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Facial anatomy

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DOI: 10.1016/j.clindermatol.2013.05.022 · Source: PubMed

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Clinics in Dermatology (2014) 32, 14–23

Facial anatomy
Tania Marur, MD ⁎, Yakup Tuna, MD, Selman Demirci, MD
Department of Anatomy, Istanbul University Cerrahpaşa Medical Faculty, Istanbul, Turkey

Abstract Dermatologic problems of the face affect both function and aesthetics, which are based on
complex anatomical features. Treating dermatologic problems while preserving the aesthetics and
functions of the face requires knowledge of normal anatomy. When performing successfully invasive
procedures of the face, it is essential to understand its underlying topographic anatomy. This chapter
presents the anatomy of the facial musculature and neurovascular structures in a systematic way with
some clinically important aspects. We describe the attachments of the mimetic and masticatory muscles
and emphasize their functions and nerve supply. We highlight clinically relevant facial topographic
anatomy by explaining the course and location of the sensory and motor nerves of the face and facial
vasculature with their relations. Additionally, this chapter reviews the recent nomenclature of the
branching pattern of the facial artery.
© 2014 Elsevier Inc. All rights reserved.

The face can be defined as the anterior aspect of the head.
As an anatomical site it extends superiorly to the hairline,
inferiorly to the chin and base of the mandible and on each
side to the auricle.1 Its physiological, expressive, aesthetic
functions and its role in identity require precise structural and
functional organization of the anatomical features.2 This
chapter describes the complex anatomy of the face in the
following order: muscles of the face, vasculature of the face,
and nerves of the face. Traditionally the face can be divided
horizontally into three parts. The midface is defined by an
upper horizontal line above the zygomatic arch extending
from the superior helix insertion to the lateral canthus. The
lower boundary extends from the inferior border of the tragal
cartilage to the oral commissure. The upper face extends
from the hairline to the upper border of the midface, and the
lower face extends from the lower border of the midface to
the chin. Another aspect of the face is the anterior and lateral
areas of the face separated by a vertical line of retaining
ligaments (temoral, lateral orbital, zygomatic, maseteric, and
⁎ Corresponding author. Tel.: + 902124143057.
E-mail address: tania@mynet.com (T. Marur).
mandibular) extending from the lateral orbital rim to the oral
commissure.1 The International Anatomical Terminology
names eight facial regions.3 The face has also been divided
into aesthetic units.4 This chapter uses the division of the
face into three horizontal areas as a way of grouping the
mimetic musles.
Muscles of the face
The muscles of the face can be divided into two groups:
mimetic muscles and muscles of mastication.
Mimetic muscles
The mimetic muscles (Figure 1) play an important role in
the expression of feelings and thoughts by elevating or
depressing the eyebrows and lips. Located around the eyes
and mouth, they also also provide sphincteric action to these
orifices.2 The muscles of facial expression originate from the
facial skeleton that supports the overlying soft tissue and

