Journal of Plastic, Reconstructive & Aesthetic Surgery (2020) 73, 1130–1134

Location of the split line of the deep

temporal fascia when reducing a zygomatic
arch fracture
Jung-Ah Park a, Shin-Hyo Lee a, Tae-Jun Ha a, Je-Sung Lee a,
Hye-In Lee a, Soon-Heum Kim b, Ki-Seok Koh a, Wu-Chul Song a,∗
a
Departments of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine,
Seoul, Republic of Korea
b
Department of Plastic and Reconstructive Surgery, Research Institute of Medical Science, Konkuk
University School of Medicine, Seoul, Republic of Korea

Received 17 September 2019; accepted 5 January 2020

KEYWORDS Summary Background: The deep temporal fascia (DTF) is known to separate into two layers
Split line of deep that descend to attach to the zygomatic arch. When surgeons reduce an isolated fracture of the
temporal fascia; zygomatic arch through a temporal approach, the temporal incision site needs to be superior
Deep temporal fascia; to the split line of the DTF.
Zygomatic arch Materials and Methods: Sixty-seven hemifacial cadavers were investigated after removing the
fracture; skin, subcutaneous tissue, and superficial temporal fascia. The superficial layer of the DTF was
Gillies approach exposed. We cut the superficial layer along the line along, which it adhered to the deep layer
inseparably. The heights of the split line of the DTF from the superior border of the zygomatic
arch and from the top of the helix were measured at three points: at the jugale, zygion, and
3 cm from the tragus.
Results: In all cases there were thick identifiable deep layers of the DTF. The mean heights of
the split line of the DTF from the superior border of the zygomatic arch were 49.8, 46.7, and
42.6 mm at the jugale, zygion, and 3 cm from the tragus, respectively; the corresponding mean
heights of the split line from the top of the helix were 19.1, 15.6, and 11.4 mm.
Conclusions: Knowledge of the mean height of the split line of the DTF will be helpful for
surgeons to determine the temporal incision site for ensuring the safe reduction of a zygomatic
arch fracture.
© 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-
sevier Ltd. All rights reserved.

Introduction

∗ Corresponding Understanding the precise anatomy of the fascial layers,

author.
E-mail address: anatomy@kku.ac.kr (W.-C. Song). fat pads, and their topographic relationships with nerve

https://doi.org/10.1016/j.bjps.2020.01.017
1748-6815/© 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Split line of deep temoporal fascia 1131

