Int. J. Oral Maxillofac. Surg.

2003; 32: 414–418

doi:10.1054/ijom.2002.0372, available online at httm://www.sciencedirect.com

Research and Emerging Technologies

Anatomy
K. S. Koh1, H. J. Kim2, C. S. Oh3,
Branching patterns and I. H. Chung4
1
Department of Anatomy, Konkuk University,
Chungju, Korea; 2Division in Anatomy and

symmetry of the course of the Histology, Department of Oral Biology, College

of Dentistry, Oral Science Research Center,
Brain Korea 21 Project for Medical Sciences,

facial artery in Koreans Yonsei University, Seoul, Korea; 3Department

of Anatomy, Sungkyunkwan University,
Suwon, Korea; 4Department of Anatomy,
College of Medicine, Brain Korea 21 Project
for Medical Sciences, Yonsei University,
K. S. Koh, H. J. Kim, C. S. Oh, I. H. Chung: Branching patterns and symmetry of Seoul, Korea
the course of the facial artery in Koreans. Int. J. Oral Maxillofac. Surg. 2003; 32:
414–418.  2003 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. The topography and the course of the facial artery were investigated in
47 Korean cadavers. The final branch of the facial artery was the lateral nasal
branch in 44.0% whereas it was the angular branch in 36.3% of the cases. In 54.5%
of the cases, the facial artery ended symmetrically. According to previous studies,
variations in the distribution pattern of the facial artery have been regarded as
racial difference. However, in this study we showed that the diverse pattern of the
facial artery distribution demonstrates individual variation rather than racial
difference. The superior and inferior labial arteries on the right side were more
dominant than those on the left. The average distance between the branching
points for the inferior alar branch and for the lateral nasal branch was 15.9 mm,
and it was 25.2 mm between the points for the superior labial branch and for the Key words: facial artery; symmetry; branching
inferior alar branch. The branching point of the inferior labial branch was 30.9 mm pattern.
apart on average from that of the superior labial branch. The courses of the facial
arteries showed no significant differences based on either laterality or gender. Accepted for publication 20 December 2002

Introduction
Understanding of the anatomy of the
facial artery is necessary not only
because it can be used as a pedicle for
some flap, such as nasolabial skin
and oral mucosal flaps10,18,22,24, but
because it is involved in other types of
facial surgery such as rhinoplastic and
orofacial surgery4,8,14,16,19,20.
Previous studies have shown that
there is a racial variation in the origin,
the ramification pattern, and the distri-
bution patterns of the facial artery1,17.
In addition, interindividual variations
and intraindividual laterality in its
course have been investigated13. The
final branches of the facial artery in
adults have been described in various
reports2,15,18. However, the distribution
0901-5027/03/000414+05 $30.00/0 
patterns of the facial artery described in
these reports differed significantly from
each other.
Recently, the facial artery musculo-
mucosal (FAMM) flap was introduced
by P et al.21 and has been widely
used for different purposes, such as
reconstruction of oronasal fistulas7 and
closure of soft tissue defects in the man-
dibular vestibule9. Although the FAMM
flap has many advantages with its long
rotational arc, its use is limited by vari-
ations in the course of the facial artery.
Therefore, knowledge about the precise
course and branching pattern of the
facial artery is required.
The aim of this study was to investi-
gate the branching pattern of the facial
artery and to evaluate the symmetry in
2003 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
its course of distribution, thereby pro-
viding critical information for oral and
maxillofacial surgical treatment.
Materials and methods
Ninety-one faces from 47 Korean
cadavers (44 bilateral specimens and 3
unilateral specimens) were dissected.
Thirty-three of the specimens were male
and 14 were female, with an average age
of 56 years (ranging 18–94 years).
The distribution patterns of the
arteries were classified into six cat-
egories: forehead, angular, nasal, alar,
superior labial, and inferior labial. These
categories represent the final branch
of the facial artery as described by
N18 with minor modifications.