0738-081X/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.clindermatol.2013.05.022
Facial anatomy
Fig. 1 Mimetic muscles and masticatory muscles (1) temporalis,
(2) frontalis, (3) corrugator supercilii, (4) orbicularis oculi, (5)
procerus, (6) nasalis, (7) levator labii superioris aleque nasi, (8)
levator labii superioris, (9) zygomaticus minor, (10) zygomaticus
major, (11) orbicularis oris, (12) masseter, (13) buccinator, (14)
risorius, (15) modiolus, (16) depressor anguli oris, (17) depressor
labii inferioris, (18) mentalis, (19) platysma, (20) sternocleidomas-
toid, (21) occipitalis.
insert into the skin. Although they commonly overlap each
other, four anatomic layers can be distinguished: first-layer
muscles: orbicularis oculi, risorius, zygomaticus minor,
depressor anguli oris; second-layer muscles: depressor labii
inferior, risorius, zygomaticus major, levator labii superioris
aleque nasi, platysma; third-layer muscles: orbicularis oris,
levator labii superioris; and fourth-layer muscles: buccina-
tors, mentalis, levator anguli oris. The more superficial three
layers are invested by the superficial fascia, the superficial
musculoaponeurotic system (SMAS), so they form the
SMAS-mimetic muscle complex. Because the facial nerve
lies deep to this plane, the superficial muscles receive their
neurovascular supply from their posterior surface, whereas
the deeply situated muscles buccinator, mentalis, and levator
anguli oris supply to their anterior surface.1,5,6
Muscles of the upper face
Frontalis
The largest muscle of the upper face is the frontalis
muscle. It is the anterior belly of the occipitofrontalis muscle
15
of the scalp. It has no bony attachment. Its fibers arise from
the epicranial aponeurosis and extend vertically downward
to terminate on the skin of the brow and into the orbicularis
oculi and corrugator supercilii muscles. The frontalis muscle
has one function—to elevate the eyebrows and produce
horizontal forehead furrows, giving the face a surprised look.
Normal resting tension of the musle keeps the brows in
normal position. The temporal branch of the facial nerve
innervates the muscle.7-9
Orbicularis oculi
The orbicularis oculi is directly beneath the skin of the
eyelids. This broad, flat, sphincter-like muscle surrounds the
orbital opening and spreads into the anterior temporal region,
infraorbital cheek, and the superciliary region. It is divided
anatomically into two parts: the orbital (voluntary) and
palpebral portions (voluntary and involuntary). The palpe-
bral part can be further subdivided into pretarsal and
preseptal parts. The orbital part arises from the nasal part
of the frontal bone, the frontal process of the maxilla, and the
medial canthal tendon. Its upper fibers blend with the
frontalis. As it inserts subcutaneously into the lateral orbital
region (crow’s feet), it overlies some of the elevators of the
upper lip and ala. Contraction causes closing of the eye by
lowering the upper eyelid for protection of the eye globe. The
innermost pretarsal part arises from the medial canthal
tendon, which inserts into the anterior lacrimal crest and
laterally into the lateral palpebral raphe. The pretarsal portion
is involved in blinking, which is important in moistening the
cornea. The central preseptal portion courses in front of the
orbital septum and has similar attachments as the pretarsal
part. The maximal orbital closure depends on contraction of
all the parts of the orbicularis oculi. Temporal and zygomatic
branches of the facial nerve supply the muscle.6-10
Corrugator supercilii
The corrugator supercilii is a small and pyramidal-shaped
muscle arising from the medial end of the superciliary arch of
the frontal bone. It passes laterally and upward and fans out
to insert into the dermis of the middle of the eyebrow. It lies
deep behind the frontalis and orbicularis oculi muscles.
Contraction of the muscle depresses the brow and produces
vertical wrinkles known as frown lines. Temporal branches
of the facial nerve supply the muscle.
Procerus
This single muscle arises in the midline from the lower
part of the nasal bone. It passes upward vertically to insert
into the skin over the glabella between the corrugators. Its
fibers are fused with corrugator supercilii and adjacent
medial part of orbicularis oculi. Contraction of this muscle
produces horizontal creases at the bridge of the nose by
16
pulling the forehead down. The muscle is supplied from the
temporal branch of the facial nerve.
Depressor supercilii
This is a thin slip of muscle formed by the superomedial
fibers of the orbital part of the orbicularis oculi in the
subcutaneous superciliary tissue.7-9
Muscles of the midface
Most of the mimetic muscles originate from this region.
They converge together with the muscles of the lower face
mostly to the modiolus, which is a dense fibromuscular knot
situated just lateral to the external commissure of the mouth.
Orbicularis oris