and vessels in the temporozygomatic area is important for
ensuring the safety of surgical procedures performed by
surgeons in this area. Although many studies have investi-
gated the complex anatomical structures in this area, the
literature contains confusing descriptions of the anatomical
layers and fat pads with different denomination1 , 2 . The
anatomical layers of the temporal area above the zygomatic
arch (in the order from superficial to deep) are the skin, sub-
cutaneous tissue, superficial temporal fascia (temporopari-
etal fascia), loose areolar tissue, deep temporal fascia (DTF,
temporal fascia), temporalis muscle, and periosteum1 , 3 , 4 .
The DTF is a fascial layer covering the lateral surface
of the temporalis muscle and it has been widely accepted
that this layer is divided into two layers: superficial and
deep1 , 3 , 4 . These two layers run downward and attach to
the lateral and medial borders of upper surface of the
zygomatic arch, and between the two layers there is a
superficial temporal fat pad that contains the middle tem-
poral vein, which is a branch of retromandibular vein1 , 5 .
The relationships of these fascial attachments are of clin-
ical importance when performing a closed reduction of
an isolated zygomatic arch fracture through a temporal
approach, which is also known as the Gillies approach6–8 .
In this approach, after performing a scalp incision in the
temporal area, the elevator is inserted into the deep
layer of the deep temporal fascia (DLDTF), so that it is
located posteriorly to the zygomatic arch when elevating
the fractured fragment3 . Therefore, it is helpful to know
where the DTF splits into two layers when surgeons per-
form temporal incision superior to the split line of the
DTF.
However, the authors of one study questioned whether
there are actually two layers of the DTF9 . They reported
that there were no thick identifiable fascial layers covering
the temporalis muscle in 130 surgery cases, and so con-
cluded that the DTF comprises a single layer rather than
two layers.
The aim of this study was to identify whether the DTF
comprises two layers and, if so, to measure the height of
the split line of the DTF from the superior border of the
zygomatic arch in the presence of the two layers.
Materials and methods
This study investigated 67 hemifacial specimens obtained
from 57 fixed and 10 fresh Korean adult cadavers. The
mean age at the time of death was 78.4 years, with an age
range of 56–97 years. The specimens comprised 45 sides
from 25 males and 22 sides from 11 females. Appropriate
consents and approval were obtained from the families
before the specimens were used. After removing the skin
from the temporozygomatic area, we removed the subcuta-
neous tissue, superficial temporal fascia, and loose areolar
tissue. We then exposed the superficial layer of the deep
temporal fascia (SLDTF), lifted up the SLDFT and identified
the location where SLDTF fused with DLDTF using a blunt
instrument. After confirming the accurate location of split
line, we cut the SLDTF along the line along which it adhered
to the DLDTF inseparably. Removing the SLDTF exposed the
superficial temporal fat pad, in which the middle temporal
vein was found buried (Figure 1).
Two lines were created: (1) one following the superior
border of the zygomatic arch and (2) the other parallel to
the superior border of the zygomatic arch at the uppermost
point of the helix. The heights of the split line of the
DTF from the superior border of the zygomatic arch were
measured at three points: at the jugale, zygion, and 3 cm
from the tragus (Figure 2A). The jugale is defined as the
point where the frontal and temporal processes of the zy-
gomatic bone meet, and the zygion is defined as a point of
the most-lateral outer curvature of the zygomatic arch5 , 10 .
We measured the height of the split line from the top of the
helix at the three same points, as well as the distance be-
tween the line at the top of the helix and the upper margin
of the middle temporal vein at the zygion (Figure 2B).
Two observers measured the heights of the split line
twice. The interobserver and intraobserver reproducibilities
of the height measurements of the split line were evaluated
by calculating the intraclass correlation coefficients. We
also evaluated the side-related and sex-related differences
in the heights of the split line, as well as differences be-
tween the fresh and fixed cadavers using Student’s t-test.
All data analyses were performed using the Statistical

Figure 1 Cadaveric dissection of temporozygomatic area. (A) Removal of the skin, subcutaneous tissue, superficial temporal
fascia, loose areolar tissue, and the exposure of the superficial layer of the deep temporal fascia (SLDTF). (B) Cutting and lifting up
the SLDTF and the exposure of superficial temporal fat pad (STFP). (C) Cutting off the superficial layer of the deep temporal fascia
where it tightly adheres to the deep layer of the deep temporal fascia (DLDTF) to show split line (black dots) of the deep temporal
fascia. The middle temporal vein (MTV) is embedded in the superficial temporal fat pad.
1132 J.-A. Park, S.-H. Lee and T.-J. Ha et al.

Figure 2 The heights of the split line of the deep temporal fascia (DTF) at three points: the jugale, the zygion, and 3 cm from the
tragus. The split line of the DTF is shown with black dots. (A) The heights of the split line from the superior border of the zygomatic
arch (black arrows) were measured. (B) The heights of the split line of the deep temporal fascia from the top of the helix (black
arrows) were measured. The vertical distance between the line at the top of the helix and the upper margin of the middle temporal
vein at the zygion (red arrow) was measured.

