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 1 Anatomy
STUART J. SALASCHE, MD and STEPHEN H. MANDY, MD
Introduction
A working knowledge of anatomy is essential to perform
any of the myriad of procedures in dermatologic surgery.
Most surgical skills, even the basic ones, such as scar orien-
tation and level of undermining, are predicated on a basic
command of anatomy. More complicated tasks, such as
nerve block anesthesia, designing tissue flaps and grafts for
advanced repair of surgical defects, and the placement of
botulinum toxin and fillers, require an even more intimate
understanding. Without an in depth working understand-
ing of the pertinent ana omy, there is a real potential for the
surgeon to cause damage by cutting into a vital structure
or to be so insecure as to not progress in one’s acquisition
of sophisticated surgical skills.
Surface Landmarks and
Surface Anatomy
Being a keen observer of the surface anatomy of the face
enables the surgeon to assess the patient for the vagaries of
aging, to identify the reservoirs of redundan skin available
for repairs, and to identify optimal placement of scars. It
also allows the surgeon to project and visualize the course
or location of the deeper vital structures onto the surface.
MASSETER MUSCLE AND MIDPUPILLARY LINE
The masseter muscle is a good starting point. It is the large
muscle of mastication that occupies the lateral portion of
the cheek below the zygomatic arch (Fig. 1.1). The parotid
gland rests on this muscle. At its anterior border on a line
drawn from the tragus to the middle of the upper cutaneous
lip, the parotid duct can be identified as it dips inward, pierc-
ing the buccinator muscle to open into the mouth at the
level of the second upper molar Also at the jaw line, just at
the anterior border of the lower masseter muscle, the facial
artery and vein enter onto the face. Pulsation of the artery
is often possible at this location. The superficial temporalis
artery pulse can be felt just anterior to the ear at its superior
attachment. Just beyond this, it splits into superior and pari-
etal branches.
The midpupillary line is identified with the patient sitting
up and gazing straight ahead. Three important openings in
the skull can be located. The superior orbital foramen is
located at the superior orbital rim, often palpable as a notch
along the rim. Through it exits the important supraorbital
neurovascular complex. Similarly, the infraorb tal foramen,
about 1 cm below the inferior orb tal rim contains the
infraorbital neurovascular artery, vein and sensory nerve.
Finally, the mental foramen, located in the alveolar bone of
the mandible in the midpupillary line and just below the
canine tooth, contains the mental artery, vein, and nerve.
All three foramena may be somewhat medial to the midpu-
pillary line The exact location of all three of these orifices
is important when performing respective nerve blocks of
the sensory nerves exiting them.
RELAXED SKIN TENSION LINES
The lines and wrinkles that develop with age and sun expo-
sure become an easily recogn zab e road map of the face.
These wrinkles and creases, first noted as hyperanimation
smile lines or frown (scowl) lines, may become permanently
etched as elastic tissue degenerates and becomes ineffective
in resisting the pull of the underlying muscles of facial
expression. These are referred to as the relaxed skin tension
lines (RSTLs; Fig. 1.2) and run perpendicular to the exer-
tion of the mimetic muscles below. These lines are often the
best choice for the placement of elective scar lines on the
face. When they are readily apparent, no problem is posed
in designing scar orientation. In younger people, having
them animate by grimacing, wrinkling the forehead,
smiling, or puckering will usually expose the RSTLs suffi-
ciently to make the correct cho ce. Similarly, pinching the
skin from various directions will also reveal the flow of the
RSTLs. Scars not oriented within or parallel to the RSTLs
are generally more noticeable, as they do not go with “flow”
of the region. This is especially apparent when the patient
is smiling or going through some other active form of
dynamic emotional expression.
COSMETIC UNITS AND JUNCTION LINES
One of the major conceptual advances over the past decade
or so in reconstructive and aesthetic surgery is th refine
ment and widespread acceptance of the junction lines and
cosmetic (aesthetic) units of the face (Fig. 1.3). Cosmetic
unit junction lines are the lines on the face at the borders
of the cosmetic units. They include the well-defined melo-
labial fold that separates the cheek from the lip, the mental-
labial crease that divides the chin from the cutaneous lower
lip, the hairline, and the jaw line. More subtle junction lines
separate the cheek from the nose (nasofacial) and lower
eyelid from the cheek. The nose has several subunits defined
by the alar groove, the dorsal crests, and the nasofacial line.
Collectively these are the outlines that caricaturists use
along with exaggerated features (broad forehead, wide-set
eyes, protruding nose) to rapidly define an individual’s
countenance and personality. They are also the best loca-
tion for camouflaging scars. Since lines and shadows are
1
 1 • Anatomy 1.e1

ABSTRACT KEYWORDS
Dermatologic, oncological, and aesthetic surgery require regional anatomy
an intimate knowledge of the bony structures, muscles, anatomic variation
vessels, and nerves of the head and neck. They also require retaining ligaments
an understanding of their relationship to each other, as fat compartments
well as the tissue planes and supporting structures in which skeletal aging
they reside. Preservation of function and appearance is
the definitive goal of surgical intervention and depends
upon the intimate fami iarity of the structural and func-
tional anatomy. Awareness of the constant evolution in
our understanding and variations of anatomic knowledge
require continued vigilance to remain proficient.
2 1 • Anatomy

Superficial temporal a. Forehead

Superior

ook
Glabella
forehead
wrinkle Hairline
Supraorbital n. line
Nasal root

tt
Supratrochlear n

/ Temple .m
m
Lateral
sidewall

s :
Anterior ethmoid n. Eyelid
Nasal
dorsum

Angular a. Nasofacial Ala nasi

sulcus
Nasal tip
Transverse facial a. Dorsum
Philtrum
Upper Melo-labial
Lateral nasal a. cutaneous

ok
fold
lip
Infra oral
Superior labial a. Mandibular crease
border Vermillion–lip
Inferior labial a
Lower
m
Verm lion–cutaneous

/ t
s: ::/
cutaneous junction
Facial a. lip

Chin
s
p s
Labiomental
line
Massater m.
Fig. 1.3 Cosmetic units and junction lines.
Fig. 1.1 Regional anatomy based on masseter muscle and arterial
system of the face.

k e rrss
and ear are subdivided into smaller units. The nose in par-
e
ooook
ticular has been defined to include the root, dorsum, lateral
side walls, paired alae nasi, soft triangles, columella, and tip.
Several useful principles of closure have been derived

include: m e
from the conceptualization scheme noted previously. These

ss: / / /
Scars should be oriented within junction lines or within

h tp
■

or parallel to the RSTLs.

■ Closures should be confined to a single cosmetic unit
Scowl lines when possible.
■ When closure is not possible within a single cosmetic
Crow’s feet
unit, skin should be recruited from adjacent units and

rrss
scar lines oriented so they lie within the intervening junc-

e
tion lines and within or parallel to the RSTLs.
k e
oook
■ When a defect involves several cosmetic units, consider
repairing each unit individually.
When most of a cosmetic unit or subunit is missing, con

me
■

sider sacrificing the remaining portion and replace he

entire unit.1

t
Fig. 1.2 Relaxed tension ines of the face.
FREE MARGINS: CONCEPT OF TENSION
VECTOR OF CLOSURE ht tp
Another important concept when performing facial surgery
is that of the free margins—the eyebrows, eyelids, lips, and

e r
kke s
rs
anticipated in these areas, scars tend to visually disappear
when placed within them. Conversely, scars crossing junc-
eerrs
nostril rims. These structures are extremely important, as
s
they offer little resistance to the forces of wound closure and
k
tion lines stand out as noticeable.
Cosmetic units are the areas cordoned off by the junction
/ e o ok
can be easily distorted by excess tension. This can occur
from the immediate direct exertion of tension by a side-to-
lines. They share common characteristics of skin color and

. m ee
texture, pore size, elasticity, thickness, presence or absence/ side closure or the delayed application of tension as a second
intention healing wound or split-thickness graft site con-
. m e
s :////t m
of hair, and shading. The cheek, temple, chin, and eyelids
are their own well-defined units, whereas the nose, cheek, :
ss /
unsettling and functionally disabling Ectropion of the /t
tracts. The resulting asymmetries can be both cosmetically
/ t m
 1 • Anatomy 3

lower lid can lead to permanent visual problems, while ecla-

e r
e s
r s
bion and lack of a proper oral seal can cause problems with

k
phonation, eating, and drinking, in addition to being aes-
thetically unpleasing.

/e
Tension vectors of closure can be favorably manipulated
by one of several techniques:
■
/ t t . m
Offset bias suturing: Each suture is skewed a bit from its
/: /
t t p
t ss
anticipated placement 90 degrees to the long axis. The

p
cumulative effect is to favorably alter the tension vector
hht
the requisite number of degrees to avoid pulling the free
margin in question out of position.
■ Flaps: Tissue rearrangement is designed so the tension
vector is favorably disposed and avoids pulling on free
margins.
■

eerrss
Suspension or anchoring suture: Instead of directing buried
suture toward the free margin, a suture is placed from
the undersurface of the closure down to and anchored

/ e b
to the underlying periosteum or perichondrium of the
e / e
t e
area. All tension is then directed downward toward these
m
strong, unyielding structures, and away rom the eyelid
/
: / / t
or eyebrow at risk of being distorted.
s
tps : s ////
Fig. 1.4 Facial skeletal resorption with arrow ize indicating degree.

hhtttp
■ Full-thickness skin graft: Placement of a full-thickness
graft prevents wound contraction and the development
of a tension vector of closure in any direction.
subcutaneous fat compartment and bind the muscles of
facial expression to undersurface of the dermis degenerate
Concavities and Convexities:
rrss s
and the RSTLs become permanently etched on the face

e e
Implications for Second
k k ee r s
(Glogau III) If the patient has significant photo-damage

oook
with deposition of solar elastosis within the papillary
Intention Healing dermis, the lines become even more prominent, usually

m ee /
The face is not a flat structure. Rather, it is composed of
with a pronounced roadmap of lines all over the face
(Glogau IV). /
/://t/ t . m
undulating well-defined elevations and depressions that
/://t/ t . m
Aging has a profound effect upon the facial skeleton, the

t pps
need to be taken into consideration when planning clo-
s
sures. Scar lines that traverse from convexity to concavity
t t pps
greatest on the bones of dental origin, the maxilla and man-
s
dible. These recede in their anterior pro ection and height
t
h tt
may contract in an unbecoming manner and may require
preplanning with an S-plasty configuration for appropriate
closure. However, the major effect of whether an area is flat,
hhtt
beginning at a relatively early age Regression of the orbital
rim creates inferolateral and superomedial enlargement of
the orbit causing loss of support for the periorbital soft
concave, or convex determines how well defects resolve tissues (Fig. 1.4). Enlargement of the piriform aperture
when allowed to heal by second intention. Although the deepens the nasolabial groove, and these changes, previ-
rrss
e k e rrss
size and depth of the defect have some impact on the final
e e
healing, defects on concave surfaces such as the temple, the
ously attributed to gravity, create laxity of restraining
fascial tissues and a generalized sagging of the skin that
k o
medial canthus, and the alar groove do well, whereas
b o o k manifests as brow ptosis, dermatochalasis of the upper

/
ee e
defects on convex surfaces such as the malar eminence the
e
tip of the nose, and the chin generally heal poorly with
eyelids, hollowing under the eyes, vertical lines in the pre-
e /
auricular area, deepened melo-labial folds, rhytids of the
e
t .
: //t. m
m
webbed or elevated scars. Defects on flat surfaces, such as

: / / t
/ .
t m
. m
perioral area, and pronounced jowls. These areas of redun
the forehead or cheek, typically respond somewhere in
between.
p /
dant and excess, along with the temple and the glabella,
ss
constitute the reservoirs of skin available for recruitment
t p
The Aging Face
for tissue rearrangemen s
hh
Generalized lipodystrophy of subcutaneous fat and spe-
cific resorption of the facial fat compartments and particu-
larly the buccal fat pad (Figs. 1.5 and 1.6) leads to a volume
With time, predictable wrinkles and sagging take place. This depletion of the face, resulting in a sunken appearance of

e r
e s
r s k e r
e s
is compounded by changes related to overexposure to ultra-
s
violet radiation in sunlight. Up until 30 years of age, people
the cheeks and a hollowing of the temples.4 What used to
be thought of as a simple act of gravity creating a sagging
k b o k
do not have wrinkles at rest (Glogau I). The RSTLs first
appear as hyperanimation lines perpendicular to the pull of
face is now known to be a much more complicated interac-
tion of fat atrophy, bone resorption, dynamic musculature,
/ e
/ e
the underlying muscles of facial expression (Glogau II).
ee
and changes in collagen and elastin.
ee/
/ t tm
Crow’s feet lines and small crinkles under the eyes when
. m
smiling are often the first to become noticeable. With time,
: /
Damage also results in splotchy hyperpigmentation and

/ / t .
t
hypopigmentation; vascular changes in the form of elan-
: / m
m
s /
the elastic tissue and collagen fascicles that traverse the
p ss /
giectasia of the cheeks and poikiloderma of the neck and
4 1 • Anatomy

Subcutaneous
midligament line

A´ A Dermis
B B
Sub-Q
SMAS

tps
Periosteum/
Ret nacula deep fascia
cutis
Bone
Retaining
ligament

r
F g 1 5 SMAS, Superficial musculoaponeurotic system.