The orbicularis oris encircles the mouth and acts as a
sphincter around the mouth. It is divided into two parts: a
deep part and a superficial part corresponding to the double
function of the upper lip. The deep orbicularis oris muscle
extends from one modiolus to the contralateral modiolus. Its
contraction brings the lips together. The superficial orbicu-
laris oris muscle intermingles with the facial-expression
muscles. It asists in facial expression and retracts the lower
lip. The marginal mandibular and buccal branches of the
facial nerve supply the muscle.
Buccinator
The buccinator is attached laterally to the alveolar process
of the maxilla and mandible, and pterygomandibular raphe.
Its fibers run towards the modiolus and insert into the
orbicularis oris. It presses the cheeks against the molar teeth
during chewing and blowing. Buccal branches of the facial
nerve supply the muscle.
Zygomaticus major
Zygomaticus major extends from the zygomatic bone
downwards to the modiolus at the corner of the mouth. Its
fibers also insert into the orbicularis oris and levator anguli
oris. Contraction causes elevation of the angle of the mouth
as during laughing. Zygomatic and buccal branches of the
facial nerve supply the muscle.
Zygomaticus minor
Zygomaticus minor extends medially to the zygomaticus
major and is attached to the lateral surface of the zygomatic
bone. It passes inferomedially to insert into the upper lip. The
muscle raises the upper lip and deepens the nasolabial
T. Marur et al.
furrow. It receives its nerve supply from the zygomatic and
buccal branches of the facial nerve.
Levator labii superioris aleque nasi and levator
labii superioris
Levator labii superioris aleque nasi arises from the frontal
process of maxilla and passes inferolaterally to insert into the
nasal cartilage and upper lip. Levator labii superioris runs
laterally to the former muscle. It arises just superior to the
infraorbital foramen and overlies the infraorbital vessels and
nerve. It descends from the infraorbital margin of the maxilla
deep behind the orbicularis oculi to the upper lip. Contraction
of both muscles causes elevation of the upper lip and
deepening of the nasolabial furrow. Levator labii superioris
aleque nasi also dilates the nostrils. Both muscles are
supplied from the zygomatic and buccal branches of the
facial nerve.
Levator anguli oris
Levator anguli oris arises from the canine fossa of the
maxilla below the infraorbital foramen and inserts into the
modiolus near the oral angle. Contraction raises the corner of
the mouth and deepens the nasolabial furrow. Bilaterally it
causes the expression of happiness. It is supplied from the
zygomatic and buccal branches of the facial nerve.
Risorius
The origin of risorius shows great variability. It can attach
to the zygomatic arch, parotid and masseteric fascia, and
from the platysma over the lateral cheek. Its fibers run to the
modiolus at the corner of the mouth. It pulls the corner of the
mouth laterally as in laughing. It is supplied from buccal
branches of the facial nerve.
With the exception of the procerus, the muscles of the
nose are localized in the midface. All nasal muscles are
supplied by buccal branches of the facial nerve.
Nasalis
Nasalis consists of two parts. The upper transverse part on
the nasal dorsum, also known as compressor naris, and the
lower alar part traveling downwards on the sides of the nose,
known also as dilator naris. The transverse part arises from
the maxilla over the canine tooth and travels superomedially
to the dorsum of the nose to decussate with the fibers of the
opposite side. Thus it compresses the nasal aperture between
vestibule and nasal cavity. The alar part arises from the
maxilla inferior and maxilla medial to the transverse part and
attaches to the alar cartilage of the nose. Contraction causes
dilatation of the nostrils by depressing the alar laterally.
Excessive contraction of the muscle can cause oblique
rhytides of the upper lateral nose known as “bunny lines.”
Facial anatomy
Depressor septi
This muscle arises from the maxilla superior to the central
incisor and partly includes fibers of the orbicularis oris. It
runs upwards to the columella of the nose to attach to the
inferior surface of the cartilage of the nasal septum. It pulls
the nasal septum downwards.7-9,11
Muscles of the lower face
Depressor anguli oris
This muscle originates from the oblique line and the
mental tubercle of the mandible lateral to the depressor labii
inferioris. It extends upward and medially to the orbicularis
oris. It inserts into the modiolus and the skin and mucous
membrane of the lateral lower lip. It draws the lateral corner
of the mouth inferiorly and everts the lower lip.
Depressor labii inferioris
The depressor labii inferioris arises from the oblique line
of the mandible deep behind the depressor anguli oris. It runs
superomedially to insert into the skin and mucosa of the
lower lip. Its fibers blend also with orbicularis oris. It