gomatic arch were 49.8 ± 5.8, 46.7 ± 5.4, and 42.6 ± 8.0 mm
Table 1 The heights of the split line of the deep temporal
(mean±SD) at the jugale, zygion, and 3 cm from the tra-
fascia from the superior border of the zygomatic arch and from
gus, respectively; the corresponding heights of the split line
the top of the helix at three points; the jugale, zygion, and a
from the top of the helix were 19.1 ± 10.9, 15.6 ± 9.6, and
distance of 3 cm from the tragus. The negative value represents
11.4 ± 10.8 mm. The intraobserver and interobserver repro-
that the split line was beneath the line drawn at the level of the
ducibilities of the height measurements of the split line
superior border of the helix.
from the superior border of the zygomatic arch and from the
Jugale Zygion 3 cm from top of the helix were excellent overall (ICC > 0.9 for all).
the tragus We compared the mean heights of the split line of the
From superior border of zygomatic arch DTF between males and females, between right and left
Mean ± SD 49.8 ± 5.8 46.7 ± 5.4 42.6 ± 8.0 sides, and between fixed and fresh cadavers. The mean
Range 33.6–59.8 33.3–60.6 26.9–57.5 height of the split line appeared to be somewhat longer in
males than in females, but the difference was only signifi-
From the top of helix
cant (p < 0.05) at the jugale. The height of the split line at
Mean ± SD 19.1 ± 10.9 15.6 ± 9.6 11.4 ± 10.8
the jugale was significantly shorter in females than in males
Range −11.4–40.1 −6.5–35.1 −12.5–30.6
(p < 0.05). There were 34 and 33 measurements made
on the right and left sides, respectively, and no significant
side-related difference was found (p > 0.05). The measured
Package for the Social Sciences (version 24 for Windows, mean height of the split line appeared to be slightly larger
SPSS Statistics, IBM, Chicago, IL, USA). The criterion for in fresh cadavers than in fixed cadavers, but the difference
statistical significance was p < 0.05. was not significant (p > 0.05). The distance between the
line at the top of the helix and middle temporal vein at
the zygion was –3.5 mm on average, and the maximum and
Results minimum distances were 26.1 and –25.4 mm, respectively.

A thick DLDTF could be identified between the superficial

temporal fat pad and the temporalis muscle in all speci-
mens. In most cases the SLDTF was present as a thick layer
lying above the superficial temporal fat pad, but in some
cases the SLDTF was mixed with a superficial temporal
fat pad at the lower part, and therefore it appeared like
an incomplete fascia rather than a complete fascia. The
inferior part of the DTF was attached to the superior border
of the zygomatic arch rather than the medial surface.
The maximum, minimum, and mean heights of the split
line of the DTF from the superior border of the zygomatic
arch and from the top of the helix are listed in Table 1. The
heights of the split line from the superior border of the zy-
Discussion
The DTF is generally known to constitute a thick single layer
at the upper part, starting from the superior temporal line,
and it separates into two layers as it descends toward the
zygomatic arch3 . However, where the DTF divides into su-
perficial and deep layers has been controversial. Campiglio
et al. reported that the DTF splits into two separate sheets
at 5 cm above the zygomatic arch11 , while Deepika et al.
reported that the temporalis fascia separated into two
layers at 2–3 cm above the zygomatic arch12 . Babakurban et
Split line of deep temoporal fascia 1133

Figure 3 Surgical reduction of zygomatic arch fracture through Gillies approach. (A) Temporal incision at hair-bearing area and
the insertion of the elevator deep to the fractured zygomatic arch. (B) Diagrammatic coronal section of temporozygomatic area
showing the appropriate route of dissection deep to DLDTF. (C) The diagrammatic coronal section of temporozygomatic area showing
that dissection between the two layers of the deep temporal fascia has the possibility of a middle temporal vein injury and the
inappropriate position of the elevator. DLDTF, deep layer of the deep temporal fascia; SLDTF, superficial layer of the deep temporal
fascia.

