The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Applied Anatomy
of the Face and Neck

FOAD NAHAI, JUAN DIEGO MEJIA,
FARZAD R. NAHAI
CHAPTER 40

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Part VIII  Face Lift and Neck Lift
The first rule of anatomy is variation.
P
recision in aesthetic surgery depends not only on the technical skills of the op-
erator, but almost equally on the surgeon’s detailed knowledge of anatomy. This
is particularly pertinent in dealing with aesthetic surgery of the face. A thorough
knowledge of the anatomic layers and structures of the face and neck is a prereq-
uisite for successful and safe aesthetic surgery. This includes a comprehensive un-
derstanding of the anatomy in three dimensions. The relationship of the underlying
bony skeleton, muscles, and subcutaneous tissues, including fascial layers and fat
compartments, not only enhances our comprehension of the aging process but is
also a key to successful rejuvenation. Anatomic structures and relationships are not
consistent, and the surgeon must be aware of possible variations. The anatomy may
vary from individual to individual as well as from one side to the other in the same
person. Prior surgical interventions may also alter the anatomy and should be taken
into account in all secondary aesthetic procedures of the face and neck as well as
of the body.
Subcutaneous Fat Compartments of the Face
For many years the subcutaneous fat of the face was believed to be a confluent mass.
However, recent anatomic studies by Rohrich and Pessa have demonstrated that this
fat exists in distinct anatomic compartments, as shown. These fat compartments are
separated by fascial septa that arise from the superficial fascia and insert into the dermis.

Perforating vessels arising from deep arteries travel through these septa to supply the
skin and define the overlying vascular territories or angiosomes.
Anatomic Features
Forehead and Temporal Fat Compartments
The forehead is composed of three fat compartments: the central, middle temporal,
and lateral temporal–cheek compartments. The central compartment is located in
the midline region of the forehead. It is bounded by the middle temporal fat on ei-
ther side. Its inferior border is the nasal dorsum. This central fat compartment is lim-
ited on each side by the central temporal septum. Perforators from the supratrochlear
vessels travel through this septum, which explains why the subcutaneous boundaries
of the central temporal septum coincide with the known clinical limits of the fore-
head flap. The middle temporal compartments lie on either side of the central fore-
head fat. Its inferior border is the orbicularis retaining ligament. Laterally, it is limited
by the superior temporal septum and the lateral temporal–cheek compartment. The
lateral temporal–cheek fat is the lateralmost compartment of the face. It spans from
the forehead to the cervical region, connecting the temporal fat to the lateral cheek
and cervical subcutaneous fat.
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Chapter 40  Applied Anatomy of the Face and Neck

Orbital Fat Compartments
There are three periorbital fat compartments: the superior, inferior, and lateral or-
bital compartments. The superior fat is bounded by the orbicularis retaining liga-
ment as it courses around the superior orbit. Medially and laterally, it is limited by
the canthi. The inferior orbital fat lies immediately below the inferior lid tarsus. In-
feriorly, it is bounded by the orbicularis retaining ligament. The medial and lateral
extents are also the canthi. The lateral orbital fat is located in the temporal region.
Its superior border is the inferior temporal septum, which carries perforators from
the zygomaticoorbital branch. Inferiorly, its boundary is the superior cheek septum.
The zygomatic major muscle adheres to this compartment.
Nasolabial Fat Compartment
The nasolabial fat is the medialmost of the facial compartments. The orbicularis re-
taining ligament represents its superior border. Laterally, it is bordered by the me-
dial cheek compartment, and inferiorly by the nasolabial fat. The lower border of
the zygomaticus major muscle is adherent to this fat structure. Perforator vessels from
the angular artery run within the nasolabial septum located between the nasolabial
fat and the upper lip fat.
Superficial Cheek Fat Compartments
There are three distinct superficial cheek fat compartments: the medial, middle, and
lateral temporal–cheek fat.
Medial cheek fat is lateral to the nasolabial compartment. This limit is defined by a
septum carrying perforators from the facial and infraorbital arteries. Its superior
boundary is the orbicularis retaining ligament and the lateral orbital compartment.
The lateral boundary is the middle cheek septum and the middle cheek fat. The jowl
lies inferior to this compartment. The facial vein is consistently found at the deep
surface of the medial cheek fat.
The middle cheek fat lies between the medial and lateral temporal–cheek compart-
ments. The middle cheek septum is the medial boundary of this compartment; it car-
ries perforators of the transverse facial artery to the skin. This fat compartment is
found anterior and superficial to the parotid gland. The zone where the medial cheek
fat meets the middle cheek fat corresponds to the location of the parotidomasseteric
ligaments. Its superior border is defined by the superior cheek septum. The conflu-
ence of septa where this compartment meets the medial cheek fat and the inferior
orbital fat forms the zygomaticus ligament. The middle cheek fat is adherent to the zy-
gomaticus major muscle at its superior portion. Care must be exercised during a face
lift, because the plane between the lateral and middle cheek compartments can eas-
ily lead into the buccal fat pad and deep neurovascular structures.
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The lateral temporal–cheek fat is the most lateral compartment of the face. In the
cheek, this fat lies immediately superficial to the parotid gland. It spans from the
forehead to the cervical region, connecting the temporal fat to the cervical subcuta-
neous fat. The lateral cheek septum is located anterior to this compartment and cor-
responds to the first transition zone encountered during a face lift. Multiple perfo-
rator vessels from the superficial temporal artery travel through this septum up to
the forehead region. The superior and inferior temporal septa represent its superior
boundaries.
Deep Medial Cheek Fat Compartment
The deep medial cheek fat is deep to the medial and middle superficial cheek com-
partments of the face. It lies inferior to the orbicularis oculi muscle and has the or-
bicularis retaining ligament as its superior boundary. The inferior boundary is the
suborbicularis oris fat. The most lateral boundary is the capsule of the buccal fat
pad and the zygomaticus major muscle. The medial boundary is the pyriform liga-
ment surrounding the nasal base. The posterior border is the periosteum of the max-
illa and a potential space exists between the periosteum and the deep medial fat (Ris-
tow’s space), which is a potential site for fat transfer.
Functional Significance
It is unlikely that the face ages as a confluent mass. A smooth transition between sub-
cutaneous fat compartments is characteristic of a youthful face. With aging, some-
what abrupt contour changes between these regions occur. Both volume and position
affect the superficial and deep fat compartments in the aging face. These changes may
occur as a combination of ligament laxity and volume loss as described by Lambros.
When performing a face lift, the surgeon encounters zones of adherence that alter-
nate with zones of easy dissection, which suggests that barriers exist between differ-
ent zones of facial fat. These areas occur in the transition between compartments.
Transition zones between compartments are regions of potential injury to deeper
structures, including branches of the facial nerve. This can occur when transition is
performed in too deep a plane during a face lift.
There is a concept that deep cheek fat supports the overlying subcutaneous fat. Loss
of volume of the deep medial cheek fat may be a primary determinant of midfacial
aging and diminished midface projection. In the aging face, the downward migra-
tion of the nasolabial fat as a result of ligament laxity is not the only cause of the
observed changes in this area. It seems that the volume of the nasolabial fat is pre-
served, whereas there is loss of projection of the medial and middle superficial fat
compartments of the cheek secondary to deep medial fat atrophy. These findings sug-
gest that one of the reasons for a prominent nasolabial fold with aging is, in part, a
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Chapter 40  Applied Anatomy of the Face and Neck

