Cosmetic

Anatomical Considerations to Prevent Facial

Nerve Injury
Jason Roostaeian, M.D.
Rod J. Rohrich, M.D.
James M. Stuzin, M.D.
Los Angeles, Calif.; Dallas, Texas; and
Coconut Beach, Fla.
Summary: Injury to the facial nerve during a face lift is a relatively rare but
serious complication. A large body of literature has been dedicated toward bet-
tering the understanding of the anatomical course of the facial nerve and the
relative danger zones. Most of these prior reports, however, have focused on
identifying the location of facial nerve branches based on their trajectory mostly
in two dimensions and rarely in three dimensions. Unfortunately, the exact lo-
cation of the facial nerve relative to palpable or visible facial landmarks is quite
variable. Although the precise location of facial nerve branches is variable, its
relationship to soft-tissue planes is relatively constant. The focus of this report
is to improve understanding of facial soft-tissue anatomy so that safe planes of
dissection during surgical undermining may be identified for each branch of
the facial nerve. Certain anatomical locations more prone to injury and high-
risk patient parameters are further emphasized to help minimize the risk of
facial nerve injury during rhytidectomy.  (Plast. Reconstr. Surg. 135: 1318, 2015.)

I
njury to the facial nerve during a face lift is a
relatively rare but serious complication. The
incidence of facial nerve injury in the litera-
ture has ranged from less than 1 percent to as
high as 20 percent.1–5 Although the incidence
varies depending on technique and surgeon, the
vast majority of series have placed the incidence
well below the 1 percent range. Fortunately, the
incidence of permanent injury is considerably
less and reported to be approximately 0.1 percent
in most series.1,6,7 One must remember, however,
that the rates in the literature are based on self-
reported retrospective case series by highly expe-
rienced surgeons and therefore likely represent
an incidence that is below average.
The importance of avoiding facial nerve injury
with any elective procedure, such as a face lift, is
evidenced by a large body of literature dedicated
toward bettering our understanding of the ana-
tomical course of the facial nerve and the relative
danger zones.1,3,8–19 Most of these prior reports,
however, have focused on identifying the location
of facial nerve branches based on the trajectory
of the facial nerve, mostly in two dimensions and
rarely in three dimensions. Unfortunately, the
exact location of the facial nerve relative to pal-
pable or visible facial landmarks is quite variable.
Therefore, information regarding the “typical”
location of the facial nerve, albeit helpful, can be
less practical for surgeons.
Although the precise location of facial nerve
branches is variable, its relationship to soft-tissue
planes is relatively constant.20 Therefore, under-
standing the nerve’s location relative to fascial
planes throughout the face allows the surgeon to
determine the appropriate depth of dissection for
the nerve to remain protected (Fig. 1). In addi-
tion, it is important for the surgeon to be aware of
regions where the risk of nerve injury is greatest.
We believe that the facial nerve is at greater risk
for injury where nerve branches sit most super-
ficially and are adjacent to retaining ligaments.
These ligaments often require release for proper
redraping of soft tissues and can push the dissec-
tion into a deeper plane, creating greater risk for
nerve injuries (Fig. 2).
The focus of this report is to improve under-
standing of facial soft-tissue anatomy so that safe

From the Division of Plastic Surgery, David Geffen School
of Medicine at the University of California, Los Angeles; the
Department of Plastic Surgery, University of Texas South-
western Medical Center; and private practice.
Received for publication May 27, 2014; accepted October
22, 2014.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001244
Disclosure: Rod J. Rohrich, M.D., receives instru-
ment royalties from Eriem Surgical, Inc and book roy-
alties from Quality Medical Publishing and Taylor
and Francis Publishing. No funding was received
for this article. The other authors have no financial
interest to declare in relation to the content of this
article.

1318 www.PRSJournal.com
Volume 135, Number 5 • Preventing Facial Nerve Injury

Fig. 1. Cadaver dissection displaying the course of the buccal branch distal to the parotid.
Note that it remains just deep to the masseteric fascia, which is being grasped (left) and
reflected (right) to reveal the nerve. This exemplifies the importance of understanding
where the facial nerve lies with respect to fascial planes in the face to avoid injury.

Fig. 2. Retaining ligaments of the face. (From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial
and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441–449.)

planes of dissection during surgical undermining to injury and high-risk patient parameters are
may be identified for each branch of the facial further emphasized to help minimize the risk of
nerve. Certain anatomical locations more prone facial nerve injury during rhytidectomy.