al. investigated the mean vertical lengths of the superficial
temporal fat pad between the two layers of the DTF, and
found that these lengths were 37, 24, and 23 mm in the
anterior, middle, and posterior parts, respectively1 . The
results of the present study are in agreement with all these
previous studies indicating that the DTF splits into two
identifiable layers. We measured the heights of the split
line of the DTF from the superior border of the zygomatic
arch in this study at three different points because the
location of the split line differs in the anterior to posterior
parts due to the presence of the fat pad between the two
layers. The mean heights of the split line tended to be
higher at the anterior part, being 49.8, 46.7, and 42.6 mm
at the jugale, zygion, and 3 cm from the tragus.
Li et al. claimed that there was no definite DLDTF above
the zygomatic arch in 130 surgery cases9 . They found only
a small amount of loose connective tissue between the
temporalis muscle and superficial temporal fat pad in a
few cases, and so considered that the DTF comprised a
single layer rather than two layers9 . In the present study,
we found two clearly identifiable layers: one covering the
temporalis muscle and the other covering the superficial
temporal fat pad. The DLDTF was a thick layer along the
entire course to the zygomatic arch, whereas the SLDTF
(covering the superficial fat pad) lost its fascial layer just
above the zygomatic arch and became mixed with the fat
pad to appear like a cribriform fascia in certain cases.
The location of the split line of the DTF and two fas-
cial attachments to the zygomatic arch can be applied
clinically when reducing an isolated zygomatic arch. The
zygomatic arch is susceptible to local trauma, such as
due to sports injuries and physical assaults, because it is
a laterally prominent element of the craniofacial skele-
ton13 , 14 . Isolated fractures of the zygomatic arch represent
approximately 10% of all zygomatic fractures and 5% of all
facial fractures14 , 15 . Surgical treatment of an isolated zygo-
matic arch fracture depends on the presence of functional
and cosmetic impairment16 . One of the main surgical ap-
proaches for the closed reduction of an isolated zygomatic
arch fracture is a temporal approach, which was first in-
troduced in 1927 by Gillies17 , 18 . In the Gillies approach, the
temporal incision begins at 1 to 2 cm above and anterior to
the helix of the ear to avoid the superficial temporal artery,
and the surgeon passes the elevator deep into the DLDTF, so
that the elevator is placed medially when reducing the frac-
tured segment of the zygomatic arch (Figure 3A and B)16 .
Approaching the temporal area through dissection between
the two layers of the DTF instead of dissection beneath both
of its layers can damage the middle temporal vein, which
is buried in the superficial temporal fat pad (Figure 3C)19 .
An even more serious aspect of dissection between the two
layers of the DTF is that the surgeon may not place the
elevator medial to the zygomatic arch, because the inferior
part of the DTF abuts the superior border of the zygomatic
arch rather than its medial surface (Figure 3C). Therefore,
the temporal incision would be better to be done superior
to the split line, which indicates the importance of knowing
where the DTF is divided into two layers.
The most frequently observed type of isolated fracture
of the zygomatic arch is an M-shaped fracture with bone
displacement but with all the fracture sites still in con-
tact13 , 15 . The zygomatic arch is weakest at approximately
1.5 cm posterior to the zygomaticotemporal suture, in the
zygomatic process of the temporal bone20 . The importance
of accurately locating where the elevator is inserted under
the fractured segment of the zygomatic arch means that the
heights of the DTF measured at the zygion and 3 cm from the
tragus in the present study could be useful for determining
the optimal temporal incision site in patients with isolated
zygomatic arch fracture. Our results indicate that the
1134
temporal incision site would be at least 46.7- and 42.6-mm
superior to the border of the zygomatic arch at the zygion
and 3 cm from the tragus, respectively. We chose these two
points on the zygomatic arch because (1) they are common
fracture sites and (2) the temporal incision site would be
hidden underneath the hair above these points, which pro-
vides an esthetic advantage. Because the Gillies approach
uses the helix as a starting point to decide the temporal
incision site, we also measured the mean heights of the split
line from the top of the helix; these were 15.6 ± 9.6 and
11.4 ± 10.8 mm at the zygion and 3 cm from the tragus, re-
spectively. The distance between the line at the top of the
helix and middle temporal vein at the zygion was –3.5 mm
on average, which suggests that the middle temporal vein
was usually located beneath the line at the top of the helix.
The mean heights of the split line of the DTF from the
superior border of the zygomatic arch at the zygion and
3 cm from the tragus were 46.7 and 42.6 mm, respectively;
the corresponding mean heights from the top of the helix
were 15.6 and 11.4 mm. These results will be clinically use-
ful when the surgeon is deciding the temporal incision site
for reducing an isolated zygomatic arch fracture through
a temporal approach. We suggest that approximately 5 cm
superior to the superior border of the zygomatic arch or
2 cm superior to the top of the helix at the zygion would
be appropriate locations for the temporal incision site to
allow the accurate insertion of the elevator and to prevent
damage to the middle temporal vein.
Declaration of Competing Interest
The authors declare that they have no conflict of interest
concerning the materials or methods used in this study and
no source of funding.
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