The volume of the nasolabial fat compartment is preserved with age (black arrow);
however, there is loss of projection of the superficial cheek fat compartments (red
arrow). A prominent nasolabial fold with age is, in part, a form of pseudoptosis: loss
of projection of the superficial cheek fat makes the nasolabial fold appear more
prominent.
Muscles of the Scalp and Brow
The muscles of the scalp, brow, and periorbital region are major contributors to fa-
cial animation and appearance. Emotional expressions and overall facial appearance
depend on the actions of these muscles. With age and repeated contractions, these
muscles produce lines or rhytids reflecting the insertion of the muscles into the over-
lying skin. These characteristic changes result in the familiar patterns of expression
and aging on the face. The muscles of the scalp and brow include the epicranius, pro-
cerus, corrugator supercilii, and orbicularis oculi muscles. These muscles are respon-
sible for movements of the scalp, forehead, and eyebrows and the rhytids that mark
the forehead, glabella, and periorbital areas.
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Part VIII  Face Lift and Neck Lift
form of pseudoptosis: loss of projection of the superficial medial and middle cheek
fat makes the nasolabial fat appear more prominent, when in fact, its volume has
not changed. Clinically, when fat is injected into the deep medial fat compartment
(deep and medial to the zygomaticus major muscle), this improves midface projec-
tion, re-creates a youthful cheek, diminishes the prominence of the nasolabial fold,
and improves the lid-cheek junction.

Epicranius
Anatomic Features
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Chapter 40  Applied Anatomy of the Face and Neck
The epicranius or scalp muscle is made up of the occipitofrontalis, the major por-
tion, and a variably developed temporoparietalis. The occipitofrontalis is a wide, fi-
bromuscular layer that covers the entire scalp from the nuchal line to the eyebrows.
It comprises two paired muscle bellies—the occipital bellies (occipitalis muscles) and
the frontal bellies (frontalis muscles); these are connected by the galea aponeurotica.
The frontal bellies or frontalis muscles, which are clinically significant, are thin, rec-
tangular muscles without any bony attachments. These muscles are connected pos-
teriorly to the galea aponeurotica at or in front of the coronal suture; they insert an-
teriorly into the glabellar musculature, where the medial fibers of the frontal belly
intermingle with the procerus, while the intermediate fibers mingle with the corru-
gator supercilii and the orbicularis oculi. The medial fibers of the frontal bellies may
be joined together for a variable distance above the root of the nose. Supratrochlear
and supraorbital branches of the ophthalmic artery supply the frontalis; it is inner-
vated by multiple branches of the frontal branch of the facial nerve.
Orbicularis oculi
muscle
Oblique head of
corrugator muscle
Procerus muscle
Transverse head of
corrugator muscle
Frontalis (frontal belly of
occipitofrontalis) muscle
Galea aponeurotica
Orbicularis oculi muscle
Oblique head
of corrugator muscle
Procerus muscle
Transverse head
of corrugator muscle
Levator labii superioris
alaeque nasi muscle
Temporalis (temporoparietalis) muscle
Frontalis (frontal belly of
occipitofrontalis) muscle
Galea aponeurotica
Occipital belly of
occipitofrontalis
muscle