depresses the lower lip inferiorly and laterally.
Mentalis
This is a small muscle attached in the incisive fossa of the
mandible. It descends to insert into the skin of the chin. The
three muscles of the lower face mentioned above are supplied
from the marginal mandibular branch of the facial nerve.
Platysma
This thin subcutaneous sheetlike mimetic musle is located
in the skin of the neck and has no bony attachments. It
originates from the fascia of the upper parts of the pectoralis
major and deltoid at the level of the second rib. It ascends to
the face to insert into the inferior border of the mandible,
perioral muscles, modiolus, and the skin and subcutaneous
tissue of the lower face. The lateral fibers of the muscle pass
posteriorly to the angle of the mandible. The fibers meet in
the midline and form an inverted V at the lower chin region.
Platysma acts as a depressor of the lower lip. It also depresses
the mandible and pulls the angle of the mouth laterally and
downwards. The whole musle contraction causes skin ridges
in the neck. The muscle is supplied from the cervical branch
of the facial nerve.
Muscles of the ear are functionally not of great
importance. There are three auricular muscles of note,
which extend from the head to the auricle.7-9,11
17
Masticatory muscles
In contrast to the mimetic muscles, which are located on
the anterior aspect of the face, the masticatory muscles are
found in the lateral aspect of the face. Muscles of mastication
include the temporalis, masseter, lateral and medial ptery-
goid. They lie deep behind the deep fascia of the midface and
are supplied by the branches of the mandibular nerve.
Temporalis
This muscle arises from the temporal planum made up of
the frontal, temporal, sphenoid, and parietal bones on the
lateral aspect of the cranium. The fibers pass forward and
downward through the gap lateral to the zygomatic arch and
terminate inserting on the apex of the coronoid process.
Temporalis closes the mouth by elevating the mandible and
retracts the mandible from protrusion.
Masseter
This muscle (Figure 1) is covered posteriorly by the
parotid gland. It is composed of superficial, middle, and deep
layers. These layers arise from the inferior border and medial
surface of the zygomatic arch and the anterior surface of the
articular tubercle of the temporal bone. Its fibers terminate at
the lower half of the lateral aspect of the mandibular ramus,
mandibular notch, and coronoid process. Its function is to
close the jaw, especially in the molar region. It also acts in
retracting the mandible.
Lateral pterygoid
Under cover of the temporalis, the lateral pterygoid
originates with its two heads from the infratemporal fossa.
The superior head arises from the infratemporal surface and
infratemporal crest of the greater wing of sphenoid bone, the
inferior head from the lateral plate of the pterygoid process.
The muscle inserts into the neck of the mandible and capsule
of the temporomandibular joint. It acts in opening the lower
jaw. Together with the medial pterygoid, it protrudes the
mandible and moves it from side to side.
Medial pterygoid
With its superficial and deep heads, it arises from the medial
surface of the lateral pterygoid plate and tuberosity of maxilla
respectively. It descends posterolaterally like the masseter and
inserts inferior to the mandibular foramen into the medial
surface of the mandibular ramus. It elevates the mandible.12
Arteries of the face
The vessels of the face form a series of plexuses: deep
facial plexus, subcutaneous plexus, and subdermal plexus.
18
Perforating arteries connect these plexuses. The facial plexus
provides deep circulation to the anterior face lying deep
behind or passing through the mimetic muscles. This plexus
communicates with the subdermal plexus via a dense
population of small musculocutaneous penetrating branches
of facial, infraorbital, and supratrochlear arteries. In the
lateral face, the large sparsely populated fasciocutaneous
perforators of the transverse facial, submental, and posterior
auricular arteries reach the subdermal plexus passing through
the deep facial planes and subcutaneous layers. The
boundary of this distinct blood supply occurs immediately
lateral to the nasolabial region, dividing the face into an
anterior and lateral region.13
The primary blood supply of the face is from the branches
of the external carotid artery. The internal carotid artery
makes a smaller contribution. It supplies the central face that
consists of the eyes, the upper two thirds of the nose, and the
central forehead.
The chief branch of the external carotid artery for the face
is the facial artery. It arises at the level of the greater cornu of
the hyoid bone in the carotid triangle of the neck. The level of
the origin is situated 1 to 3.5 cm away from the bifurcation
of the common carotid artery14 (Figure 2). It ascends under
cover of the posterior belly of the digastric and stylohyoid
