Anatomy Head and Neck

1
Anatomy of the head and neck

Ahmed M. Afifi and Risal Djohan
Aesthetic and reconstructive surgery of the head and neck

SYNOPSIS
depends on appreciating the three-dimensional anatomy and
 The superficial fascial layer of the face and neck is formed of the the functional and cosmetic methods of rearranging the dif-
superficial cervical fascia (enclosing the platysma), the superficial ferent structures. This chapter is not intended to be a detailed
facial fascia (also referred to as the SMAS), the superficial description of the head and neck anatomy, which is beyond
temporal fascia (often called the temporoparietal fasica), and the such a limited space. It rather offers a different perspective on
galea. the anatomy that is more relevant to the plastic surgeon, and
 The deep fascial layer of the face and neck is formed of the deep highlights certain anatomical regions that have fundamental
cervical fascia (or the general investing fascia of the neck), the importance or are more controversial.
deep facial fascia (also known as the parotidomasseteric fascia),
and the deep temporal fascia. The deep temporal fascia is
continuous with the periosteum of the skull.
 The deep temporal fascia splits into two layers at the level of the
The fascial planes of the head and
superior orbital rim. The two layers insert into the superficial and neck and the facial nerve
deep surfaces of the zygomatic arch.
 The facial nerve is initially deep to the deep fascia, eventually A peculiar feature of the anatomy of the head and neck is the
penetrating it towards the superficial fascia. The fat and concentric arrangement of the facial soft tissues in layers.
connective tissue filling the space between the superficial temporal These layers have different names and characteristics from
fascia and the superficial layer of the deep temporal fascia is a one area of the head and neck to the other, but they maintain
subject of significant debate. Its importance stems from the their continuity across boundaries (Fig. 1.1). Unfortunately,
temporal branch of the facial nerve crossing from deep to inconsistent nomenclature has been used to describe these
superficial in this layer. layers leading to significant confusion among readers. The
 Most surgeons believe that it is the superficial temporal fat pad that facial nerve usually passes in defined planes in between these
fills this space. Others believe there is a distinct fascial layer in this layers, crossing from one layer to the other only in specific
region, named the parotidomasseteric fascia. well described zones. Knowledge of these planes and their
 The facial nerve is at significant risk of injury in the area right
relation to the facial nerve is vital if plastic surgeons are to
safely access the soft tissues and bony structures of the head
above the zygomatic arch.
and neck.1,2 In the following discussion, we will not only
 Pitanguy’s line is an accurate description of the course of the
describe the anatomy and nomenclature of these layers as
largest and more significant branch of the temporal division of the mostly agreed upon, but also try to elucidate the sources of
facial nerve. deliberation and confusion in describing this crucial anatomy.3
 The marginal mandibular nerve can be located above or below the
The neck, cheek (lower face), temple and the scalp are
level of the mandible. It is usually located between the platysma arbitrarily divided by the lower border of the mandible, the
and the deep cervical fascia, and is always superficial to the facial zygomatic arch and the temporal line, respectively. In general,
vessels. there are two layers of fascia, a superficial and deep, which
 There are multiple fat pads in the face. They can be superficial to
cover these regions and extend over other structures, such as
the SMAS, between the SMAS and the deep fascia, or deep to the the eyelid and the nose (Fig. 1.1).
deep fascia. The superficial layer of fascia is formed by the superficial
 Knowledge of the sensory nerves is important, especially with our cervical fascia (platysma), the superficial facial fascia (SMAS),
current understanding of their role in migraine headaches. the superficial temporal fascia (temporoparietal fascia) and
©
2013, Elsevier Inc. All rights reserved.
Descargado para Andres Diaz (andres.diaz@unimilitar.edu.co) en Univ Granada Militar New de ClinicalKey.es por Elsevier en febrero 28, 2018.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados.
4 • 1 • Anatomy of the head and neck
Galea
Skin
Periosteum
Subcutaneous Temporal bone
fat
Temporalis
Superficial temporal
(temporo-parietal) fascia
Deep temporal fascia
Zygomatic
arch
Coronoid
process
Deep facial fascia
Parotid gland
Superficial facial fascia, Deep

enclosing mimetic cervical fascia
muscles of face (SMAS)
Mandible
Superficial cervical fascia

(enclosing platysma) Fig. 1.1 The facial layers of the scalp, face, and neck.
the galea aponeurotica (Figs 1.1, 1.2). To be more precise, this The deep layer of fascia is formed by the deep cervical fascia,
superficial fascia splits to enclose many of the facial muscles. the deep facial fascia (parotidomasseteric fascia), the deep
This is a consistent pattern seen all over the head and neck temporal fascia and the periosteum. This layer is superficial
region; e.g. the superficial cervical fascia splits into a deep and to the muscles of mastication, the salivary glands and the
superficial layer to enclose the platysma, the superficial facial main neurovascular structures (Figs 1.1, 1.2). Over bony areas,
fascia splits to enclose the midfacial muscles, and the galea such as the skull and the zygomatic arch, this deep fascia is
splits to enclose the frontalis. The two layers of the superficial inseparable from the periosteum.
fascia then rejoin at the other end of the muscle, before split- The facial fat pads are localized collection of fat present
ting again to enclose the next muscle and so on. deep to the superficial layer of fascia. These are separate
The fascial planes of the head and neck and the facial nerve 5
STF
B
A
SMAS Platysma
STF SMAS Platysma
Superficial layer reflected
Zygomatic
ligament Mandibular
and nerve ligament
and
buccal
nerve
Fig. 1.2 The different fascial layers of the face and neck.
(A) Dissection in the superficial plane, between the skin and
the superficial fascia. (B) Elevation of the superficial fascial
layer, formed of the superficial cervical fascia (platysma), the
C superficial facial fascia (SMAS), and the superficial temporal fascia
(temproparietal fascia). (C) Note the proximity of the nerve (on the
The nerves penetrate the deep fascia towards their blue background) to the zygomatic and mandibular ligaments (on
innervation of the SMAS and Platysma surgical the instrument).
anatomically and histologically from the subcutaneous fat individuals and from one area to another, and it can be fatty,
present between the skin and the superficial fascia. These fibrous, or muscular.6 The muscles of facial expression, e.g.
fat pads include the superficial temporal fat pad, the galeal orbicularis oculi, oris, zygomaticus major and minor, frontalis,
fat pad, suborbicularis oculi fat pad (SOOF), the retro- platysma are enclosed by (or form part of) the SMAS. The
orbicularis oculi fat pad (ROOF), and the preseptal fat of the SMAS is often referred to as the superficial facial fascia. In
eyelids. Deep to the deep fascia are several other fat pads; the reality, the superficial facial fascia covers the superficial and
deep temporal fat pads, the buccal fat pads, and the postseptal deep surfaces of the muscles. However, these layers are hard
fat pads of the eyelids.4 to separate intraoperatively (except in certain areas such as
the neck). Dissection superficial to the superficial facial fascia
(just under the skin) will generally avoid injury to the under-
The fascia in the face lying facial nerve. However, such dissection can compromise
the blood supply of the overlying skin flaps. Often, the
The first layer the surgeon encounters in the face deep to the surgeon can safely maintain this superficial fascia in the lower
skin and its associated subcutaneous fat is the SMAS face and neck (whether it is the platysma or the SMAS) with
(Superficial Musculo-Aponeurotic System) (Figs 1.1, 1.2).5 the skin, allowing a secure double layer closure and maintain-
The SMAS varies in thickness and composition between ing skin vascularity (e.g. during a neck dissection). In the
anterior (medial) face, the facial nerve branches become more