Functional Significance
The frontal bellies, acting from above, elevate the eyebrows and forehead. Acting
from below, they pull the scalp forward. The frontal bellies are responsible for the
transverse forehead wrinkles, reflecting attachments or insertions of the muscle into
the overlying forehead skin. Although transverse forehead wrinkles are produced by
either action of the frontal bellies, increased tone in the brow depressors, corruga-
tor, procerus, and orbicularis leads to an increase in frontalis tone. This muscle imbal-
ance and increase in tone deepens the forehead lines. The occipital bellies draw the
scalp backward, acting in opposition to the downward action of the frontalis. Im-
provement in brow position after a forehead lift may be attributable to reduced tone
in the frontalis following modification of the brow depressors, allowing unopposed
action of the occipitalis to elevate the brow. This relationship is the basis of the “func-
tional brow lift” in which no brow fixation is performed.
Galea Aponeurotica
Anatomic Features
The galea aponeurotica is an integral part of the occipitofrontalis and epicranius
muscles. It is a thick, fibrous layer with sagittally running fibers between the occipi-
tal and frontal bellies. Posteriorly between the separate bellies of the occipitalis, the
galea is attached to the external protuberance and highest nuchal line of the occipi-
tal bone. Anteriorly it splits to enclose the frontal bellies and continues as a narrow-
ing triangular portion between the two frontal bellies as they converge at the root
of the nose. Laterally on each side, coronally running fibers encompass the tem-
poroparietalis and the external ear muscles. The galea is firmly attached to the over-
lying skin by the firm superficial fascia, which continues as the temporoparietal fas-
cia, eventually attaching to the zygoma. On its deep surface the galea is connected
to the epicranium by loose connective tissue and allows movement of the galea and
scalp. In the forehead above the level of the supraorbital ridge, there are no nerves
or vessels deep to or within this loose connective tissue. This allows rapid, safe brow
elevation in the subgaleal or subperiosteal plane. However, the endoscope is essen-
tial to visualize the area between the supraorbital rim and supraorbital ridge, where
the supraorbital nerve may emerge through a foramen.
The temporoparietalis is a very thin sheet of muscle lying between the frontal bel-
lies of the occipitofrontalis and the auricular muscles. It is variably developed and
may be absent.
Procerus
Anatomic Features
The procerus is a small, thin, pyramid-shaped muscle extending from the nasal dor-
sum to the central forehead. It is considered one of the nasal muscles and may be as
large as 2 by 8 cm. It takes origin from the fascia overlying the distal portion of the
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nasal bones and upper lateral nasal cartilage and inserts into the skin of the lower
forehead between the eyebrows, intermingling with the medial fibers of the frontalis.
Branches of the facial artery supply the procerus. It is innervated by the upper buc-
cal branches of the facial nerve.
Functional Significance
The function of the procerus is to pull downward on the medial eyebrows. This ac-
tion augments the glabellar prominence, producing transverse glabellar wrinkles that
are improved with procerus muscle excision.
Corrugator Supercilii
Anatomic Features
The corrugator supercilii is a long, narrow muscle measuring approximately 1 by
5 cm, wider at its origin, narrowing toward its insertion. It lies deep to the frontalis
and orbicularis oculi at the medial end of the eyebrow. Originating from the medial
end of the supraciliary arch, it has transverse and oblique heads, with fibers running
laterally and slightly upward toward their insertion into the central part of the hair-
bearing brow. It is supplied by the supratrochlear and supraorbital vessels. Although
classically it has been thought that the muscle is innervated by the frontal branch of
the facial nerve, Boyd showed that there is additional innervation of the muscle me-
dially through the buccal branches of the facial nerve.
Functional Significance
The corrugator supercilii pulls the eyebrows medially and downward, producing ver-
tical glabellar wrinkles. The depth of these frown lines is related to the thickness of
the muscles, their constant contractions, and the thickness of the overlying skin. The
transverse head may at times act as an elevator of the medial brow.
Orbicularis Oculi
Anatomic Features
The orbicularis oculi, the most superficial muscle, is a relatively large, flat, broad, el-
liptical muscle that not only occupies the upper and lower lids and covers the orbit
but also extends beyond the orbit onto the cheek and temporal regions. Its fibers
form an uninterrupted ellipse. It comprises the orbital, palpebral, and lacrimal por-
tions. The orbital portion is thicker and darker in color than the palpebral portion.
Many of its fibers insert into the skin and subcutaneous tissues of the eyebrow and
constitute the depressor supercilii. It takes origin from the nasal portion of the frontal
bone and the frontal process of the maxilla. The fibers of insertion intermingle with
the frontalis and corrugator muscles, inserting into the skin and subcutaneous tis-
sues of the eyebrow. The palpebral portion is thinner and lies within the eyelids. The
lacrimal portion of the muscle lies behind the lacrimal sac. The transverse facial,
supratrochlear, and supraorbital vessels supply this muscle. The orbicularis is inner-
vated by the temporal, zygomatic, and buccal branches of the facial nerve.
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Chapter 40  Applied Anatomy of the Face and Neck

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Functional Significance
The orbicularis oculi is a powerful sphincter of the eyelids. It is innervated by the
temporal and zygomatic and buccal branches of the facial nerve. The palpebral por-
tion can act involuntarily to close the eyelid, or reflexively, as in blinking. The orbital
portion is under voluntary control, and when the entire muscle contracts, in addi-
tion to closing the eyelids, the skin of the forehead, cheek, and temple are all drawn
toward the medial and lateral canthus, resulting in crow’s-feet and eyelid wrinkles.
The medial fibers of the orbital portion, known as the depressor supercilii, will de-
press the medial eyebrow.
The orbicularis oculi is responsible for eyelid movement, both the sphincteric con-
tracture of protective squeezing and normal blinking movements. Historically, the
orbicularis has been classified anatomically as having a pretarsal, preseptal, and or-
bital division. Clinical surgical experience in patients who undergo deconstruction
of the eyelids with myoneurectomy to relieve blepharospasm has shown that there
is a division of labor between the extracanthal orbicularis and the inner canthal
orbicularis.
The extracanthal portion of the orbicularis (left) is responsible for squeezing and
animation of the eyelid fissure, while the inner canthal portion of the orbicularis
(center) is responsible for normal blinking, eyelid tone, and tear-pump movement. A
division of labor in any muscle group implies a division of innervation, and it has
been shown by both clinical experience and EMG studies to be true of the orbicu-
laris muscle.
The extracanthal orbicularis (right) is animated primarily by the zygomatic branches
of the facial nerve, and the inner canthal orbicularis is innervated by vertical exten-
sion of the buccal branch of the facial nerve.
Extracanthal portion of
orbicularis oculi muscle
Inner canthal portion of
orbicularis oculi muscle
Zygomatic
branches
of facial
nerve
Buccal branch
of facial nerve

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Chapter 40  Applied Anatomy of the Face and Neck
The inner canthal orbicularis muscle segment is much thicker than the extracanthal,
has multiple heads, and functions well as the sole motor for eyelid blinking, tone,
and tear-pump movement. A counterpull at the lateral canthus to the inner canthal
orbicularis contracture is necessary for the proper biomechanics of eyelid closure.
Orbicularis oculi
muscle
Lacrimal sac
Heads
of orbital
orbicularis
oculi muscle
Lacrimal sac
Heads of
pretarsal
orbicularis
oculi muscle
Heads of
preseptal
orbicularis
oculi muscle
Incision in
orbicularis
oculi muscle
Dissections of branches of the facial nerve in the lower lid canthal area have verified
this pattern of innervation. Other studies have shown vertical branches of the zygo-
matic nerve that run perpendicularly into the pretarsal area, and these researchers
have raised concerns of possible denervation of the lower lid with surgical incisions
in that area. Recent EMG studies have shown that traditional subciliary incisions
and muscle flap dissections in this area produce no denervation.