Fig. 2 Arteries of the face. (1) common carotid artery, (2)
external carotid artery, (3) facial artery, (4) inferior labial artery, (5)
superior labial artery, (6) lateral nasal artery, (7) angular artery, (8)
dorsal nasal artery, (9) supratrochlear artery, (10) supraorbital
artery, (11) superficial temporal artery, (12) transverse facial artery,
(13) middle temporal artery, (14) zygomaticoorbital artery, (15)
frontal branch of superficial temporal artery, (16) parietal branch of
superficial temporal artery, (17) infraorbital artery, (18) external
nasal artery.
T. Marur et al.
muscles and grooves the submandibular gland, making a loop.
Then it crosses the inferior border of the mandible in an
oblique direction to enter the face at the anteroinferior angle of
the masseter muscle. The facial artery is extremely winding
and tortuous.9 Its branching pattern shows great variability.
Nakajima et al and Loukas et al popularized a new
nomenclature for the branching pattern of the facial artery.
According to this new nomenclature at the corner of the
mouth the facial artery gives off the inferior labial artery and
then bifurcates near the oral commissure into the superior
labial artery and lateral nasal artery. The superior labial artery
gives off septal branches to the nose. It runs between the
mucosa and orbicularis oris at approximately the border
between the white and red lips and anastomoses with the
opposite artery in the middle of the lip. The lateral nasal artery
extends between the nose and cheek and gives off superior
and inferior alar arteries to supply the nose. The inferior alar
branch supplies the alar base and nostril floor and upper lip;
the superior alar branch participates in the vascular plexus of
the nasal dorsum and tip. The lateral nasal artery terminates as
the angular artery at the medial canthus.15,16 The angular
artery lies 6 to 8 mm medial to the medial canthus and 5 mm
anterior to the lacrimal sac.10 It ends joining the dorsal nasal
branch of the ophthalmic artery. The facial artery can also
terminate as a rudimentary branch with no superior labial
artery, lateral nasal, or angular arteries.15-17 The facial artery
and its branches supply mainly the mental region, the lips, the
inferior part of the parotidomasseteric region, as well as the
buccal, orbital, infraorbital, and nasal regions.11
The superficial temporal artery is the smaller of the two
terminal branches of the external carotid artery system
(Figure 2). It arises deep within the parotid gland and ascends
between condyle of the mandible and external auditory
meatus. Before leaving the parotid gland, it gives off a small
horizontal branch, the transverse facial artery. This artery
runs parallel and about a finger’s breadth inferior to the
zygomatic arch. It crosses the masseter muscle in company
of the Stenon’s duct. In the lateral face, it supplies the parotid
gland and duct, facial nerve, facial muscles, and skin. The
superficial temporal artery crosses the zygomatic process of
the temporal bone deep behind the dermis within the SMAS.
At the superior border of the zygomatic arch, the superficial
temporal artery provides a second branch, the middle
temporal artery, which supplies the deep temporalis facia
and the temporalis muscle. Entering the temporal fossa, the
superficial temporal artery terminates, dividing into frontal
and parietal branches. The frontal branch supplies the
forehead, forming anastomosis with the ipsilateral supraor-
bital and supratrochlear arteries and the contralateral anterior
branch of the superficial temporal artery. The parietal branch
supplies the parietal skull and has anastomotic connections
with the ipsilateral and contralateral arteries.4,8-11
The maxillary artery is the second terminal branch of the
external carotid artery. It arises posterior to the neck of the
condyle of the mandible. It runs in the infratemporal fossa
superficial to the lateral pterygoid muscle. It supplies the
Facial anatomy
deep face and nasal and oral cavities. Its first part lies deep
behind the mandibular ramus. From this part arises the
inferior alveolar artery, which enters the mandibular canal
through the mandibular foramen to supply the lower gingiva.
It terminates as the mental artery, leaving the mental foramen
to supply the lower lip and chin. The branches of the second
part supply the masticatory muscles. An important branch for
the face, the infraorbital artery, arises from its third part and
runs in the infraorbital canal in the floor of the orbit. It leaves
the canal through the infraorbital foramen to reach the face
(Figure 2). Here it anastomoses with the facial artery and
dorsal nasal branch of the ophthalmic artery and supplies the
midface and nasal dorsum.8
The internal carotid artery participates with its first
branch, the ophthalmic artery, to supply blood to the face.
The ophthalmic artery provides the primary blood supply to
the eyes, upper two-thirds of the nose, and the anterior part of