superficial just under or within the SMAS layer. Subcutaneous fat
The next layer in the face is the deep facial fascia, which is
also known as the parotidomasseteric fascia (Figs 1.1, 1.2). Deep temporal fascia
Over the parotid gland, this layer is adherent to the capsule Hair
of the gland. The facial nerve is initially (i.e. right after is exits
the parotid gland) deep to the deep facial fascia. Most of the Superficial
muscles of facial expression are superficial to the planes of the temporal
nerve. The nerve branches pierce the deep fascia to innervate Temporal bone
fascia
the muscles from their deep surface, with the exception of the
mentalis, levator anguli oris and the buccinators (Fig. 1.2). Frontal branch Temporalis
These three muscles are deep to the facial nerve and are thus of facial nerve
innervated on their superficial surface.
Sentinel vein
Middle temporal fat pad
The fascia in the temporal region
Zygomatic
The cheek and lower face are separated from the temporal arch
region by the zygomatic arch. There are two layers of fascia
in the temporal region (below the skull temporal lines); the
superficial temporal fascia (also known as the temporoparietal
fascia, TPF) and the deep temporal fascia (Figs 1.3, 1.4A).7–9 Ear
The deep temporal fascia lies on the superficial surface of the
temporalis muscle. Between the superficial and deep temporal Coronoid process
of mandible
fascia is a loose areolar plane that is relatively avascular and
easily dissected. However, the frontal branch of the facial Facial nerve Masseter
nerve is within or directly beneath the superficial temporal
fascia (Fig. 1.4A).5 Therefore, dissection in this plane should Parotid-masseter
be strictly on the deep temporal fascia, which can be identified fascia
by its bright white color and sturdy texture. To ensure that the Skin
surgeon is in the right plane, he can attempt to grasp the
areolar tissues over the deep temporal fascia using an Adson SMAS
forceps; if in the right plane, one will not catch any tissue. Fig. 1.3 The facial layers of the temporal region. The fat/fascia in the
Once deep enough and right on the deep temporal fascia, subaponeurotic plane (arrow; between the the temporal fascia and deep temporal
dissection can proceed quickly using a periosteal elevator fascia) is intimately related to the facial nerve. Some authors believe that there is a
hugging the tough deep temporal fascia (Fig. 1.5). separate fascial layer in this space referred to as the parotidomasseteric fascia.
In the region right above the zygomatic arch the space
between the superficial TPF and the deep temporal fascia
(sometimes referred to as the subaponeurotic space) and the
fat/fascia it contains is both a debatable and an important
subject (Fig. 1.4). Its importance stems from the facial nerve and deep surfaces of the zygomatic arch. There are three fat
crossing this space from deep to superficial right above the pads in this region.7,12 The superficial fat pad is located
zygomatic arch. A third layer of fascia has been described in between the superficial temporal fascia and superficial layer
this space (between the superficial and deep layers), and is of the deep temporal fascia, and as described above, is analo-
referred to as the parotido-temporal fascia, the subgaleal gous with the parotido-temporal fascia, subgaleal fascia, and/
fascia, or the innominate fascia.10,11 The term “fascial layer” is or the loose connective tissue between the superficial and
used loosely, as there is no general consensus as to how thick deep temporal fascia. The middle fat pad is located directly
connective tissue must be before it can be considered a “fascial above the zygomatic arch between the superficial and deep
layer”. What some authors refer to as “loose connective layers of the deep temporal fascia. Finally, the deep fat pad
tissue” may be called a “fascial layer” or a “fat pad” by others. (also know as the buccal fat pad) is deep to the deep layer of
Our own cadaver dissection showed that this third fascial the deep temporal fascia, superficial to the temporalis muscles
layer could often be identified. It extends for a short distance and extends deep to the zygomatic arch. It is considered an
above and below the arch. Directly superficial to the arch, the extension of the buccal fat pad.
facial nerve is deep to this layer, piercing it to become more Most of the controversy in describing the fascial layers in
superficial 1–2 cm cephalad to the arch (see below). the temporal region arises from confusing the superficial tem-
Above the zygomatic arch and at the same horizontal level poral fascia with the superficial layer of the deep temporal fascia.
as the superior orbital rim, the deep temporal fascia splits into This is very significant since the facial nerve is deep to or
two layers; the superficial layer of the deep temporal fascia within the former and superficial to the latter. The second
(sometimes referred to as the middle temporal fascia, inter- baffling point is the location of the deep temporal fascia super-
mediate fascia, or the innominate fascia) and the deep layer ficial to the temporalis muscle. There is another fascial
of the deep temporal fascia (Fig. 1.3).7 The deep and superfi- layer on the deep surface of the muscle; this is not the deep
cial layers of the deep temporal fascia attach to the superficial temporal fascia and is of little significance from a surgical
The fascial planes of the head and neck and the facial nerve 7
Superficial Layer of deep

Facial Nerve temporal fascia Middle temporal fat pad
Superficial Deep
Temporal Temporal
Fascia Fascia
Galea
Periosteum
A B
Temporalis Muscle
Superficial
Fig. 1.4 The different planes of dissection in the temporal region. (A) Dissection
Layer between the superficial temporal fascia (temporoparietal fascia) and the deep
temporal fascia. In this plane, the surgeon should try to stay right on the deep
temporal fascia. (B) Dissection deep to the deep temporal fascia. This is a safe plan
that will lead to the zygomatic arch. The facial nerve will be protected by the
C superficial layer of the deep temporal fascia. (C) Dissection deep the temporalis
muscle. The muscle can be left as part of the skin flap. This is a safe and easy plan if
Deep Layer no exposure of the arch is needed.
standpoint. The final controversy is what exactly is the innomi- proceed deep to the temporalis muscles, elevating them with
nate fascia? This term is often used to describe the superficial the coronal flap (Fig. 1.4B). Using this avascular plane avoids
layer of the deep temporal fascia above the arch. Other sur- potential traction or injury to the frontal nerve, and ensures
geons reserve the term to the areolar tissue between the super- good aesthetic results as it prevents possible fat atrophy or
ficial layer of the deep temporal fascia and the superficial retraction of the temporalis muscle.
temporal fascia (i.e., the innominate fascia can be synony- While the fascial layers in the temporal region are well
mous with the parotidotemporal fascia or subgaleal fascia or described, there is more debate and variability of the anatomy
the superfical temporal fat pad).13 of the fascial layers and the facial nerve directly superficial to
The plane of dissection in the temporal region depends on the arch.12,14,15 The superficial facial fascia (SMAS) is continu-
the goal of the surgery (Fig. 1.4). In general, the surgeon ous with the TPF, but it is not clear if the deep facial and deep
should avoid the superficial temporal fascia as it harbors the temporal fasciae are continuous to each other or attach and
frontal branch of the facial nerve. During surgery to expose arise from the periosteum of the arch separately. In addition,
the orbital rims and the forehead musculature, the dissection the thickness of the soft tissues from the periosteum to skin
plane is between the superficial temporal fascia and deep is minimal and the tissues are tightly adherent, making
temporal fascia (Fig. 1.4A). To expose the arch, the superficial identification of the facial planes and the facial nerve
layer of the deep temporal fascia is divided and dissection hazardous in this region.16 The frontal branch of the facial
proceeds between it and the middle fat pad (the superficial nerve pierces the deep temporal fascia to become more super-
layer of deep temporal fascia will act as an extra layer protect- ficial near the vicinity of the upper border of the arch, and this
ing the nerve) (Fig. 1.4B). Finally, when a coronal approach is area constitutes one of the danger zones of the face (see
used, but the arch does not need to be exposed, dissection can below).
Deep temporal fascia 1

2
Temporalis
Cross section
Fig. 1.6 Fascial layers of the neck. 1, Investing layer of deep cervical fascia; 2,
pretracheal fascia; 3, carotid sheath; 4, superficial fascia; 5, prevertebral fascia.
Superficial temporal fascia Loose areolar tissue
(Reprinted with permission from www.netterimages.com ©Elsevier Inc. All rights
(temporo-parietal fascia)
reserved.)
Fig. 1.5 Dissection in the temporal layer.
posteriorly. It splits to enclose the sternocleidomastoid and
the trapezius muscles. It also splits to enclose the parotid and
the submandibular glands. The deep facial fascia, or parotido-
The fascia in the neck masseteric fascia, is therefore considered the continuation of
the deep cervical fascia into the face.
The nomenclature used to describe the different fascial layers
in the neck also creates significant confusion. There are two
different fascias in the neck: the superficial and the deep (Figs
1.3, 1.6). The latter is composed of three different layers: (1)
the superficial layer of the deep cervical fascia, also known
Retaining ligaments and adhesions
the general investing layer of deep cervical fascia; (2) the of the face
middle layer, commonly named the pretracheal fascia; and (3)
the deep layer, or the prevertebral fascia (Figs 1.3, 1.6). The The ligaments of the face maintain the skin and soft tissues of
pretracheal fascia encircles the trachea, thyroid and the the face in their normal positions, resisting gravitational
oesophagus, while the prevertebral fascia encloses the prever- changes. Knowledge of their anatomy is important for both
tebral muscles and forms the floor of the posterior triangle of the craniofacial and the aesthetic surgeon for several reasons.
the neck. For practical purposes, it is the superficial cervical For the aesthetic surgeon, these ligaments play an important
fascia and the superficial layer of the deep cervical fascia that role in maintaining facial fat in its proper positions. For ideal
the plastic surgeon encounters.17,18 aesthetic repositioning of the skin and soft tissues of the face,
The superficial cervical fascia encloses the platysma muscle numerous surgeons recommend releasing the ligaments. For
and is closely associated with the subcutaneous adipose the craniofacial surgeon, the zones of adherence represent
tissue. The platysma muscle and its surrounding superficial coalescence between different fascial layers, possibly luring
cervical fascia represent the continuation of the SMAS into the the surgeon into an erroneous plane of dissection. In facial
neck. In general, when skin flaps are raised in the neck, the reconstruction or face transplants, reconstructing or maintain-
platysma muscle is maintained with the skin to enhance its ing these ligaments is important to prevent sagging of the soft
blood supply (e.g. during neck dissections). However, in tissues with its functional and aesthetic consequences.
necklifts the skin is raised off the platysma to allow platysmal Various terms have been used to describe these ligamen-
shaping and skin redraping. Tissue expanders placed in the tous attachments. Moss et al. classified them into ligaments
neck could be placed either deep or superficial to the platysma. (connecting deep fascia/periosteum to the dermis), adhesions
Placing them superficially will create thinner flaps that are (fibrous attachments between the deep and the superficial
more suitable for facial resurfacing, while placing them deeper fascia), and septi (fibrous wall between layers).21
allows a more secure coverage of the expander.19,20 In the periorbital and temporal region, various ligaments
The superficial layer of deep cervical fascia, or the general and adhesions have been described with numerous names
investing layer of deep cervical fascia, is what plastic surgeons given to each (Fig. 1.7). Along the skull temporal line lies
commonly refer to simply as the “deep cervical fascia”. It temporal line of fusion, also know as the superior temporal
encircles the whole neck and has attachments to the spinous septum.21 This represents the coalition of the temporal fascia
processes of the vertebrae and the ligamentum nuchae with the skull periosteum. These adhesions end as the
Retaining ligaments and adhesions of the face 9
Temporalis
Superior temporal septum
Temporal ligamentus adhesion
Supraorbital ligamentus adhesion
Corrugator supercilii
Lateral brow thickening