Other studies have shown that even if the zygomatic branches in the lower lid are re-
moved by tumor resection, that lower lid reinnervation occurs rapidly and the lower
lid quickly regains normal function. Intentional denervation of the zygomatic branches
to the extracanthal orbicularis in the lower lid in patients undergoing myoneurectomy
produces no alteration in blinking, tone, or lid position in these patients.
The muscles of the forehead, brow, and eyelids control brow position. Their actions
may also influence facial appearance, creating a tired, angry, or surprised look in some
individuals. Chronic contraction or muscle hypertrophy with associated muscle im-
balance can cause the development of characteristic transverse forehead wrinkles, ver-
tical and transverse glabellar frown lines, and medial eyelid folds and lateral crow’s-
feet. Repositioning and selective muscle resection can reverse these aging changes.
The frontalis, procerus, corrugator supercilii, and orbicularis are all intermingled in
the medial brow. The degree of development or muscle bulk will vary from individ-
ual to individual, depending on habits such as squinting and frowning, which lead
to muscle hypertrophy. The procerus, frontalis, and orbicularis are all on the same
plane. The corrugator is in a deeper plane at its origin, but laterally it intermingles
with the frontalis and orbicularis. As they exit the orbit, the supratrochlear and supra-
orbital nerves are intimately involved with these muscles. The supratrochlear nerve
is intermingled with the procerus as well as with the medialmost fibers of the cor-
rugator. During resection of the procerus and medial corrugator fibers, the supra-
trochlear nerve must be identified and preserved. The nerve may not be immediately
visible, and muscle separation or partial resection may be necessary for exposure.
The supraorbital nerve is intermingled with the more lateral fibers of the corrugator
supercilii. If it exits the orbit through a foramen, it is rarely involved with the mus-
cles and is readily identified. However, if it exits through a notch, it is often sur-
rounded by fibers of the corrugator, which may be separated or resected to clearly
identify the nerve.
Brow position and dynamics are a function of the balance between the upward and
lateral pull of the frontalis and the downward and medial pull of the procerus, cor-
rugator, and orbicularis. Resection of the procerus, corrugator, and orbicularis mus-
cles will alter this dynamic balance and allow the frontalis to elevate the brow with
relatively less opposition. This is the underlying hypothesis of medial brow elevation
after endoscopic forehead procedures. The lateral fibers of the orbicularis will pull
the lateral brow downward; therefore resection of the lateral orbicularis fibers should
facilitate lateral brow elevation.
The frontalis and corrugator supercilii are innervated by the frontal branch, the pro-
cerus by the upper buccal branches, and the orbicularis by the zygomatic and buc-
cal branches of the facial nerve. Therefore, if the frontal branch is injured or para-
lyzed, some forehead movement is preserved, especially brow depression around the
root of the nose.
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Chapter 40  Applied Anatomy of the Face and Neck
This young woman, in undergoing a meningioma resection, had an injury to the
frontal branch of the facial nerve on her right side; the asymmetry of the brow po-
sition is evident (left). With forceful contraction to produce a frown (right), the left
corrugator produces a vertical line; the right corrugator is paralyzed and the medial
brow remains smooth. However, the procerus, innervated by buccal branches of the
facial nerve, contracts forcefully, producing typical transverse wrinkling.
Muscles of the Face
The position, tone, and function of the muscles of the face are important for con-
veying facial expression; an understanding of the anatomy of these muscles, espe-
cially their innervation, is essential to avoid injury during aesthetic surgery. The
mimetic muscles move the skin of the midface and lips and control the size and shape
of the mouth. Freilinger et al described them in four layers. The superficial layer in-
cludes the depressor anguli oris, the zygomaticus minor, and the orbicularis oculi.
The next layer includes the depressor labii inferioris, the risorius, the platysma, the
zygomaticus major, and the levator labii superioris alaeque nasi. The next layer in-
cludes the orbicularis oris and the levator labii superioris. The deepest layer includes
the mentalis, the levator anguli oris, and the buccinator.
The muscles of the first three layers are innervated by the facial nerve on their deep
surface, but the muscles in the fourth layer are innervated by the facial nerve on their
superficial surface. The superficial musculoaponeurotic system (SMAS) and the mus-
cles of the upper three layers that it invests can be thought of as a unit controlling
facial skin movement, similar to the arrangement of muscles and fascia controlling
scalp and forehead movements.

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Part VIII  Face Lift and Neck Lift
Orbicularis oculi muscle
Oblique head
of corrugator muscle
Procerus muscle
Transverse head
of corrugator muscle
Frontalis (frontal belly of
occipitofrontalis) muscle
Levator labii superioris muscle
Levator anguli oris muscle
Zygomatic minor muscle
Zygomatic major muscle
Parotid gland
Parotid duct
Buccal fat pad
Buccinator muscle
Platysma muscle
Temporalis (temporoparietalis) muscle
Nasalis muscle
Levator labii superioris
alaeque nasi muscle
Levator labii superioris muscle
Zygomatic minor muscle
Zygomatic major muscle
Depressor septi muscle
Risorius muscle
Orbicularis oris muscle
Depressor anguli oris muscle
Depressor labii inferioris muscle
Mentalis muscle
Depressor anguli
oris muscle
Orbicularis oculi muscle
Corrugator muscle
Nasalis muscle
Parotid gland
Parotid duct
Frontalis (frontal belly of
occipitofrontalis) muscle
Temporalis (temporoparietalis) muscle
Procerus muscle
Levator labii superioris
alaeque nasi muscle
Levator labii superioris muscle
Zygomatic minor muscle
Zygomatic major muscle
Mentalis muscle
Risorius muscle
Orbicularis oris muscle
Depressor anguli oris muscle
Depressor labii inferioris muscle
Platysma muscle
Buccinator muscle