Fig. 1. Branches of the facial artery and anatomical landmarks described in this study. ANG:
angular artery; LN: lateral nasal artery; IA: inferior alar branch; SL: superior labial artery; IL:
inferior labial artery; SI: sill; STO: stomion; MM: the point at which the facial artery first
appears at the lower border of mandibular margin; MA: mandibular angle.
The duplex arteries, which had two
arterial trunks, were also investigated.
The symmetry of the final branches of
the facial arteries was evaluated on both
sides of the 44 bilateral specimens. In
this study, the branching patterns of the
facial artery were classified into type A,
B, C or D based on the existence and
location of the common trunk for the
facial arterial branches.
In addition, the superior and inferior
labial arteries were dissected in the lip
region. We determined the dominant
pattern of labial artery based on its
Fig. 2. Several types of facial artery according to its termination pattern.
Branching patterns and symmetry of the facial artery
diameter and crossing aspect over the
midline. When the arteries on both sides
had similar diameters and did not cross
over the midline, they were defined to be
equal.
The topographic course of the facial
artery was investigated through four
items of measurement using digital cali-
pers (model no. CD-15CP, Mitutoyo
Co., Japan) (Fig. 1). The four items of
measurement were as follows: (1) the
distance from the point at which the
facial artery first appears in the lower
border of the mandible to the mandibu-
415
lar angle; (2) the distance between the
artery and the stomion at the height of
the oral commissure; (3) the horizontal
distance between the artery and the sill;
(4) the distance between the branches of
the facial artery.
Results
The facial arteries were classified into six
categories based on the pattern of their
final arterial branches (Fig. 2). In the
forehead category, the facial artery
ended as the supratrochlear branch,
supplying the forehead. There was no
difference in the distribution pattern of
the facial artery according to age or sex.
In 12.1% (11/91) of dissections, two
arterial trunks of the facial artery,
classified as a duplex artery, were
observed. All duplex arteries ended as an
angular artery, except one case where
one trunk ended as a lateral nasal artery
and the other as an anastomotic branch
with the infraorbital artery (Fig. 3).
In the bilateral specimens, the sym-
metric distribution of the facial artery
was observed in 54.5% (24/44). In cases
of symmetric facial arteries, 50.0% (12/
24) of the cases ended as an angular
artery, 45.8% (11/24) of the cases ended
as a lateral nasal artery, and 4.2% (1/24)
of the cases ended as an inferior labial
artery.
The branching patterns of the facial
artery were classified into four types
(Fig. 4). In type A, no common trunk
was observed in the branches of the
facial artery. In type B, the superior
labial artery shared a common trunk
with the inferior labial artery. In type C,
the superior labial artery shared a com-
mon trunk with the lateral nasal artery
or the inferior alar branch. Type D
represented the case in which the lateral
nasal artery shared a common trunk
with the inferior alar branch.
The dominant aspects of the labial
arteries were classified into three cat-
egories in comparison with the contral-
ateral arteries in terms of diameter and
crossing pattern over the midline (Fig.
5). In the case of the superior labial
artery, it was dominant on the right side
in 48.8% (20/41) of the bilateral speci-
mens and on the left side in 4.9% (2/41)
of the cases while the other specimens