Sentinel vein
Lateral orbital thickening
Zygomaticotemporal nerve
Attachment of orbicularis retaining ligament
Zygomaticofacial nerve
Inferior temporal septum
Frontal branch of facial nerve
Fig. 1.7 The ligaments of the periorbital region.
temporal ligamentous adhesions (TLA) at the lateral third of it finally blends with the lateral orbital thickening (LOT). The
the eyebrow. The TLA measure approximately 20 mm in LOT is a condensation of the superficial and deep fascia on
height and 15 mm in width, and begins 10 mm cephalad to the frontal process of the zygoma and the adjacent deep tem-
the superior orbital rim. Both the temporal line of fusion and poral fascia. The ORL and the orbital septum both attach to
the TLA are sometimes referred to collectively as temporal the arcus marginalis, a thickening of the periosteum of the
adhesions. The inferior temporal septum extends posteriorly orbital rims.23 The ORL is also referred to as the periorbital
and inferiorly from the TLA on the surface of the deep tem- septum and, in its inferior portion, as the orbitomalar liga-
poral fascia towards the upper border of the zygoma. The ment. The ORL ligament attaches to the undersurface of the
supraorbital ligamentous adhesions extend from the TLA orbicularis oculi muscle at the junction of the pretarsal and
medially along the eyebrow. orbital parts.
The orbicularis retaining ligament (ORL) lies along the In the midface, the retaining ligaments have been divided
superior, lateral and inferior rims of the orbit, extending from into direct, or osteocutaneous ligaments, and indirect liga-
the periosteum just outside the orbital rim to the deep surface ments. Direct ligaments run directly from the periosteum to
of the orbicularis oculi muscle (Fig. 1.8).22,23 This ligament the dermis, and include the zygomatic and mandibular liga-
serves to anchor the orbicularis oculi muscle to the orbital ments. Indirect ligaments represent a coalescence between the
rims. The orbicularis oculi muscle attaches directly to the superficial and deep fascia, and include the parotid and the
bone from the anterior lacrimal crest to the level of the medial masseteric cutaneus ligaments (Fig. 1.9, and see Fig. 1.2C). The
limbus. At this level the ORL replaces the bony origin of the retaining ligaments indirectly fix the mobile skin and its inti-
muscle, continuing laterally around the orbit. Initially short, mately related superficial fascia (SMAS), to the relatively
it reaches its maximum length centrally near the lateral immobile deep fascia and underlying structures (masseter
limbus.24 It then begins to diminish in length laterally, until and parotid).
muscle (namely the zygomaticus major, zygomaticus minor

and the levator labii superioris). This fascial layer extends
caudally over the muscles, gradually becoming thinner and
allowing the muscle to be more discernible. The superior
Skin boundary of the prezygomatic space is the orbicularis retain-
Orbicularis oculi ing ligament, which separates it from the preseptal space. The
more rigid inferior boundary is formed by the reflection of the
Orbicularis retaining
ligaments fascia covering the floor as it curves superficially to blend
with the fascia on the undersurface of the orbicularis oculi.
This inferior boundary is further reinforced by the zygomatic
Orbital septum
retaining ligaments. Medially, the space is closed by the
origins of the levator labii and the orbicular oculi muscle from
the medial orbital rim. Finally, the lateral boundary is formed
superiorly by the LOT over the frontal process of the zygoma
and more inferiorly by the zygomatic ligaments.32 The facial
Upper tarsus nerve branches cross in the roof of (i.e. superficial to) this
space. The only structure traversing the pre zygomatic space
is the zygomatico facial nerve, emerging from its foramen
located just caudal to ORL.
Lower tarsus
Orbicularis oculi The malar fat pad

Orbital septum This is a subcutaneous pad of fat superficial to the SMAS
(which encloses the orbicularis oculi) in the cheek.33 This pad
Orbicularis retaining is triangular in shape, with its base at the nasolabial crease
ligaments and its apex more laterally towards the body of the zygoma.
Orbital rim Elevation of the malar fat pad is important for facial rejuvena-
tion and in facial palsy.
Fig. 1.8 The orbicularis retaining ligaments.