Muscles of the Mouth
The shape and size of the mouth and the position of the lips are controlled by an ex-
tensive collection of small muscles: a group of muscles that elevates and retracts the
upper lip, a group that depresses and retracts the lower lip, and a sphincter that con-
trols the size and shape of the mouth. Elevators and retractors of the upper lip in-
clude the levator labii superioris alaeque nasi, levator labii superioris, zygomaticus
major, zygomaticus minor, levator anguli oris, and risorius. Depressors and retrac-
tors of the lower lip are the depressor labii inferioris, depressor anguli oris, and men-
talis. The sphincter function is controlled by the buccinator and orbicularis oris (see
the illustrations on p. 1286).
Levator Labii Superioris Alaeque Nasi
Anatomic Features
The levator labii superioris alaeque nasi is a long, narrow muscle that takes origin
from the upper part of the frontal process of the maxilla. The fibers pass obliquely
downward and laterally along the nasofacial line superficial to the levator labii su-
perioris. This muscle has two slips of insertion: the medial slip inserts into the lower
lateral cartilage of the nose and the lateral slip inserts into the lateral part of the up-
per lip, blending with the levator labii superioris and orbicularis oris fibers. It is in-
nervated by the buccal branches of the facial nerve and receives its blood supply from
the facial artery.
Functional Significance
The medial insertion slip dilates the nostril and the lateral insertion slip elevates and
everts the upper lip.
Levator Labii Superioris
Anatomic Features
The levator labii superioris is a narrow, triangular muscle lying deep to the levator
labii superioris alaeque nasi that takes origin from the zygoma and maxilla along
the inferior orbital rim just above the infraorbital foramen. The fibers course medi-
ally from this orbital origin toward the lip where they insert into the muscular sub-
stance of the upper lip between the lateral slip of the levator labii superioris alaeque
nasi and the levator anguli oris. The blood supply is through the transverse facial ar-
tery, and the muscle is innervated by the buccal branch of the facial nerve.
Functional Significance
The levator labii superioris elevates and everts the upper lip, and, along with the zy-
gomaticus minor, it forms the nasolabial sulcus.
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Chapter 40  Applied Anatomy of the Face and Neck

The zygomaticus major and zygomaticus minor muscles are important considera-
tions during dissection deep to the mobile SMAS, as in deep plane and composite
face lifts. These muscles lie superficially just below the malar fat pad and the dissec-
tion of the deep plane lift is just above them. The lower margin of the orbicularis
oculi is also beneath the malar fat pad but superficial to these two muscles.
Zygomaticus Major
Anatomic Features
The zygomaticus major is a relatively long, thin (1 by 7 cm) muscle that originates
from the zygoma behind and above the origin of the zygomaticus minor. The fibers
course medially toward their insertion in the lip. It is supplied by the transverse fa-
cial artery and innervated by buccal branches of the seventh nerve that enter its deep
surface.
Functional Significance
The zygomaticus major draws the angle of the mouth upward as well as laterally.
Zygomaticus Minor
Anatomic Features
The zygomaticus minor is also a long, thin (1 by 4 cm) superficial muscle that orig-
inates on the lateral surface of the zygoma just behind the zygomaticomaxillary su-
ture. The fibers also insert into the muscular substance of the upper lip. It lies super-
ficial to the levator labii superioris and is supplied by the transverse facial artery and
innervated by the buccal branches of the facial nerve.
Functional Significance
The zygomaticus minor elevates the upper lip and forms the nasolabial sulcus with
the levator labii superioris.
Levator Anguli Oris
Anatomic Features
The levator anguli oris, a small quadrangular muscle, lies deep to the zygomaticus
minor and levator labii superioris. It originates on the maxilla just below the orbital
foramen and inserts into the muscle substance of the lip.
Functional Significance
The levator anguli oris raises the angle of the mouth and deepens the nasolabial fold.
The infraorbital neurovascular bundles lie between the levator anguli oris and the
levator labii superioris.
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Depressor Labii Inferioris
Anatomic Features
The depressor labii inferioris is continuous with the platysma at its origin from the
oblique line of the mandible between the mental foramen and the symphysis. Its fibers
run upward and medially, inserting into the lip.
Functional Significance
The depressor labii inferioris draws the lip downward and laterally.
Depressor Anguli Oris
Anatomic Features
The depressor anguli oris pulls the angle of the mouth downward and is continuous
with the platysma at its origin from the oblique line of the mandible below and lat-
eral to the origin of the depressor labii inferioris. The platysma produces similar ac-
tions in the lower lip.
Mentalis
Anatomic Features
The mentalis is a very thick, small muscle that originates from the incisor foramen
of the mandible and inserts into the chin.
Functional Significance
The mentalis raises and protrudes the lower lip, creating chin wrinkles.
Buccinator
Anatomic Features
The buccinator is a relatively large, thin, deep muscle that lies in the cheek in the in-
terval between the maxilla and mandible. It is innervated by the buccal branches of
the facial nerve.
Functional Significance
The buccinator compresses the cheek against the teeth. The name buccinator (trum-
peter) reflects its function of expelling air between the lips, as in blowing. Superfi-
cial to the buccinator posteriorly, the buccal fat pad separates it from the mandibu-
lar ramus, masseter, and temporalis. The parotid duct pierces the muscle opposite
the upper third molar, and this muscle is spread when the buccal fat pad is removed
through an intraoral incision. The facial artery and buccal branches of the facial
nerve cross the muscle.
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Orbicularis Oris
Anatomic Features
The orbicularis oris is a very superficial muscle constituting the bulk of the lips and
acts as an oral sphincter. The majority of the muscles of facial expression insert into
this muscle, which is made up of several layers of muscle fibers all running in differ-
ent directions. The fibers from nine muscles converge at the oral commissure, form-
ing the modiolus. The zygomaticus major, levator anguli oris, and depressor anguli
oris can fix the modiolus in any given position, thus influencing the position of the
oral commissure.
Functional Significance of the Mimetic Muscles
The muscles of facial expression are innervated by the seventh nerve, and their func-
tion must be preserved during aesthetic facial surgery. The fascial layers of the face
have a constant position relative to the nerves and muscles; precise facial dissection
technique and knowledge of the location of these muscles and nerves will minimize
the risk of postoperative muscle weakness and asymmetry.
The mimetic muscles control facial expression (such as smiling and grimacing), the
position and shape of the mouth, and even to a certain extent the position of the eye-
lid and eye shape. The effect of these muscles on the nasolabial fold is not clearly es-
tablished. The nasolabial fold deepens when the face is animated, as in smiling, and
the nasolabial fold disappears with facial paralysis. Rubin et al showed that the na-
solabial fold is composed of subcutaneous fat, muscle fibers of the lip elevators, and
striated muscle fibers originating from the fascia. The authors hypothesized that the
fold becomes more prominent with age as a result of loss of subcutaneous fat. Pessa
and Brown showed that resection of the levator labii alaeque nasi and partial resec-
tion of the levator labii superioris muscle decrease the medial nasolabial fold and
soften the acute nasolabial angle seen with aging. Experience with botulinum toxin
injections has confirmed these findings. These authors further studied the effect of
individual mimetic muscles on the nasolabial fold in cadavers. They identified the le-
vator labii alaeque nasi as the primary facial muscle responsible for creating the me-
dial nasolabial fold. They demonstrated that the levator labii superioris defined the
middle nasolabial fold and the zygomaticus major had a slight effect, deepening the
lateral portion of the nasolabial fold. Hypothetically, subperiosteal face lifts in which
the origins of several of these mimetic muscles are rearranged may alter the depth
and prominence of the nasolabial fold.
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Muscles of the Neck
Platysma
Anatomic Features
The platysma is key to the changes in the neck attributed to aging, and modification
of this muscle not only is necessary to improve the appearance of the aging neck, but
also has a dramatic effect on neck reshaping. With aging, the platysma descends and
tends to become redundant centrally in the submental region. This is manifest by ver-
tical platysmal bands that are first seen with animation but later become permanently
visible. The amount of subcutaneous tissue overlying and attached to the platysma,
especially in the jowl and submental region, can also cause descent of the platysma,
which contributes to submental fullness and flattening of the cervicomental angle.
The platysma is a large, broad, thin sheet of muscle spanning the neck from the
mandible to below the clavicle. It originates from the fascia overlying the pectoralis
and deltoid muscles. The fibers cross the clavicle and course upward and medially.
The anterior fibers interlace and mingle with fibers from the opposite side below the
symphysis of the mandible, inserting into it and laterally along the border of the
mandible into which they also insert. Posteriorly, fibers cross the lower border of the
mandible and insert into the SMAS. The dominant pedicle is a branch of the sub-
mental artery, and the minor pedicle is a branch of the suprasternal artery. It is in-
nervated by the cervical branch of the facial nerve.
Functional Significance
Within the submental area the anatomy of the muscle varies greatly from individual
to individual. Cardoso de Castro’s anatomic studies led him to classify the relation-
ship of the two platysma muscles and their interdigitations or decussation in the sub-
mental area into three types:
Type I
Most common: occurs in 75% of cases; demonstrates a limited decus-
sation of the platysma muscles extending 1 to 2 cm below the mandibu-
lar symphysis
Type II
Occurs in 15% of cases; demonstrates decussation of the platysma
from the mandibular symphysis to the thyroid cartilage
Type III
Occurs in 10% of cases; demonstrates no decussation or interdigitations
This confirms our clinical impression that in the majority of patients there is very
limited interdigitation of the muscles medially, as evidenced by the two visible
platysma bands in an aging neck.
Functionally, the platysma draws down the lower lip and the angle of the mouth and
diminishes the neck-jaw angle. The platysma may vary in size and extent. Asymme-
try of the platysma is not uncommon, and rarely, the platysma may be absent on one
side. In a thin neck, tightness and youthful contour of the facial-mandibular line as
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Chapter 40  Applied Anatomy of the Face and Neck

