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Safely Navigating Around The Fac Ial Ner Ve in Three Dimensions
Safely Navigating Around The Fac Ial Ner Ve in Three Dimensions
Safely Navigating Around The Fac Ial Ner Ve in Three Dimensions
KEYWORDS
Facial Nerve Facelift Anatomy SMAS
Facial nerve injury during facelift surgery is a rare Where the nerves remain protected at a plane
but real occurrence, with a reported incidence deep to the dissection and where the nerve tran-
ranging from 0.5% to 2.6%.1–6 The danger zones sits to a superficial plane in locations that dissec-
of the various facial nerve branches have been tion must and can avoid has been learned from
well described in the literature1,2,7–16 but usually surgical dissection. From this clinical information,
from a two-dimensional perspective, which can the transit path of the facial nerve branches can
be difficult to translate to surgical technique. In be inferred without actually exposing them to
many of these classic descriptions, emphasis is injury.
on nerve trajectory in relation to surface anatomy This article describes in three-dimensional
and bony landmarks, with sparse and often con- accurate surgical terms where the facial nerve
flicting information on the nerve’s transition point branches are located and how they can be
between fascial planes. In the temporal region in protected while dissecting above and below the
particular, the literature reflects confusion regard- superficial musculoaponeurotic system (SMAS)–
ing the naming of fascial planes and their relation- platysma plane.
ships with the frontal branch of the facial nerve. Although a sub-SMAS–platysma facelift is
Some of the confusion about the anatomy of the believed to put the facial nerve at a higher risk
facial fascia and the facial nerve branches can be for potential injury,6,17–20 the authors have found
explained by the uncertainty of the anatomist extensive dissection of this plane to be safe if
working with the indistinct definition of the subcu- performed with a clear understanding and respect
taneous fascias in cadavers. The superficial and for the facial nerve danger zones (Fig. 1). The ana-
deep fascial layers in the cheek tend to be fused, tomic descriptions and surgical technique are
particularly in preserved cadavers. Earlier anato- based on the senior author’s observations from
mists who wrote the standard text books were more than 2500 SMAS–platysma facelifts.
not really concerned with the significance of the
transit of the facial nerve branches in relation to FRONTAL BRANCH
cosmetic surgery. Only in the operating room
with live patients can the superficial and deep fas- The classic descriptions of the frontal branch of
cial planes be readily distinguished and separated the facial nerve by Furnas,8 and later by Pitanguy
with dissection. and Ramos,7 describe the trajectory of a single
In surgery, the motor nerves are sometimes ramus in relation to the tragus and the lateral
exposed but mostly remain hidden beneath the brow. The presence of multiple frontal branch
deep facial fascia. The general course of the facial rami and the variable region over which these
plasticsurgery.theclinics.com
nerve branches is known from cadaver dissection. rami cross the zygomatic arch was observed
a
Division of Plastic Surgery, University of California, San Francisco, CA, USA
b
California Pacific Medical Center—Davies Campus, San Francisco, CA, USA
c
Division of Plastic and Reconstructive Surgery, University of Utah, Salt Lake City, UT, USA
* Corresponding author. California Pacific Medical Center—Davies Campus, 45 Castro Street, Suite 111, San
Francisco, CA 94114.
E-mail address: owsley@drjohnowsley.com (J.Q. Owsley).
while crossing the arch at a subfascial plane over- dissection. Over the posterior third of the zygo-
lying the periosteum. Recent cadaver dissection matic arch, the plane between the superficial
suggests that the parotid–masseteric fascia above (SMAS) and deep fascia can be easily separated
the arch merges into the fibroareolar innominate up to and often beyond the superior arch border.