Superior
temporal septum

Inferior
temporal
septum

Tear
trought lig. Orbicularis
retaining lig.

Zygomatic
cutaneous
ligaments

Plastysma
auricular fascia

Masseteric
cutaneous
h
Upper masseteric ligaments
cutaneous lig. Mandibular
Mandibular septum
cutaneous lig.
Fig. 1.6 Retaining ligament.

: / /
/ t
/ .t.
rims of the ears; and the signature damage of ultraviolet The Musculoaponeurotic System //t/.t
t t p
t ss:
radiation, the deposition of solar elastotic material in the
p
leathery appearance. hht
papillary dermis, giving the skin a yellowish, thickened, and

An accurate assessment of the aging face is important

INTRODUCTION
Humans communicate by use of the muscles of facial
not only in correctly judging where there is available skin expression (the mimetic muscles). By use of this silent mode
for recruitment in tumor defect repair but also for determin- of interacting, human discourse is enriched by nuance and

eer s
ing which cosmetic procedure is most applicable for any
s
part cular patient. An upper lid blepharoplasty may only
k k eerrss subtlety. Shades of annoyance, reverie, indifference, skepti-
cism, sarcasm and so on are molded onto the spoken word.

ok
compound severe brow ptosis if that condition is not also

e o
b
ook
o
addressed. Similarly, it is important to recognize if a resur-
Muscles of facial expression are unique in that they are
the only muscles to insert into the skin. They do so via

ee/ /
facing (ablative laser, chemical peel, etc.), revolumizing fibrous septae that connect the superior portion of the
e
: //t.tm m
(fillers), or tissue tightening procedure (radiofrequency, muscle to the undersurface of the dermis and are part of
m
ultrasounds, etc.) would offer a particular patient the great-
: / / t .
t m
the branching network of fibers known as the retinacular
/ /
est benefit.
ss
cutis. This is part of a larger complex system of fibrous septa
 1 • Anatomy 5

Middle forehead

keerr
compartment Sup. temporal
Central forehead septum
Inf. temporal
compartment
septum
Lat. temporal-cheek
compartment

: /t
Sup. orbital
compartment Orbicularis
retaining lig.

Inf. orbital
compartment
Lat. orbital
compartment
Sup. cheek
h
Nasolabial
compartment septum

Medial cheek
compartment s
es
r
Middle cheek
compartment
Platysma
Sup. jowl auicular lig.
compartment
Inf jowl Massenteric

/ttm
compartmen
Mandibular
cutaneous lig.
Mandibular
septum
cutaneous
ligaments

hht p
Fig. 1.7 Retaining ligaments and fat compartments of the face.

in the subcutaneous layer of the face that connect to the

rrss
retaining ligaments and contribute to the septa that create

e
the fat compartments of the face. They also insert or inter-

k e
digitate with the other mimetic muscles. So while the fron- Temporal fat pad

b
talis muscle wrinkles the forehead and raises the eyebrow

/ e
it helps open the eye widely by partially inserting in o the
e
/ t m. e
upper fibers of the orbicularis oculi muscle (Fig 1 7).
Innervation of the muscles is exclusively y branches of
t
s /: / /
the facial or cranial nerve VII This occurs at the lateral
s
hhtttp
tp
undersurface of the muscle The muscles are most effective Sub
and concentrated in the midplane of the face and exert their orbicularis Lateral
oculi fat
major effect around the two major orifices of the face—the
eyes and the mouth.
The aponeurotic component is made up of retaining liga- Buccal
ments that are strong and deep fibrous attachments that
rrss
Periauicular
originate from the periosteum or deep fascia and travel per-
e e
pendicularly through the facial layers to insert in the dermis
k
(Figs. 1.8 and 1.9). These ligaments act as anchor points, ke
Deep medial

e / e
retaining and stabilizing the skin and superficial fasc a
/ e
(superficial musculoaponeurotic system [SMAS]) to the
e
Sub mental

: / / / .
t m
. m
underlying deep fascia and skeleton They tend o be more
t
t p ss: /
laterally displaced on the face in the SMAS of the cheek and
the superficial temporalis fascia of the temple, which has a
p
Fig. 1.8 Fat compartments.

t
hht
superior temporal septum and an inferior temporal septum.
The orbicular retaining ligament surrounds the orbit con- hht
edge of their anatomic relationship is essential to avoid
necting medially to the tear trough ligament (Fig. 1.10). nerve damage during dissection.
The other major components of the aponeurotic system
are the zygomatic cutaneous, masseteric, and mandibular MUSCLES ACTING AROUND THE EYELIDS

e e s
ligaments and the galea aponeurotica is spread over the
r r s
expanse of the skull, connecting the anteriorly displaced
k ee r s The frontalis muscle is the primary muscle of the forehead,
k oo
frontalis muscle with the occipitalis muscle of the neck.3

b
These ligaments and fascial components restrict cutaneous k and its main function is to wrinkle the skin of the forehead
and elevate the eyebrow. Accordingly, it has been called the
/ e
/ e
mobility and may be necessary to surgically disrupt in order
e /
“surprise” muscle. Through its interdigitations with the
ee
/ t .
t m
to mobilize tissue for closures. It is also important to recog-
m
nize that these retaining ligaments often share intimate
: / / / t .
t m
upper fibers of the orbicularis oculi muscle, it also ass sts in
m
opening the eye widely. Injury to the temporalis muscle

s /
relationships with branches of the facial nerve, so knowl-
ss /
results in flattening the skin of the forehead brow ptosis,
6 1 • Anatomy

ee
Frontalis m.

k
o
Cor ugator supercilli m.

Procerus m.
Orbicularis oculi m.
Nasalis
Levator labii

h
superioris alaeque nasi
Levator labii superioris
Zygomaticus minor
Levator labii anguli oris

e
kk r s Zygomaticus major
Men al s

b o Depressor labii inferiorsi

Riso ius Depressor anguli oris

Platysma
Fig. 1.9 Muscles of facial expression.

htt
Sub galea plane
Galea
hht
and the larger transverse head that runs laterally to insert
widely into the skin of the eyebrow. It functions mainly
to pull the eyebrow medially and slightly downward, and
Sup. temporal septum
creates the vertical scowl lines of the glabella. Recently the
Inf. temporal septum

e rrs
depressor supercilii has been described. It arises just above
s
and deep to the corrugator supercilii and extends vertically
k e
oooo
Temporal adhesion superior to also attach into the skin of the medial eyebrow.
Lat. orbital thickening
It appears that there are three muscles that act in concert
to depress the medial eyebrow: the most deeply placed
SMAS
mme
depressor supercilii, the middle oblique head of the corru-

/:/tt
Sub-SMAS plane
medial/superior orbicularis oculi muscle.
p s s ://tt
gator supercilii, and the vertically oriented fibers o the
/
Zygomatic ligament

Masseteric ligaments
hh t
t p
The key to the orbital region is he large, sphincter-like
t t
circumferential orbicularis ocul muscle. It has both outer
orbital and inner palpebral portions. The orbital portion
originates broadly from the superior and inferior bony
orbital rims and inserts into the medial and lateral canthal
tendons, as well as the superficial temporalis fascia. It also

k errss
interdigitates with fibers from the frontalis, corrugator
e
supercilii and procerus muscles. The orbital division is

ooook
Deep fascia
under voluntary control and acts to close the eye tightly and
Mandibular ligament depress the eyebrow. Unilateral contraction results in a
Sub-Q

. m
m e
wink. The palpebral portion over the orbital septum and
tarsal plate acts to gently close the eye (voluntary) or blink
t
Skin

s : / ///t.
(involuntary). The muscle is innervated by fibers of the tem-
:
hhtt
Fig. 1.10 Sagittal section of the r ta ning ligaments. SMAS, Superficial
musculoaponeurotic sys em.3 ps
poral and zygomatic branches of the facial nerve.

MUSCLES ACTING AROUND THE NOSE

The nose is relatively devoid of musculature when com-
and accentuation of the effects of dermatochalasis and pared with the eyes and lips. The muscles consist mainly of

k eerrs
upper visual field gaze.
s
The corrugator supercilii muscle has come under intense
k eerrss the procerus muscle that extends down from the frontalis
vertically onto the upper nose across the root and into the

ok
nterest with widespread popularity of botulinum toxin
injections. The muscle originates from the frontal bone of
e o
b
ook
o
aponeurosis of the nasalis muscle on the nasal dorsum.
Contraction, usually in concert with the adjacent lip eleva-
the medial orbit in line with and just above the medial

m ee/ /
canthal tendon insertion. It has two slips—the obl que head
tors, “scrunches” up and shortens the nose and causes the

m e
transverse RSTLs across the root. The levator labii superi-

/ / t .
t m
that runs a short distance superiorly to insert into the skin
: / / / t .
t m
oris alaeque nasi arises from the maxilla under the medial
/
pss s
of the medial eyebrow and helps depress the medial brow, orbicularis oculi and descends vertically to the mid-upper
 1 • Anatomy 7

lip, but also sends slips to the lateral ala nasi. In concert (pterygoid, masseter, and temporal muscles). The former
r s
r s
with alar fibers of the nasalis muscle, it aids in dilating the
e e k e e s
r sare innerva ed entirely by the facial (VIIth cranial) nerve,

k o o k
nostril with each inspiration. The broad thin nasalis muscle
is the intrinsic nasal muscle with alar fibers just discussed,
o
whereas the latter are supplied by motor fibers of the tri-
geminal (Vth cranial) nerve. The facial nerve has the great-

e / eeb
transverse fibers over the dorsum that just tense the skin
over the dorsum, and the depressor septi portion that pulls
est clinical relevance to dermatologic surgeons and will be
the topic of this section. /
/t
down the septum and aids in deep inspiration.
m
: FACIAL NERVE (CRANIAL NERVE VII)
s
hhtttpps t t pp
MUSCLES ACTING AROUND THE MOUTH
As noted earlier, the mouth is the most expressive part of
the face. This is due to the myriad number of muscles that
hht
The facial nerve is a complex structure with an anatomy
that varies from patient to patient. The possibility of injur-
ing or severing one of the branches of this nerve is of para-
not only insert into the overlying skin but also insert and mount importance in every procedure performed on the
exert motion from every possible direction into the sphincter- face, whether extirpating a tumor, repairing the defect after

e r
e s
r s
like orbicularis oris muscle. Further modulation of fine
muscular movement is aided by a structure called the modi-
k eerrss
removing the tumor, or performing cosmetic “lifting” pro-
cedures. The consequences of such a dire event can be cos-
k
olus (hub, Latin), from which the orbicularis originates.
Lying about 1 cm lateral to the oral commissure it is a ook
metically and functionally devastating for the patient and
a source of medical–legal concern for the surgeon. It is

e e
/ e
muscular platform-like confluence of several of the muscles
e /
important to know the projected pathway and expected
e
: / / t
/ m
inserting into the orbicularis and acting on the orner of
.t m
the mouth, including the zygomaticus major, levator anguli
/ / t m
depth within the skin of all the motor nerves within the
.t m
surgical field, so one can not only attempt to avoid them,
:
t ppss /
oris, risorius, depressor anguli oris, buccinator, and pla-
t p ss
p /
but also include during the informed consent process a dis-

t
tysma muscles. Actions are amplified or muted by fine-
hht
tuning of the synergistic and antagonistic muscles. The
action of the orbicularis muscle itself is to draw the lips
t
hht t
cussion of the potential consequences of injuring them.
After leaving the interior skull at the stylomastoid
foramen, the facial nerve classically divides into two major
together and to pucker the lips. trunks within the substance of the parotid gland, the supe-
There are four lip elevators. From most medial to lateral, rior temporofacial and the inferior cervicofacial, which in

rrss s
they include the levator labii superioris alaeque nasi, levator turn divide into the five major branches: the temporal, zygo-

e
labi superioris, zygomaticus major, and zygomaticus minor.
e k eer s
matic, buccal, marginal mandibular, and cervical branches

k
They are all important in smiling, sneering, and snarling
movements. The upper lip and corner of the mouth are
b oo
o
(Fig 1.11) In reality, the temporal and marginal mandibu-
lar branches are single terminal rami in about 85% of the

e
muscles. The buccinator muscle, beloved by trumpet
m /e
/e
retracted and elevated by the risorius and levator anguli oris
ee/
population; the other branches cross-arborize and have
multiple rami, making the muscles by these latter nerves

s /:
tucked inward between the teeth
s
//tt m
players, plays an important role in chewing by keeping food
/:/t/tm
.m
less prone to permanent paresis. Obviously the former are
at greater risk for lasting damage if severed or injured

hh t
t t p
The muscles working on he lower lip include the men-
t
talis muscle, which wrink es the skin of the chin and also
helps pouch out and protrude the lower lip (sniveling); the
during surgery.

depressor anguli oris, which retracts and depresses the

corner of the mouth; and the depressor labii inferioris
muscle, which, as the name implies, depresses the lower lip.

e rrss
The depressor anguli oris can be injected with botulinum
e
toxin to improve the down turning of the corner of the
k
mouth that occurs with age. The latter two are important
b
Temporal

ee e
(along with the upper lip elevators and angle retractors) n
/ / e
attaining the wide, happy, toothy grin associated with