1319

PREVENTING INJURY TO FACIAL
NERVE BRANCHES
Frontal Branch
Anatomy
The frontal branch has long been considered
one of the more vulnerable facial nerve branches,
given its fewer number of branches, lack of signifi-
cant arborization to other facial nerve branches,
and relatively superficial nature. With the devel-
opment of deeper rhytidectomy techniques, such
as the subperiosteal face lift, reports of injury to
the frontal nerve have been reported to be as high
as 20 percent in some series.5 Therefore, a signifi-
cant body of literature has been dedicated toward
improving our understanding of the anatomy of
the frontal branch.
Early reports on the anatomy of the frontal
nerve, starting with Furnas and later Pitanguy and
Ramos, described the frontal branch as a single
ramus crossing the zygomatic arch.10,11,21 More
recent reports, however, have confirmed the
frontal branch to have between two and five rami
crossing the central third to half of the zygomatic
arch.14,17,21 Moreover, some of these reports have
found that there is arborization between the vari-
ous rami of the frontal nerve but not with other
branches of the facial nerve.14 Nevertheless, the
interconnections between the rami can likely
explain the return of function by 6 months often
seen after inadvertent injury.
The course of the frontal nerve was perhaps
first best described by Pitanguy and Ramos, where
they found that the frontal branch typically fol-
lows a trajectory from 0.5 cm below the tragus to
1.5 cm above the lateral brow.10 Others since have
better defined the precise course of the frontal
branch relative to both soft-tissue and bony land-
marks. In two separate studies, Ozersky et al. and
Gosain et al. found the anterior and middle rami
of the frontal branch to lie 2 to 3 cm from the
lateral orbital rim at the level of the lateral can-
thus.14,22 Tzafetta and Terzis, in a recent report,
found the trajectory of the nerve to be slightly
inferior to that described by Pitanguy at the level
of the lateral brow, averaging 1 ± 0.5 cm.17 Trinei
et al. described the sentinel vein as an important
landmark in proximity to the frontal branch.
They found the frontal branch to consistently lie
cephalad to the sentinel vein by a mean distance
of 6.8 mm.23
Perhaps more important than knowing the
distance of the frontal branch from surround-
ing structures is understanding its course rela-
tive to adjacent fascial layers. The location of
1320
Plastic and Reconstructive Surgery • May 2015
the frontal branch within the temporal fascia
was first best described by Stuzin et al.24 In their
investigation, they found the level of the nerve to
be just deep to the temporoparietal fascia when
cephalad to the zygomatic arch. Therefore, the
safe plane of dissection when working above the
zygomatic arch is superficial to the temporopari-
etal fascia or, when dissecting deeper, directly on
or beneath the superficial leaf of the deep tem-
poral fascia (Fig. 3).
At the level of the zygomatic arch, it is evi-
dent that the frontal branch is relatively deep and
adjacent to the periosteum. Techniques such as
the high superficial musculoaponeurotic system
(SMAS), where the SMAS is cut just above the
superior border of the arch, would be thought to
lead to frequent nerve injury. However, the clini-
cal series using this technique report no incidence
of frontal branch nerve injury.25,26 One study by
Trussler et al. described the relationship of the
frontal branch to additional fascial layers and/or
fat pads.26 In their study, they described an addi-
tional fascial layer deep to the temporoparietal
fascia, previously identified by Tolhurst et al., to
which the nerve lies deep based on histologic sec-
tions up to 1.5 cm above the arch.26,27 In a recent
article, Singh et al. described the depth of the
nerve relative to the sub-orbicularis oculi fat pad
and retro-orbicularis oculi fat pad.28 They found
that the frontal branch passes lateral to the sub-
orbicularis oculi fat pad and lies just superficial to
the retro-orbicularis oculi fat pad and therefore
dissection deep to this plane would keep the nerve
protected. The retro-orbicularis oculi fat pad is
contiguous with the sub-SMAS fat, therefore again
confirming the safety of dissection deep to loose
areolar tissue just above the deep temporal fas-
cia. It is important to note that the frontal branch
becomes more superficial as it moves superiorly.
It always remains deep to the temporoparietal
fascia layer, however, as it will ultimately inner-
vate the frontalis along its deep surface, which is
in a plane contiguous with the temporoparietal
fascia/SMAS.24
Safe Dissection
Based on the anatomical studies described
above, the key to preventing injury to the frontal
branch is to stay superficial to the temporopari-
etal fascia in the subcutaneous fat when dissect-
ing inferior to superior. The sentinel vein, which
courses through the various fascial layers up to
the skin, can be used as a landmark indicating
proximity to the nerve while dissecting within the
temporal region. When using a lateral or superior
Volume 135, Number 5 • Preventing Facial Nerve Injury