fascia that overlies the superficial layer of the At a point 1 to 2 cm above the lateral arch in the
deep temporal fascia at 2 or 3 cm above the preauricular lateral temporal region, the deep and
mid-anterior arch in the area of dense interfacial superficial fascia become fused and cannot be
adhesion. Initially, the nerve lies just above the dissected further. This location is the transition of
insertion of the superficial layer of the deep tempo- the superficial temporal artery from beneath the
ral fascia into the arch. Within the area of dense superficial layer of the deep temporal fascia to
adhesion containing the innominate fascia, the reach the undersurface of the temporoparietial
frontal branch gradually passes upward to enter fascia.
the deep surface of the superficial temporoparietal In the middle and anterior third of the arch, the
fascia where it continues forward (Fig. 3). planes become densely adherent at the superior
In performing the senior author’s facelift opera- arch border and further blunt separation is pre-
tion, the SMAS is divided over the entire length vented. When dissecting from above the arch in
of the body of the arch to the origin of the zygoma- the temporal region, a safe plane of easy cleavage
ticus muscle. No frontal branch injuries have exists between the superficial temporoparietal fas-
occurred. The level of division is determined by cial and the deep temporal fascia, with the nerve
the point of resistance to blunt elevation of the contained within the superficial fascia. Blunt
SMAS over the arch. The fact that the nerve dissection can be performed safely and without
does not cross to a superficial plane until it is resistance until the area of fascial fusion is encoun-
above the arch is further demonstrated by the tered in the mid and anterior temporal region,
safe performance of the high-SMAS operation, in typically 2 to 3 cm above the arch and heralded
which the SMAS is divided along the superior bor- by the sentinel vein, which runs between the two
der of the zygomatic arch, where the nerve is planes in this location.
safely protected beneath the deep fascia.36,37 Within this area of dense interfascial adhesion,
Additional evidence of its deep position on the the frontal branch rami are in jeopardy as they
periosteum across the arch is the high rate of cross from deep to superficial fascial planes
reported frontal branch injuries after subperiosteal (see Fig. 3).24 As this area is approached, careful
dissections over the arch, ranging from 11% to subcutaneous dissection or an atraumatic subper-
20%,32,33 although refinements in technique have iosteal approach will protect the nerves from
allowed this rate to be reduced to just 1%.38 injury. Blind scissor subcutaneous dissection in
Protection of the facial nerve branches during the temporal region and over the mid arch can
sub-SMAS elevation in the cheek is facilitated by penetrate the temporoparietal fascia and result in
dissecting the sub-SMAS plane first. During injury to the frontal branch. Indiscriminate applica-
a sub-SMAS dissection of the cheek, the caudal tion of electrocautery can also cause frontal
zygomatic arch should be approached using blunt branch injury.
anterior margin of the masseter, the buccal rami of the mandible at a level deep to the parotid–
perforate the fascia and enter the buccal fat com- masseteric and deep cervical investing fascia. In
partment where they innervate the facial levator most instances, the nerve continues forward
muscles from their deep surface. above the inferior border of the mandible deep to
During a sub-SMAS dissection of the cheek, the the masseteric fascia. In those cases in which it
buccal branches become vulnerable at the ante- exits the parotid below the inferior mandibular bor-
rior extent of the parotid gland, where they can der, it runs anteriorly and crosses the surface of
be seen running deep to the masseteric fascia. the posterior digastric muscle and then the cap-
At the anterior margin of the masseter muscle, sule of the submandibular gland, lying deep to
a line of fibrous attachments between the masse- the investing cervical fascia and curving a variable
teric fascia and the SMAS is encountered, which distance below the mandible. The nerve pene-
constitute the supporting ligaments of the mid- trates the deep cervical fascia at the inferior border
cheek.22,46 Once the anterior edge of the parotid of the mid-mandible near the anterior margin of the
is reached, the safest and most efficient method masseter muscle, where it then crosses superficial
for separating the SMAS from the underlying mas- to the facial artery to enter the buccal space lying
seteric fascia is blunt dissection using a peanut beneath the platysma, ultimately innervating the
sponge. This blunt dissection is facilitated by major lip depressors and the mentalis muscle
dissecting in the sub-SMAS plane before subcuta- (Fig. 7).51
neous undermining. At the anterior border of the During a sub-SMAS cheek dissection, the great-
masseter, where the buccal rami emerge from est danger zone for the marginal mandibular nerve
beneath the fascia to enter the buccal space, is in the lower anterior cheek as the buccal space
limited and cautious blunt dissection can be is approached. Blunt dissection using a peanut
used to accomplish adequate mobilization of the sponge can be performed over the masseteric
SMAS–platysma flap (Fig. 6). fascia to mobilize the SMAS–platysma flap
adequately, but extreme caution should be used
MARGINAL MANDIBULAR NERVE at the lower anterior border of the masseter mus-
cle, because this is the region where the anterior
The classic descriptions of the mandibular branch facial artery and crossing marginal mandibular
of the facial nerve, most notably by Dingman and branch are encountered (Fig. 8). Injury to a low-
Grabb,9 focus on nerve trajectory rather than lying mandibular branch can occur below the man-
fascial plane.1,47–50 The mandibular branches dible only if the dissection inadvertently extends
have been found to remain above the inferior deep to the cervical investing fascia.