: / .
///t. m
m
laughing. The marginal mandibular nerve innervates all
t
three muscles. Finally, the platysma muscle, innervated by
: me
Zygomatic

p s s
the cervical nerve, stretches broadly from the chest upward
t t p
hh t
across the expanse of the neck over the jaw line to blend
with the angle of the mouth depressors. Despite being thin
in some people, it helps cover and protect the marginal
mandibular nerve at the anterior border of the masseter
muscle at the jaw line.

ke Nerves
Buccal
Motor
Mandibular
INTRODUCTION Cervical

/ .
ss / t
There are two kinds of muscles of the face: the muscles of
: /
facial expression and the skeletal muscles of mastication Fig. 1.11 Facial nerve.
8 1 • Anatomy

because it is relatively superficial and covered by only a vari-

e
kkerrs
TEMPORAL NERVE

k e rrss
able platysma muscle at the jaw line at the anterior border

oook
The temporal nerve can be roughly projected onto the skin of the masseter muscle. It may be at, above, or below the
from a line connecting a point 0.5 cm below the tragus of aw line between its exit from the parotid and the anterior

ee/ e
the ear to a point 2 cm above the lateral eyebrow, where it
/
innervates the frontalis muscle. Some fibers go to the upper
border of the masseter muscle. Skin cancers as well as deep
e
acne scars occur frequently in these locations, making

: / / t .
t m
. m
orbicularis muscle. Like the other branches, it is protected

: / / t
/ .
t m
. m
surgery dangerous for the unwary. The marginal mandibu-

t p ss : /
in its initial course by the parotid gland through which it
runs. It is most vulnerable at the zygomatic arch and the
p t p ss : /
lar nerve is just posterior to the mandibular ligament and
about 10 mm anterior to the ante ior margin of the mas-
p
t
hht t
temple, where it resides deep in superficial temporal fascia
below the inferior temporal septum (see Fig. 1.5). Remem-
t
hht t
seter muscle. Injury to the nerve results in an inability to
retract or depress the corner of the mouth when smiling.
ber that the neurovascular bundle containing the sensory The unopposed pull from the unaffected side causes the
auriculotemporal nerve and superficial temporalis artery damaged-side lower lip to flatten and rotate inward upon
and vein are more superficial in the lower subcutaneous fat smiling (see Fig. 1.11).

k eerrss
above the superficial temporal fascia. The temporal nerve is
most vulnerable during extirpative surgery involving inva-
eerrss
The cervical branch innervates the platysma muscle and
is rarely clinical consideration.

ok
sive or recurrent skin tumors that frequently occur in this

b o
area. Imprecise undermining in the wrong plane may also
e Sensory Nerves of the Head
/
ee/ and Neck
damage the nerve. It is prudent to recognize that mo or

m
nerves, as myelinated nerves, are also subject to the effects

/ .
///t m
of local anesthesia, and repeat injections as may occur in
: / /
ss
Mohs micrographic surgery can cause deep, long-lasting
p ss :
The major sensory nerves of the head and neck run inde-
p
hhttttp hhttttp
nerve blocks. This can cause the unwary surgeon and the pendently of the motor nerves. In general, they course as
patient needless concern for the 10 or more hours it takes part of neurovascular bundles consis ing of the nerve, an
nerve function to return. In general, if the surgery has artery, and a vein. Compared with the motor nerves, they
exposed a fascial plane that moves easily in a side-to-side are more superficial and hence more prone to surgical
manner to the probing (gloved) finger, the superficial tem- injury and/or involvement with invasive skin cancers. Inva-

k e r s
poral fascia and the temporal nerve are probably intact. If
s
the tissue is an immovable, tightly bound-down glistening
e e rrs
ok
membrane, the temporal fascia over the temporal muscle of
mastication has been reached, and the nerve has a much
higher probability of having been severed.
sive skin cancers can envelop the nerve or travel along
s
it beyond the main tumor mass by perineural invasion.
k e
ooook
This sometimes results in paresthesia and dysesthesia, but
more mportantly in larger subclinical extensions, larger
defects, and a higher incidence of recurrences and metas-

mme /
Damage to the temporal nerve results in paresis of the e
tases. On the other hand, injury to a sensory nerve is not as
m m
s :/
frontalis, with an ipsilateral inability to wrinkle the fore-
/ t
head, raise the eyebrow, and open the eye widely. The
s :/tt.
serious as cutting a motor nerve. Damage is usually not
/
permanent, and there is often a full reversal of anesthesia

t t
hh t p s
asymmetry is discomforting and functional upper visual
field problems may ensue if the resulting brow ptosis is t
hh t
t t p s
or dysesthesia with time. The latte is dependent upon the
distance regeneration has to occur from the sensory gan-
compounded by significant dermatochalasis of the upper glion to point of injury. Sensory nerves generally regrow
lid skin. but very slowly. Patients must realize that it may take up to
a year for sensation to return, and in some cases regrowth
is not complete. The major nerves of the face are the tri-

kkeerrs rrss
ZYGOMATIC AND BUCCAL NERVES
geminal (Vth cranial) nerve and the neck branches of the

k
The zygomatic nerve divides into many arborizing rami
ookee cervical plexus (C2, C3).

/ e o
after leaving the parotid gland, and has interconnections
o
with branches of the buccal nerve. It primarily innervates
With a good grasp of the anatomy of the sensory nerves,
one can perform specific nerve blocks (mental, infraorbital,

. m e /
the orbicularis oculi muscle but also the corrugator super-
m e
cilii and procerus muscles and upper fibers of the levator
. m
m e
supratrochlear, and supraorbital) or regional blocks, which
use combinations of nerve blocks to anesthetize whole

: / t
//t.
labii superioris complex. The zygoma ic branches travel
s : s : / t
/// .
areas for surgical procedures, such as on the nose, ear, and
:
t
hh t
t p
t p s
deep to the zygomatic ligaments along the zygomatic arch.
The buccal nerve shares connections with the zygomatic
t
hh
nerve, but primarily innervates the levator labii superioris,
t
t p
t s
forehead/scalp. Unfortunately, much of the cheek is inner-
p
vated by small terminal branches and requires local anes-
thesia, often with multiple injection sites.
levator labii superioris alaeque nasi, buccinator, zygomati-
cus major and minor, levator anguli oris, and orbicularis TRIGEMINAL NERVE (CRANIAL NERVE V)
oris muscles.

kkeer
MARGINAL MANDIBULAR AND eer s
As the nerve of the embryonic first branchial arch, the
s
trigeminal nerve supplies motor fibers to the muscles of
k
CERVICAL NERVES

/ e ooook
mastication, secretory fibers to the lacrimal, parotid, and
mucosal glands, and sensory innervation to the face and

. m ee /
The marginal mandibular nerve, like the temporal branch
is most often a solitary ramus after leaving the parotid
m
anterior scalp. It has three main sensory branches origi-

m e
nating from the middle cranial fossa-situated trigeminal
.
:
ss / /
/ t
/ t
gland. It innervates the lip depressors, the risorius muscle,
and the mentalis muscles It is particularly prone to injury :////t m
or gasserian ganglion, which divide the face and scalp
both horizontally and vertically (Fig. 1 12). These nerve
 1 • Anatomy 9

A
Trigeminal ganglion
Pterygopalatine ganglion

Frontal nerve
Nasociliary nerve

/ / t
/ tm
Ophthalmic ne ve
m
(supraorbital fissure)

s : • Lacrimal nerve
• Anterior ethmoid nerve
• External nasal branch
anterior ethmoid nerve
Maxillary nerve
(foramen rotundrum)
• Nasopalatine nerve Cervical plexus
• Infraorbital nerve • Lesser
• Zygomaticotemporal nerve occipital nerve
• Zygomaticofacial nerve • Greater
auricular nerve
Mandibular nerve

t/t. me
(foramen ovale)
m
• Mental nerve
• Transverse
cervical nerve

• Buccal nerve
Lingual nerve
• Inferior alveolar nerve
• Auriculotemporal nerve

Ophthalmic nerve (V1)

B

k eer ss
• Supraorbital ne ve (lateral branch)
• Supraorbital nerve (medial branch)

ok
• Sup atrochlear nerve
• Infratrochlear nerve
• Lacrimal nerve
• External nasal branch
(anterior ethmoidal nerve)

Maxillary nerve (V2)

• Zygomaticotemporal nerve
• Zygomaticofacial nerve
• Infraorbital nerve

Mandibular nerve (V3)

kkeerrss
• Auriculotemporal nerve
• Buccal nerve
• Mental nerve

Cervical plexus
• Lesser occipital
nerve (C2)
• Great auricular
nerve (C2, C3)
• Transverse cervica
nerve (C2, C3)
Fig. 1.12 Sensory nerves. (A) Deep. (B) Cutaneous.

e e r s
divisions have been classically designated as the ophthalmic
eerrs
divides into the infratrochlear nerve to the medial canthus
k
k
(V1), maxillary (V2), and mandibular (V3) nerves.
ok
and the root of the nose, and the external nasal branch of
the anterior ethmoidal nerve. The latter reaches the surface
Ophthalmic Nerve (V1)

m ee / ee/
of the nose between the nasal bones and the upper lateral

: //t/.tm
The ophthalmic nerve (V1) exits the skull at the supraor- cartilage to supply the dorsum, tip, and columella of the

/ /
/ t
/ .
t m
bital fissure. It has three main branches: the nasociliary,
.m
nose. Blisters of herpes zoster in its distribution require

ss
the frontal, and the lacrimal nerves The nasociliary further
s
ophthalmic examination, as the cornea is supplied by a
10 1 • Anatomy

common nerve origin. The frontal nerve divides into the depend on a named artery), such as the paramedian fore-
r
kke s
rs
supratrochlear nerve, which reaches the surface via the
e
supratrochlear notch in the supraorbital rim about 1 cm
k eerrss head flap, is dependent on knowledge of the location of the
major vessels of the face—in this case, the supratrochlear

o o
lateral to midline to supply the medial upper eyelid and
o artery

ee e
forehead/scalp and the supraorbital nerve, which surfaces
/ /
at the supraorbital foramen about 2.5 cm from midline in

/ t
/ .
t m
m
the midpupillary line to supply the upper eyelid and the
/
forehead/scalp. Finally, the lacrimal nerve supplies the
EXTERNAL CAROTID SYSTEM

lateral upper eyelid. s :
Maxillary Nerve (V2)
The maxillary nerve (V2) emerges from the foramen rotun-
dum and also divides into three main branches. The largest,
the infraorbital nerve, exits the infraorbital foramen 0.5 to
: / / t
/ .t
The external carotid system is the main blood supply to the
lower face, temple, and posterior scalp.
t pp :
hhttt
The main branch of the external carotid artery to the
central face, the facial artery, enters onto the face after
exiting the submandibular gland at the anterior border of
the masseter muscle at the jaw line (see Fig. 1.1). It runs
obliquely superior within the substance of the lip depressor

k eer ss
1 cm below the infraorbital rim in the midpupillary line
r
to innervate the upper lip, medial cheek, lateral nose, and
k eerrss
muscle complex toward the commissure of the lip. Within
the substance of the orbicularis oris muscle, it first gives off

ok
lower eyelid. The smaller zygomaticofacial supplies the
malar eminence, and zygomaticotemporal innervates the oook
the inferior labial artery that runs medially through the
lower lip to meet its pair from the other side. Next, at the
temple region.
/e e
level of the upper lip, the similarly disposed superior labial

m
artery is given off and runs transversely through the upper
Mandibular Nerve (V3)
: // lip to meet its contralateral partner.
/ // m
ss
The mandibular nerve (V3) is the largest of the three tri-
p s
tps
After giving off the superior labial artery, the facial artery

hhtttp
geminal divisions and the only one to carry motor fibers to
the muscles of mastication Like the others, it has three
main branches: the auriculotemporal, buccal, and mental
nerves. The auriculotemporal runs deeply beneath the
mandible and reaches the cutaneous surface superior to the
hhtttp
becomes known as the angular ar ery as it makes its way
up toward the alar base and consequently upward along-
side the nose to anastomose with the dorsal nasal artery,
a branch of the ophthalmic artery of the internal carotid
system. This anastamotic complex at the medial canthal

k e rrs
parotid gland in company with the superficial temporal
s
artery and vein to supply the lateral ear, temple, and
e e rrs
level is an important vascular pedicle for the dorsal nasal
s
or Rieger flap. Recent anatomic studies revealed that the
k e
ok ooook
parietal/temporal scalp. The buccal nerve divides into many angular artery has four variations that occur with nearly
branches in the region of the buccinator muscle before equal frequency. The illustration (Fig. 1.13) depicts the vari-

ee/ e
reaching and supplying the medial cheek. It is not available
/
for nerve block. The mental nerve exits the mental foramen
ations.2 The complex anastomotic vascular arrangement in

/ / t m. m
of the alveolar bone in the midpupillary line, along with the
/ t
t ppss : /
mental artery and vein to supply the chin and lower lip.
The infraorbital and mental nerves are prime candidates
t
hh t
for nerve block anesthes a These two nerves, along with
the infratrochlear, supratrochlear, and supraorbital, can be
blocked in various combinations for regional blocks of the
nose and forehead/scalp.
AA AA

k eerrs
Vascular System LNA LNA

o e
The incredibly rich blood supply to the face is responsible FA FA

m ee/ /
for the wide array of surgical procedures that can be carried 19.3% 31.6%

: / /
/ t
/ .t.m
out there. The vascular system to the face is unique in being
supplied by two separate artery complexes, the external and

t t ppss
the internal carotid systems (see Fig. 1.5). These systems

hht
have rich anastomoses, and here is also an extremely rich
cross-anastomosis involving paired bilateral arteries such
as the superior labial arteries and the supratrochlear arter-
OA

ies. Furthermore, unlike the blood supply on the trunk and

extremities, where perfusion of the surface is via vertically

ee s
oriented perforating vessels from the underlying skeletal
r s
muscles, the final perfusion of the skin of the face is through
k
LNA LNA

ok
the horizontally displaced subdermal plexus that lies high
in the subcutaneous fat just under the reticular dermis. This
e
FA FA

m ee /
allows for wide undermining of side-to-side closures and
the seemingly endless number of random flaps (no named
.
22.8% 26.3%

:///t/t m
artery in pedicle) that have been designed to repair defects
t
Fig. 1.13 Variations of the angular artery. AA, Angular a tery FA, faci l

s
of the face. Proper design of axial pattern flaps (ones that artery; LNA, lateral nasal artery.
 1 • Anatomy 11

Opthalmic
Supraorbital art. and v.
art. and v.