the forehead. It enters through the optic canal the bony orbit.
Its branches include the lacrimal, supraorbital, supratro-
chlear, infratrochlear, and external nasal arteries (Figure 2).
The supraorbital artery exits the orbit with the supraorbital
nerve through the supraorbital foramen, or notch, to supply
the skin and muscles of the forehead and scalp. Its terminal
branches anastomose from the opposite side with the
supratrochlear artery, the frontal branch of the superficial
temporal artery. Supratrochlear and dorsal nasal arteries are
the terminal branches of the ophthalmic artery. Both leave
the orbit by piercing the orbital septum. The supratrochlear
artery supplies the medial forehead and scalp, as well as the
root of the nose. The dorsal nasal artery anastomoses with the
lateral nasal and infraorbital arteries. It provides blood
supply to the medial eyelids and dorsal nasal skin. The
external nasal branch, a branch of the anterior ethmoidal
artery, supplies the skin of the nasal dorsum and tip.8,9
Venous drainage of the face
Most of the veins of the face run parallel to the arteries
they accompany and show many variations. In the classic
pattern, supratrochlear and supraorbital veins join near the
medial canthus to form the angular vein. The angular vein
runs behind the angular and lateral nasal artery downwards in
the nasolabial fold. At the lower border of the nose, it unites
the superior labial vein to become the facial vein, which
crosses the body of the mandible. The facial vein is the major
venous drainage of the superficial regions of the face. In its
course it receives the deep facial vein, which drains the
pterygoid venous plexus of the infratemporal fossa, the
masseteric and parotid veins, and veins from the inferior
eyelid and lips.9-11,18
The superficial temporal vein unites the maxillary vein
within the parotid gland to form the retromandibular vein.
The retromandibular vein divides into anterior and posterior
branches between the external carotid artery and facial nerve
19
before leaving the parotid gland. Inferior and anterior to the
angle of the mandible, the anterior branch joins the facial
vein to form the common facial vein, which terminates
entering the internal jugular vein. The common facial vein
may also open into the external jugular vein. The posterior
branch unites the posterior auricular vein and forms the
external jugular vein to drain the deep regions of the
face.9,10,19
The superficial veins of the face are of great clinical
importance as they have connections with the cavernous
sinus. As the flow in the angular vein goes in both directions,
into either the facial vein or the ophthalmic veins, blood from
the face may enter the cavernous sinus via the latter. Thus
infections from the face may spread intracranially. The area
around the nose, medial canthus, and lips, drained through
the facial vein, is therefore called the “danger triangle” of the
face. This bilateral triangle popularized by Maes in 1937 is
bounded by the bridge of the nose and the angle of the
mouth. The communication of the facial vein with the
cavernous sinus can be through the angular vein; supraor-
bital, supratrochlear, and superior ophthalmic veins; or deep
facial vein, pterygoid plexus, and inferior ophthalmic vein.
According to classic clinical and anatomical textbooks, these
veins have no valves, and studies have showed that the
superior ophthalmic vein and the tributaries of the angular
vein (supraorbital and supratrochlear veins) and the facial
vein are not valves. Thus for the spread of infections in
retrograde flow into the cavernous sinus, the important factor
is not the valves but the consistent access of facial veins to
the cavernous sinus.9,11,18
Lymphatic drainage of the face
A thorough study of the mapping of the lymphatic
drainage of the face shows that the lymphatic vessels are
sparse and are found in a range of three to five. They extend
in a direction from medial to lateral. Lymph vessels above
the eyebrow drain to the preauricular and deep parotid lymph
nodes. Lymph vessels from lateral eyelids drain mainly to the
parotid lymph nodes. Lymph from the medial canthus,
following the facial vein, empties into the submandibular
lymph nodes but also into the buccinator and parotid lymph
nodes. The external nose and cheeks drain directly to the
submandibular lymph nodes in the submandibular triangle.20
The primary drainage of the perioral region is to the
submental lymph nodes. Lymphatics from the central part of
the lower lip, anterior tip of the tongue, floor of the mouth,
and chin drain into the bilateral submental lymph nodes,
whereas lymphatics from the upper lip and lateral parts of the
lower lip empty to the ipsilateral submandibular lymph
nodes. Some lymph may go to the parotid and submental
lymph nodes. Submental lymph nodes between the anterior
bellies of the digastric muscles drain to the ipsilateral
submandibular lymph nodes. From the submandibular and
20 T. Marur et al.