border of the mandible, except in 19% of cases Dissection beneath the platysma in the neck
where they can dip 1 to 3 cm below the mandible should be initiated several centimeters below the
before crossing the anterior facial vessels. angle of the mandible where the correct plane
The mandibular branch exits the caudal edge of can be established. The subplatysmal areolar
the parotid gland anterior to or just below the angle tissue can then be bluntly swept away from the
Fig. 6. After exiting the mid–parotid gland, the buccal Fig. 7. The marginal mandibular nerve emerges from
branch rami travel deep to the masseteric fascia. At the parotid gland at or below the angle of the mandi-
the anterior margin of the masseter muscle, amidst ble and runs anteriorly, remaining deep to either the
the masseteric retaining ligaments of the cheek, the masseteric or deep cervical investing fascia. It transi-
buccal rami perforate the fascia and enter the buccal tions to a subplatysmal plane as it crosses the facial
fat compartment. artery at the inferior border of the mandible.
474 Owsley & Agarwal
tissue bridge is preserved to protect the path of temporoparietal fascia. For the zygomatic, buccal,
the mandibular and cervical nerve branches, as and most mandibular branches, this transition
seen in Figs. 9 and 11. occurs at the anterior border of the masseter mus-
cle, where they exit from beneath the masseteric
DISCUSSION fascia to enter the buccal space. In cases where
the mandibular nerve arcs below the mandibular
Although much literature discusses the anatomy border, it pierces the deep cervical fascia just
and injury of the facial nerve branches, the fascial before crossing the border of the mandible and
plane of the nerves, particularly where they change the anterior facial artery, after which it runs
from one plane to another, is rarely emphasized beneath the platysma in the buccal space before
and often contradictory. All five motor branches of innervating the lip depressor muscles.
the facial nerve exit from the peripheral margin of Because of its early transition from beneath the
the parotid gland, lying deep to the parotid fascia, deep fascia to a subplatysmal plane, the cervical
which continues as the masseteric fascia, which branch is the motor branch most susceptible to
is in continuity with the deep temporal fascia above injury during a facelift. Fortunately, cervical branch
and the investing deep cervical fascia below. injury is usually inconsequential and therefore has
Only one branch, the cervical, immediately not been a major concern during facelift surgery.
penetrates the deep fascia after exiting the parotid In most patients, loss of platysma function has
gland and travels to the undersurface of the no effect on the lip depressors.