well as the submental and anterior neck regions are influenced by the tone of the
platysma. When the tone is normal, these angles are sharp and well defined; when
the tone is poor, the angles may become blurred and indistinct. Baker and colleagues
stated that retaining ligaments within the neck support the platysma and tightly
maintain it in position against the deep cervical fascia, creating the acute cervico-
mental angle characteristic of youth. These fibers or ligaments are present along the
posterior mandibular border throughout the subplatysmal fat and extend between
the platysma and hyoid and upper aspect of the thyroid cartilage. Thus, as this platys-
mal support weakens with age, the anterior free edge of the muscle no longer firmly
adheres to the deep cervical fascia and droops, forming platysmal bands. Loss of skin
elasticity is also a contributing factor. With these changes, the acute cervicomental
angle is gradually lost and assumes an oblique direction. Excess fat may accumulate
superficial to the platysma in the jowl, in the submental region, and centrally in the
subplatysmal region. Hypertrophy of the anterior belly of the digastric muscles may
add further fullness to this midline region. The platysma covers the submandibular
glands, and with platysmal laxity or glandular hypertrophy, a bulge gradually be-
comes visible below the jawline laterally, within the submental triangle.
Correction of the aging neck focuses on tightening the platysma centrally and in its
upper lateral region by tightening its attached SMAS. Usually the medial platysma
is approached through a submental incision, and the skin and subcutaneous tissues
are separated from the muscle and the redundant muscle tightened after contouring
the fat superficial and deep to the platysma. When the submandibular glands are
prominent, the platysma can be tightened over them, although gland resection is
more effective.
Muscles of Mastication
Masseter
Anatomic Features
The masseter is a large, quadrilateral muscle
originating in three layers that fuse anteri-
orly. The fibers run downward and backward
from the maxillary and zygomatic origins to
the mandibular insertion. The superficial
layer, the largest portion of the muscle, has a
thick aponeurotic origin from the zygomatic
process of the maxilla and the lower border
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25 mm
Mandibular ligament

of the anterior two thirds of the zygomatic arch. The middle and deep layers take
origin from the deep surface of the zygomatic arch.
The anterior edge of the masseter has a concavity that faces the oral commissure. In
the upper part, the anterior border of the masseter angles backward parallel to the
nasolabial fold. At the level of the oral commissure, the anterior border of the mus-
cle changes direction and angles forward to insert into the body of the mandible. This
anterior curvature of the masseter is associated with an attachment on the body of
the mandible that is 25 to 30 mm more anterior than is usually illustrated. This tri-
angular-shaped forward prolongation of the muscle’s lower anterior part is the ba-
sis for the jowl recess.
Superficial to the masseter lie the SMAS, platysma, risorius, zygomaticus major,
parotid gland, and parotid duct. The masseter is lined by the thin but strong mas-
seter fascia. After exiting the parotid gland, branches of the fascial nerve travel be-
neath this fascia, which acts as a protective layer. The transverse facial artery crosses
the muscle. On its deep surface lie the ramus of the mandible, the insertion of the
temporalis, and the buccal fat pad that separates it from the buccinator.
Temporalis
Anatomic Features
The temporalis is a large, fan-shaped muscle originating from the entire temporal
fossa and the deep temporal fascia. Its fibers converge and descend deep to the zy-
gomatic arch to insert onto the coronoid process of the mandible. The outer border
is separated from the zygoma by the deep temporal fat pad. The temporalis muscle
is covered by several fascial layers that are important for safe elevation of the fore-
head and lateral upper face.
Functional Significance
These large muscles of mastication are important landmarks during forehead and
subperiosteal face lifts. The origins of the superficial layer of the masseter from the
zygomatic process of the maxilla and the lower border of the zygomatic arch are
taken down during a subperiosteal face lift. Branches of the facial nerve, transverse
facial artery, and parotid duct cross the superficial surface of the masseter muscle.
The buccal fat pad lies between the masseter and buccinator. The temporalis is in-
vested by the deep temporal fascia and separated from the zygoma by the deep tem-
poral fat pad. The temporal crest lines represent the origin of the temporalis.
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Facial Bones
Anterior temporal crest line
Frontal bone
Mandible
Maxilla
Temporal bone
Nasal bone
Supraorbital bone
Zygoma
Zygomaticofacial bone
Mental bone
Infraorbital bone
Sphenoid bone
Frontal bone
Mandible
Temporal bone
Zygoma
Sphenoid bone
Maxilla
Nasal bone
Infraorbital foramen
Mental foramen
Parietal bone
Occipital bone