The buccal fat pad
The zygomatic and the masseteric ligaments together form The buccal fat pad is an underappreciated factor in post trau-
and inverted L, with the angle of the L formed by the major matic facial deformities and senile aging , and is frequently
zygomatic ligaments (Fig. 1.9, and see Fig. 1.2C). These liga- overlooked as a flap or graft donor site.34,35 Senile laxity of the
ments are typically around 3 mm wide and are located 4.5 cm fascia allows the fat to prolapse laterally, contributing to the
in front of the tragus and 5–9 mm behind the zygomaticus square appearance of the face.36 With many traumatic injuries
minor muscle.25–28 Anterior to this main ligament are multiple the fat herniates, either superficially, towards the oral mucosa,
other bundles that form the horizontal limb of the inverted L. or even into the maxillary sinus.24,37–39 This fat is anatomically
The vertical limb of the L is formed by the masseteric liga- and histologically distinct from the subcutaneous fat. It is
ments, which are stronger near their upper end (at the zygo- voluminous in infants to prevent indrawing of the cheek
matic ligaments), and extend along the entire anterior border during suckling, and gradually decreases in size with age.40 It
of the masseter as far as the mandibular border.5,29 The parotid functions to fill the glide planes between the muscles of
ligaments, also referred to as preauricular ligaments, repre- mastication.
sent another area of firm adherence between the superficial It is usually described as being formed of a central body
and deep fascia.25,27,28 The mandibular ligaments originate and four extensions, the buccal, pterygoid and superficial and
from the parasymphysial region of the mandible around 1 cm deep temporal. The body is located on the periosteum of the
above the lower mandibular border.27,28 There are several posterior maxilla (surrounding the branches of the internal
descriptions of other retaining ligaments in the face, most maxillary artery) overlying the buccinator muscle and extends
notably the mandibular septum and the orbital retaining forwards in the vestibule of the mouth to the level of the
septum.30,23 maxillary second molar. The buccal extension is the most
superficial, extending along the anterior border of the mas-
seter around the parotid duct. Both the body and the buccal
extension are superficial to the buccinator and deep to the
The prezygomatic space deep facial fascia (parotido-masseteric fascia), and are inti-
mately related to the facial nerve branches and the parotid
The prezygomatic space is a glide plane space overlying the duct. The buccal extension is in the same plane as the facial
body of the zygoma, deep to the orbicularis oculi and the artery, which marks its anterior boundary. The pterygoid
suborbicularis fat (Fig. 1.8).31 Its floor is formed by a fascial extension passes backwards and downwards deep to the
layer covering the body of the zygoma and the lip elevator mandibular ramus to surround the pterygoid muscles. The
The facial nerve 11
Zygomatic cutaneous ligament
Preauricular parotid cutaneous ligament
Parotidomasseteric cutaneous ligament
Platysma cutaneous ligament
Mandibular ligament
Fig. 1.9 The retaining ligaments of the face. (Reproduced with permission from Gray’s Anatomy 40e, Standring S (ed), Churchill Livingstone, London, 2008.)
deep temporal extension passes superiorly between the tem- plane to another in certain zones.1 It is in these “danger zones”
poralis and the zygomatic arch. The superficial temporal that dissection should be avoided or done carefully. In the rest
extension is actually totally separate from the main body, and of the face, the dissection can proceed relatively quickly by
lies between the two layers of the temporal fascia above the adhering to a certain plane, either superficial or deep to the
zygomatic arch.41 plane of the nerve.
The facial nerve nucleus lies in the lower pons and is
responsible for motor innervation to all the muscles derived
The facial nerve from the second branchial arch. A few sensory fibers originat-
ing in the tractus solitarius join the facial nerve to supply
During most facial plastic surgeries, whether congenital, the skin of the external acoustic meatus. The nerve emerges
reconstructive or aesthetic, there are one or more branches of from the lower border of the pons, passes laterally in the
the facial nerve that are at risk for injury. Although there is cerebello pontine angle and enters the internal acoustic
abundant literature on the anatomy of the facial nerve meatus. The facial nerve then traverses the temporal bone
branches, the majority of publications describe two- (being liable to injury in temporal bone fractures) to exit the
dimensional anatomy, depicting the trajectory of the nerve skull through the stylomastoid foramen. Just after its exit it
and its surface anatomy in relation to anatomic landpoints is enveloped by a thick layer of fascia that is continuous with
(see Fig. 1.3).9,16,42–49 However, it is the third dimension, the the skull periosteum, and is surrounded by a small aggrega-
depth of the facial nerve in relation to the layers of the face tion of fat and usually crossed by a small blood vessel. This
that is most relevant to the practicing surgeon. In spite of the makes its identification at this area a challenging task. Several
significant variability in the branching patterns, the facial methods for identification of the facial nerve trunk have been
nerve consistently passes in defined planes, crossing from one described:
Temporal branches
Zygomatic branches
Posterior
auricular nerve
Zygomaticotemporal divison
Cervicofacial division
Parotid gland
Buccal branches
Marginal mandibular
branches
Cervical branch
Fig. 1.10 The facial nerve.
1. If the tragal cartilage is followed to its deep end, it especially that the muscles they innervate show little if any
terminates in a point. The nerve is 1 cm deep and cross innervation, making injury to these branches much more
inferior to this “tragal pointer”. There is an avascular noticeable.
plane right on the anterior surface of the tragus that
allows a safe and quick dissection to this tragal pointer.
Frontal (temporal) branch
2. By following the posterior belly of the digastric
posteriorly, the nerve is found passing laterally This consists of 3–4 branches that innervate the orbicularis
immediately deep to the upper border of the posterior oculi muscle, the corrugators and the frontalis muscle. Several
end of the muscle. anatomic landmarks are used to describe their surface
3. If the anterior border of the mastoid process is traced anatomy. The most common description is Pitanguy’s line;
superiorly, if forms an angle with the tympanic bone. extending from 0.5 cm below the tragus to a point 1 cm above
The nerve bisects the angle formed between these two the lateral edge of the eyebrow (or 1 cm lateral to the lateral
bones (at the tympanomastoid suture). canthus).50,9 Ramirez described the nerve as crossing the zygo-
matic arch 4 cm behind the lateral canthus.51 However, other
4. By feeling the styloid process in between the mastoid
surgeons describe the area spanning the middle two thirds of
bone and the posterior border of the mandible. The
the arch as the territory of the nerve. Gosain et al. found
nerve is just lateral to this process.
frontal nerve branches are found at the lower border of the
5. By following the terminal branches of the nerve zygomatic arch between 10 mm anterior to external auditory
proximally. meatus and 19 mm posterior to the lateral orbital rim.16 Finally,
The nerve passes forwards and downwards to pierce the Zani et al. in 300 cadaver dissections reported that the nerve
parotid gland. In the parotid gland the nerve divides into the is in a region limited by two straight diverging lines; the first
zygomaticotemporal and the cervicofacial divisions, which in line from the upper tragus border to the most cephalic wrinkle
turn divide into the five terminal branches of the facial nerve: of the frontal region, and the second line from the lower
frontal, zygomatic, buccal, marginal mandibular, and cervical tragus border to the most caudal wrinkle of the frontal region.45
(Fig. 1.10). However, the zygomatic and buccal branches show Although there is no connection between the frontal nerve
significant variability in their location and branching patterns and other branches of the facial nerve, there are connections
as well as a significant overlap in the muscles they innervate within the frontal branches themselves.16 In addition, the
– they are sometimes grouped together and referred to as more posterior divisions of the frontal nerve may be less clini-
“zygomaticobuccal”. The temporal and the mandibular cally significant than the anterior branches, the injury of
branches are perhaps at the highest risk for iatrogenic injury, which will lead to noticeable brow deformities.16 A line from
The facial nerve 13
the tragus to 1 cm above the lateral eyebrow or 1.5 cm lateral Marginal mandibular
to the lateral canthus seems to be a fairly accurate marking of
the largest branch of the frontal nerve. The marginal mandibular nerve is one of the most commonly
With this great variation in surface anatomy, it is the plane encountered branches of the facial nerve, and is in jeopardy
of the nerve (the depth) that is most important (see Fig. 1.4). in multiple operations, including neck dissections, sub-
After emerging from the parotid gland, the nerve is protected mandibular sialadenectomy, and exposure of the mandible.59
by the deep facial fascia (parotidomasseteric fascia) lying on There are numerous descriptions and variations of both the
the masseter muscle. In midfacial procedures (e.g. facelift), trajectory of the nerve and its plane (i.e. depth), necessitating
dissection is usually superficial to the deep facial fascia (which care in a wide are of dissection in the lower face and the sub-
protects the nerve deep to it). In the temporal area, the nerve mandibular triangle.2,44,60–64 In addition, the nerve can vary
is on the undersurface of the superficial temporal fascia (see between a single branch and up to 3 or 4 branches.2,61,65,66
Fig. 1.5A). Here dissection is usually deep to the nerve, either After exiting the parotid gland near its lower border, the
directly superficial or deep to the deep temporal fascia (or nerve loops downward, often below the mandibular border.
the superficial layer of the deep temporal fascia). However, Whether the nerve crosses the mandibular border into the
the crossing of the nerve from deep to superficial in the vicin- submandibular triangle in all individuals is a matter of
ity of the zygomatic arch is a matter of debate. This is largely debate.2,60,67 Although several cadaver studies found the nerve
because of the confusion regarding the anatomy of the fascia to be more commonly above the mandibular border, clinical
in relation to the arch. Directly over the arch, the facial layers experience has shown that it is frequently located in the sub-
are tightly adherent (with little thickness of tissues from mandibular triangle, up to 3 or even 4 cm below the mandi-
the bone to the skin). While the SMAS is continuous with the ble.2,44,60,68–70 This might also vary with the position of the neck,
temporoparietal fascia across the arch, it is not clear if the and the surgeon must consider the wide variability of the
deep facial fascia is continuous with the deep temporal fascia nerve location in his dissection.2 The nerve then passes
or they are separate layers that adhere to the periosteum of upwards back into the face midway between the angle and
the zygomatic arch.7,8,52,53 At the lower border of the arch, the mental protuberance. Once the nerve crosses the facial vessels,
nerve is very close to the periosteum.54–57 The nerve is still its major trunk is usually above the border of the mandible,
deep to the SMAS/TPF and deep to the areolar tissue between although smaller branches may continue in the neck to supply
the TPF and the DTF (which as described above is sometimes the platysma.2
considered as a separate layer of fascia called the parotido- After exiting the parotid gland, the nerve is initially deep
temporal fascia). This deep location of the nerve allows safe to the parotidomasseteric fascia. In the submandibular trian-
transection of the SMAS at the level of the zygomatic arch in gle, the nerve is usually described as lying between the
facelift surgeries.58 The nerve passes from its deep location platysma and the deep cervical fascia. However, it might occa-
to the STF in the region right above the zygomatic arch.13 sionally be found deep to the deep fascia near the superficial
In this area, the fascia layers are more tightly adherent, surface of the submandibular gland. The nerve is deep to the
which is a warning sign that the facial nerve is in close prox- platysma and superficial to the facial vessels throughout its
imity. Dissection in this transition zone, extending over the course. As the nerve crosses into the lower face, the platysma
arch and the 2–3 cm above it, should be done carefully (see thins and the nerve can be injured during a subcutaneous
Fig. 1.3). dissection.
The marginal mandibular nerve supplies the lower lip
Zygomatic and buccal branches muscles, depressor anguli oris, mentalis, and the upper part
of the platysma.65,61 Injury to the marginal mandibular branch
These branches emerge from the parotid and diverge usually causes a recognizable deformity,71–73 and several surgi-
forwards lying over the masseter muscle under the parotido- cal maneuvers have been advocated to protect the nerve.74,75
masseteric (deep facial) fascia. The exact point where they When exposing the mandible, the surgeon can identify the
pierce the deep fascia is variable, but is in the vicinity of the nerve in the usual subplatysmal location. However, it might
anterior border of the masseter. The upper branches to the be safer and faster to go to a deeper plane, elevating the deep
midfacial muscle (zygomatic branches) pierce the deep fascia fascia and/or the facial vessels and using them to protect the
approximately 4 cm in front of the tragus in close proximity nerve. Dissection above the platysma laterally will also avoid
(around 1 cm inferior) to the zygomatic ligaments (see Fig. nerve injury.
1.2C). These branches soon innervate the zygomaticus major
muscle through its deep surface. The buccal branches emerge
from the parotid in the same plane as the parotid duct (deep Cervical branch
to the parotidomasseteric fascia). They pierce the deep fascia
at the anterior edge of the masseter, close to the masseteric The cervical branch of the facial nerve primarily supplies the