platysma, which it innervates. The other branches However, in approximately 2% of the popula-
continue beneath the deep fascia for a variable tion, typically those who exhibit a ‘‘full denture
distance after exiting the parotid gland before smile’’52 in whom the cervical branch probably
they pass to a more superficial plane or enter the innervates the depressor anguli oris in continuity
buccal space to reach their respective target mus- with the platysma, the platysma is a contributing
cles. For the frontal branches, this point is above lip depressor, and injury to the cervical branch of
the mid-anterior zygomatic arch, where they cross the facial nerve results in ‘‘pseudo-paralysis of
to a more superficial location to run within the the marginal mandibular nerve.’’53 The authors
suspect that many if not most of the marginal man-
dibular nerve injuries reported in the literature
actually represent pseudo-paralysis caused by
platysmal dysfunction secondary to cervical
branch injury. They observed this in their own
series of 2000 consecutive cases, in which all but
one case of lip depressor weakness after a facelift
were caused by a cervical nerve injury rather than
a mandibular nerve injury.54
Clinical distinction between these injuries may
be difficult because of variable overlapping func-
tion and interconnections of nerve supply to the
lip depressors. Injury to the marginal mandibular
nerve typically causes paralysis of the depressor
labii inferioris, depressor anguli oris, and mentalis
muscles, resulting in an inability to move the lower
lip downward and laterally and to evert the vermil-
ion border of the lower lip. The deformity appears
as an elevation of the lip on the affected side and
a relative retraction downward on the normal
side. Mentalis function has only recently been
acknowledged to distinguish cervical branch injury
from marginal mandibular dysfunction. The pres-
ence of lower lip eversion indicates a functioning
mentalis and therefore suggests an intact mandib-
Fig. 11. The cervical branches can often be seen cours-
ing upwards within the fibrous bands between the
ular branch. In the authors’ experience, cervical
parotid–masseteric fascia and platysma in the region branch injury is always associated with spontane-
anterior to the mandibular angle. The cervical branch ous recovery without special treatment.
extends forward on the undersurface of the platysma, In multiple anatomy texts and surgical articles,
which it innervates (arrows). the course of the marginal mandibular branch of
476 Owsley & Agarwal
the facial nerve is described as ‘‘running deep to 9. Dingman RO, Grabb WC. Surgical anatomy of the
the platysma,’’ with warnings against dissecting mandibular ramus of the facial nerve based on the
in a subplatysmal plane within 3 cm of the inferior dissection of 100 facial halves. Plast Reconstr Surg
border of the mandible.1,48,49,55–57 This description 1962;29:266.
differs from the authors’ observations in live 10. Zani R, Fadul R, Dias Da Rocha MA, et al. Facial
SMAS–platysma facelift dissections, in which the nerve in rhytidoplasty: anatomic study of its trajec-
mandibular branch is never visualized in the neck tory in the overlying skin and the most common sites
but courses beneath the deep cervical fascia until of injury. Ann Plast Surg 2003;51:236.
it crosses the anterior facial vessels in the mid- 11. Gosain AK, Sewall SR, Yousif NJ. The temporal
mandible. branch of the facial nerve: how reliably can we pre-
This discrepancy has several explanations. dict its path? Plast Reconstr Surg 1997;99:1224.
In cadaver dissections, the deep cervical fascia, 12. Seckel BR. Facial danger zones: avoiding nerve
which is less distinct and harder to appreciate injury in facial plastic surgery. St. Louis (MO): Quality
than platysma muscle fibers, may have simply Medical Publishers; 1994.
not been recognized. Additionally, what were 13. Myckatyn TM, MacKinnon SE. A review of facial
believed to be mandibular branches traveling on nerve anatomy. Seminars in plastic surgery. Facial
the undersurface of the platysma in the lateral Paralysis 2004;18(1):5.
mandibular location may have been cervical 14. Wilhemi BJ, Mowlavi A, Neumeister MW. The safe
branches. During live facelift dissections, the face lift with bony anatomic landmarks to elevate
authors have observed that cervical branches of the SMAS. Plast Reconstr Surg 2003;111:1723.
the facial nerve are frequently visualized in the 15. Owsley JQ. SMAS-platysma face lift. Plast Reconstr
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it is beneath the masseteric or deep cervical fas- 17. Baker DC. Editorial: deep dissection rhytidectomy:
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