Fig. 3. Fascial layers in the temporal region. The frontal nerve remains
just deep to the temporal parietal fascia, which is in continuity with the
superficial musculoaponeurotic system (SMAS). Therefore, a superficial
approach to the temporoparietal fascia and/or directly on the deep
temporal fascia maintains safe planes of dissection. The long arrow indi-
cates a recommended path of dissection toward the zygomatic arch,
where the superficial leaf of the deep temporal fascia is penetrated to
ensure a fascial layer of protection from the frontal branch. (Printed
with permission from Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA.
Anatomy of the frontal branch of the facial nerve: The significance of
the temporal fat pad. Plast Reconstr Surg. 1989;83:265–271.)

approach, staying right on or deep to the superfi-
cial leaf of the deep temporal fascia is a safe plane
of dissection. It is also important to be mindful of
traction or pressure type injuries, particularly with
endoscopic technique where there can be injury
to the nerve when dissecting the tissue bluntly
adjacent to the frontal branch.
Zygomatic and Buccal Branches
Anatomy
The buccal branch is considered the most
commonly injured facial nerve branch.29 How-
ever, because of its significant arborization, the
injuries are typically short lived and are often less
clinically significant compared with other facial
nerve branches. Among the early work on facial
nerve anatomy, Davis et al. described a total of
six different branching patterns. The most com-
mon pattern they found, type 3, was present in
67 percent of their 350 dissections. Consistent
decussations between zygomatic and buccal
branches were noted within this most common
branching pattern.30 More recent work indeed
shows that zygomatic and buccal branches are
more likely to have a greater number of rami
and interconnections compared with other facial
nerve branches. Tzafetta and Terzis found at least
three rami and up to six rami, with a mean of
3.7 for zygomatic and buccal branches.17 In the
majority of their dissections (70 percent), they
found interconnections between the zygomatic
and/or buccal branches with either each other
or the marginal mandibular branch. The inter-
connections and overlapping branching patterns
of zygomatic and buccal branches likely explain
the spontaneous recovery of motor function fol-
lowing most injuries. Nevertheless, even tempo-
rary paresis can be significantly distressing for