cutaneous ligaments (see Fig. 1.2C). Together, the zygomatic platysma. It has received little attention in the literature, as
and buccal branches supply the orbicularis oculi, midfacial injury of this nerve may pass unnoticed. However, such injury
muscle, orbicularis oris, and the buccinator. Unlike the mar- may cause weakness of the lower lip depressors, which is
ginal mandibular and the frontal divisions, there are a number often confused with injury to the mandibular nerve (marginal
of communicating branches between the buccal and zygo- mandibular nerve pseudoparalysis).76,77 However, mentalis
matic divisions, and injury to a single branch of these nerves function differentiates the two conditions, as it is preserved
is usually unnoticeable. Facial lacerations medial to the level in cases of cervical branch injury.
of the lateral canthus are usually not amenable to exploration The cervical nerve exits the parotid gland and passes
or repair of the facial nerve. 1–15 mm behind the angle of the mandible. It then passes
forwards, in the subplatysmal plane 1–4.5 cm below the separate flap for various uses, although once separated from
border of the mandible.78 The cervical nerve is often com- the skull bones it significantly retracts.87,88
posed of more than one branch. It may communicate with the Five arteries supply the scalp. From the front, there is the
marginal mandibular nerve (which might explain the lower supraorbital artery and the supratrochlear artery (branches of
lip asymmetry after its injury), and consistently communi- the ophthalmic artery from the internal carotid artery), the
cates with the transverse cervical nerve, although this latter superficial temporal artery from the side, and the posterior
communication is currently of little significance.79,60 auricular and the occipital arteries form the back (the latter
three arteries arise from the external carotid artery). In general,
these vessels run along the galea as they enter the periphery
Connection with sensory nerves of the scalp. At this level, they give multiple perforating
branches to the deeper subgaleal fascia. Closer to the vertex,
Several authors have noticed connections between the most of the vessels become more superficial, anastomosing
branches of the facial nerve with sensory nerves, including with the contralateral vessels. This explains why scalp flaps
the infraorbital, mental nerves and transverse cervical (formed of skin and galea with an intact subdermal plexus)
nerves.66,78,80,81 The exact clinical importance of this finding is can be safely extended across the midline, while pure galeal
yet to be seen. Interestingly, a face transplant recipient per- flaps cannot.89
formed at the Cleveland Clinic developed 2-point discrimina- The nerve supply of the anterior part of the scalp is by four
tion in the cheek, although only the facial nerves (and not the branches of the trigeminal nerve: STN, SON, ZTN, and the
sensory nerves) were repaired.82 auriculotemporal nerve. The posterior part of the scalp
(roughly behind the level of the auricle) is supplied by four
branches of the cervical nerves (C2 and C3): the great auricu-
lar nerve, the lesser occipital nerve, the greater occipital nerve,
The scalp and the third occipital nerve.
The five layers of the scalp are well known by the mnemonic
SCALP:
• Skin The musculature
• Connective tissue
In general, the muscle of the forehead and eyebrow are
• Galea Aponeurotica
arranged in three planes: the superficial plane right under the
• Loose areolar tissue skin formed by the frontalis, procerus, the orbicularis oculi;
• Pericranium. the deep plane formed by the corrugators, and an intermedi-
The gale aponeurotica is also known as the epicranial ate plane formed by the depressor supercilii (Fig. 1.11).
aponeurosis and corresponds to the SMAS in the face. Peculiar
to the scalp is the tight connection of the skin to the galea by
a dense network of connective tissue fibers. This makes sepa- Frontalis, galeal fat pad, and the glide plane
ration of the skin from the galea difficult (similar to the palm)
and bloody. In addition, this connective tissue lace stents the The frontalis muscle originates from the galea aponeurosis
vessels open which, combined with the scalp’s rich vascular- and inserts distally (inferiorly) into the eyebrow skin inter-
ity, leads to profuse bleeding. digitating with the procerus, corrugator and the orbicularis
The galea is a dynamic structure, being controlled by the oculi. Just above the nasion, both frontalis muscle are contigu-
frontalis muscle anteriorly and the occipitalis posteriorly. The ous with each other. At a variable point (1.5–6 cm) above the
skin moves together with the galea due to their tight attach- level of the superior orbital rim, the muscles diverge, with
ment. This is important in brow rejuvenation where weaken- the medial borders becoming connected by an extension of
ing of the brow depressor muscles allows the epicranial the galea aponeurotica.90 This divergence point is higher in
aponeurosis to move backwards leading to elevation of females. This is important when injecting botulinum toxin for
the brow. treatment of forehead rhytides.
The loose areolar tissue between the galea and the perios- Deep to the frontalis at the level of the eyebrows is the
teum is also referred to as the subgaleal fascia. This fascia is galeal fat pad, a band of fibroadipose tissue that is frequently
loose especially over the vertex of the scalp, allowing a quick encountered in brow lift procedures.91 This fat pad extends for
dissection with minimal bleeding. It becomes more dense 2–2.5 cm above the supraorbital rims being intimately related
closer to the supra orbital rims. Most surgeons consider this to the corrugator muscles. Between the galeal fat pad and the
layer as a potential dissection “plane” rather than a discrete periosteum is the glide plane space, which allows mobility of
“layer”.8,83 However, it has been shown to be a distinct layer the brow over the underlying bone. Similar to the SMAS in
that can be elevated independently as a vascularized flap.84 the face, the galea aponeurotica in the scalp seems to split to
This is especially possible closer to the zygomatic arch and cover both deep and the superficial surfaces of the frontalis.
the supraorbital rims where this layer is more substantial. It At the level of the supraorbital rim, the fascia covering the
is formed histologically of multiple lamina, with most of the deep surface of the frontalis becomes more adherent to the
vasculature along the superficial and the deep lamina.31,85,86 periosteum, sealing the galeal fat pad and the glide plane
The pericranium is simply the periosteum of the skull space above it from the eyelids. It is possible that the weak-
bones and is tightly adherent to normal sutures but easily ness of these attachments may be predisposed to brow ptosis,
dissected over the flat skull bones. It can be elevated as a especially laterally.92,93
The musculature 15
Layer 1
1. Depressor anguli oris
2. Zygomaticus minor
3. Orbicularis oculi
Layer 2 3
4. Depressor labii inferioris
5. Risorius
6. Platysma
7. Zygomaticus major
8. Levator labii superioris 8
alaeque nasi 10
2
Layer 3 7 12
9. Orbicularis oris
13
10. Levator labii superioris
5
Layer 4
11. Mentalis 1 9
12. Levator anguli oris 6
13. Buccinator 4
11
Fig. 1.11 Muscles of facial expression.
Corrugators reaching almost to the level of the SON.94 The muscle then
passes laterally to insert in the skin of the eyebrow, reaching as
The anatomy of the corrugators has gained significance far as the lateral third of the eyebrow. Janis et al. found that the
recently, with the realization of its role in browlift, migraine lateral most extension of the muscle is 43 mm from the midline
surgery and treatment of forehead rhytides. This renewed and 7 mm medial to the lateral orbital rim, while the most
interest has led to multiple anatomical studies that agree that superior extension is 33 mm cephalad to the level of the nasion.
the muscle is larger than originally described.94,95 The muscle The nerve supply of the corrugator is probably from both
originates from the supraorbital ridge, and passes obliquely the frontal (temporal) and the zygomatic divisions of the
upwards and laterally to insert into the skin of the eyebrow. facial nerve.66,70,96,97 The branch(es) from the frontal nerve enter
Usually described as being comprised of a transverse and an the muscle from its lateral end, and hence the importance of
oblique head, Park et al. found that this distinction is not clear complete muscle excision lateral to the SON so as not to leave
and described the muscle as being formed of three or four intact innervated muscle. The zygomatic (or upper buccal)
parallel muscle groups with loose areolar tissue in between.94 division sends a nerve that travels cranially along the side of
Janis et al. similarly found that both heads are indistinguish- the nose to innervate the nasalis followed by the procerus and
able shortly after their origin.95 In all cases, the muscle fibers the corrugator.66,97
blend together laterally, and become more superficial. Medial
to the SON, the corrugator is clearly separated from the over- Procerus
lying frontalis/orbicularis oculi muscle. However, it becomes
more superficial laterally near its insertion blending with the This small muscle arises from the nasal bone and the upper
frontalis. This close interdigitation with the orbicularis lateral cartilages and ascends superiorly to insert into the
explains the difference in description of the anatomy in this glabellar skin between the eyebrows and blending with fron-
region between the different authors. Intraoperatively, the talis along the medial ends of the eyebrow.98 Contraction of
corrugator can be recognized by its parallel oblique fibers, the procerus produces transverse glabellar rhytids.
darker color and deeper location, as opposed to the orbicula-
ris oculi which is more superficial and inferior, is lighter in Depressor supercilii
color, and has a circular orientation of the fibers.
The muscle origin is approximately 2.5 cm in width and This small muscle lies between the orbicularis oculi and the
1 cm in height, starting a few millimeters lateral to midline and corrugators, although some authors consider it part of either
muscle.92,99–101 It arises from the frontal process of the maxilla Based on its dominant deep pedicle, the muscle’s arc of rota-
2–5 mm below the frontomaxillary suture, slightly posterior tion is at the zygomatic arch, and can be rotated as a flap for
and superior to the posterior lacrimal crest.99 Daniel and coverage of the orbit, upper cheek and ear.103,104 The muscle is
Landon described it as running vertically between the pale also frequently used for facial reanimation.
circular orbicularis oculi more superficially and the brownish
transverse corrugator lying in a deeper plane.100 It finally
inserts into the dermis of the medial eyebrow. The masseter muscle
This strong muscle arises from the lower border and inner
Midfacial muscles surface of the zygomatic arch by two heads: a superficial head
from the anterior two-thirds of the arch and a deep head
From lateral to medial, the zygomaticus major, zygomaticus
forms the posterior third. The superficial head descends
minor, and the levator labii superioris originate from the ante-
downwards and backwards, while the deep head descends
rior surface of the maxilla (Fig. 1.11). Their line of origin is a
vertically downwards. Both heads then insert together at the
curved line, convex downwards, with the medial limit higher
lateral and inferior surfaces of the mandible.
than the lateral end. These muscles form the floor of the prezy-
gomatic space, and are covered by a fascial membrane that is
more stout superiorly, being around 2–3 mm thick. This fascial
membrane is identified by its pale color and coarse lobulation.
The medial pterygoid muscle
The levator labii superioris origin reaches the inferior orbital The medial pterygoid muscle arises by two heads: a small
rim while the zygomaticus major origin is separated from the superficial head from the maxillary tubercle behind the last
inferior orbital rim by the front of the body of the zygoma. The molar and a deep large head from the medial surface of the
three muscles insert into the substance of the upper lip. medial pterygoid. Both heads run downwards and backwards
The levator labii superioris alaeque nasi originates from the to insert on the inner surface of the angle of the mandible. In
frontal process of the maxilla. Its fibers pass downwards and mandibular fractures the action of this muscle is responsible
laterally to insert into the lower lateral cartilage of the nose for the upwards and forwards movement of the posterior
and the upper lip. segment.
The levator anguli oris arises from the maxilla below the
orbital foramen lying deep to the lip elevators. It is one of the
few facial muscles innervated on their superficial surface. The lateral pterygoid muscle
The depressor labii inferioris and the depressor anguli oris
are continuous with the platysma and draw the lip down- This muscle also has two heads, a smaller upper head from
wards and laterally. infratemporal surface and ridge of greater wing of sphenoid,
The mentalis is a thick small muscle that is important in and a lower larger head from the lateral surface of the lateral
exposure of the mandible and in chin surgery. It arises from pterygoid plate. The fibers pass backwards to insert into the
the buccal surface of the mandible over the roots of the inci- anterior surface of the neck of the mandible and the capsule
sors and inserts into the chin. Repair of the mentalis is vital of the temporomandibular joint. Some of the fibers pierce the
after buccal incisions to prevent chin ptosis. capsule to attach to the intraarticular disc. In condylar frac-
tures, this muscle is responsible for the displacement of the
mandibular condyle, while in Le Fort fractures, the muscle
Muscles of mastication pulls the maxillary segment downwards and backwards
resulting in premature contact of the molar and an anterior
The four muscles of mastication, the temporalis, masseter, and open bite.
lateral and medial pterygoids, are mostly present in the tem-
poral and infratemporal fossae and control mandibular move-
ment during speech and mastication. Being derivatives of the Actions of muscle of mastication
first pharyngeal arch, they are all supplied by the mandibular
Together, these muscles control most of the movements of the
division of the trigeminal nerve.
mandible. Elevation of the mandible is achieved by the tem-
poralis and the masseter, while the pterygoids protract the
The temporalis muscle mandible and move it to the contralateral side.
The temporalis arises from the bony floor of the temporal