Supratrochlear
ookk
Lac imal
art. and v.
Sentinel v.

art. and v. Temporal

art.

s/://
Nasociliary
art. and v.
Medial

tt
temporal
v.
Dorsal nasal
Zygomatico
art. and v.
-temporal
art.

Angular Ant. and

art. and v. post.
deep
temporal art.

Zygomaticofacial
Sup. labial art. and v
art. and v. Infraorbital
Facial art. and v.
art. and v.
Fig. 1.14 Periocular vascular anatomy. (Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A. Blindness caused by cosmetic filler injection: a
review of cause and therapy. Plastic and Reconst Surg. 2014;134:1197–1201.)

ke
the periocular area is cause for concern, as many arteries
o kk
o INTERNAL CAROTID SYSTEM

/eb o
connect directly or indirectly to the retinal and internal
carotid arteries and have resulted in blindness and s rokes
e
when injected with particulate material such as intrader-
m /e ee/
The main volume of blood from the internal carotid system
is dedicated to supplying the brain. A portion is allotted to
m
mal fillers (Fig. 1.14).5
/:///t. / t . m
the face, predominantly to the ophthalmic artery whose
/: / t
t t t s
Other main branches off the external carotid include the

p s
occipital artery that cou ses posteriorly and superiorly in
t s
terminal branches exit the skull as the supraorbital and

p s
supratrochlear arteries, as part of he same-named neuro-
t
hh t
company with the sensory occipital nerve between the tra-
pezius and sternocleidomastoid muscles, to run just above
the occipital muscle to supply the posterior scalp. The post-
hhtt
vascular bundles (see Fig. 1.14). They exit their respective
foramen and pierce the overlying frontalis muscle to run
superiorly. At this point, they are displaced deep in the sub-
auricular artery arches around the styloid process to a cutaneous fat above the frontalis fascia and subsequently
groove between the mastoid process and the external ear to over the galea aponeurotica as they course superiorly over
rrss
e
above and behind the ear.
k e rrss
supply the posterior ear and portions of the adjacent scalp
e the scalp. They supply the forehead and anterior scalp (see
Fig 1 14) As noted earlier, the supratrochlear artery is
k o o k
After giving off the facial and occipital arteries, the exter-
b o recruited for the classic and extremely useful axial midline

e / e
nal carotid artery divides into its two terminal branches the
/ e
superficial temporal artery and the internal maxillary
e
and paramedian forehead flap. Both arteries partake in the
e /
rich anastomotic network over the scalp by connecting with
e
: / / / .
t m m
artery. The latter branch is primary interna to he mouth
t . : / / t
/ .
t m
. m
branches of the superficial temporalis and occipital arteries.

t p ss: /
and nose, but after several divisions does supply terminal
vessels that exit the infraorbital and mental foramen as
p t p ss: / This network is so powerful that traumatic scalping can be
repaired by vascular reconnection of even one of these

hht t
same-named arteries, along with their respective veins and
sensory nerves. They provide important anastomoses with t
hht t major vessels that supply he s alp
The other major branch off the ophthalmic artery is the
the facial artery. dorsal nasal branch (in some studies noted as the infratroch-
The more important division to dermatologic surgeons is lear artery) at the medial canthus. It runs inferiorly along
the superficial temporal artery. This runs superiorly in front the side of the nose in the medial canthal region to supply

e r
e s
of the ear within the substance of the parotid gland, along
r s
with the same-named vein and the auriculotemporal nerve,
k e r
e s
r s the bridge of the nose and to connect with the angular
artery of the external carotid system.
k b o k
a sensory branch of the mandibular nerve of the trigeminal
(Vth cranial) nerve. As the neurovascular bundle exits the
It is interesting that above the zygomatic arch, the neu-
rovascular bundles containing the major arteries and veins
/ e
/ e
superior pole of the parotid gland, the artery is palpable at
ee
all course in the deep subcutaneous plane above the fascia
ee/
m
the level of the superior attachment of the ear. At this point,
. m t . m
or muscles of facial expression. Conversely, below the arch,
. m
ss////t / / t
it splits into anterior and parietal branches to supply the the vessels are usually within the substance of the mimetic
temple/lateral forehead and parietal scalp, respectively. :
ss /
muscles and do not course in the company of the major
12 1 • Anatomy

Superficial temporal a. Frontal branch Facial

s • Malar node

Zygomaticoorbital a.
ookk
Preauricular
and parotid
• Infraorbital
node
Buccinator

me
Infra-auricular
Transverse ac al a. nodes
Postauricular

Occipital
///.t
Mandibula
node
Submental
Spinal Submandibular
accessory
chain Superficial
cervical node
Internal jugular
chain

o k
Fig 1. 6 Lymphatic drainage.

/ / / t
p /
s
Fig. 1.15 Venous system of the face and corresponding arteries.
sensory nerves. Knowledge of the route and depth of the
vessels will aid in preserving them during a procedure in the
/
superficial nodes then proceeds to the deeper cervical
:
ss /
systems in the neck (the spinal accessory internal jugular,
p
hhttttp
and transverse cervical lymph node basins).
The real wild cards in the system are the lymph nodes
within the substance of the parotid gland. These nodes are
difficult to assess clinically, and even lymphoscintigraphy
may prove troublesome due to the proximity of the parotid

k e rrs
region. On the other hand, when they have to be cut, as in
s
a lip wedge excision, knowing that the labial artery is
e e rrs
gland. They drain a wide area, including portions of the
s
anterior scalp, forehead, lateral eyelids, cheeks, nose, and
k e
ok ooo
located in the very posterior portion of the distal orbicularis upper lip. Subsequent drainage is to the deeper neck node
oris allows the surgeon to locate and clamp it off immedi- basins
ately before it retracts into the substance of the muscle.
/ Special Structures: Lip, Nose,
VENOUS SYSTEM

p : Eyelids, and Ear /

t
hhtt p
The vascular drainage of the face, for he most part, parallels
t
the arterial supply. Generally, he veins have a straighter, less
tortuous path than their counterpart arteries (Fig. 1.15).
LIP
The lips are the guardians of the oral seal that is required
for phonation and mastication. On a social level, the mar-
LYMPHATIC SYSTEM
velously expressive lips convey our nonverbal communica-

kkeerrss rrss
The advent and widespread use of lymphoscintigraphy tion. As such, they are at once the least complicated and the
have at once confirmed and expanded much of what we
k
ookee most mobile of the special structures of the face. The two

/ e o
know about the lymphatics of the head. The system is cer-
o
tainly much more variable than once believed. The impetus
are related; by not having a constricting solid structure
such as the bony/cartilaginous frame of the nose or the

. m e /
for this interest is that melanoma, squamous cell carci-
m e
noma, and Merkel cell carcinoma all tend to metastasize
. m
m e
form-shaping tarsal plate of the eyelid, the lips are quite
flexible, stretchable, and elastic. Having only a very thin

s : / t
///t.
first to primary echelon nodes, and a complete examination
: : / t
// t
subcutaneous fat layer in the cutaneous portion also facili-

hhtttpps
for these tumors includes evaluati n of the draining lymph
nodes either by manual pa pation or by histopathologic
evaluation, following sentinel lymph node biopsy.
Some generalities apply to the lymphatic system of the
hhtt p
head and neck. First, the central face and scalp are usually
devoid of lymph nodes, except for a few inconsistent, ectopic
tates this ability.
Internally, the lips consist sole y of the orbicularis oris
muscle and the myriad muscular insertions attached to it.
They are covered on the outside by skin, on the inside by a
wet mucosa, and at the vermilion by a dry modified mucosa
(Fig. 1.17). The submucosa contains many salivary glands

eerrs
nodes found above the mimetic muscles in the subcutane-
s
ous fat. Generally they are encountered by accident during
k eerrs
on the oral portion
s
The lips may be divided into vermillion and cutaneous
k
ok
surgery or found in the pathology specimen. Next, afferent
drainage is organized in flow patterns that proceed in a
e ooook
cosmetic units. The cutaneous upper lip is the most compli-
cated section, having a small triangular portion that extends

m e/ /
superior to inferior, diagonal direction toward the collect-
e
ing, primary echelon nodes in the upper neck region These
superior and lateral to the alar base and a central subunit,

m e
the philtrum. Two convex philtral crests (columns, ridges)

: / / t m
include the submental, submandibular jugulodigastric,
/ / / / t .
t . m
define the midline concave philtral bowl. The lower portion
/ /
s
and occipital lymph nodes (Fig 1 16). Drainage from these
s
of the latter is the beautiful downward-curving Cupid’s
 1 • Anatomy 13

A Surface Anatomy Collumella

s Philtrum
• Column
Soft triangle

• Groove Alar cartilage

Cupid’s bow • Lateral crus
White roll • Medial crus

//tt
Tubercle
Nasal bone

hh t
Cutaneous
Lateral ca tilage
upper lip
Septal angle

Alar cartilage
B Cross Section of Lip Histology • Lateral crus
Verm • Medial crus
il

o
io

Labial artery Fig. 1.18 Structures of the nose.

Orbicularis oris

//t.t. .t
osa

muscle
osa

/ t
/
separated from each other by the midline dorsum of the
:
muc
Muc

Epidermis
s s :
nose unit. The heart-shaped convex tip of the nose is the
p
Sub

Hair follicle
Subcutaneous
tissue
hhtt p
most prominent feature of t e nose and is bounded by
the paired alae nasi. The columella is the midline structure
below the tip separating the nostril apertures and culminat-
Sweat gland ing in the upper philtrum of the lip. The RSTLs of the upper
nose run obliquely out from the medial canthus down the
Salivary gland

e ss
r
Inner lip (skin) Outer lip (skin)

k e s
dorsum and lateral sidewall. They end part-way down, as
r s
there are no skin l nes on the lower nose. As noted earlier,
e
kFig. 1.17 Structures of the lip and cross section.
ook
they un transversely across the root.
The lower nose is supported by the paired, upper lateral

ee/ / e
bow. The philtrum is a reservoir of extra skin and interdigi-
m ee/
cartilages, which act as extensions of paired nasal bones
The paired, lower lateral, or alar cartilages begin as medial
m
/ t . m
tating orbicularis muscle that allows for the dramatic
/: t / t . m
crura that form the columella. As they swing back and
/ / t
t pps
stretching and vertical shortening of the upper lip when
s
smiling or opening the mouth wide. In many people, the
t t ss:
curve, they form an arch that is the tip of the nose. As the

hhtt
sharp cutaneous/vermi ion junction line has a superim-
posed white roll. This 1- to 2-mm, glabrous strip of skin is
due to an anterior bulging of the orbicularis oris muscle.
It can be quite prominent, especially in younger patients,
and is an important consideration in placing transverse
rrs
scar lines
p
lateral crura diverge obliquely pward and laterally away
t
hh
from the midline vertical nasa septum cartilage, they
support the ala nasi. It is important to recognize that the
ala nasi are composed of fibro-fatty muscular tissue and are
devoid of cartilage. Their ability to flare (and not collapse)
with each inspiration is due to the involuntary contraction

k eerrss of the levator labii superioris alaeque nasi and nasalis

muscl s If these latter muscles have been removed during
NOSE ook
o tumor extirpation, then a cartilage strut must be included

e ee
The nose is an extremely complex, aesthetically and func-
e
in the surgical repair or the nostril will collapse during
inspiration. /
e
: / / .
t m
. m
tionally important midline structure that is all too often the
t : / / / ..m
The upper portion of the nose is innervated by the
t
p ss: /
site of invasive skin cancers It is supported by a bony/
cartilaginous infrastructure that features the inflexible
t p t p /
infratrochlear (V1) of the trigeminal, whereas he anterior
ss
branch of the external ethmoid nerve (also V1) supplies the
p
t
hht t
paired nasal bones superiorly and the highly mobile paired
upper lateral/alar cartilage complex inferiorly (Fig. 1.18). t
hht t
tip. The lateral portions of the nose are innervated by the
infraorbital nerve (V2).
Conversely, the skin over the rigid bony upper portion is
highly movable (zone 1), while the skin over the mobile car- EYELIDS
tilage portion is thick, sebaceous, and bound down (zone 2).

e r
e s
On the surface the nose can be broken down into several
r s
cosmetic subunits. These include the root of the nose that
eerrs
The eyelid is perhaps the most complicated structure on
s
the face and of extreme functional importance. Successful
k
k
extends from medial canthus to medial canthus. The skin
lines in this concave unit run transversely across it. Obl t ook
repair of the unique structures that compose the eyelids
are contingent on thorough knowledge of the anatomy, as
/ e
/
eration of the concave nature of this area during repairs
ee e it is so closely related to function. The eyelids guard the
ee/
:///t/.tm m
causes the profile to be dramatically altered and the nose to globe and orbit and are structured on the orbicularis oculi
m
appear very large on the frontal view. The paired lateral
: / / t
muscle, whose orbital and palpebral components have been
/ / .
t m
s
sidewalls separate the nose from the cheek and are in turn
ss
discussed earlier in this chapter. As noted, the orbicularis is
14 1 • Anatomy

A Cross Sectional Anatomy

Whitnall’s check ligament

Fat pad of eyebrow
Orbital fat
Orbital septum Levator palpebrae superioris m.
Levator aponeurosis Superior rectus m.
Orbicularis oculi m

ttt
Superior tarsal plate Cornea
Lens

Inferior tarsal plate Inferior rectus m.