1321

both the patient and the surgeon and therefore
prevention of injury is key.
Given their proximity to a high density of
retaining ligaments, which can tend to lead to
dissections into a deeper plane as mentioned
above, the zygomatic and buccal branches have
specific regions at relatively higher risk for injury.
The area perhaps at greatest risk for injury of a
facial nerve branch is the region just inferior and
lateral to the zygoma (Fig. 4). In this area, the
zygomatic branches lie relatively superficially and
are adjacent to a high density of zygomatic and
upper masseteric retaining ligaments. In a recent
study by Alghoul et al., they noted that two or
three zygomatic branches (and an occasional buc-
cal branch, when three rami are present) passed
between the zygomatic and upper masseteric liga-
ments.31 These branches were relatively deep at
a depth of 4.07 ± 1.29 mm relative to the deep
fascia. More superficial was an inferior zygomatic
branch that passed inferior to the upper masse-
teric retaining ligament or penetrated its inferior
margin in 54 percent of cases. The mean distance
of this nerve from the upper masseteric retaining
ligament was 1.42 ± 1.56 mm and was located 1.41
± 0.95 mm beneath the deep fascia. This is likely
the branch that is most commonly injured during
face lifts given its close proximity to retaining liga-
ments and its relatively superficial course. These
Fig. 4. Mapping of the extratemporal facial nerve with India
ink. The region of zygomatic eminence is free of facial nerve
branches and remains a sort of watershed between the frontal
and zygomatic branches as shown here. Techniques such as the
extended SMAS, high SMAS, and finger-assisted malar elevation
are safely preformed by staying deep to the malar fat pad but
superficial to the mimetic muscles that are in continuity with the
SMAS. (Printed with permission from Tzafetta K, Terzis JK. Essays
on the facial nerve: Part I. Microanatomy. Plast Reconstr Surg.
2010;125:879–889.)
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Plastic and Reconstructive Surgery • May 2015
branches go on to reach the undersurface of the
zygomaticus major and lie on the superficial sur-
face of the buccal fat pad and are likely to affect
smile when injured.
Safe Dissection
The key to preventing injury of the zygomatic
and buccal branches is to be aware of the relative
danger zones adjacent to retaining ligaments.
As these retaining ligaments are encountered,
it is helpful to dissect both cephalad (above the
upper zygomatic ligaments) and caudal (at least
5 mm below the upper masseteric ligaments) to
the retaining ligaments to establish the proper
plane of dissection superficial to the SMAS. Once
the appropriate depth is ensured, the remaining
zygomatic and upper masseteric retaining liga-
ments just lateral to the zygoma can then more
safely, yet still cautiously, be divided as needed.
As noted above, some of the zygomatic and buc-
cal branches can be less than 1 mm deep to the
SMAS in the region adjacent to the upper masse-
teric ligaments, and therefore this region must be
approached with extreme caution.31 A relatively
safe area of dissection is directly over the zygo-
matic eminence. This is an area that is relatively
free of facial nerve branches, lying in between
frontal branches above and zygomatic branches
below. Techniques such as the extended SMAS,
high SMAS, and finger-assisted malar elevation
are safely preformed by taking advantage of this
watershed area over the zygomatic eminence and
staying deep to the malar fat pad but superficial to
the mimetic muscles.
Marginal Mandibular Branch
Anatomy
Similar to the frontal branch, the assumed rel-
ative lack of decussations with other facial nerve
branches and fewer number of rami have led
most surgeons to consider the marginal mandibu-
lar nerve at higher risk for permanent injury.32 In
their landmark study, Dingman and Grabb stud-
ied 100 facial halves and found two or greater
rami in nearly 80 percent of their dissections.12
They also found that the marginal mandibular
nerve anterior to the facial vessels was above the
lower border of the mandible in 100 percent of
their dissections. In 19 percent, they found the
nerve below the lower border of the mandible
posterior to the facial vessels. Tzafetta and Terzis
also found at least two branches of the marginal
mandibular (mean, 2.3 ± 0.48), and in 30 percent,
the branches ran along the caudal mandibular
border; in 40 percent, approximately 2 cm above;
Volume 135, Number 5 • Preventing Facial Nerve Injury
and in 30 percent, 1 cm below.17 Although some
have reported the marginal mandibular branch as
low as 2 to 4 cm, this is a rare finding and in many
cases likely a cervical branch to the platysma.1
Tzafetta and Terzis also found that decussations
between the marginal mandibular nerve and the
buccal branch were quite common, present in 50
percent of their dissections.17
As with all other branches of the facial nerve,
the exact location and number of rami for the mar-
ginal mandibular nerve are variable, whereas its
relationship to fascial layers is constant. The nerve
exits the anterior caudal margin of the parotid
and remains deep to the parotid masseteric fascia
and deep cervical investing fascia (Fig. 5). When
the nerve travels inferior to the mandible, it runs
across the surface of the posterior digastric mus-
cle and the submandibular gland.3 Staying deep
to the platysma and deep fascia, it runs superficial
to the facial artery as it rises above the mandibular
border.33 It is in this region, where the marginal
mandibular nerve crosses the facial vessels, that
the nerve is at relatively high risk for injury as it
moves into a more superficial position. Hazani
et al. have identified that, approximately 3 cm
anterior to the mandibular tuberosity, the mar-
ginal mandibular nerve transitions over the facial
vessels.34 The lower masseteric retaining ligaments
Fig. 5. Cadaver dissection displaying the marginal mandibular
nerve branches (blue arrows) as they exit the caudal border of
the parotid gland. Note that the marginal mandibular nerve
remains encased in sub-SMAS flap, and as shown in Figure  1,
remains deep to the masseteric fascia. The blue tabs reveal the
distal branching pattern of the marginal mandibular nerve.
along the caudal border of the masseter are a use-
ful landmark and should likewise be a point of cau-
tion when being released from either a medial or
lateral approach. These ligaments form a fibrous
attachment between the platysma and the skin,
and is a region where it is easy to dissect deep to
the platysma and injure the underlying branches.
Safe Dissection
To prevent injury to the marginal mandibular
branch, one can ensure safety by always staying
superficial to the platysma-SMAS. It is important
to note that the platysma can be particularly atro-
phic, thin, and lax, making the dissection at times
difficult. During subcutaneous dissection in the
neck, the platysma can be tented superiorly when
retracting for exposure, especially along the cau-
dal border of the masseter. This makes inadver-
tent dissection deep to the platysma with scissors
or a liposuction cannula possible, thereby putting
the underlying nerves at risk. In particular, when
transitioning from the preplatysma plane caudally
in the neck and moving superiorly along the jaw
line, careful dissection is necessary to avoid get-
ting deep to the platysma along the caudal border
of the masseter. The prominence of the mandibu-
lar body, and the fibrous adhesions of the lower
masseteric ligaments, can obscure tissues planes
and force difficult angles of dissection, making it
easier to go deep to the platysma in this region.
When elevating the SMAS plane laterally
in the cheek, the marginal mandibular nerve
remains encased in sub-SMAS fat after exiting
the tail of the parotid. In this region, blunt dis-
section under direct visualization should be used
when possible, as there tends to be a looser areo-
lar relationship anterior to the parotid, with less
dense attachments.33 Again, it is safest to limit
release of ligaments only until adequate mobility
of facial soft tissues is achieved. Further dissection
is unnecessary and puts critical structures such
as facial nerve at risk. Special care should also be
taken around the region where the facial vessels
cross the mandible anterior to the mandibular
tuberosity. This is where the marginal mandibu-
lar nerve becomes more superficial crossing over
the vessels as detailed above. Excessive cautery
should also be avoided in this area when bleeding
is encountered from the vasculature of the under-
lying facial vessels.
Cervical Branch
Anatomy
The cervical branch has received relatively less
attention in the surgical literature despite likely
1323
 Plastic and Reconstructive Surgery • May 2015