fossa, with attachments to the deep surface of the deep tem- The pterygomasseteric sling
poral fascia. It passes deep to the zygomatic arch to insert into
the coronoid process of the mandible and the anterior border The masseter and the medial pterygoid insert respectively
of the ramus of the mandible almost down to the third molar into the lateral and medial surfaces of the lower edge of the
tooth. It receives its blood supply from the anterior and pos- mandible near the mandibular angle. These insertions are
terior deep temporal arteries, arising from the maxillary artery connected to each other by the pterygomasseteric sling, a
and supplying the muscle through its deep surface.102 It fibrous raphe extending around the mandibular border and
receives secondary blood supply from the middle temporal connecting both insertion.105 Disruption of this raphe will lead
artery, which arises from the superficial temporal artery near to an unaesthetic upward retraction of the masseter, most
the zygomatic arch and travels along the deep temporal fascia. visible on clinching the jaws.106
The sensory innervation 17
The aesthetic importance of the masseter three branches; the supraorbital, supratrochlear, and the infra-
trochlear nerves (Fig. 1.13A and see Fig. 1.12). The first two
and the temporalis muscle are particularly important due to their role in triggering
frontal migraine and the possibility of their injury during
Atrophy, hypertrophy, or displacement of either the masseter
forehead and eyebrow rejuvenation.108 In addition, successful
or the temporalis can be aesthetically bothersome. Masseter
anesthetic blocks of the SON can effectively anesthetize large
hypertrophy leads to an increased bigonial angle, although
areas of the scalp.
most cases of benign masseteric hypertrophy (BMH) are actu-
The SON exits the orbit through either a notch or foramen
ally caused by a laterally positioned mandibular ramus and
located at the level of the medial limbus.111 There is significant
not by a true hypertrophy of the muscle. Deformities of the
variation in its exit point,108,111–117 which can be a notch, a
temporalis muscle are more common, and are usually iatro-
foramen, or a canal. This point of emergence is approximately
genic due to improper resuspension of the origin of the muscle
25–30 mm from the midline. It is usually a few millimeters
during a coronal incision leading to retraction of the muscle
above the orbital rim, but can be up to 19 mm above it.112–115
inferiorly. This leads to a visible bulge above the zygoma and
The nerve then divides into a superficial (medial) and a deep
a depression near the origin of the muscle. Repair of the
(lateral) branch. The superficial division passes superficial to
atrophy or displacement of the masseter and the temporalis
the frontalis to supply the forehead skin.108 The larger deep
often involves the use of alloplastic implants, as the muscle
division, which is more prone to iatrogenic injury, passes
cannot usually be stretched to their original lengths.
cephalad in a more lateral location. As its name suggests, it is
in a deeper plane lying between the galea and the perios-
teum.116,117 It passes upwards 1 cm medial to the temporal
The sensory innervation fusion line, and supplies sensation to the fronto-parietal scalp.
Forehead dissection is safer in the subperiosteal plane as
The anatomy of the sensory nerves and their relation to the opposed to a subgaleal (subfrontalis) plane which places the
surrounding muscles has gained significant importance with deep branch of the SON in risk.118
the recognition of their role in the aetiology of migraine head- The STN emerges from the medial orbit above the trochlea
aches.107,108 Knowledge of the anatomy of these nerves is also approximately 1 cm from the midline, and is usually com-
important both to avoid iatrogenic injury and for local anes- posed of multiple branches. It supplies the central forehead.
thetic blocks.109,110 In general, the face is supplied by the three The ITN is a smaller nerve that supplies the medial eyelid and
divisions of the trigeminal nerve (through three branches a small part of the medial upper nose.
from each division), with the scalp receiving additional supply The maxillary division contributes three branches to the
from the cervical superficial spinal nerves (Fig. 1.12 and see sensory supply of the head; the zygomaticotemporal, zygo-
Fig. 1.9). maticofacial, and the infraorbital nerve (Fig. 1.13B, and see
The frontal division of the trigeminal nerve supplies the Fig. 1.12). The ZTN pierces the temporalis muscle and emerges
upper eyelid, forehead and a large portion of the scalp through through the deep temporal fascia 17 mm lateral and 7 mm
A1 - external nasal
A2 - infratrochlear A4
A3 - supratrochlear
A3
A4 - supraorbital
B1 - infraorbital B3
B2 - zygomaticofacial A2 GON
C3
B3 - zygomaticotemporal A1 B2
LON
C1 - mental B1
C2 - buccal C2
C3 - auriculotemporal
GAN
GAN - greater auricular nerve C1
LON - lesser occipital nerve