did not display any dominance, classified
as equal. The inferior labial artery was
dominant on the right side in 43.2%
(19/44) of the bilateral specimens and on
the left side in 15.9% (7/44) of the cases.
The other specimens were classified as
equal.
416 Koh et al.
Fig. 3. A case of duplex artery that had two arterial trunks. One trunk ended as a lateral nasal
artery and the other as an anastomotic branch with the infraorbital artery.
Fig. 4. Schematic diagrams of the branching patterns of the facial artery. ANG: angular artery;
LN: lateral nasal artery; IA: inferior alar branch; SL: superior labial artery; IL: inferior labial
artery.
Several measurements between the
branching points of the facial artery
branches were performed. The average
distance between the branching points
for the inferior alar branch and for the
lateral nasal branch was 15.9 mm, and it
was 25.2 mm between the points for
the superior labial branch and for the
inferior alar branch. The branching
point of the inferior labial branch was
30.9 mm apart on average from that of
the superior labial branch. There was no
correlation in the distance between the
branches of the facial artery with either
sex or laterality of the specimen (Table
1). The symmetry in the course of the
facial artery was estimated by measuring
the contralateral distance between the
anatomical surface landmarks and the
facial artery. The average distance from
the mandibular angle to the point where
the artery appears at the lower border of
the mandible was 27.0 mm. The horizon-
tal distance between the stomion and the
facial artery at the height of oral com-
missure was 44.8 mm on average, and
the distance between the artery and the
sill at its height was 16.5 mm. No stat-
istically significant difference in the
course of the artery was found between
the right and left sides. In addition, the
course of the artery did not show any
gender-based difference except for the
distance from the sill to the artery
(Table 1).
Discussion
On the anterior surface of the face, the
facial, transverse facial, and infraorbital
arteries from the external carotid artery
are distributed23,25. Among these
arteries, the facial artery is usually the
largest and plays a major role in supply-
ing blood to the face1,13. The facial
artery shows individual variations in sev-
eral aspects, and it also presents some
laterality in the same person depending
on the haemodynamic balance between
the transverse-maxillary system and the
facial system13,23. Comparison of the
final branch of the facial artery in vari-
ous populations is shown in Table 2. In
Korean specimens used in this study, the
facial artery ended as the lateral nasal
artery in 44.0% of the cases and as the
angular artery in 36.3% of the cases. In
Japan, A2 reported that the facial
artery ended as the lateral nasal artery in
64.4% and as the angular artery in 12.0%
of the cases. M et al.15 dissected 50
facial arteries of adult French cadavers
and reported that the facial artery ended
as the lateral nasal artery in 78% and as
the angular artery in only 4% of the
cases. According to N18, in 25
British specimens, the final branch of the
facial artery was the angular artery in
68%, whereas it was the lateral nasal
artery in 26% of the cases. Some investi-
gators have regarded these discrepancies
as racial differences1,17. In this study, the
distribution pattern of the facial artery
in Koreans was quite different from
that of Japanese though they are all
Mongoloids. This demonstrates that
the diverse pattern of the facial artery
distribution does not reflect a racial
difference.
 Branching patterns and symmetry of the facial artery 417