attached to the platysma and therefore at high risk

Fig. 6. A cadaver dissection revealing the extremely thin, nearly
translucent nature of the platysma that is often found.
being one of the most commonly injured branches
of the facial nerve.33 It is at high risk for injury
because of its relatively superficial nature and inti-
mate attachment to the platysma (Fig. 6). This is
particularly true as one moves toward the midline,
where the terminal end branches are intimately
for injury with dissection along the platysma. Many
have reported injury to the cervical branch as a
marginal pseudoparalysis because of the effect of
the platysma on lip depression.33,35 Cervical branch
injury can still be distinguished from the marginal
mandibular nerve, however, based on the ability to
pucker the lower lip with intact orbicularis oris and
mentalis function. Complete return of function
has been reported in nearly all cases of cervical
branch injury, and it is likely that there are many
incidents of injury that go unnoticed in patients.
The cervical branch of the facial nerve exits
the caudal edge of the parotid gland just ante-
rior to the angle of the mandible and, unlike the
marginal mandibular branch, perforates the deep
cervical fascia soon thereafter. It goes on to take
a relatively superficial position in the fibroareo-
lar connective tissue that attaches to the under-
surface of platysma. Chowdhry et al. found the
mean branching point of the cervical branch to lie
1.74 cm from the angle of the mandible along a
trajectory that is perpendicular to a line from the
mastoid to the mentum (Fig. 7).36 Of note, it is in
this region laterally below the mandible that the
platysma forms dense attachments with the sterno-
cleidomastoid muscle, making the dissection more
difficult, creating a higher risk for nerve injury. In
another study of 20 hemifaces, the cervical branch

Fig. 7. A fresh cadaver dissection displaying the lower branches of the facial nerve. The cer-
vical facial trunk is labeled as it exits the caudal border of the parotid. Note that the cervical
branch point is below the mandibular border and divides into the cervical and marginal
mandibular nerves. (Printed with permission from Chowdhry S, Yoder EM, Cooperman RD,
Yoder VR, Wilhelmi BJ. Locating the cervical motor branch of the facial nerve: Anatomy and
clinical application. Plast Reconstr Surg. 2010;126:875–879.)