Knowledge of the bony anatomy is essential to performing both open and endo-
scopic techniques for facial rejuvenation. It is especially important for subperiosteal
lifts of the forehead and midface.
Detailed knowledge of the shape and contour of the bone, its foramina, the vessels
and nerves they emit, and the muscles that take origin and insert into the bone will
facilitate endoscopic as well as open dissection and minimize the risk of injury.
Frontal Bone
Anatomic Features
The frontal bone forms the forehead and is connected anterolaterally with the zy-
goma and centrally with the nasal bones, frontal process of the maxilla, and lacrimal
bone. The central portion of the frontal bone is rounded. This frontal tuberosity lies
on either side of the midline approximately 3 cm above the orbit. It is variable in size
and is usually more pronounced in women and children. This convexity will influ-
ence access incisions and endoscopic pathways across the forehead and mandates
the use of curved instruments. Below the frontal tuberosity and approximately 1 cm
above the orbit there is a pair of curved superciliary arches. These arches are more
pronounced in men. The smoother area between the two arches is the glabella. These
upper orbital rims are sometimes reduced to give the lateral brow a lighter, more
open look. The orbital rims lie below the superciliary arches.
Foramina
The supraorbital notch, or foramen, is located at the junction of the medial third
and lateral two thirds of the orbital rim (midpupillary line). This foramen contains
the supraorbital nerve and vessels. Approximately 1 cm medial to the supraorbital
foramen is the frontal notch or foramen. It is present in only 50% of patients. The
supratrochlear vessels and nerves pass through this foramen.
Muscle Origins and Insertions
The temporalis muscle originates from the temporal fossa, which is located primar -
ily on the temporal bone, but anteriorly is made up of the greater wing of the sphe-
noid and a small portion of the frontal bone. The temporal line or crest originates
along the zygomatic process of the frontal bone and extends upward and backward
across the frontal and parietal bones. It usually begins as a single line or crest, and
as it passes posteriorly, it divides into two. The origin of the temporalis includes this
line or crest, and the deep temporal fascia is firmly adherent to this line. The transi-
tion from subperiosteal to subgaleal forehead dissection takes place at this line. The
corrugator supercilii takes origin from the medial end of the superciliary arch. The
orbicularis oculi takes origin from the nasal part of the frontal bone. None of the
forehead muscles inserts into bone. They exert their actions directly on the overly-
ing skin.
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Temporalis
Corrugator supercilii
Platysma
Buccinator
Procerus
Nasalis
Orbicularis oculi
Levator labii superioris
Zygomaticus major
Mentalis
Depressor labii inferioris
Zygomaticus minor
Masseter
Levator anguli oris
Temporalis
Masseter
Orbicularis oris
Depressor anguli oris
Orbicularis oris
Temporalis
Platysma
Buccinator
Nasalis
Orbicularis oculi
Zygomaticus major
Mentalis
Depressor labii inferioris
Masseter
Levator anguli oris
Temporalis
Masseter
Depressor anguli oris
Orbicularis oris
Levator labii superioris
alaeque nasi
Medial palpebral ligament
MUSCLE ORIGINS AND INSERTIONS