GON - greater occipital nerve
Fig. 1.12 The sensory supply of the face.
6
5
5 7
4
4
3
2 8
1
1 2
1. Maxillary division of the trigeminal n.

1. Trigeminal n. 5. Supraorbital n. 2. Zygomatic n.
2. Trigeminal ganglion 6. Supratrochlear n. 3. Infraorbital n.
A 3. Ophthalmic division 7. Infratrochlear n. B 4. Zygomaticofacial n.
4. Lacrimal n. 8. External nasal n. 5. Zygomaticotemporal n.
3
4
2
C 1. Mental n. 3. Mandibular division of the trigeminal n. Fig. 1.13 (A–C) The sensory nerves of the face. (Reprinted with permission from
2. Buccal n. 4. Auriculotemporal n. www.netterimages.com ©Elsevier Inc. All rights reserved.)
cephalad to the lateral canthus to supply the temporal fore- The mandibular division also gives three branches to the
head.119 It has also been incriminated as a cause of temporal face: the auriculotemporal, the buccal and the mental nerves
migraine. The zygomaticofacial nerve exits the orbit through (Fig. 1.13C, and see Fig. 1.12). The mental nerve is at risk for
a foramen in the zygomatic bone to innervate the skin of the injury in exposures of the mandible. It is the continuation of
cheek below the zygoma. The infraorbital nerve is the direct the inferior alveolar nerve, exiting the mandible through the
continuation of the maxillary nerve and passes to the cheek mental foramen which is located in line with the mandibular
through a foramen 1 cm below the infraorbital rim lying along first premolar (or first molar in children). It soon divides into
in the same vertical plane with the SON and the mental nerves 2–3 branches to innervate the lower lip and the chin.
(roughly along the midpupillary line).115 It supplies the skin The auriculotemporal nerve passes around the neck of the
of the cheek and the upper lid. mandible and ascend over the posterior root of the zygomatic
Anatomy of the eyelids 19
arch, giving a branch to supply the temporomandibular joint. interconnecting system, which allow either of the system to
As its names indicates, it supplies the auricle (and the external support the ear.122–124
acoustic meatus and the tympanic membrane) and the skin of The sensory nerve supply of the ear is derived from com-
the temple. It also carries parasympathetic postganglionic bination of cranial and extracranial branches. The posterior
fibers to the parotid gland, explaining its role in the develop- ear and lobule are innervated by the greater auricular nerve
ment of Frey’s syndrome (gustatory sweating). The best place (C2,C3) and the lesser occipital nerve (C2). The anterior ear
for an auriculotemporal nerve block is 10–15 mm anterior to and tragus are supplied by the trigeminal nerve (auriculotem-
the upper origin of the helix.112 poral branch of V3). The inferior ear and parts of the preau-
The buccal nerve runs in deep plane on the surface of the ricular area are innervated by the greater auricular nerve
buccinators. It sends branches to the skin of the cheek before (C2,3). The superior portion of ear and mastoid region are
piercing the buccinator to supply the mucous membrane of innervated by lesser occipital nerve (C2).
the cheek.
Of all the cervical cutaneous nerves, the great auricular
nerve has the most significance to the plastic surgeon.120 It
supplies the lower two-thirds of the lateral surface of the ear, Anatomy of the eyelids
the posterior and lower cheek, and the skin over the mastoid.
It appears around the midpoint of the posterior border of the There is no consensus on the “ideal” aesthetic eyelids, with
sternomastoid passing obliquely upwards towards the angle several factors such as age, ethnicity and surrounding skeletal
of the jaw. However, along the mid-belly of the muscle, it structure causing wide variation in the normal eyelids.
gently curves changing its direction towards the ear lobe. It In general, the palpebral fissure measures 29–32 mm hori-
passes either superficial or deep to the sternomastoid fascia.121 zontally and 9–12 mm vertically, with the lateral canthus
It can be consistently found at a point on the mid-belly of the 1–2 mm higher than the medial canthus. The upper eyelid
sternomastoid muscle 6.5 cm caudal to the bony external usually covers the upper 1–2 mm of the iris (lying approxi-
auditory meatus.120 mately halfway between the edge of the pupil and the limbus),
while the lower eyelid rests at roughly the level of the inferior
limbus. The highest point of the upper eyelids lies just nasal
to the center of the pupil. Ensuring the eyelids lies at their
Anatomy of the ear normal position is important after periorbital surgery, espe-
cially if the canthal tendons are disrupted.
The appearance of individual ear is unique. Its shape and The eyelids can be separated into an anterior lamella,
contour follows the cartilaginous framework that is envel- formed of skin and orbicularis oculi muscle, and a posterior
oped by a very thin skin and soft tissue. In general, there are lamella, formed by the tarsus and the conjunctiva (Fig. 1.14).
three parts of external ear: helix-antihelical complex, conchal The skin of the eyelids is the thinnest skin of the body,
complex, and lobule. Each of these complexes has its own mainly due to its thin dermis, and is relatively more elastic.
convoluted structures forming the surface anatomy with spe- As the skin crosses over the orbital rims, it abruptly thickens.
cific landmark nomenclature.122 Incisions in the eyelids usually heal rapidly and with minimal
These three divisions of ear are closely related to the scarring.
embryological development process. The ear arises from the The orbicularis oculi lies directly deep to the skin with
first and second branchial arches, also known as mandibular minimal subcutaneous fat in between, and is divided into
and hyoid. These arches then continued to develop into hill- pretarsal, preseptal (both lying in the eyelid) and orbital
ocks between the 3rd and 6th week of gestation. Located (around the eyelids) portions. The pretarsal muscle arises
anteriorly, the first branchial arch forms into three hillocks: medially by two heads that surround the lacrimal sac and
root of helix, tragus, and superior helix. The second branchial attach to the anterior and posterior lacrimal crests. The deep
arch, which is located posteriorly, gives rise to the other three head, also known as Horner’s muscle, also attaches to the
hillocks: antihelix, antitragus, and lobule. They become fully fascia over the lacrimal sac. This peculiar arrangement allows
formed structures by the 4th month and continue to develop the muscle to play an important role in the lacrimal pump
around the external meatus, which canalize by week 28. The mechanism.125 The preseptal orbicularis originates from the
middle ear arises from the first pharyngeal arch during the medial canthal ligament and inserts on the zygoma lateral to
4th week and forms into the incus and malleus. The stapes, the orbital rim. The orbital part of the orbicularis muscle origi-
on the other hand, is formed from the second arch.122,123 nates from the medial canthal ligament and the adjacent max-
The component of soft tissue covering the framework com- illary and frontal bones, and inserts with the preseptal portion
prised of vestigial intrinsic muscles of the ear, such as helicis into the lateral palpebral raphe (see below).
major and minor, tragicus and antitragus, and the transverse The tarsi provide support and rigidity to the eyelids. They
and oblique muscles. Most of the extrinsic muscle covering are formed of collagen, aggregens and chondroitins. The
are auricularis muscles (anterior, superior, and posterior). All upper tarsus measures 10–12 mm, while the lower tarsus
of these structures are vascularized by the arborization of measures 4–5 mm.126 The edges of the tarsi are firmly attached
vessels from superficial temporal and posterior auricular to the eyelids margins, while the opposite edge is convex
arteries. The majority of the anterior surface of the ear is giving the tarsus a semilunar shape. The Meibomian glands
supplied by the latter through its perforating branches and are embedded within the tarsus, and their ducts orifices are
over the helical rim. The branches of the superficial temporal located along the eyelid margin posterior to the eyelashes.
artery only supply the superior helical rim and triangular Between the dust orifices and the lashes is the “gray line”,
fossa and scapha network. These vasculatures form which can be seen as a faint gray line or groove. This line
Whitnall’s ligament
Levator palpebrae superioris
Superior rectus
ligaments
ROOF
Arcus marginalis
Orbital septum
Levator aponeurosis
Müller’s muscle
Tarsus
Orbicularis oculi
Inferior tarsal muscle
Orbital septum
Orbital fat
Arcus marginalis
Malar crease
ligaments
Inferior rectus
SOOF
Inferior oblique
Lockwood’s ligament Fig. 1.14 Sagittal view through the eyelids.
corresponds to a terminal extension of the orbicularis muscle to skin to form the upper eyelid crease. The deep part of the
known as Riolan’s muscle.127 The gray line serves as an impor- elevator muscle is the Muller’s muscle, which is sympatheti-
tant landmark; this is the plane between the anterior and cally innervated.128 In hyperthyroidism, sensitization of the
posterior lamella of the eyelids. Muller muscle leads to upper eyelid retraction and pseudo-
The orbital septum extends from the edges of the tarsi to proptosis. On the other hand, in Horner’s syndrome loss of
the orbital rims, attaching to the edge of the rim except infe- this muscle action leads to ptosis. Muller’s muscle also sends
riorly, where it extends for 1–2 mm on the anterior surface of a lateral extension surrounding the lacrimal gland and playing
the inferior orbital rim, sharing a common origin with the a role in tear excretion.129
orbicularis retaining ligament (see above). Directly deep to the The capsulopalpebral fascia assists in lower eyelid retrac-
septum is the orbital fat and the retractors of the upper and tion and coordinates it with eyeball movement. It arises as an
lower eyelids. extension of the inferior rectus muscle and inserts into the
The levator palpebrae superioris is the important upper lower edge of the lower tarsus and the adjacent orbital
eyelid retractor; injury or weakness to this muscle leads to septum.130 It might contain true muscle fibers, the inferior
eyelid ptosis. Originating from the back of the orbit, its mus- tarsus muscle, on its upper surface (similar to the Muller
cular fibers pass forwards above the superior rectus muscle. muscle in the upper eyelid).
They then turn into the fibrous levator aponeurosis and curve The medial and lateral canthal ligaments are of significant
inferiorly into the upper eyelid. This transition is encircled by importance due to their role in supporting and shaping the
the Whitnall’s ligament. The Whitnall’s ligament sends medial eyelids.131,22 Unfortunately, there is significant confusion in
and lateral horns to attach to the zygomatic bone laterally and terminology between the terms ligaments/tendons/and
the medial canthal ligament and the posterior lacrimal crest raphe when describing these structures.131–133 Laterally, the
medially. These attachments maintain the eyelids opposed to tarsi are attached to the orbital rim by the superficial and deep
the eyeball with its movement. The levator aponeurosis inserts parts of the lateral canthal ligament. The deeper stronger part
into the anterior surface of the tarsus, sending fibrous attach- attaches to Whitnall’s tubercle, located on the deep surface of
ments thought the orbital septum and the orbicularis muscle the lateral orbital wall 3 mm behind the rim.134 The superficial
Anatomy of the nose 21
part attaches to the anterior surface of the lateral orbital rim the superior portion of the upper lateral cartilages, is called
and the adjacent temporalis fascia and lateral orbital thicken- the keystone area. The most caudal portion of the framework
ing. The orbicularis oculi muscles, superficial to the tarsi and is supported by a uniquely shaped lower lateral (alar) carti-
the ligaments, curve around the eyelids and interlace together lage. Inferior medial portion of this cartilage is called medial
forming the lateral orbital raphe, which is superficial to the crus. As it ascends, it becomes middle or intermediate crus,
superficial part of the lateral canthal tendon.133 Medially, and continues curving laterally to become lateral crus. The
the medial canthal ligaments arise from the medial edge of junction between the middle and lateral crus is called the
the upper and lower tarsus, and is similarly formed of ante- dome, the most angulated portion of the structure and play
rior and posterior limbs that attach to the anterior and poste- an important role in forming tip definition of the nose. There
rior limbs of the lacrimal crest. are accessory cartilages, which are interspersed in the aponeu-
rosis connecting the lateral crus and piriform aperture.139–141
The inner lining of the nose is mostly covered by thin
Anatomy of the nose mucosa, providing passage of the airway. Destruction or inap-
propriate reconstruction of this thin mucosal lining can cause
The nose is strategically located in the central portion of the a narrowing of the breathing pathway.
face with three-dimensional projection associated with The surface anatomy of the nose follows the underlying
complex and intricate anatomy. Nose anatomy can be divided structural anatomy of its framework in combination with the
into three parts: the outer skin and soft tissue envelope, bony skin and soft tissue envelope. The most cephalad portion of
and cartilaginous framework, and inner lining. The intricate the nose is called the root or radix of the nose. This continues
relationship between first two components form contour caudally in the midline as a sloping downward segment
reflections, which make up a unique individual nasal appear- called dorsum of the nose. The tip of the nose has several
ance varying from one to another.135–137 landmark anatomies. The region just above the tip of the nose
The skin and soft tissue covering of the nose is variable in is called the supra-tip region or break. It is the surface land-
its thickness, texture, and components. It is relatively thin in mark above the dome (lateral genu) of the lower lateral carti-
the cephalad two-thirds of the nose, especially at the osseo- lages. The dome of each lower lateral cartilages mark the tip
cartilaginous junction (rhinion). The lower third portion of the defining points, and the region caudal to this points form
nose covering has thicker skin and subcutaneous tissue with infra-tip lobule and columella. The lateral curvature portion
varying degree of sebaceous gland, contributing to the nasal of the nose is called alar lobule, which forms the nostril
tip morphology.138 The nerves and vasculatures reside within opening. These surfaces form topographic subunits of the
this subcutaneous tissue. The nasalis muscle lies under the nose that are often used in recognizing the boundaries of light
subcutaneous tissue, and partially covers the bone and reflections bordering the anatomic landmarks: dorsum, side-
cartilages. walls, nostril sills, nasal tip, soft triangles, and columella.142
The skeletal framework of the nose is structured by nasal The nose is vascularized by dual blood supply. Superiorly,
bones and cartilages. They determine the individual nose con- the branches of the ophthalmic, anterior ethmoids, dorsal
figuration and shape. Starting from its most cephalad, the nasal, and external nasal arteries supply the proximal portion
paired nasal bones bridge the frontal process of the maxilla, of the nose. The inferior region and tip of the nose is primarily
and frontal bones at the nasofrontal suture. The overlapping supplied by branches of facial artery, which include superior
region between the inferior portion of the nasal bones with labial and angular vessels.143
Access the complete reference list online at http://www.expertconsult.com