parotid lymph nodes, lymph empties into the jugulodigastric

lymph nodes.4,9,21
Lymphoscintigraphy has demonstrated that lymph vessels
in the face may bypass the submandibular lymph nodes and
drain into the cervical nodes and the nodes at the base of the
neck.22

Cranial Nerve VII (the facial nerve)

Cranial Nerve VII is the nerve to the muscles of the

face. Its complex anatomy can be explained by its course
through the cranial cavity and temporal bone. Acording to
its topographic localization, the nerve can be divided into
the following parts: intracranial, intratemporal, and extra-
temporal.23,24 For dermatologists, the anatomy of the face
and extratemporal components of the facial nerve are of
great importance.
The facial nerve consists of two roots: the facial nerve
proper and the intermedius nerve. The facial nerve proper is
the motor root and forms the major portion of the facial
nerve. Its motor nucleus, which supplies the voluntary
mimetic muscles and stylohyoid muscle, is located in the
caudal brain stem adjacent to the superior olivary nucleus of
the auditory system. The motor neurons for the stapedius
muscle and posterior belly of the digastric muscle are
separately located in the brain stem. The cell bodies of the
facial motor nerve that supplies the upper face via its frontal
branch receives bilateral descending cortical inputs, whereas
the remaining part of the face receives descending cortical
inputs from the contralateral side alone. The motor root exits
the brain stem at the cerebellopontine angle where it is joined
by the intermedius nerve. The intermedius nerve carries both
the visceral motor fibers (parasympathetic component) and
the general and special sensory neurons. The nucleus of the
solitary tract in the rostral medulla receives the sensory taste
input from the anterior two thirds of the tongue and the
general sensory neurons from the skin of the external
auditory canal. Both the facial nerve proper and the
intermedius nerve enter the internal auditory meatus of the
temporal bone with the vestibulocochlear nerve to travel in
the facial canal.9,23,24 The intratemporal component of the
facial nerve exits the canal through the stylomastoid foramen
behind the ear. Here starts the extratemporal facial nerve
(Figure 3). In the adult, it is protected laterally by the tip of
the mastoid process, the tympanic ring, and the mandibular
ramus. In children younger than 2 years of age, it is relatively
superficial.23 After leaving the stylomastoid foramen, the
facial nerve produces suprahyoid motor branches to the
posterior belly of the digastric muscle and stylohyoid
muscle, and the posterior auricular nerve produces branches
to the superior and posterior auricular muscles and occipital
muscle. Then it courses anterior to the posterior belly of the
digastric muscle to penetrate the posterior edge of the parotid
gland. Here it divides into superior and inferior divisions.25
Fig. 3 Terminal branches of the facial nerve on the face. (1)
temporal branch, (2) zygomatic branch, (3) buccal branch, (4)
marginal mandibular branch, (5) cervical branch.
A trifurcation or quadrifurcation of the facial nerve trunk is
also possible.26 The typical peripheral branching of the facial
nerve into five terminal branches is in the substance of the
parotid gland. The facial nerve branches that exit the gland
are deep behind the SMAS. The frontal and zygomatic
branches arise from the superior division. The marginal
mandibular and cervical branches derive from the inferior
division. The buccal branch receives contributions from both
divisions but sometimes not from the superior division.
The frontal nerve leaves the superior border of the parotid
gland and travels within the SMAS over the zygomatic arch
and temporal area (Figure 3). It is located within a triangle
bounded laterally by a line drawn 0.5 cm below the tragus to 2
cm above the lateral eyebrow, inferiorly by the zygomatic arch
and medially by the margin of the lateral orbital rim.23,25
The zygomatic branch exits the superomedial border of
the parotid gland and passes transversely over the zygomatic
bone towards the lateral canthus (Figure 3). There may be up
to three zygomatic branches. The buccal branch leaves the
anterior border of the parotid gland and shows near relation
with the parotid duct (Figure 3). As a single branch, it can be
located above or below the duct.24 Two branches of the
buccal nerve have also been observed: one superior and one
inferior to the duct. Both zygomatic and buccal branches
cross the masseter muscle and buccal fat pad, lying deep
behind the SMAS. There are anastomoses between the two
branches.27
Facial anatomy 21

The marginal mandibular branch exits from the inferior

border of the parotid gland (Figure 3). Its relation to the
inferior border of the mandible is used as an important
landmark for surgical procedures of the face and neck.
Anterior to the facial artery, it passes over the inferior border
of the mandible. Posterior to the facial artery, it passes most
commonly above the inferior border of the mandible, but it
may also run below its inferior border.24,28 It may pass either
superficially or deep behind the facial artery, but it is almost
always superficial to the retromandibular and facial veins.29
The cervical branch courses into the neck from the
inferior border of the parotid gland (Figure 3). It runs
superficially in the subdermal plane as it supplies the inferior
portion of the platysma. It is normally the smallest among the
other branches.24