22% of the cases. In foetus specimens,

they also found that when a facial artery
on one side ended as the angular artery
which extended the other side, the con-
tralateral artery in the same individual
was less developed and ended in either
the upper or lower lip. In the adult
specimens used in this study, such cases
were observed in only three bilateral
cadavers. In our specimens, the final
branches of the facial artery showed
symmetry in 54.5% of the cases, and they
ended mostly as the angular or lateral
nasal artery. If asymmetries, most ended
as the lateral nasal artery on one side
and as the superior labial artery on the
other side. This suggests that individual
developmental differences affect the
vascularization pattern of the facial
artery.
In this study, the superior labial artery
shared a common trunk with the ipsi-
lateral inferior labial artery in 12.8% of
the samples studied. A similar incidence
(10%) was reported by D &
M6. The superior and inferior
labial arteries are attractive anatomical
structures because they supply blood to
the upper or lower lip and anastomose
with its counterpart on the opposite side.
The dominance of these arteries between
contralateral sides was investigated. A
right-side dominance was observed in
both the superior and inferior labial
arteries. Although there is no strong
evidence, this appears to be the conse-
quence of differential arterial develop-
Fig. 5. Three cases representing a lateral dominance of the labial arteries. A: right-side
ment. According to B et al.3,
dominance in both the superior and inferior labial arteries. B: equal in the superior labial artery handedness was suggested as one of the
and a right-side dominance of the inferior labial artery. C: left-side dominance in both the important factors that determine arterial
superior and inferior labial artery. development. They suggested that right-
handed subjects had higher blood flow
Table 1. Distances between the branches of the facial artery, and between the anatomical rate in the left internal carotid artery.
landmark to the facial artery However, no significant difference in the
left and right common carotid artery
Measurements Male (mm) Female (mm)
flow rate in accordance with handedness
MM–IL 26.28.1 (54) 25.07.8 (23) was reported. They also suggested that
IL–SL 32.511.1 (46) 27.29.5 (23)
right-handed subjects had higher flow
SL–IA 25.66.2 (42) 24.25.0 (19)
IA–LN 16.34.7 (40) 15.24.5 (14) rate in the right external carotid
LN–ANG 32.511.1 (19) 24.09.0 (8) artery than in the left. D S
MA–FA 27.25.6 (64) 26.84.8 (27) et al.5 reported that increased blood
STO–FA 45.75.5 (57) 43.56.4 (24) flow is associated with arterial growth in
SI–FA* 17.97.5 (44) 13.04.7 (21) rabbits.
SI–LN 16.33.2 (50) 14.84.5 (20) The inferior alar branch originates
*P<0.05 compared between male and female (Student’s t-test). from the angular artery and supplies
Note: The data is expressed as a meanSD. The parentheses expresses the number of blood to the inferior edges of nasal ala.
dissections. MM=mandibular margin; IL=inferior labial; SL=superior labial; IA=inferior A previous study12 suggested that this
alar; LN=lateral nasal; ANG=angular; MA=mandibular angle; FA=facial artery; SI=sill. branch originated from the superior
labial artery in 37%. H10 sug-
gested the angular artery as the alar
In addition, some investigators K & J11 observed that the branch of the superior labial artery and
reported differences in distribution pat- facial artery ended as the angular artery stated that the angular artery gave off
tern of the facial artery between adults in 58%, as the superior labial artery in many branches that supplied blood to
and foetuses. In 110 human foetuses, 20%, and as the inferior labial artery in the cheek and nostrils. Yet, in this study,
418 Koh et al.
Table 2. Comparison of this study with previous published data on the final branches of the
facial artery
Aratani (1960) Mitz et al. (1973)
Branches 208 sides 50 sides
Supratrochlear 3.8%
Angular 12.0%
Lateral nasal 64.4% 78.0%
Inferior alar 7.7%
Superior labial 2.9% 10.0%
Inferior labial 5.8%
the inferior alar branch originated from
the facial artery in 89.0% of the cases
and, therefore, we considered the
inferior alar branch as a branch of the
facial artery. The duplex artery in this
study comprised 12.1%, which was simi-
lar to the reported value (10%) from
N’s study18 but differed from the
study (4%) reported by M et al.15
In all the measurements performed,
males had greater arterial dimensions
than females, but this does not have
statistical significance except for the dis-
tance between the sill and the facial
artery. The metric data between the
branching points of the facial artery are
critically important for prevention of
necrosis and other complications of flap
surgery.
Recently, the FAMM flap has been
widely used for intraoral surgeries. The
FAMM flap has several advantages over
conventional flaps because it has a long
rotational arc and does not shrink post-
operatively7,9. By using this technique,
scar formation can be avoided and a wet
surface is maintained. In addition, it
provides a better elastic cushion to
recipient sites because the FAMM flap
can be transferred with mucosal tissue as
well as with muscle. The knowledge
about the variations of the facial artery
is essential for the success of FAMM
flap applications, and therefore it should
be considered in the flap design. In cases
where the facial artery terminates as the
inferior labial artery, found in 5.5% of
the cases in this study, surgical planning
of FAMM flap should be limited. The
study about the distribution of the facial
artery provides useful information for
clinical applications in different fields of
oral and maxillofacial surgery.
Acknowledgment. This paper was
supported by Konkuk University in
2000.
Niranjan (1988) Present (2002)
50 sides 91 sides
— — 4.4%
4.0% 68.0% 36.3%
26.0% 44.0%
— 2.0% 3.3%
4.0% 6.6%
8.0% — 5.5%
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Address:
Dr. Ki-Seok Koh
Department of Anatomy
College of Medicine, Konkuk University
322 Danwol-Dong, Chungju, 380-701, Korea
Tel: +82 43 840 3733
Fax: +82 43 851 9329
E-mail: kskoh@kku.ac.kr