Capsulopalpebral fascia
Orbital septum Inferior oblique m.
Maxillary sinus

Orbital fat
Orbital septum
Gland of Krause
Muller’s m.
Orbicularis oculi m.
Gland of Wolfring

t p s
Levator aponeurosis
Conjunctiva
hh
• Pa pebral
• Bulbar

Superior palpebral fold Tarsal plate

Glands of Zeis Meibomian glands
Glands of Moll Ciliary muscle of Riolin
Mucocutaneous junction

B Surface Landmarks
s
ht tp
Lacrima g and

Superior punctum

Superior canaliculus
Fundus
Papilla Lacrimal sac
Inferior punctum
Inferior canaliculus Nasal cavity

Nasolacrimal duct

Inferior meatus
Inferior concha

Fig. 1.19 Structures of the eye and lachrimal apparatus.

k eerr k ee
responsible for closing the lid. The levator palpebrae superi-rrsthe orbital septum to form the superior palpebral fold about

ok e o ook
oris muscle and aponeurosis is responsible for opening the
eye (Fig. 1.19). It is innervated by the oculomotor or third
10 mm above the lid margin and then continues downward
to at ach to the anterior surface of the tarsal plate. It also

m e/ /
cranial nerve. It arises from the superior orbit and divides
e
into two components: Muller’s muscle, which attaches into
sends fibers through the pretarsal orbicularis to insert into

m
the lid skin. This is why the skin in the pretarsal area ise
: / / t .
t m
the superior margin of the tarsal plate under sympathetic
/ : / /
/ t
/ .
t
bound down, whereas it is loose and eventual y redundant m
pss ss
nerve control, and the levator aponeurosis which fuses with in the preseptal area above the superior palpebral fold. The
 1 • Anatomy 15

space between the orbital septum and the levator aponeu-

e r
e s
r s
rosis contains the orbital fat pads. The skin of the eyelids is
kerr
Triangular fossa

k
the thinnest and most elastic in the body. It contains little
subcutaneous fat. Cr ra of antihelix

ee/ e
The posterior portion of the eyelid closest to the globe
/ e
contains the tarsal plate that consists of dense fibrous Scapha

: / / t
/ .
t m m
tissue. This gives form to the lids and also contains the seba-
. Concha
/.
Crus of helix

p ss : /
ceous Meibomian glands. The conjunctiva covers the poste-
rior eyelids as well as the globe Hair follicles of the eyelashes
t p
• Cymba

t
hht t
(cilia), with both sebaceous glands (Zeis) and sweat glands
(Moll) exit onto the lid margin below the muscular layer,
• Cavum

Helix
Tragus

while the Meibomian glands exit onto the lid closer to the External acoustic
conjunctival surface. Antihelix meatus
The lacrimal system is important to eye homeostasis (see

r s s
Fig. 1.19) The lacrimal gland is situated in the postseptal
e e r
space lateral to the fat pads. The lacrimal collecting system
Antitragus

k
consists of the upper and lower lacrimal puncta at the
medial eyelid margins, which open into the lacrimal cana-
Lobule

e / e
/ e
liculi at the medial margin of the tarsi. The upper and ower
e
/ / t
/ tm
canaliculi converge under the medial canthal tendon as the
m
common canaliculus, to run horizontally into the nasolac-
:
Fig. 1.20 The ear.

ss /
rimal duct on the side of the nose opposite the medial
t p
t
hht t
canthus, and drains as the nasolacrimal canal into the nose
beneath the inferior turbina e.
superior portion of the external auditory canal is supplied
by branches of the auriculotemporal branch of the man-
EAR
dibular division (V3) of the trigeminal nerve. The lower

rss s
The ear appendage is essentially skin stretched over a rather posterior surface as well as the lower anterior helical

e e rr s
intrica ely molded cartilage infrastructure. It is important
e k e portion, is innervated by the great auricular nerve (C2, C3),

k b ook
to the dermatologic surgical, as it has a high risk for both
basal cell (BCC) and squamous cell carcinomas (SCC). Inva-
wh le he upper posterior portion and the upper vertical
por ion of the anterior helical area are supplied by the lesser

ee/ ee
sive SCC tumors of the helical rim tend to reach the arger
lymphatic and venular vessels of perichondrium at a shal-
occipital nerve (C2, C3). Variable contributions of the
cranial nerves IX and X supply the remaining portions of ee/
/ / t m
m
lower depth than elsewhere on the body, making metastases
/ t
the external auditory canal. Understanding this innerva-
/ tm. m
t pps
from this area a real threat.
: /
The outer rim of the ear is the convex helix that extends :
tion pattern is required for regional nerve block of the ear.

t
hh t
upward from the lobule o curve around, and ending as the
crus of the helix that divides the concha bowl into the upper
References
1. Salasche SJ. Anatomy. In: Rohrer TE, Cook JL, Nguyen TH, et al, eds.
cymba and the lower cavum (Fig. 1.20). Opposite the cavum Flaps and Grafts in Dermatologic Surgery. Philadelphia: Elsevier; 2007:
and guarding the external auditory meatus is the small 1-14.
protuberance, the tragus. Also superior to the lobule is the 2. Kim Y, Choi D, Gil Y-C, Hu KS, Tansatit T, Kim HJ. The anatomic origin

rss
e k eerss
convex antihelix. This structure parallels the helix in its
e
vertical dimension and is separated from it by the depres-
and course of the angular artery regarding its clinical implications.
Dermatol Surg 2014;40(10):1070-1076.

k b oo k
sion between them, the scapha. The antihelix splits at its
3. Alghoul M, Codner M. Retaining ligaments of the face: review of
anatomy and clinical implications. Aesthet Surg J. 2013;33(6):769-782.

/
ee e
superior end into two crura to form a central concavity,
/ e
the triangular fossa. Only the lobule is not supported by
4 Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and

e /
clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;
119(7):2219-2227.
cartilage.

: // .
The sensory innervation of the ear is complicated. The / t
/ t . m
5. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A Blind-

s
ps
anterior surface closest to the cheek as well as the anterior-
tps
ness caused by cosmetic filler injection: a review of cause and therapy.
Plast Reconstr Surg. 2014;134(6):1197-120
 2 Basic Principles
oo kkeer
inrss
Flap
e
e e b
Reconstruction
b
: //t.t
ASHLEY WYSONG, MD, MS, and SHAUNA HIGGINS, MD

The reconstruction of wounds has long been a challenge to dermatologic surgery is the Keystone flap, which relies on
surgeons. Whereas some wounds may be left to heal by musculocutaneous and fasciocutaneous vascular perfora-

k eerrss
second intention or closed in a simple side-to-side linear
fashion others require more complex movement of local or
k eer ss
tors taken together with venous and neural connections
within the flap s base, which may increase the perfusion,

ok
distant tissue to restore functional and anatomic relation-
ships, and to optimize the cosmetic outcome.
e oook
and thus the reliability, of any flap.
The most common flaps used in dermatologic surgery,

m ee/ /
Surgeons have used skin flaps to repair wound defects for
centuries. The term “flap” was derived from the Dutch word e
composed of primarily of subcutaneous tissue and skin

m
(and sometimes superficial muscular fascia), are axia and

: / /
/ t
/ .
t m
“flappe” during the 16th century “Flappe” referred to
/ / t
/ t m
random perfusion flaps. Axial flaps (also called arterial
: /
s
tps
something that was fastened by one side and hung broad
s
tps
flaps) have a relatively large-diameter, named artery present

hhttp
and loose. As early as 700 BCE the Sushruta Samhita first
documented a technique of reconstructing a large nasal tip
defect with a cheek flap.1 Since that time, surgeons’ knowl-
edge of biology, anatomy, and physiology has greatly
increased. This understanding allows us to significantly
hhtttp
within the pedicle of the flap, which directly provides nutri-
ents to the full extent of the flap. This named artery typi-
cally lies in the subcutaneous layer superficial to the muscle
fascia. On the face, the most commonly used axial flap is the
paramedian forehead flap, which depends on the supra-

k e rrs
decrease the likelihood of surgical complications such as
s
hemorrhage, hematoma, infection, and flap failure. This
e e rrs
ok
chapter addresses some basic principles of flap reconstruc-
tion including flap design, construction, classification and
practical tips.
trochlear artery (and occasionally branches of the supraor-
s
bital artery) for survival. A random flap, the most commonly
k e
ooook
used flap design in reconstructive dermatologic surgery,
depends on the small, unnamed perfusion plexus of highly
anastomotic vessels in the dermis to provide nutrients to the

m me
flap. Because the arterial input of random pattern flaps is

s //t/t.
much less predictable, attention to proper flap design and
Basic Terminology delicate surgical technique is required to ensure surgical

hhtttp
A skin flap is a construct typically consisting of skin and
subcutaneous tissue with a partially intact vascular supply
that is transferred or repositioned from an adjacent or more
distant donor site to a recipient site. The recipient site is
called the primary defect and, in dermatologic surgery, is
success.
hht t
Blood flow is the most crucial factor for flap viability. Vas-
cular perfusion pressure is a description of the force of
blood flow through a vessel. Perfusion pressure and blood
flow in the body’s vessels are analogous to water flowing
from a faucet through a garden hose. The greatest pressure

kkeerrss rrss
usually the wound resulting from the removal of a cutane- and highest flow wi l be at the faucet head. As water travels

k ee
ous tumor (Fig. 2.1). The secondary defect is defined as
ook
farther away from the faucet, its pressure and flow decrease

/ e o
the wound that is created by cutting, lifting, or sliding the
o
flap to fill the primary defect (see Fig. 2.1). The base of the
in strength. To maintain sufficient flow to the distal tip of
the hose, the perfusion pressure within the hose must

. m e /
flap is the area that remains attached to the skin adjacen
m e
to the defect. It is this base, also known as the pedicle of the
. m
m e
exceed the resistance of the hose. Similarly, in the human
body, the perfusion pressure of any vessel that supplies

: / t
//t.
flap, that contains the vascular supply necessary for initial
s : s : / t
///t.
blood and nutrients to the skin must exceed he capillary
:
t
hh t p
furthest from the flap’s base s
flap survival. The tip of the flap is the portion of the flap
t hhttpt s
resistance in order to maintain vessel patency and preserve
p
continued blood flow. A critical pressure is required to
maintain patency of capillaries. Below this certain pressure,
the capillaries will close, and insufficient blood will be sup-
Flaps Defined by Blood Supply plied to the distal portions of the flap. The greater the dis-
tance from the feeding artery or arteriole, the lower the

eer s
There are many classification schemata for reconstructive
s
flaps One common method of defining flaps is to determine
k eer s
perfusion pressure will be (Fig. 2.2). Thus beyond a certain
s
distance, the flap tip will no longer receive blood nutrients,
k
ok
the flap’s perfusion sources. Flaps may be categorized based
on vascular supply as musculocutaneous, fasciocutaneous
e o ok
and it will thus necrose.2,3
An understanding of perfusion pressures has dictated

m e/ /
axial, or random. A musculocutaneous flap includes muscle
e
tissue in the base of the flap, whereas a fasciocutaneous flap
that flaps be designed with appropriate flap length to pedicle

m
width ratio. Until 1970, it was widely believed that thee
//t/t m
includes only the fascial covering of the muscle in the
: / / t .
t m
viable length of a flap was directly proportiona to the width
/ /
s
pedicle. An example of a musculocutaneous flap used in
16
ss
of the base. Surgeons believed that in order to double the
 2 • Basic Principles in Flap Reconstruction 16.e1

e s
ABSTRACT
r
KEYWORDS

ke
Reconstruction of the skin is challenging and rewarding to
oo
the dermatologic surgeon. When second intention or side
b o
flap
axial pattern flap

ee/ e
to-side linear closure is not possible, more complex move-
/ e
ment of local or distant skin in the form of cutaneous flaps
random pattern flap
advancement flap

: / / t
/ .tm m
is necessary to repair a surgical defect The basic terminol-
.
ogy, physiology, and types of local flaps will be discussed in
rotation flap
transposition flap
this chapter. s interpolation flap
 2 • Basic Principles in Flap Reconstruction 17

length of the flap, one would simply need to double the

rrss
width of the flap base, thereby including a sufficient number
k ee
oo k
of vessels in the pedicle to sustain the flap tip. Many felt that
there was no ultimate limit to flap length. In 1970 Milton
disputed this conventional hypothesis by publishing his

e/e
Secondary research on axial flaps in the pig model. He discovered tha /
e
tm
.m
lobe “flaps made under the same conditions of blood supply

p ss: /:/
survive to the same length regardless of wid h.”8 Daniel and
Williams confirmed Milton’s research on axial flaps and

hhttttp
Primary Future site
lobe of further studied survival of random pattern flaps. Although
secondary they concluded that “an increase in width did not result in
defect an increased length of survival,”4 their data showed a trend
Primary toward wider pedicles allowing greater flap length survival.
defect Base of Studies by Stell in a pig model and confirmed when extrapo-
flap

k eerrss
lated to humans suggested that viable flap length was
not di ectly proportional to pedicle width, and that beyond

ook
a certain pedicle width, greater recruitment of random
vessels cannot support the flap tip (see Fig. 2.2).3 Clinical

m //
e
Fig. 2.1 The wound resulting from the extirpation of the umor is the vival trend. e /
experience with random flap survival has echoed this sur-

: /
/ t
/ .t.m
primary defect. The secondary defect is defined as he wound created

/
by cutting, lifting, and sliding the flap to fill the primary defect. Here,
: / t .t m
Overall, perfusion pressure limits the ult mate length of
/
ss ss
both axial and random flaps. The greater the perfusion pres-

ht p p
the secondary defect will be filled by he second lobe of the flap. The

t
base of the flap is that area that emains attached to the contiguous
skin adjacent to the defec t t t p
sure in the flap’s pedicle, the longe the flap can be without
hht
undergoing necrosis. Moreover, the greater the perfusion
pressure at the flap’s base, the more narrow the pedicle may
be. Arteries always have greater perfusion pressures than
distal arterioles and capillaries. Accordingly, the longest

e rrs
viable flaps with the narrowest bases (largest length-to-base
s
ratios) are arterial flaps. Therefore a paramedian forehead
k e
oook
flap that uses the supratrochlear artery may be at least four
times as long as the flap’s pedicle width (at least a 4 : 1 ratio;

e/
Fig. 2.3). Musculocutaneous flaps have the next greatest
e
blood supply in the pedicle, followed by fasciocutaneous and
m
random flaps in descending order.

s /
/ t .
The commonly used random pattern flaps are largely

t
hh p
t p s
supported by the redundant subdermal vascular plexus
in the skin. Fig. 2.4 highlights he innate vasculature of
A the skin, upon which flap survival depends. The deeper,
muscular-based arteries supply the subdermal plexus,
which subsequently perfuses the intradermal plexus. The
intradermal vasculature alone is usually unable to support

k errss
tissue viability, ue to low perfusion pressures and blood
e
flow within these distal capillaries.2,6,7 However, the subder-
High Flap survival Flap necrosis
oook
mal plexus, found in the mid to superficial subcutaneous
fat, contains both arterioles and capillaries with sufficient
/
Capillary perfusion

. m me
perfusion pressure to sustain tissue viability following flap
e
movement. This anatomy is critical to understand when
t
mmHg
pressure

: / /
/ / t .
undermining (dissecting under the flap and its surrounding
ss
t
hhtt p
area to allow tissue movement) a cutaneous flap. If under-
p
mining is performed superficial to the subdermal plexus
(i.e., within the dermis), the flap has a significantly increased
Critical closing pressure
chance of undergoing tissue ischemia.
Low The perfusion pressures of random cutaneous flaps vary
Proximal Distal with the flaps’ locations on the body.3,4,6,8–13 As soon as a
B

k e r
e ss random pattern flap is incised and raised, there is a signifi-
cant decrease in the perfusion pressure to the distal, dis-

b o k
Fig. 2.2 Flap perfusion pressures necessary for flap survival. The graph
rup ed skin.14,15 Fortunately at normal skin temperature,
the amount of blood flowing through the facial skin is 10

e / e
shows how perfusion pressure decreases the greater the distance that

/
the blood must flow from the feeding artery or arteriole (A and B) Show
e
times greater than that needed to supply the skin’s basic
ee/
m
that despite greater recruitment of random arterioles there is a point

t m ///t/tm
metabolic needs.16–19 Other areas of the body are not as well
m
s/ t
where perfusion pressure is less than the capillary resistance. At this supplied with this redundancy of blood supply A general
point of no flow, the flap will necrose.
s
rule is that the more distant the surgical flap is located from
Another random document with
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irtautui suloinen mielikuva sydämestäni, joka sitä jonkun aikaa oli
hellinyt ja vaalinut. Tahtoni ei voinut sille mitään. Ja minusta tuntui,
että eilisillasta oli kulunut lukemattomia päiviä, että Maurice,
rakkautemme, kihlajaisemme, kaikki oli jo kaukana minusta,
menneisyyden verhon takana, josta se, mikä kerran on ollut rakasta
todellisuutta, häämöittää himmeänä ja värittömänä kuin uni.

Sydämeni tykki ankarasti, kun Maurice astui eteeni. Hänen

ylpeytensä oli saanut kolauksen, mahdollisesti tunsi hän kenties
hiukan omantunnon vaivoja, mikä seikka teki hänet vieläkin
kärtyisämmäksi. Kuitenkin ojensi hän minulle kätensä.

— Arvaatte kai, minkätähden olen tullut näin aikaiseen aamulla?

Olen hyvin levottomassa ja kiusallisessa mielentilassa ja odotan
teiltä selityksiä.

— Minkä johdosta? Minun käytökseni oli aivan johdonmukainen ja

luonnollinen. Samaa en voi sanoa teidän käytöksestänne.

— Tuo on taas sitä naisten tavallista kiemurtelua, sanoi hän

rypistäen kulmakarvojaan. Tehän väännätte koko asian.

— Todellakin? Haluaisinpa tietää, mitenkä te sen esitätte.

Clairmont oli istuutunut. Hän nojasi kyynärpäätään pöytään ja

koputteli hermostuneesti jalkaterällään lattiaan.

— Te pidätte minua pilkkananne, Hellé. Eilen te teitte

varomattomuuden, jolla voi olla ikäviä seurauksia. Hankitte minulle
vihamiehen… ja sitten loukkasitte minua julmasti.

— Minäkö loukkasin teitä?

 — Älkää tekeytykö viattomaksi. Tiedätte mitä tarkoitan.

— Selittäkää sananne.

— Hitto vieköön, rakas ystävä, te olette tahtonut kuuluttaa julki

jalomielisiä tunteitanne, joita maailma ei käsitä sillä tavoin kuin te
näytte luulevan. Te olette rikkonut tahdikkaisuutta vastaan. Rebussat
on syvästi loukkaantunut. Hän ei tule antamaan sitä anteeksi.

— Tarvitsetteko siis häntä niin suuresti?… Niin, todellakin, teidän

kunniamerkkinne näyttää teistä olevan vaarassa, tuo kallisarvoinen
kunniamerkki, jonka loiste sokaisi teidät eilen niin, että olitte kuuro ja
mykkä kaikelle muulle.

— Te laskette leikkiä kanssani. Hetki on huonosti valittu.

— No hyvä, sanoin minä suuttuneena hänen kiertelyistään,

vastaan teille siis suorasti, olkoon että se tuntuisi teistä raa'altakin;
tämä keskustelu on paljon vakavampi kuin mitä luulettekaan ja
meidän on tällä hetkellä puhuttava aivan avoimesti. Te syytätte
minua tahdikkaisuuden puutteesta ja minä syytän teitä kunnian ja
rehellisyyden puutteesta. Minä olen ollut varomaton, myönnettäköön.
Te olette ollut heikko ja raukkamainen.

— Minä olen menetellyt niinkuin jokainen hyvin kasvatettu mies

olisi menetellyt tällaisessa tapauksessa. Minä vaikenin, niinkuin
tulikin tehdä.

— On tapauksia, jolloin vaikeneminen on halpamaisuutta.

— Hellé!
 — Vaikenemalla teitte itsenne myötärikolliseksi panetteluun. Tekö
menettelitte niinkuin hyvinkasvatetun miehen tulee? Olisin
mieluummin nähnyt, että olisitte menetellyt niinkuin mies, vaikkakin
se olisi sotinut sovinnaisuutta, varovaisuutta ja etujanne vastaan.

— Minä tein niinkuin minua halutti tehdä. Ja jos en puolustanut

Genesvrier'ta, tapahtui se siksi, että minulla oli painavia syitä vaieta.

— Haluaisinpa tietää nuo syyt.

— Älkää toivoko, että sanoisin teille ne kaikki.

— En pelkää totuutta.

— Siinä teette väärin.

— Puhutteko? sanoin vihdoin hetken vaitiolon jälkeen.

Kumealla äänellä hän vastasi:

— Sitä pahempi! Itse olette niin tahtonut.

— No siis?

— No niin! Rakas ystävänne Antoine Genesvrier ei ole se synnitön

sankari, jona te häntä ihailette ja jumaloitte. Hänestä on liikkeellä
kaikenlaisia huhuja… Hän on, piru vie, ovela, hyvin ovela, hyvin
taitava, mutta ei kuitenkaan tarpeeksi salatakseen maailmalta
kepposensa.

— Mitä tarkoitatte?

Hän hymyili ilkeän ivallisesti.

 — Säälin teidän kaunista harhakuvaanne, Hellé. Te luulette
itseänne hyvin viisaaksi, ja kuitenkin olette ihmeteltävän lapsellinen.
Mutta tietäessäni sen mitä tiesin, vaikenin armeliaisuudesta ja
hienotunteisuudesta, nähdessäni teidän jumaloivan ihailunne
kuvittelemaanne suurmiestä kohtaan.

— Minä välitän vähät teidän hienotuntoisuudestanne ja

armeliaisuudestanne. Te olette sanonut joko liian paljon tai liian
vähän, Maurice. Puhukaa suunne puhtaaksi!

— Tietäkää siis, että pidän vähän liiallisena ystävyyttänne miestä

kohtaan, joka on kylmäverisesti pitänyt teitä leikkikalunaan… Oh,
olen kuullut hänestä kerrottavan paljon asioita näinä viime päivinä!…
Olette luullut hänen ihailevan teidän suurta älyänne ja kenties, koska
ylpeyttänne hiveli se tietoisuus, että te yksin kaikista naisista olitte
voinut valloittaa tuon voittamattoman sankarin, kenties tuotti teille
iloa ajatus, että hän todella rakasti teitä… Hellé raukka! Elämä
täydentää teidän kasvatustanne teidän omalla kustannuksellanne.

— Mitä tiedätte? Puhukaa!

— Tulette katumaan itsepintaista tiedonhaluanne. Olisin halunnut

odottaa ja paljastaa teille totuuden myöhemmin.

— Puhukaa, minä vaadin sitä!

— Teidän on täytynyt olla hyvin… kokematon, (joka on anteeksi

annettava, jopa kunnioitettavakin ominaisuus teidän ijällänne)
voidaksenne olla huomaamatta, että yritettiin päästä käsiksi teidän
rahoihinne. Oli turvattava nuo filantropiset yritykset ja Tulevaisuuden
yhteiskunta. Mutta tämä ei olisi vielä mitään. Antoine Genesvrier on
osoittanut julkeaa kunnioituksen puutetta teitä kohtaan tuodessaan
luoksenne tuon Marie Lamiraultin, rakastajattarensa, ja lapsen, jota
hän ei ole uskaltanut tunnustaa omakseen.

Silmiäni hämärsi. Tunsin hermojeni pingoittuvan ja veren

jähmettyvän suonissani; mutta vastustamattomasti järkeni,
sydämeni, vaistoni nousivat kapinaan:

— Se on mahdotonta.

— Te olette ainoa, joka ette tiedä tästä suhteesta. Marie Lamirault

jakoi suosionsa Genesvrier'n ja Louis Florentin kesken. Niin minulle
on kerrottu ja minä uskon sen. Mitä lapseen tulee…

— Antoine ei ole voinut minua niin halpamaisesti pettää. Minä en

tahdo epäillä häntä sellaisesta.

— Ottakaa asiasta selko ja näette, että olen puhunut totta.

Hän puhui niin varmalla, niin voitonriemuisella äänellä, että

voimani minut hetkeksi petti. Clairmont näki minun olevan
mielenliikutuksesta kuolon kalpean; saatoin tuskin hengittää, olin
itkuun purskahtamaisillani. Hän ei enää voinut hillitä vihaansa:

— Se järkyttää teitä siis niin kovin! sanoi hän tarttuen ranteisiini…

Ah, siis oli epäilykseni oikea! Te rakastitte häntä, rakastatte häntä
vielä!