Sensory and autonomic innervation of the face

The skin of the face, except for a small area around the
mandibular angle and the auricular lobe, is largely innervated
through the three branches of the trigeminal nerve, the fifth
cranial nerve (CN V). The small area is supplied by the great
auricular nerve. The first and smallest branch of the
trigeminal nerve is the ophthalmic nerve (V1) that innervates
the upper one third of the face. It originates at the semilunar
ganglion and divides into three branches—lacrimal, frontal
and nasociliary—before it enters the orbit through the
superior orbital fissure. These branches participate in sensory
innervation of the skin over the forehead, upper eyelid, and
upper dorsum of the nose. The lacrimal nerve is the smallest
of the ophthalmic branches. It enters the orbit through the
superior orbital fissure and extends along the superior border
of the rectus lateralis muscle. It leaves the orbit by piercing
the orbital septum to supply the skin of the lateral part of the
upper eyelid. The nasociliary nerve is placed deeper in the
orbit than the frontal and lacrimal nerves. Near the medial
wall of the orbit, it continues as the anterior ethmoidal nerve
and passes through the anterior ethmoidal foramen to supply
the upper nasal and septal mucosa. The external nasal branch
is the terminal branch of the anterior ethmoidal nerve, which
supplies the skin of the tip and the lateral sides of the nose
(Figure 4). The nasociliary nerve gives off long ciliary
nerves, which supply the ciliary body, iris, and cornea. The
infratrochlear nerve branches out from the nasociliary nerve
near the anterior ethmoidal foramen and provides sensation
to a small area on the medial aspect of the upper eyelid and
bridge of the nose. The frontal nerve is the largest branch of
the ophthalmic nerve. It gives rise at about the middle of the
orbit to supraorbital and supratrochlear nerves. The supra-
orbital nerve is the largest extracranial branch of the
ophthalmic nerve (Figure 4). It exits from the orbit at the
supraorbital foramen or notch. Then it courses deep behind
the periorbital and frontalis muscles and produces palpebral
branches to the upper eyelid. Beyond the orbital rim, it
Fig. 4 Cutaneous innervation of the face. Ophthalmic nerve (V1),
(1a) supraorbital nerve, (1b) supratrochlear nerve, (1c) infratro-
chlear nerve, (1d) external nasal nerve; Maxillary nerve (V2), (2a)
zygomaticotemporal nerve, (2b) zygomaticofacial nerve, (2c)
infraorbital nerve; Mandibular nerve (V3), (3a) auriculotemporal
nerve, (3b) buccal nerve, (3c) mental nerve.
divides into superficial (medial) and deep (lateral) branches.
The superficial branch passes over the frontalis muscle and
supplies the skin of the forehead and only the anterior margin
of the scalp. The deep branch runs between the galea
aponeurotica and pericranium to supply sensation to the
frontoparietal scalp. The supratrochlear nerve exits the orbit
at its upper medial corner and runs 1 cm medially to the
supraorbital nerve (Figure 4). It may also exit through the
frontal or supratrochlear notch or foramen, if present. It
supplies sensory innervation to the skin of the lower medial
forehead, the conjunctiva, and upper eyelid.2,4,8,11
The maxillary nerve is the intermediate branch of the
trigeminal nerve and provides most of the sensation to the
midface. It exits the skull through the foramen rotundum to
enter the pterygopalatine fossa. The zygomatic branch starts
in the pterygopalatine fossa and enters the orbit through the
inferior orbital fissure. It extends along the lateral wall of the
orbit and divides into zygomaticofacial and zygomaticotem-
poral nerves (Figure 4). Both nerves pass through foramens
in the zygomatic bone to the face and supply the skin on the
cheek and the skin over the temple respectively. The
infraorbital nerve is the largest sensory branch of the
22
maxillary nerve (Figure 4). It runs through the orbital floor in
the infraorbital canal and exits the infraorbital foramen to
enter the face about 6 to 7 mm inferior to the infraorbital
margin. At this point, the infraorbital nerve it is between the
levator labii superioris and levator anguli oris. It supplies the
skin on the medial cheek, the lower eyelid, ala nasi and
lateral part of the nose, and the upper lip.
The mandibular nerve is the third and largest divison of
the trigeminal nerve. It not only has sensory fibers but also
contains all the motor fibers of the trigeminal nerve. After
arising at the semilunar ganglion it leaves the skull through
the foramen ovale to enter the infratemporal fossa, where it
divides into an anteriorly and posteriorly. The buccal nerve
arises from its anterior division and supplies the buccal
mucosa and the skin of the cheek (Figure 4). The posterior
division gives off two sensory branches, the auriculotem-
poral and lingual nerves. The auriculotemporal nerve
supplies the skin over the temporal and preauricular region
(Figure 4). The lingual nerve provides sensory innervation
to the anterior two-thirds of the tongue. The posterior
branch enters the mandibular foramen as the inferior
alveolar nerve. It passes through the mandibular canal to
the mental foramen to exit as the mental nerve. The mental
nerve lies together with the supraorbital and infraorbital
nerves in the same vertically oriented midpupillary line, 2.5
cm lateral to the midline. As the terminal branch of the
inferior alveolar nerve the mental nerve innervates the skin
of the chin and the lower lip (Figure 4). Auriculotemporal,
buccal and mental nerves are the three main skin branches
of the mandibular nerve.2,4,8,11
There is a direct connection between trigeminal and facial
nerve branches which may play an important role in sensory
recovery of the face after trauma. Some authors mention the
presence of deep facial sensation after trigeminal neurect-
omy. This is explained through the afferent innervation
carried by the 7th cranial nerve.30
The sympathetic innervation of the face derives from the
preganglionic neurons that are located in the spinal cord from
T1 to T4 segments. The synapsis to the postganglionic
neuron is in the superior cervical sympathetic ganglion
opposite the second and third cervical vertebra. Stimulation
of the sympathetic system causes vasoconstriction of the skin
arteries of the face. Parasympathetic supply is mostly to the
salivary glands, lacrimal gland, and glands of nasal mucosa.
Secretory fibers to the submandibular and the sublingual
glands arise from the superior salivatory nucleus of the facial
nerve and to the lacrimal gland from the lacrimal nucleus of
the facial nerve. Inferior salivatory nucleus of the glosso-
pharyngeal nerve controls the secretion of the parotid gland.2
Acknowledgment
The authors thank Miss Buket Serdar for her technical
support in drawing the figures.
T. Marur et al.
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