Functional Significance
The shape—specifically, the convexity—of the frontal bone will influence the loca-
tion of incisions and endoscopic access to the forehead. If there is significant curva-
ture of the forehead, the central access incision should be placed closer to the hair-
line to reduce the arc that the rigid endoscope must traverse. Conversely, if the
forehead is relatively flat, the access incision may be placed farther back on the scalp,
still affording access to the glabella and orbital rim. The curved forehead instruments
are designed to overcome this contour barrier.
Along the supraorbital margin, where the orbital rim is smooth medially, the peri -
osteum appears less adherent. The supraorbital nerve exits the orbit through the
supraorbital notch or foramen. If a foramen is present, it is usually located approx-
imately 5 to 10 mm above the orbital rim, but may rarely be as high as 20 mm or so.
The periosteum and deep temporal fascia are firmly adherent to the temporal crest.
The transition from subperiosteal to subgaleal forehead dissection takes place at this
line, making this an important landmark during endoscopic forehead dissection.
This line also represents an important preoperative landmark; if the lateral access
incisions are placed lateral to this line, brow fixation can be done by suturing the
galea to the superficial layer of the deep temporal fascia. Incisions lateral to the line
also protect the lateral branch of the supraorbital nerve. If the incision is medial to the
anterior temporal crest line, other methods of fixation may be required, because there
will be no strong fascial layer under the access incision. This crest line is readily pal-
pable in most patients. If it is not, forced contraction of the temporalis (clenching of
the teeth) will delineate the anteromedial border of the muscle, indicating its origin
from the anterior crest line.
Zygomatic Bone
Anatomic Features
The zygomatic bone forms the cheek prominence and contributes to the lateral wall
of the orbit and the walls of the temporal and infratemporal fossae. The orbital bor-
der (anterosuperior) is smooth and forms part of the orbital rim. The frontal process
articulates with the zygomatic process of the frontal bone anteriorly and with the
greater wing of the sphenoid posteriorly. On the orbital aspect of the frontal process
approximately 1 cm below the frontozygomatic suture line, there may be a tubercle
into which the lateral canthal ligament inserts. The temporal process runs posteri-
orly and articulates with the zygomatic process of the temporal bone.
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Foramina
Along the lateral surface of the zygoma near the orbital border, one or perhaps two
zygomaticofacial foramina are present. Through this foramen (or foramina) the zy-
gomaticofacial nerve and vessels pass. The zygomaticotemporal foramen, which con-
tains the zygomaticotemporal nerve as it leaves the orbit, is located more superiorly
and posteriorly within the temporal fossa.
The masseter has an extensive area of origin from the posteroinferior border of the
zygoma. The zygomaticus major originates on the lateral surface of the zygoma just
above and behind the origin of the zygomaticus minor, whereas the zygomaticus mi-
nor originates on the lateral surface of the zygoma just below and anterior to the
origin of the zygomaticus major. The origin of the levator labii superioris is along
the lateral portion of the infraorbital rim of the zygoma.
Functional Significance
Deep plane face-lift dissection is above the origin of the zygomaticus major. During
subperiosteal face-lift dissection the periosteal attachments to the zygoma are com-
pletely freed. This includes portions of the zygomatic origin of the masseter, the ori-
gin of the zygomaticus major and minor, and the levator labii superioris. The attach-
ment of the temporoparietal fascia to the zygoma is also divided. Subperiosteal
dissection along the zygoma through a temporal, eyelid, or intraoral incision may
lead to disruption of the zygomaticofacial nerve, which can be easily identified and
preserved. The zygomaticotemporal nerve is not involved in this dissection.
Nasal Bones
Anatomic Features
The nasal bones are small paired, oblong bones that vary in size and shape from in-
dividual to individual. A small vascular foramen on the external surface transmits a
small vein. The nasal bones are covered by the nasalis and procerus muscles. The pro-
cerus muscle takes origin from the nasal bone and upper lateral cartilage. Removal
of the procerus requires dissection down onto the nasal bones. With elevation of the
forehead, some of the pull can be transferred to the nasal tip.
Maxilla
Anatomic Features
The maxilla is the second largest facial bone; it forms the entire upper jaw and con-
tributes most of the roof of the mouth, lateral wall and floor of the nose, and floor of
the orbit. It contains the maxillary sinus. The maxilla comprises a body and four
processes: zygomatic, frontal, palatine, and alveolar. The zygomatic process articu-
lates with the zygoma and the frontal process articulates with the frontal bone and
nasal bones.
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Foramina
Above the canine fossa and approximately 1 cm below the orbital rim is the infra-
orbital foramen, which contains the infraorbital nerve and vessels. Above is the ori-
gin of the levator labii superioris and below is the origin of the levator anguli oris.
The nerve is located between these two muscles as it exits the infraorbital foramen,
in the midpupillary line.
The orbicularis oculi originates from the frontal process of the maxilla. The levator
labii superioris alaeque nasi originates from the upper part of the frontal process of
the maxilla and the levator labii superioris originates immediately above the infra-
orbital foramen. The levator anguli oris takes origin from the canine fossa just be-
low the infraorbital foramen and the buccinator from the alveolar process above the
three molars.
Aging Changes
At birth the vertical length of the maxilla is much smaller than its horizontal diam-
eters (transverse and anteroposterior). The frontal process is well developed, but the
body is little more than the alveolar process with tooth sockets lying just below the
orbit. With growth, as the maxillary sinus enlarges and the alveolar processes de-
velop, the vertical height increases significantly. With age, especially after loss of the
teeth, vertical height diminishes, and there is a gradual regression toward the neona-
tal state.
Functional Significance
During subperiosteal face-lift dissection, the infraorbital foramen must be identified
and the nerve and vessel preserved. It is easily identified 1 cm below the orbital rim
in the midpupillary line. The origin of the mimetic muscles from the maxilla is taken
down during subperiosteal face-lift dissection.
Mandible
Anatomic Features
The mandible is the largest and strongest of the facial bones; it has a U-shaped body
and two vertical rami extending upward from the posterior part of the body. The
external surface of the body is marked in the midline by a line or ridge, the symphy -
sis mend representing the line of fusion of the two halves of the fetal mandible. The
symphysis extends inferiorly to the mental protuberance in the midline and the men-
tal tubercles on each side. The mental tubercle and protuberance represent the chin
prominence.
Foramina
The mental foramen is located 1 cm below the second premolar or the gap between
the first and second premolars. Through this foramen pass the mental nerve and ves-
sels. The midpupillary line is also a good landmark for identification of the nerve.
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The buccinator originates from the outer surface of the alveolar process of the
mandible opposite the three molars. The mentalis takes origin from the incisive fossa
of the mandible. The depressor labii inferioris takes origin from the oblique line of
the mandible above the origin of the depressor anguli oris between the symphysis
and the foramen. The depressor anguli oris originates from the oblique line of the
mandible below the origin of the depressor labii inferioris and below the mental fora-
men. The temporalis inserts into the coronoid process. The masseter inserts into most
of the outer surface of the ramus. The platysma inserts along the outer inferior bor-
der of the mandible.
Aging Changes
After all of the permanent teeth have erupted, the mandible undergoes constant
change and remodeling. The depth of the body increases, the alveolar portion of the
bone grows larger, and the bone becomes thicker and deeper. The mental foramen
in the early years is much closer to the upper border of the bone and opens midway
between the upper and lower borders of the bone in the adult. With old age, espe-
cially when the teeth are lost, the bone is reduced in size. After loss of the teeth, the
alveolar portion is absorbed so that the mental foramen is closer to the alveolar bor-
der. With age, the angle between the ramus and the body also decreases. At birth this
is an obtuse angle, but it eventually reaches a 90-degree angle in adulthood and in
old age reverts to a more obtuse angle.
Blood Supply of the Facial Soft Tissues
Arterial Supply
The face and scalp are extremely well vascularized through an extensive network of
intercommunicating vessels. These vessels not only communicate with each other but
across the midline with corresponding vessels on the opposite side. The facial soft
tissue blood supply is abundant, and a clear understanding of the communications
between the underlying vessels and the overlying subcutaneous tissues and skin makes
it possible to perform aesthetic facial surgery safely with minimal risk of skin necro-
sis, even in patients who smoke.
The entire blood supply of the face and scalp is based on the carotid system. