):22-27.
8. De Vos MC, Van den Brande H, Boone B, Van Borsel J.
Facial exercises for facial rejuvenation: a control group
study. Folia Phoniatr Logop. 2013;65(3):117-122.
9. van Lieshout PH, Bose A, Namasivayam AK. Physiological
effects of an 8-week mechanically aided resistance
facial exercise program. Int J Orofacial Myology.
2002;28:49-73.
10. Roggen A. Hou je gezicht fit: gelaatsoefeningen voor jong
en oud. Antwerpen: Manteau; 2001.
11. Roizen M, Oz M. You: Being Beautiful. New York: Free
Press; 2008.
12. Bergfeld WF. A lifetime of healthy skin: implications for
women. Int J Fertil Womens Med. 1999;44(2):83-95.
13. Chieffi M. Cosmetological aspects of ageing: biological
and medical aspects. In: Lansing AI. Cowdry’s Problems of
Ageing: Biological and Medical Aspects. 3rd ed. Baltimore:
Williams & Wilkins; 1952:909-923.
14. Bolognia JL. Aging skin. Am J Med. 1995;98(1A):99S-103S.
15. Lana e Silva N, Vieira VS, Motta AR. Eficácia de duas
técnicas fonoaudiológicas da estética facial no músculo
orbicular dos olhos: Estudo piloto. Revista CEFAC.
2010;12(4):571-578.
Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjx238/4818300
by guest
on 20 January 2018
14 Aesthetic Surgery Journal
16. Matos KDF, Loreto PM, Nery TCS, Souza VAM, Souza
CB. Análise da eficácia de um trabalho fonoaudiológico
com enfoque estético. Revista Fragmentos de Cultura
(Goiânia). 2010;20(3):413-432.
17. Takacs AP, Valdrighi V, Assencio-Ferreira VJ.
Fonoaudiologia e estética: Unidas a favor da beleza facial.
Revista CEFAC. 2002;4(2):111-116.
18. Mattia FA, Czlusniak G, Ricci CCPP. Contribuição da fono-
audiologia na estética facial: Relato de caso. Revista Salus-
Guarapuava-PR. 2008;2(2):15-22.
19. Santos CCG, Ferraz MJPC. Atuação da fonoaudiologia
na estética facial: Relato de caso clínico. Revista CEFAC.
2011;13(4):763-768.
20. Frazão Y, Manzi S. Eficácia da intervenção fonoaudi-
ológica para atenuar o envelhecimento facial. Revista
CEFAC. 2012;14(4):755-762.
21. Volk GF, Wystub N, Pohlmann M, Finkensieper M,
Chalmers HJ, Guntinas-Lichius O. Quantitative ultrasonog-
raphy of facial muscles. Muscle Nerve. 2013;47(6):878-883.
22. Volk GF, Sauer M, Pohlmann M, Guntinas-Lichius O.
Reference values for dynamic facial muscle ultrasonogra-
phy in adults. Muscle Nerve. 2014;50(3):348-357.
23. Gervasio A, D’Orta G, Mujahed I, Biasio A. Sonographic
anatomy of the neck: The suprahyoid region. J Ultrasound.
2011;14(3):130-135.
24. Alfen NV, Gilhuis HJ, Keijzers JP, Pillen S, Van Dijk JP.
Quantitative facial muscle ultrasound: feasibility and
reproducibility. Muscle Nerve. 2013;48(3):375-380.
25. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy,
safety, and patient satisfaction of a monophasic cohesive
polydensified matrix versus a biphasic nonanimal stabi-
lized hyaluronic acid filler after single injection in nasola-
bial folds. Dermatol Surg. 2013;39(7):1097-1105.
26. Luebberding S, Krueger N, Kerscher M. Comparison of
validated assessment scales and 3D digital fringe projec-
tion method to assess lifetime development of wrinkles in
men. Skin Res Technol. 2014;20(1):30-36.
27. Ooe M, Seki T, Miura T, Takada A. Comparative evalu-
ation of wrinkle treatments. Aesthetic Plast Surg.
2013;37(2):424-433.
28. Clementoni MT, Lavagno R, Munavalli G. A new multi-modal
fractional ablative CO2 laser for wrinkle reduction and skin
resurfacing. J Cosmet Laser Ther. 2012;14(6):244-252.
29. Levenberg A, Halachmi S, Arad-Cohen A, Ad-El D,
Cassuto D, Lapidoth M. Clinical results of skin remode-
ling using a novel pneumatic technology. Int J Dermatol.
2010;49(12):1432-1439.
30. Arizola HGA, Brescovici SM, Delgado SE, Ruschel CK.
Face changes on patients after aesthetic speech therapy
treatment in school-practice of speech therapy. Revista
CEFAC. 2012;14(6):1167-1183.
31. Paes C, Toledo P, Silva H. Fonoaudiologia e estética facial:
estudo de casos. Revista CEFAC. 2007;9(2):213-220.
32. Shin SJ, Her Y, Yu DS, Kim CW, Kim SS. Twenty-four-
week multicenter, evaluator-blinded clinical study of the
efficacy and safety of a dextran filler in the treatment of
nasolabial folds. Dermatol Surg. 2014;40(6):652-657.
33. Ascher B, Bayerl C, Brun P, et al. Efficacy and safety of
a new hyaluronic acid dermal filler in the treatment of
severe nasolabial lines - 6-month interim results of a ran-
domized, evaluator-blinded, intra-individual comparison
study. J Cosmet Dermatol. 2011;10(2):94-98.
34. Nahm WK, Su TT, Rotunda AM, Moy RL. Objective
changes in brow position, superior palpebral crease, peak
angle of the eyebrow, and jowl surface area after volumet-
ric radiofrequency treatments to half of the face. Dermatol
Surg. 2004;30(6):922-928; discussion 928.
35. Ruiz-Esparza J, Gomez JB. The medical face lift: a nonin-
vasive, nonsurgical approach to tissue tightening in facial
skin using nonablative radiofrequency. Dermatol Surg.
2003;29(4):325-332; discussion 332.
36. Weiss RA, Weiss MA, Beasley KI. Monopolar radio frequency
(RF) mediated skin contraction of the lower face: study of
35 patients. Am Soc for Laser Med Surg. 2003;15(Suppl):120.
37. Jacobson L, Geronemus R. Treatment of nasolabial folds
and jowls were non-invasive radiofrequency device. Am
Soc for Laser Med Surg. 2003;15(Suppl):117.
38. Fitzpatrick RE, Iyer S. Collagen and tissue tightening par-
adigm for treatment of the cheeks and neck using radiof-
requency. Am Soc for Laser Med Surg. 2003;15:114.
39. Alster TS, Tanzi EI. Treatment of prominent nasolabial
folds and cheek laxity with a nonablative radiofrequency
device. Am Soc for Laser Med Surg. 2003;15(Suppl):112.
40. Suber JS, Dinh TP, Prince MD, Smith PD.
OnabotulinumtoxinA for the treatment of a “gummy
smile”. Aesthet Surg J. 2014;34(3):432-437.
41. Kim K, Jeon S, Kim JK, Hwang JS. Effects of Kyunghee
Facial Resistance Program (KFRP) on mechanical and
elastic properties of skin. J Dermatolog Treat. 2016;27(2):
191-196.
42. Ezure T, Hosoi J, Amano S, Tsuchiya T. Sagging of the
cheek is related to skin elasticity, fat mass and mimetic
muscle function. Skin Res Technol. 2009;15(3):299-305.
43. Aminian-Far A, Hadian MR, Olyaei G, Talebian S,
Bakhtiary AH. Whole-body vibration and the prevention
and treatment of delayed-onset muscle soreness. J Athl
Train. 2011;46(1):43-49.
44. Bosco C, Colli R, Introini E, et al. Adaptive responses of
human skeletal muscle to vibration exposure. Clin Physiol.
1999;19(2):183-187.
45. Kisner C, Colby LA. Resistance Exercise for Impaired Muscle
Performance. In: Therapeutic Exercise: Foundations and
Techniques. 6th ed. Philadelphia: F.A. Davis Company;
2012:160-161.
46. Seynnes OR, de Boer M, Narici MV. Early skeletal mus-
cle hypertrophy and architectural changes in response to
high-intensity resistance training. J Appl Physiol (1985).
2007;102(1):368-373.
47. Aagaard P, Simonsen EB, Andersen JL, Magnusson P,
Dyhre-Poulsen P. Increased rate of force development and
neural drive of human skeletal muscle following resistance
training. J Appl Physiol (1985). 2002;93(4):1318-1326.
48. Mujika I, Padilla S. Muscular characteristics of detraining
in humans. Med Sci Sports Exerc. 2001;33(8):1297-1303.
49. Andersen LL, Andersen JL, Magnusson SP, Aagaard P.
Neuromuscular adaptations to detraining following resist-
ance training in previously untrained subjects. Eur J Appl
Physiol. 2005;93(6):511-518.
Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjx238/4818300
by guest
on 20 January 2018
... studies investigating the effects either positive or negative of facial exercises for facial rejuvenation have reported a low level of evidence. 9,11,12 Kim et al. 13 reported that facial exercises increased the cross-sectional area of facial muscles, making the muscles stronger and shorter and the attached skin firmer and more elastic, and that there was a direct relationship between increased facial muscle strength and improved skin elastici-This is an Open Access article distribute under the terms of the Creative Commons Attribution Non-commercial License (https:// creativecommons.org/license/by-nc/4.0.) which permits unrestricted non-commercial use, distribution,and reproduction in any medium, provided the original work is properly cited. ...
... 8 Facial exercises have been suggested to stimulate tissue regeneration by promoting circulation to the facial muscles and enabling generated waste products to be drained more effectively. 9 However, in previous studies, inconsistent results have been reported regarding whether facial muscle exercises are effective for facial rejuvenation. 9 In a systematic review, Van Borsel et al. 10 reported that favorable and statistically significant volume changes were observed around the upper lip, jawline, and cheeks in response to repetitive isometric exercises. ...
... 9 However, in previous studies, inconsistent results have been reported regarding whether facial muscle exercises are effective for facial rejuvenation. 9 In a systematic review, Van Borsel et al. 10 reported that favorable and statistically significant volume changes were observed around the upper lip, jawline, and cheeks in response to repetitive isometric exercises. They also reported that facial exercise equipment could lead to subjective improvements of the degree of wrinkles, tone, and complexion. ...
... This non-invasive approach aims to strengthen facial muscle tone, thereby reducing sagging skin of the face [10]. It has been proposed that facial exercising aids in tissue regeneration by increasing circulation to the facial muscles and allowing for drainage of generated waste products [11]. The goal of facial exercising is to combat the multitude of underlying processes that cause wrinkling and skin laxity, including hormone level changes, muscle atrophy, and redistribution of subcutaneous fat [12]. ...
... Facial acupuncture Increase in skin oil content [13] Performed by hand, so can be used more readily on sensitive or narrow areas not amenable to certain instruments [15] Decrease in size of nasolabial folds and eye wrinkles [15] Decrease in overall melasma area and pigment darkness [16] Bruising, edema, pain at needle site [14] Foreign body granuloma [18,19] Atypical mycobacterium infection [20,21] Facial exercises Decrease in self-reported severity of wrinkles and jawline sagging [11] Potential to cause dynamic rhytides [10] Increase in muscle thickness and cross-sectional area [11,12] Increase in physician-rated upper and lower cheek fullness [17] No other adverse events reported in the literature ...
... Facial acupuncture Increase in skin oil content [13] Performed by hand, so can be used more readily on sensitive or narrow areas not amenable to certain instruments [15] Decrease in size of nasolabial folds and eye wrinkles [15] Decrease in overall melasma area and pigment darkness [16] Bruising, edema, pain at needle site [14] Foreign body granuloma [18,19] Atypical mycobacterium infection [20,21] Facial exercises Decrease in self-reported severity of wrinkles and jawline sagging [11] Potential to cause dynamic rhytides [10] Increase in muscle thickness and cross-sectional area [11,12] Increase in physician-rated upper and lower cheek fullness [17] No other adverse events reported in the literature ...
Article
Full-text available
While injectables, lasers, and surgical interventions have traditionally been used to reverse the changes associated with facial aging, other alternative therapies such as facial acupuncture and facial exercises are now being studied for facial rejuvenation. In this paper, we both summarize the concepts of facial acupuncture and facial exercises, and review seven studies that evaluate the efficacy of these modalities. Data from these studies suggest that both facial acupuncture and facial exercises have the potential to improve the skin laxity, wrinkle length, muscle thickness, and pigmentary changes associated with aging. Patients frequently reported improvement and experienced very few side effects. However, further research is necessary before these modalities are widely accepted as effective by the medical community, though the results of these studies may ultimately make providers less hesitant when patients seek out these services.
... Senėjimo požymiai pirmiausiai pasireiškia nosies-lūpų, dar kitaip vadinamoje nasolabialinėje srityje, trumpėja viršutinės lūpos ir jos kampo keliamieji raumenys, skruostų raumenys, mažėja skruostų zonos riebalinis audinys [4]. Senstančio žmogaus oda plonėja, darosi sausesnė ir ne tokia elastinga, mažiau geba apsisaugoti nuo žalingo aplinkos poveikio, sukeliančio raukšlių atsiradimą [5]. ...
... Raukšlės yra natūrali senėjimo proceso dalis, todėl didėja brandaus amžiaus moterų susidomėjimas estetinėmis veido senėjimo problemų korekcijomis. Senėjimo problemos daugelį metų buvo sprendžiamos plastinės chirurgijos pagalba [9], tačiau šiuo metu populiarėja alternatyvūs jų sprendimo būdai, tokie kaip akupunktūra, akupresūra, veido raumenų masažai ir mankšta [4,9]. ...
Article
Senatviniai pokyčiai labiausiai pastebimi veide, apima minkštuosius audinius ir juos palaikančias kaulines struktūras. Pagrindiniai sukeliantys veiksniai yra gravitacijos jėga, minkštųjų veido audinių senėjimo procesai, kaulinio audinio remodeliacija, veido raumenų aktyvumas, stomatognatinės sistemos pokyčiai ir ultravioletinių spindulių poveikis. Senėjimo požymiai pirmiausiai pasireiškia nasolabialinėje srityje, trumpėja viršutinės lūpos keliamieji ir viršutinės lūpos kampo keliamieji raumenys, skruostų raumenys, mažėja skruostų zonos riebalinis audinys. Teigiama, kad atliekant veido mankštą, galima koreguoti vertikalias raukšles virš viršutinės lūpos, stiprinant lūpos žiedinio raumens vidurinę dalį, treniruojant didįjį skruostų raumenį galima sumažinti nosies-lūpų raukšlės gylį, pagerinti medžiagų apykaitą, audinių regeneraciją bei kraujotakos ir limfotakos cirkuliaciją. Šio tyrimo tikslas – įvertinti veido mankštos poveikį brandaus amžiaus moterų veido odos parametrams. Metodai. Tyrimui buvo atrinktos trys 45-60 metų moterys. Veido odos būklė buvo vertinama prieš mankštos kursą ir po jo, naudojant diagnostinį aparatą A-ONE Smart. Vertinimo ataskaitoje pateikiami rezultatai apie raukšles, drėgmę, poras, pigmentaciją, sebumą, elastingumą, odos spalvą, odos temperatūrą. Veido mankštos programa susidėjo iš aštuonių savaičių kurso, kurį sudarė du etapai: 1) paruošiamieji pratimai veido ir kaklo raumenų apšilimui ir atpalaidavimui; 2) pratimų programa veido ovalo raumenų stiprinimui ir atpalaidavimui. Rezultatai. Bendrasis veido raukšlės gylio parametras keitėsi visų trijų tyrimo dalyvių, tačiau didžiausi pokyčiai (55,07 proc.) pastebėti antrosios tyrimo dalyvės. Nagrinėjant atskirų veido zonų raukšlių gylio parametrus nustatyta, kad visoms tiriamosioms labiausiai mažėjo kaktos srities raukšlių gylis, buvo stebima ir kitų raukšlių mažėjimo tendencija. Išvados. Aštuonių savaičių veido mankštos programa padeda sumažinti veido odos raukšlių gylį ir pagerinti brandaus amžiaus moterų odos būklę. Aštuonių savaičių veido mankštos programa efektyviausia mažinti kaktos srities raukšles.
... Although it is unclear whether changes in facial muscle strength are involved in the loss of facial muscle and skin integrity with the generation of wrinkles and sagging [8], one study reported that wrinkles could be reduced by an exercise that involves holding an instrument in the mouth [9]. Furthermore, a recent case study reported lip and tongue exercise therapy as part of the orthodontic treatment for class three malocclusion [10]. ...
... As mentioned above, it is unclear whether training-induced increases in lip closure muscle strength are associated with improvement of age-related wrinkles and sagging [8], although one study reported those possibilities [9]. We believe that the evaluation of lip muscle function with the water bottle used in this study can also be used as a means of training for lip closure muscle strength. ...
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There is no practical and accessible assessment method to evaluate lip muscle compression strength. The purpose of this study was to examine the relationship between the standard method (i.e., Iowa Oral Performance Instrument) and a practical method in healthy adults. In order to achieve our research purpose, ninety-eight healthy adults (18–40 years) completed lip compression strength measurements (standard method) and lip grasping performance tests using a standard recyclable plastic water bottle (practical method). In the overall sample, the mean and standard deviation for standard method and practical method was 26.7 (7.0) kPa and 255 (119) g, respectively. For the overall sample (n = 98), there was a positive relationship between the two strength tasks [r = 0.56 (0.41, 0.68)]. When separated by sex, positive correlations were observed for men and women with no differences between the observed correlations [difference of 0.06 (−0.2646, 0.3917)]. This result indicates that those individuals who are strong in the standard task will often be strong in the practical task. Future research is needed to determine how well changes in each test track with each other in response to a lip strength training program.
... These findings suggest that the elderly might benefit from facial muscle exercises. A recent study (Hwang et al., 2018) reported that facial muscle exercises using a Pao device significantly increased facial muscle thickness and cross-sectional area. Whether strategies that focus on maintaining healthy facial muscles improve the ability to generate distinct emotional expressions in the elderly, thus potentially increasing emotional interpretability, is an exciting area for further investigation. ...
Article
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Previous studies have found it is more difficult identifying an emotional expression displayed by an older than a younger face. It is unknown whether this is caused by age-related changes such as wrinkles and folds interfering with perception, or by the aging of facial muscles, potentially reducing the ability of older individuals to display an interpretable expression. To discriminate between these two possibilities, participants attempted to identify facial expressions under different conditions. To control for the variables (wrinkles/folds vs facial muscles), we used Generative Adversarial Networks to make faces look older or younger. Based upon behavior data collected from 28 individuals, our model predicts that the odds of correctly identifying the expressed emotion of a face reduced 16.2% when younger faces (condition 1) are artificially aged (condition 3). Replacing the younger faces with natural old-looking faces (Condition 2), however, results in an even stronger effect (odds of correct identification decreased by 50.9%). Counterintuitively, making old faces (Condition 2) look young (Condition 4) results in the largest negative effect (odds of correct identification decreased by 74.8% compared with natural young faces). Taken together, these results suggest that both age-related decline in the facial muscles’ ability to express facial emotions and age-related physical changes in the face, explain why it is difficult to recognize facial expressions from older faces; the effect of the former, however, is much stronger than that of the latter. Facial muscle exercises, therefore, might improve the capacity to convey facial emotional expressions in the elderly.
... It is, however, worth noting that two trials have recorded statistically significant increases in the volume of facial muscles (measured by ultrasound scanning) over an 8-week and 12-week period of FMED use, respectively. 4,5 What is not made clear is whether this represented muscular hypertrophy or indeed contributed to improved facial appearance. The jawline has been a long-standing tenet of beauty standards and many of the FMED on the market claim to improve the appearance of the user's jawline. ...
... Die Wahl des Stimulationsgerätes ist für den Therapieerfolg von essenzieller Bedeutung, da nur wenige Stimulationsgeräte in der Lage sind, die nötige Impulsdauer und Impulsform zu generieren. . (Ahlborn et al. 2007, Al-Majed et al. 2000, Willand et al. 2016 Literatur sowie in der hier vorliegenden Arbeit wurde die Interrater-Reliabilität zum Sunnybrook-Score als gut eingestuft (Kanerva et al. 2006 (Sauer et al. 2016, Alfen et al. 2013, Mandl et al. 2008, Hwang et al. 2018, Mastryukova et al. 2020). ...
... Studies have shown that atrophy of muscles as well as an increase in muscle cross section after exercising can be followed with ultrasound, MRI and 3D-scanners. [31][32][33][34] To verify the subjective improvement in symmetry and to show the impact of ES in muscle response and psychological influence 35 a standardized study with regular planned follow-up visits and a standardized stimulation protocol as well as patient questionnaires would be needed. A larger sample size would be helpful to detect the between-group differences more accurately. ...
Article
Introduction: Does electrical stimulation (ES) of denervated muscles delay or prevent reinnervation, or increase synkinesis? This retrospective study evaluated the outcome with and without ES of patients with acutely denervated facial muscles. Methods: The effect of ES was analyzed in two experiments: In 39 patients (6 with home-based ES, median 17.5 months) undergoing facial nerve reconstruction surgery (FNRS). Time to recovery of volitional movements was analyzed. The second experiment involved 13 patients (7 with ES, median 19 months) during spontaneous reinnervation. Sunnybrook and eFACE scoring provided functional outcome measures. Results: No difference in time of reinnervation after FNRS was found between the patients with and without ES (median (IQR) 4.5(3.0, 5.25) vs. 5.7(3.5, 9.5) months; p=0.2). After spontaneous reinnervation less synkinesis was noted (Sunnybrook synkinesis: 3.0(2.0, 3.0) vs. 5.5(4.75, 7.0); p=0.02) with ES. Discussion: We find no evidence that ES prevents or delays reinnervation or increases synkinesis in facial paralysis. This article is protected by copyright. All rights reserved.
Article
Background There are few reports on the relationship between facial expression formation and mass of the muscle responsible for facial expression. We analyzed the facial expression using facial action coding system (FACS) and examined the muscle mass and characteristics of the facial expression muscles using multi‐detector row computed tomography (MDCT) and magnetic resonance imaging (MRI). Moreover, the relation between these was statistically evaluated. Materials and Methods Ten healthy women in their 40s (43.4 ± 3.0 years, 40‐49) were enrolled. The expressive faces were analyzed by facial expression analysis software based on the FACS. The muscle mass and characteristics of the facial expression muscles were investigated using MDCT/MRI. The correlation between an integrated expression intensity value (IEIV) for FACS of the widest possible grin and muscle mass was analyzed. The mean values between the two categorized groups (G‐1 and G‐2) based on fat infiltration into the muscle were compared. Results A positive correlation is found between the IEIV and the muscle mass. The IEIV of G‐1 is significantly larger than the corresponding value of G‐2. Hence, the results indicated that the subjects with high IEIV and expressive face had thicker facial expression muscles and little fat infiltration into the muscles. Conclusion Our objective imaging diagnostic study using FACS, MDCT, and MRI corroborated the anti‐aging medical science about the facial expression muscles related to youthful facial appearance. The results of this research could contribute to the elucidation of the mechanisms involved in the facial aging process and to the development of cosmetology.
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PURPOSE: to identify possible facial changes in patients undergoing aesthetic facial treatment at the Practice School of Speech Therapy and checking whether these changes were perceived by patients, other people and by audiologists, as well as checking their satisfaction as for the results. METHOD: the study included 11 women aged 40 to 50 years (average 44.5 ± 3.6 years). Exclusion criteria: women undergoing previous speech therapy treatment, aesthetic facial surgery, or neurological disorders. They were submitted to 10 therapy sessions, with isotonic and isometric exercises. Furthermore, they answered a questionnaire about perceived changes. The "before and after" pictures were analyzed by speech-language pathologist being specialists in oral motricity who identified the presence or absence of changes. In a 100mm visual analogue scale, the satisfaction score on the facial appearance after and before treatment was flagged. RESULTS: all patients (100%) have perceived facial changes: eye and lips wrinkles' reduction as well as nasolabial furrow, more defined lips, youthful and shining skin, and mitigation of wrinkle expressions (90.91%). The others have referred the following changes (45.45%): reduction of undereyes' shadows, youthful and shining skin. The specialists have not found agreement, although they have realized changes in greater or lesser degree in the majority of the variables analyzed. The average degree of facial appearance satisfaction increased from 46.18 to 82.09 (p=0.05). CONCLUSION: speech treatment has proportioned facial changes which were noted by the patients, by others and by the specialists. The patients have shown more satisfaction with their faces' aesthetic aspects after the speech treatment.