— Minä?

— Niin, te rakastatte häntä. Millainen nainen te siis olettekaan?

Te rakastatte häntä, tuota arvon herraa, tuota maanmainiota
laupeudenharjoittajaa, tuota kirjailijaneroa, tuota marttyyria!…
Miksi ette sitten mennyt naimisiin hänen kanssaan, Hellé!
 Minä työnsin hänet luotani suuttuneena:

— En usko teitä, en tahdo uskoa teitä. Teidän menettelynne on

katalaa.
Menkää!

Hän kertasi:

— Heti ensimmäisenä päivänä olisi minun pitänyt huomata se.

Tehän aivan ahmitte hänen sanojaan…

Minä sopersin:

— Teillä ei ole todistuksia… te kerrotte häpeällisiä panetteluja. Se

on halpamaista, halpamaista.

Hulluna mustasukkaisuudesta ja raivosta hän huusi:

— Kaikki teille kelpaavatkin! Minun pitäisi hävetä — ellen sille

nauraisi — että minun pitää väistyä sellaisen kilpailijan tieltä… Hän
voisi olla vähän kauniimpi ja nuorempi edes!… No, nyt ainakin
tiedätte, mikä hän on miehiään ja että hänellä ei ole rakkaudessa
mitään ehdottomuuden vaatimuksia: eri asia on, jos te katsotte
voivanne jakaa hänen rakkauttaan tuollaisen… kanssa…

— Vaiti! Ei sanaakaan enää! En ole enää teidän morsiamenne,

olen nainen, jota loukkaatte. Lähtekää!

— Varokaa! Jos lähden, en palaa enää.

— Ulos!

Hän lähti paiskaten eteisen oven pauhinalla kiinni. Kuulin hänen

askeleensa etääntyvän puutarhan hiekkakäytävällä. Mutta sensijaan,
että olisin huutanut takaisin häntä, joka meni pois vieden mukanaan
ensimmäisen unelmani sirpaleet, oli mielessäni vain yksi ainoa
ajatus, joka purkautui nyyhkytykseen:

— Antoine ei ole voinut minua niin pettää… Se ei ole totta, se ei

ole mahdollista.
XXVIII.

Haavoittuneena ja värisevänä saavuin Châtaigneraie'n

vieraanvaraisten suojien turviin. Taloissa, joissa esi-isämme ovat
eläneet, joissa me itse olemme lapsuutemme unelmoineet, on
jotakin selittämättömän äidillistä. Jos sinne palaamme suru
vaatteissa etsimään lohtua, tunnemme meitä ympäröivien esineiden
salaperäisen myötätunnon ja orpous painaa meitä vähemmän.

Maurice oli minulle kirjoittanut muutamia päiviä ennen lähtöäni.

Ollen itse kykenemätön tuntemaan syviä tunteita, ei hän voinut
käsittää, että muillakaan voisi olla sellaisia. Kaikki näytti hänestä
voivan tulla hyväksi jälleen, hän oli epätoivoissaan minun
suuttumuksestani, jota hän ei vielä ollut saanut pois mielestään.
Mutta minä tiesin, että tämä kevyt sielu parantuisi pian ja nopeasti:
Maurice ei voinut rakastaa eikä kärsiä muualla kuin kirjoissaan, ja
rakkaus ja tuska olivat hänelle ainoastaan taiteellista huumaustilaa.
Hänen kirjeensä osoittivat oikeaksi tämän minun arveluni.
Selittämättä mitään, ottamatta takaisin sanojaan ja voimatta
ymmärtää, että olin syystä suuttunut hänen käytökseensä, hän pyysi
että unohtaisin kaikki: hän kohteli minua kuin pahantuulista lasta,
jonka pienellä hyväilyllä saattaisi jälleen lepyttää. Suuttumukseni oli
haihtunut, mutta rakkauteni oli auttamattomasti kuollut.
 Koetin selittää kaikkea tätä Mauricelle. Kirjoitin hänelle, että
annoin anteeksi hänen tulistumisensa, että en kantanut siitä mitään
kaunaa, mutta että olin liian selvästi huomannut luonteittemme
erilaisuuden. Rouva Marboy tahtoi silloin ruveta välittäjäksi.
Mauricen uskottuna hän vakuutti minulle, että me olimme luodut
toisillemme, että minun pitäisi olla kärsivällinen. »Sitten kun olette
naimisissa, kirjoitti hän, pitää rakkaus kyllä kaikesta huolen.»

Arvasin hänen ajatuksensa ja täydensin mielessäni hänen

todisteluaan: hän uskoi rakkauden kaikkivaltaan, joka saa kahden
nuoren vastanaineen kuvittelemaan olevansa täysin onnellisia. Mutta
en ollut tietämätön siitä, että kuherruskuukauden lyhyen hurmauksen
jälkeen aviopuolisot muuttuvat jälleen mieheksi ja naiseksi, jotka
ovat erilaisia luonteeltaan, ajatuksiltaan ja mielihaluiltaan. Kaukana
siitä, että he olisivat saavuttaneet sopusoinnun, he silloin vasta
alkoivat luoda sitä, päivä päivältä, epävarmoina siitä, voisivatko he
koskaan päästä siihen. Jos jotkut siinä onnistuivatkin, oli tehtävä
mahdoton useimmille heistä ja silloin oli edessä joko
molemminpuolinen välinpitämättömyys tai aviollisten riitojen
sietämätön helvetti. Mutta minä tiesin, mitkä puolet sielussani jäisivät
Mauricelle ainaiseksi arvoitukseksi; minä tiesin, mitä itse en voinut
hyväksyä hänessä, mitkä riidan aiheet salaa tulisivat ikuisesti
uhkaamaan sopuamme, ellei jompikumpi meistä, viekkaampi tai
voimakkaampi, voittaisi toista ja alistaisi häntä orjakseen. Minua
inhotti tuollainen harkittu yliote, joka olisi tehnyt Mauricesta
tahdottoman leikkikaluni, ja toiselta puolelta minä en olisi voinut
alistua miehen valtaan, joka ei ollut minua korkeammalla.

Kirjoitin rouva Marboylle; avasin hänelle sydämeni. Suureksi

hämmästyksekseni hän väitti minun olevan joka suhteessa
väärässä, syyttäen minua ylpeydestä, välinpitämättömyydestä,
kuivakiskoisesta järkeilemisestä. Totesin surulla, että me emme
puhuneet samaa kieltä, että sanat rakkaus ja avioliitto eivät
merkinneet meille samaa. Hänessä huomasi tuon vanhanaikaisen
kasvatuksen vaikutuksen, joka saa naisen kunnioittamaan miestä,
sentähden että tämä on mies, ja ottamaan vastaan samasta kädestä
hyväilyn ja kurituksen. Sitä, mitä minä nimitin ihmisarvoksi,
oikeutetuksi personallisuuden tunteeksi, nimitti hän ylpeydeksi. Sitä,
mitä minä nimitin todelliseksi sopusoinnuksi, nimitti hän tyhjäksi
haaveeksi ja naurettavaksi houreeksi. Minä arvostelin Mauricea
ilman pahansuopaisuutta, mutta en asettanut häntä korkeammalle
kuin mitä hän ansaitsi. Hän ei kuulunut minun rotuuni. Minä en voinut
häntä rakastaa.

Kun rouva Marboy huomasi, että meidän välimme oli

auttamattomasti rikkoontunut, luopui hän välitysyrityksistään, mutta
hän ei voinut salata tyytymättömyyttään. Minä olin itsekäs,
pingoittunut. En ollut enää hänen sydämensä tytär.

Silloin lähdin Châtaigneraie'hen. Kun juna jyristen lähti liikkeelle,

tunsin olevani äärettömän yksin, kaikki perhe- ja ystävyyssiteet olivat
katkenneet. Muistelin Genesvrier'ta… Valitettavasti Mauricen
vihjaukset vastoin tahtoanikin kiusasivat minua ja lamauttivat tahtoni.
En tahtonut nähdä Antoinea enkä kirjoittaa hänelle, ennenkuin olin
saavuttanut rauhan ja tasapainon.

Pitkien päivien kuluessa minä koetin keinotekoisesti tuudittaa

itseni lepoon melkein luostarimaisella elämällä. Setäni oli jättänyt
muutamia kirjoja erääseen kirstuun, joka onneksi oli säilynyt rotilta.
Siinä oli halpahintaisia painoksia ranskalaisista ja latinalaisista
klassikoista, samoja, joita opiskeluaikanani olin lukenut, öisin,
talvisen tuulen huokaillessa ulkona koetin elvyttää itsessäni
nuoruuden aikaisia tunnelmia. Mutta pian kuitenkin huomasin
ponnistelujeni teennäisyyden. Tahtoni höltyi. Vajosin unelmiin.

Talvi, joka näillä seuduin oli leuto, läheni loppuaan. Istuin eräässä
huoneessa ensimmäisessä kerroksessa vaalenneilla
musliiniuutimilla verhotun ikkunan ääressä ja katselin, miten
taivaanranta peittyi sateen harsoon tai sumuun. Puutarhassa ei ollut
kukkia ja ainoastaan puksipuut, muratit ja punakuusamat säilyttivät
vielä tumman vehreytensä, surullisina ja vakavina kuin haudat, joita
ne koristavat. Väliin kun sade lakkasi, saatoin istua tuntikausia
liikkumatta, puhumatta, tuijottaen taivaan vaihtelevain valaistusten
värittämiin maisemiin. Edessäni ei ollut enää kesän loistavaa
väriasteikkoa: vivahdukset olivat hienompia, käsittäen kaikki
harmaan, sinipunaisen, sinisen herkät yhtymät, jotka sulivat utuisen
ilman vienoon valohämytaustaan. Tämän laajan näyttämön etualalla
muodostivat viljellyt vainiot eloisia, likaisen ruskeita, raikkaan ja
kostean vihreitä väritäpliä. Mutta kauneinta maisemassa oli taivas,
— sininen, ikäänkuin maitoon kastettu taivas, jossa utuhaituvat uivat
valkeina ja pehmeinä kuin joutsenet, — harmaa taivas, joka vaihteli,
lyijynharmaasta helmenharmaaseen ja sinipunervan harmaasta
hopean harmaaseen, — noiden hallavien, raskaiden sumupilvien
täyttämä taivas, jotka tuulen kiidättäminä lentävät yhdessä
muuttolintujen kanssa, läikehtivä taivas, levoton kuin ihmiselämä.

Ensimmäinen lumikello aukaisi vihdoin metsänreunassa

vihertävän valkean kukkakupunsa. Kävin kurkistelemassa tuon
kuivuneiden oksien ja mädäntyneiden lehtien lomista pilkistelevän
lapsekkaan kukan eloonheräämistä, jota setä Sylvain oli opettanut
minua rakastamaan. Aurinko oli vielä kovin kalpea, mutta kuitenkin jo
oikea aurinko, eikä enää tuo talvinen tähti, joka peittää kolkot
kasvonsa sumuharsoon. Metsänhakkaajien nuotioiden savu kohosi
pystysuoraan kirkkaalle taivaalle. Ei tuulen henkäystäkään tuntunut.
Ilmassa oli kevättä.

Olin istuutunut kuivan ruohon peittämälle mäen rinteelle, kylvetyn

pellon reunaan, jossa keikkui raakkuvia korppeja. Hengitin keveästi,
voimakkaasti, säännöllisin ja pitkin siemauksin, niin että se tuotti
minulle nautintoa, joka aivan teki kipeää. Olisin tahtonut levittää
käsivarteni, sulkea luonnon, koko maan ja taivaan äärettömään
syleilyyn. Olin pakahtua selittämättömästä kaihosta ja ikävästä ja
äkkiä huomasin itkeväni.

Mutta nämä silmistäni vierivät kaihon kyyneleet eivät tarkoittaneet

Mauricea, jonka olin kadottanut, ehdoin tahdoin kadottanut. Tiesin
liiankin hyvin, että en ollut todella rakastanut; olin rakastanut
kangastusta, loistavampaa ja vaikeammin tavoitettavaa kuin ovat
valon ihmeellisen heijastukset autereisessa usvassa. Tunsin, että
rakkaus todellisuudessa oli jotakin valtavaa ja hirvittävää. Voi, se oli
mennyt läheltä ohitseni, tuo suuri rakkaus! Nuoruuteni oli pelännyt
sen rajua voimaa, mutta en ollut päästänyt sen kaukaista kuvajaista
silmistäni. Nyt se saapui luokseni voittajana. Se kolkutti sydämeni
ovelle.

Harhailin koko päivän siellä täällä: illalla huoneeseeni palattuani

avasin Köyhät, jonka olin tuonut maalle aukileikkaamattomana. Yön
hetket kuluivat, öljy loppui lampustani; sytytin kynttilän. Kalvas
valonsäde pilkoitti ikkunaluukkujen raosta. Suljin kirjan. Oli jo suuri
päivä.