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Volume 135, Number 5 • Preventing Facial Nerve Injury
was found to have great variability in terms of num-
ber of branches and branching pattern.37 None of
the cervical branches was ever more than 15 mm
posterior to the mandibular angle or 45 mm below
the inferior mandibular border. Only three of the
20 specimens had a single cervical branch, with two
cervical branches being most common (11 of the
20 specimens), followed by three cervical branches
in the remaining six specimens. Seven of the 20
specimens had a communicating branch with the
marginal mandibular nerve. They also found that
in every specimen there was a communicating
branch from the transverse cervical sensory nerve,
typically at 2 cm below the mandibular border.
Identification of this sensory nerve, therefore, can
help with the identification of the cervical branch
during dissection.
Safe Dissection
Based on the anatomical findings of the stud-
ies discussed above, to avoid injury to the cervical
branch, one should place SMAS incisions later-
ally along the platysma at least 15 mm posterior
and 45 mm inferior to the mandibular angle.
Subplatysmal dissection closer to the mandibular
angle and/or mandibular body should be per-
formed under direct vision, taking care to stay
superficial to the sub-SMAS fat that encases the
nerve branches. Similar to the marginal mandibu-
lar nerve, blunt dissection should be used when
dissecting beyond the tail of the parotid to avoid
injury to the cervical branch. Sharp dissection in
this region is unnecessary, given the lack of dense
ligamental attachments and overall adequate
mobility of the soft tissues.
Staying superficial to the platysma will protect
the cervical branches. Careful dissection to avoid
inadvertent dissection through the platysma with
scissors or a liposuction cannula should always
be performed as discussed above. One way to
ensure this is to maintain the fascia over the pla-
tysma during dissection. Sharp dissection into the
platysma can produce injury to the microscopic
terminal branches of the cervical nerve that infil-
trate throughout the muscle fibers of the platysma
and cause segmental paralysis. Therefore, despite
avoiding injury to the main cervical nerve branch
itself, dissection into the platysma can lead to lower
lip asymmetry postoperatively that typically is tem-
porary yet nevertheless disturbing for the patient.
DISCUSSION
The majority of series that have reported
facial nerve injury during face lifts are based on
subcutaneous techniques. Contrary to the notion
that dissecting in a deeper plane would put the
facial nerve at greater risk, the incidence with
most sub-SMAS techniques has not been reported
to be higher.25,38–40 In fact, it is likely that most
facial nerve injuries still occur during subcutane-
ous dissection even though the dissections are
performed closer to the nerves with sub-SMAS
techniques. This may be secondary to the fact that
a subcutaneous plane of dissection is used in most
face-lift techniques and by surgeons of varying
experience. Moreover, it is a nondescript plane
that is often dissected bluntly, with thickness that
is chosen by the surgeon. In contrast, the sub-
SMAS dissection is typically performed with direct
visualization of fascial planes. Visual cues (e.g., the
parotid fascia when elevating the SMAS in a deep
plane technique) can allow the surgeon to remain
confident that they are in the appropriate plane
of dissection that will avoid facial nerve injury.
Indeed, precise subcutaneous dissection is
considered by some surgeons to be the most diffi-
cult aspect of face lifting. The subcutaneous plane
is one that is created by the surgeon, with many
dense attachments making the dissection more
difficult. Retaining ligaments, such as the zygo-
matic, masseteric, and mandibular, compress the
planes of dissection and can easily mislead the sur-
geon into a deeper plane, which may jeopardize
underlying nerves. The relative compression of tis-
sue planes is also apparent as one moves medially
and the SMAS layer thins.41 Further complicating
matters is higher risk regions where the nerves sit
relatively superficially and can be as little as 1 mm
deep to the SMAS.31 Therefore, an important
point in avoiding facial nerve injury is to visualize
the precise plane superficial to the SMAS when
raising the skin during a face lift. Transillumina-
tion with a contralateral operating room light is
a helpful maneuver that again provides an addi-
tional visual cue that can help ensure the proper
depth of dissection when attempting to elevate a
precise skin flap.
There are also certain patient factors that
surgeons should be aware of that can make facial
dissections at higher risk for facial nerve injury.
These include the following: (1) relatively thin or
deflated patients with minimal subcutaneous fat;
(2) secondary/revision patients who have a scar
interface between the subcutaneous tissue and
SMAS; and (3) patients who have had significant
amount of fillers, especially those that induce scar-
ring, making precise subcutaneous or sub-SMAS
dissection difficult.
Although we have attempted to elucidate
anatomical regions at greater risk for injury for
1325

each facial nerve branch in this report, it must be
noted that there are inherent weaknesses to the
reliance on previous anatomical studies. Each of
the reviewed studies had used different methods
of anatomical preparation and reported measure-
ments using different methodologies. In addition,
it must also be kept in mind that fine anatomi-
cal relationships may differ between a cadaver
and an actual patient. With that in mind, we have
attempted to focus much of our report on proper
planes of dissection, and regions where nerve
branches may be at greater risk for injury rather
than precise anatomical locations.
CONCLUSIONS
Each facial nerve branch has a particular
region where there is greater risk for injury.
Specifically, there are regions where the nerves
become (1) more superficial and (2) run adjacent
to retaining ligaments where soft tissues are rela-
tively compressed and tend to deflect dissections
into a deeper plane. Briefly, these regions include
the superior extent of the frontal nerve adjacent
to the sentinel vein, lateral to the zygomatic emi-
nence adjacent to the upper masseteric retain-
ing ligaments where the lower zygomatic and/or
buccal branches lie superficially, anterior to the
mandibular tuberosity in the region of the facial
vessels and adjacent to the lower masseteric liga-
ments where the marginal mandibular nerve takes
a more superficial course, and approximately 1.5
to 2 cm below the mandibular angle where the
cervical nerve branches into the platysma and
there are dense attachments to the fascia of the
sternocleidomastoid muscle. It is important for
surgeons undertaking facial rejuvenation to be
aware of these higher risk regions to minimize the
chances of a facial nerve injury. Correct identifi-
cation of the proper plane of dissection in both
subcutaneous and sub-SMAS dissection is the key
for preventing facial nerve injury in face lifting.
Jason Roostaeian, M.D.
Division of Plastic Surgery
David Geffen School of Medicine at the
University of California, Los Angeles
200 UCLA Medical Plaza, Suite 465
Los Angeles, Calif. 90095
jroost@gmail.com
references
1. Baker DC, Conley J. Avoiding facial nerve injuries in rhytid-
ectomy: Anatomical variations and pitfalls. Plast Reconstr Surg.
1979;64:781–795.
2. Castañares S. Facial nerve paralyses coincident with, or subse-
quent to, rhytidectomy. Plast Reconstr Surg. 1974;54:637–643.
1326
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3. Owsley JQ, Agarwal CA. Safely navigating around the facial
nerve in three dimensions. Clin Plast Surg. 2008;35:469–477, v.
4. Azizzadeh B, Mashkevich G. Nerve injuries and treatment in
facial cosmetic surgery. Oral Maxillofac Surg Clin North Am.
2009;21:23–29, v.
5. Psillakis JM, Rumley TO, Camargos A. Subperiosteal
approach as an improved concept for correction of the aging
face. Plast Reconstr Surg. 1988;82:383–394.
6. Pitanguy I, Machado BH. Facial rejuvenation surgery: A ret-
rospective study of 8788 cases. Aesthet Surg J. 2012;32:393–412.
7. Sullivan CA, Masin J, Maniglia AJ, Stepnick DW.
Complications of rhytidectomy in an otolaryngology train-
ing program. Laryngoscope 1999;109:198–203.
8. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial
Plastic Surgery. St. Louis, Mo: Quality Medical Publishers;
1994.
9. Myckatyn TM, Mackinnon SE. A review of facial nerve anat-
omy. Semin Plast Surg. 2004;18:5–12.
10. Pitanguy I, Ramos AS. The frontal branch of the facial nerve:
The importance of its variations in face lifting. Plast Reconstr
Surg. 1966;38:352–356.
11. Furnas DW. Landmarks for the trunk and the temporofacial
division of the facial nerve. Br J Surg. 1965;52:694–696.
12. Dingman RO, Grabb WC. Surgical anatomy of the man-
dibular ramus of the facial nerve based on the dissec-
tion of 100 facial halves. Plast Reconstr Surg Transplant Bull.
1962;29:266–272.
13. Zani R, Fadul R Jr, Da Rocha MA, Santos RA, Alves MC,
Ferreira LM. Facial nerve in rhytidoplasty: Anatomic study
of its trajectory in the overlying skin and the most common
sites of injury. Ann Plast Surg. 2003;51:236–242.
14. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of
the facial nerve: How reliably can we predict its path? Plast
Reconstr Surg. 1997;99:1224–1233; discussion 1234.
15. Rudolph R. Depth of the facial nerve in face lift dissections.
Plast Reconstr Surg. 1990;85:537–544.
16. Schwember G, Rodríguez A. Anatomic surgical dissection
of the extraparotid portion of the facial nerve. Plast Reconstr
Surg. 1988;81:183–188.
17. Tzafetta K, Terzis JK. Essays on the facial nerve: Part I.
Microanatomy. Plast Reconstr Surg. 2010;125:879–889.
18. Wilhelmi BJ, Mowlavi A, Neumeister MW. The safe face lift
with bony anatomic landmarks to elevate the SMAS. Plast
Reconstr Surg. 2003;111:1723–1726.
19. Zani R, Fadul R Jr, Da Rocha MA, Santos RA, Alves MC,
Ferreira LM. Facial nerve in rhytidoplasty: Anatomic study
of its trajectory in the overlying skin and the most common
sites of injury. Ann Plast Surg. 2003;51:236–242.
20. Stuzin JM, Baker TJ, Gordon HL. The relationship of the
superficial and deep facial fascias: Relevance to rhytid-
ectomy and aging. Plast Reconstr Surg. 1992;89:441–449;
­discussion 450.
21. Singh DP, Forte AJ, Apostolides JG, et al. The sentinel fat
pads: The relationship of the ROOF and SOOF to the tempo-
ral nerve in facial rejuvenation. Aesthet Surg J. 2011;31:11–20.
22. Ozersky D, Baek SM, Biller HF. Percutaneous identification
of the temporal branch of the facial nerve. Ann Plast Surg.
1980;4:276–280.
23. Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: An
important reference point for surgery in the temporal
region. Plast Reconstr Surg. 1998;101:27–32.
24. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy
of the frontal branch of the facial nerve: The significance of
the temporal fat pad. Plast Reconstr Surg. 1989;83:265–271.
25. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast
Reconstr Surg. 1992;90:601–607.
Volume 135, Number 5 • Preventing Facial Nerve Injury
26. Trussler AP, Hatef D, Broussard GB, Brown S, Barton FE.
The viscoelastic properties of the SMAS and its clinical trans-
lation: Firm support for the high-SMAS rhytidectomy. Plast
Reconstr Surg. 2011;128:757–764.
27. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ. The sur-
gical anatomy of the scalp. Plast Reconstr Surg. 1991;87:603–
612; discussion 613.
28. Singh DP, Forte AJ, Apostolides JG, et al. The sentinel fat
pads: The relationship of the ROOF and SOOF to the tempo-
ral nerve in facial rejuvenation. Aesthet Surg J. 2011;31:11–20.
29. Stuzin JM. MOC-PSSM CME article: Face lifting. Plast Reconstr
Surg. 2008;121(Suppl):1–19.
30. Davis RA, Anson BJ, Budinger JM, Kurth LR. Surgical anatomy
of the facial nerve and parotid gland based upon a study of
350 cervicofacial halves. Surg Gynecol Obstet. 1956;102:385–412.
31. Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygo-
matic facial nerve to the retaining ligaments of the face: The
sub-SMAS danger zone. Plast Reconstr Surg. 2013;131:245e–252e.
32. Lettieri S. Lower branches of the facial nerve. Facial Plast
Surg. 2012;28:3–7.
33. Daane SP, Owsley JQ. Incidence of cervical branch injury with
“marginal mandibular nerve pseudo-paralysis” in patients
undergoing face lift. Plast Reconstr Surg. 2003;111:2414–2418.
34. Hazani R, Chowdhry S, Mowlavi A, Wilhelmi BJ. Bony ana-
tomic landmarks to avoid injury to the marginal mandibular
nerve. Aesthet Surg J. 2011;31:286–289.
35. Ellenbogen R. Pseudo-paralysis of the mandibular branch
of the facial nerve after platysmal face-lift operation. Plast
FILLER-034
Reconstr Surg. 1979;63:364–368.
36. Chowdhry S, Yoder EM, Cooperman RD, Yoder VR,
Wilhelmi BJ. Locating the cervical motor branch of the facial
nerve: Anatomy and clinical application. Plast Reconstr Surg.
2010;126:875–879.
37. Salinas NL, Jackson O, Dunham B, Bartlett SP. Anatomical
dissection and modified Sihler stain of the lower
branches of the facial nerve. Plast Reconstr Surg. 2009;124:
1905–1915.
38. Kamer FM. One hundred consecutive deep plane face-lifts.
Arch Otolaryngol Head Neck Surg. 1996;122:17–22.
39. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg.
1992;90:1–13.
40. Swanson E. Outcome analysis in 93 facial rejuvenation
patients treated with a deep-plane face lift. Plast Reconstr Surg.
2011;127:823–834.
41. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr
Surg. 1992;89:1054–1057; discussion 1058.
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