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Introduction: While the prolongation of life expectancy is due to medical, economic, social and public health advancements, longevity may not necessarily be an indicator of real development. Epidemiologic data indicate, in fact, that advanced age carries the risk of multiple diseases, disability and loss of autonomy. Materials and methods: How the years gained are lived need to be assessed evaluating quality of life, health status, and disability. Results and conclusions: Good health care planning should aim to ensure that the years of life gained are lived in good health conditions in the light of the World Health Organization's declaration that "increased longevity without quality of life is an empty prize. Health expectancy is more important than life expectancy"
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Facial skin aging is influenced by weakened mimetic muscles. Resistance training of facial mimetic muscles could be one of practical strategy to defend against age-related changes. The aim of this study was to investigate the effects of an exercise program (KFRP: Kyunghee Facial Resistance Program) designed for facial mimetic muscles on the mechanical properties and elasticity of facial skin. For this study, 16 healthy female volunteers aged 35-58 participated in KFRP for eight weeks. The mechanical and elastic properties of skin were measured using a Cutometer® on the face and neck. The parameters representing skin fatigue decreased and the parameters representing skin elasticity increased significantly compared to the baseline in all measured regions. The ability of re-deformation of skin increased significantly except the zygomaticus and platysma muscle regions. All measured regions of skin became firmer and the ability to return to the initial position was also significantly improved compared to the baseline. Visco-elasticiy of the skin was not significantly altered. The skin became more firm and elastic through KFRP. This method of resistive exercise had a significantly positive influence on the mechanical properties and elasticity of facial and neck skin.
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Background: Cross-linked dextran shows complete degradation in the vital tissue and has characteristics of neocollagenesis. However, its efficacy as a dermal filler in treating facial soft tissue defects has not been investigated. Objective: To evaluate the efficacy and safety of subcutaneous injection of a dextran filler in treating nasolabial folds for 24 weeks. Methods and materials: Twenty patients were enrolled in this 24-week multicenter, evaluator-blinded clinical study. Each patient received a single session of a dextran filler treatment in both nasolabial folds, and no touch-up injections were given. Treatment efficacy was evaluated by blinded investigators at 4, 12, and 24 weeks after baseline. Safety data were collected from patient diaries and interviews at each follow-up visit. Results: There were significant improvements (p<.0001) in the Wrinkle Severity Rating Scale scores compared with those at baseline with a mean decrease of 1.50±0.51 at 24 weeks. Only 1 mild treatment-related adverse event was noted throughout the 24-week follow-up period. Conclusion: Cross-linked dextran-derived injectable filler is considered to be a favorable measure in tissue augmentation of the nasolabial folds. Further investigation is needed to demonstrate the long-term efficacy and safety of dextran fillers.
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Background: Excessive gingival display, or a “gummy smile,” is defined as 2 mm or more of gingival exposure upon smiling. Such excessive gingival exposure can be aesthetically unappealing to patients. One factor that contributes to a gummy smile is hyperfunctional lip elevator muscles. Objectives: The authors evaluate onabotulinumtoxinA as a safe and minimally invasive treatment for a gummy smile. Methods: In this prospective study, 14 patients (13 women, 1 man) underwent pretreatment photographs and measurements, followed by bilateral injection of onabotulinumtoxinA into their lip elevator muscles. All patients selected for the study had more than 2mm of gingival show and were classified as having a “cuspid smile,” where action of all elevator muscles raised the upper lip— like a window shade—to expose the upper teeth and gingival scaffold; these patients were thought to have a better chance for a more superior result. Repeat measurements and photographs were collected at 2 weeks and 3 months. Patient-reported outcomes were collected at 2 weeks, and data were compared to determine the correlative relationship. Results: An average of 5 units (range, 4–6 U) of onabotulinumtoxinA were injected into 3 sites bilaterally. The average preinjection gingival show over the central incisors and canines were 4.89 mm and 4.25 mm, respectively. Postinjection gingival show decreased to an average of 0.75 mm (85% improvement) and 0.74 mm (83% improvement) over the central incisors and canines, respectively. Average follow-up time was 12.6 days. One patient felt the resulting smile was unattractive and opted not to undergo repeat injections, while all other study participants experienced no negative effects and wished to undergo repeat treatment. Conclusions: As treatment for a “gummy smile,” onabotulinumtoxinA provides an effective, minimally invasive, and safe therapy. This treatment option can lead to significant improvement in smile aesthetics with high patient satisfaction. Level of Evidence: 3