Clairmont oli valehdellut tai sitten taitavasti kertonut toisten

valheita. Nyt olin kerta kaikkiaan päässyt tuosta epävarmuudesta,
epäilystä, mustasukkaisesta surusta, joka oli minua vaivannut
viikkokausia ja jota en ollut uskaltanut edes itselleni tunnustaa. Olin
Antoinen teosta lukiessani tiedustellut totuutta hänen suurelta
sielultaan. Se oli minulle antanut vastauksen. Ah, kuinka tutulta ja
läheiseltä se minusta tuntui, lukiessani tuon kirjan yleviä sivuja, jotka
olivat täynnä hänen palavaa uskoaan, hänen värisevää
kärsimystään, hänen hellää sääliään! Se kutsui minun sieluani, se
viittasi kohti huikaisevia korkeuksia, missä ihmisrakkaus kohoaa
yläpuolelle itsekkyyden ja aistillisuuden, missä se laajenee, kirkastuu
ja yhtyy iankaikkisuuteen.
XXIX.

Kun tulin raatihuoneen ovelle, näin siinä ilmoituksen, johon suurin

kirjaimin oli painettu seuraavat sanat: Helppotajuisia
esitelmätilaisuuksia. Aina siitä asti kun olin tullut takaisin Parisiin, —
kolme päivää sitten — olin tuuminut tehdä kenenkään tietämättä
tällaisen seikkailuretken etäiseen esikaupunkiin, jossa en tuntenut
ketään ihmistä. Ristiriitaiset tunteeni olivat estäneet minua
menemästä Antoinen luo tai kirjoittamasta hänelle, ja minä paloin
halusta saada nähdä häntä.

Olin puettu tummaan pukuun, päällysnuttuun, joka peitti vartaloni,

ja harsoon, joka kätki kasvonpiirteeni, ja olin varmaankin jonkun
köyhän opettajattaren näköinen, joka oli tullut etsimään itselleen
hyödyllistä ja maksutonta hupia. Ihmisiä meni sisälle pilarikäytävästä
ja minä seurasin heitä umpimähkään.

Pian olin suuressa, alastomassa salissa, joka muistutti koulusalia

olkituoleineen ja penkkiriveineen. Salin perällä oli pienellä
korokkeella Tasavallan hengettären kipsinen rintakuva. Tällä
korokkeella oli vielä piano, kaksi nuottitelinettä ja viheriäisellä veralla
päällystetty pöytä. Tuoleilla istui puoli tusinaa nuoria miehiä ja naisia,
ja minä ymmärsin, että he olivat tilapäisiä esiintyjiä, jotka olivat
lupautuneet tulemaan opettamaan ja huvittamaan köyhiä ja
tietämättömiä kuulijoita. Eräällä naisella, joka oli sangen nuori, oli
kukoistavat, ruskeiden hiusten kehystämät kasvot. Toisella, joka oli
pikemminkin vanha, melkein ruma, oli hyväntahtoinen hymyily.
Heidän miestovereihinsa olivat kirjalliset toimet ja opettaja-ammatti
painaneet erikoisleimansa. Heillä oli väsyneet kasvonpiirteet,
likinäköiset silmät, yllään kuluneet lievetakit ja mustat kaulaliinat,
heidän eleensä olivat puhuvia ja havainnollisia.

Vähitellen sali täyttyi. Se oli samaa yleisöä, josta Genesvrier oli

opettanut minua tuntemaan muutamia tyyppejä, tuota kirjavaa,
värikästä yleisöä, jota ei näe muualla kuin Parisissa. Siinä näkyi
virkailijoita perheineen, vanhoja, siistejä, nukkavieruja, valkopartaisia
herroja, kirjailijoita, taiteilijoita ja nuoria työmiehiä, jotka kuuluivat
tuohon vähän edistyneemmän köyhälistön valiojoukkoon, joka
ahkerasti käy iltaluennoilla ja kansankirjastoissa. Nämä olisivat
epäilemättä toisessa yhteiskunnallisessa ympäristössä hankkineet
itselleen samat tiedot, saman opillisen sivistyksen kuin porvariston
nuorukaiset, joilla, köyhinäkin, on tilaisuus pitkiin opintoihin ja jotka
saavat nauttia hienomman kasvatuksen siunauksista. He edustivat
ilmeisesti kansan nuorta kukkaa, toistaiseksi poikkeuksellisia
tyyppejä. Monet heidän tovereistaan vetelehtivät varmaankin tällä
hetkellä kahviloissa ja biljardipöytien ympärillä, tupakansavun,
kirousten ja raa'an naurun täyttämässä ilmakehässä.

Naisyleisö kiinnitti vielä enemmän mieltäni. Näin työläisnaisia,

jotka olivat saapuneet veljineen ja ystävineen. Heidän ammattinsa,
joissa ei tarvittu muuta kuin aivan koneellista kätevyyttä, olivat
kehittäneet heissä ainoastaan heidän sormensa ja tuon naiselle
ominaisen kauneusvaiston, joka on kuin esteettisen tunteen
ensimmäinen alku-itu. Kuinka he erosivatkaan noista naapureistaan,
kahdenkymmenenviiden tai kolmenkymmenenvuotisista naisista,
joilla oli vakavat kasvot, kuihtunut iho ja älyä säteilevät silmät. Ne
olivat opettajattaria, valtion virkailijattaria, oppineita ja sivistyneitä,
jotka olivat porvareita syntyperältään ja tottumuksiltaan, mutta jotka
työ ja puute liitti köyhälistöön. Nämä, joilla ei ollut varaa käydä
teattereissa eikä vieraskutsuissa, löysivät täältä vaihtelua
arkiaskareilleen ja elämänsä pikkuhuolille. He toivat näihin
tilaisuuksiin ikäänkuin jotakin herkempää ainesta, joka oli alttiimpaa
taidevaikutuksille.

Sali oli melkein täynnä. Minä istuin takimmaisen penkin päässä

seinän vieressä ajatellen omalta kohdaltani rouva de Nébriantin
vastaanottoja ja yhdenvärin päivällisiä. Millä alentuvaisella säälillä
paroonitar ja hänen pöytäseuransa olisivatkaan katselleet näitä
minua ympäröiviä ihmisiä.

Kuuntelin keskusteluja, tarkkasin kasvojen piirteitä, panin merkille

ilmeitä.

— Viime kerralla oli hauskaa.

— Vähän liian paljon musiikkia minun mielestäni. Minä pidän

enemmän runoista.

— Voi, musiikki rupeaa itkettämään, sanoi muuan vaimo.

— Herra Genesvrier'ko tänä iltana puhuu?

— Niin.

— Kas, sepä hyvä, sanoi eräs kahdenkymmenen vuotias

ompelijatar, sitä miestä viitsii ainakin kuunnella! Hänen kielensä ei
ole solmulla niinkuin sen nuoren.
 — Senkö herra Saintis'in?

— Niin. Hän on nätti poika, mutta muuten ei mistään kotoisin, hän

sopottaa mitä sattuu.

— Se punaisiin puettu neiti vasta osaa laulaa.

— Hänellä vasta on laulunääni!…

— Kyllähän se on hyvin kaunista, kun se on surullista, sanoi se

vaimo, joka äsken oli puhunut.

— Se on yhtä kaunista kuin teatterissa eikä maksa mitään… Kas,

rouva
Peyron, oletteko tekin täällä?

— Minä olen täällä poikani seurana. Minulle, nähkääs, tämä on

liian oppinutta tai minä olen jo liian vanha käsittääkseni. Eugène,
hänellä sitä on tietoja; aina nenä kiinni kirjoissa. Minun aikanani ei
niin tehty.

— Entä vanhempi poikanne?

— Aina samanlainen vetelehtijä… Eikä hän välitä musiikista

hölynpölyä.

— Hänestä ei teille tosiaankaan ole iloa. Mutta onneksi teillä on

Eugène.

— Täytyy tyytyä heihin sellaisina kuin he ovat. Eugène, siinä vasta

poika, jollaista ei ole toista. Ferdinand on kovaluontoisempi… Mutta
ei paha hänkään, tiedän mä.

Nuori mies ja vanha nainen juttelivat minun takanani:

 — Tuo oikealla on herra Saintis. Minä tunnen hänet. Hän on ollut
viisaustieteen opettajana maaseudulla. Nyt hän on
sanomalehtimies… Tuo toinen, pitkätukkainen, on Mariot Punaisesta
kuukauslehdestä.

— Runoilijako?

— Niin, rouva. Ja tuo vaaleanpunaisiin puettu nuori tyttö on neiti

Dumesnil.

— Näyttelijätär?

— Ei, erään kuvanveistäjän tytär. Kas, isä Dumesnil on myöskin

täällä, tuolla toisella rivillä.

— Entä tuo toinen nainen?

— Hän soittaa pianoa, mutta hän ei ole pianisti ammatiltaan. Hän

on eräs naisasianainen, Marie Chauvel, esitelmöitsijä.

— Ja missä on herra Genesvrier?

— Hän on myöhästynyt… Hänen pitäisi tulla Louis Grannis'in

kanssa.

— Kuuluisan Grannis'in?

— Itsensä runoilija Grannis'in kanssa. Hän osoittaa suurta

mielenkiintoa näitä tilaisuuksia kohtaan.

— Te tunnette siis herra Genesvrier'n?

— Kyllä, rouva. Olen lääketieteen ylioppilas. Tutustuin herra

Genesvrier'hen erään sairaan luona, jota hoidin.
 — Ja mitä ajattelette hänestä?

— Minä ihailen häntä, rouva, ihailen äärettömästi. — Eräässä

sanomalehdessä näin häntä moitittavan.

— Kaikilla suurilla miehillä on vihollisia. Antoine Genesvrier on

hyvin suosittu nuorison parissa. Hän on apostoli, henki, jollaisia
nykyaikana harvoin näkee! Ja mikä suuri kirjailija! Oletteko lukenut
Köyhät, rouva?

— En.

— Se on luettava… Katsokaa, tuolla Genesvrier tuleekin

Grannis'in kanssa! Grannis on tuo vanhempi, se, jolla on
kunniamerkki.

— Hän on siis Akatemian jäsen?

— On, rouva.

— Vai niin, sanoi rouva ihailevasti.

Kaasulamput tekivät ilman hehkuvaksi. Minä nostin harsoni

nähdäkseni paremmin. Antoine oli jo puhujalavalla. Viheriän
lampunvarjostimen läpi lankeavassa valossa näyttivät hänen vielä
nuorekkaat kasvonsa minusta olevan syvän väsymyksen uurtamat,
joka tuntui vanhentaneen hänet muutamassa kuukaudessa.

Hän puhui istuen pienen pöydän ääressä. Hän kiitti Grannis'ta

siitä, että tämä oli tullut tähän tilaisuuteen, ja koruttomasti, ilman
imartelua hän palautti mieliin runoilijan loistavan elämäntyön. Sitten
hän muutamin sanoin selosti näiden esitelmätilaisuuksien syntyä,
puhui voitetuista vaikeuksista, siitä innostuksesta, jonka ne olivat
herättäneet, ja siitä avustuksesta, jota yritystä kohtaan oli osoitettu.

Tämän johdannon jälkeen Antoine selaili eteensä levitettyjä

papereita ja luki lyhyen kuvauksen eräästä Beethovenin sinfoniasta,
jonka andanten rouva Chauvel tulisi soittamaan. Ihailin sitä taitoa,
millä hän valitsi sanansa selittääkseen mahdollisimman
havainnollisesti tuon sävellyskatkelman luonteen. Se oli verrattain
lyhyt, melodisilta aiheiltaan niin jykevä ja selväpiirteinen, että miltei
jokainen kuulija saattoi tajuta sen kauneuden. Samoin selostettiin
lyhyesti kaikki muutkin ohjelman numerot. Kohtaus Shakespearen
Julius Caesarista, eräät kauniit sivut Michelet'n tuotannosta, Vignyn
Suden kuolema, Don César de Bazanin yksinpuhelu Ruy Blas'n
neljännestä näytöksestä ja eräs Haydnin jouhikvartetti miellyttivät
etenkin miehistä kuulijakuntaa. Naiset osoittivat suosiotaan
etupäässä katkelmille Gluckin Orfpheuksesta, eräälle Chopinin
nocturnolle, muutamille vienoille runo-elegioille ja tuolle kuuluisalle
kohtaukselle Molièren le Dépit amoureux'sta. Mutta kun Louis
Grannis nousi ja luki itse tunnetuimman runoistaan, yhtyivät sekä
yleisö että ohjelmansuorittajat välittömästi osoittamaan hänelle
lämmintä ja sydämellistä suosiota. Silloin Akatemian jäsen tuli
puhujalavan partaalle ja teki merkin, että hän tahtoi puhua.

Ensin hän kiitti ilmeisesti liikutettuna kuulijoita, sitten hän sanoi

olevansa iloisesti yllätetty voidessaan todeta tällaisen
lähentymisyrityksen taiteilijoitten ja kansan välillä ja antoi
tunnustuksensa tämän yrityksen alkuunpanijalle, oikeudentuntoiselle
ja lahjakkaalle miehelle, jonka työtä kirjallisuuspomot ja poliittiset
seikkailijat saattoivat vähäksyä, mutta jota kaikki ne, joilla oli sydän
paikallaan, kunnioittivat ja tukivat, sillä hän ajoi oikeuden asiaa,
johdattaen kansaa kauneuden lähteille.