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Anatomy Head and Neck

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Anatomy Head and Neck

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Anatomy of the head and neck

Aesthetic and reconstructive surgery of the head and neck

Deep temporal fascia

Superficial facial fascia, Deep

Superficial cervical fascia

anterior (medial) face, the facial nerve branches become more

Superficial Layer of deep

Deep temporal fascia 1

Superior temporal septum

Temporal ligamentus adhesion

Supraorbital ligamentus adhesion

Lateral brow thickening

Lateral orbital thickening

Attachment of orbicularis retaining ligament

Inferior temporal septum

Frontal branch of facial nerve

Fig. 1.7 The ligaments of the periorbital region.

muscle (namely the zygomaticus major, zygomaticus minor

Orbicularis oculi The malar fat pad

Fig. 1.8 The orbicularis retaining ligaments.

Zygomatic cutaneous ligament

Preauricular parotid cutaneous ligament

Parotidomasseteric cutaneous ligament

Platysma cutaneous ligament

Fig. 1.10 The facial nerve.

Fig. 1.11 Muscles of facial expression.

The temporalis arises from the bony floor of the temporal

LON - lesser occipital nerve

Fig. 1.12 The sensory supply of the face.

1. Maxillary division of the trigeminal n.

Lockwood’s ligament Fig. 1.14 Sagittal view through the eyelids.

Access the complete reference list online at http://www.expertconsult.com

15. Ishikawa Y. An anatomical study on the distribution of

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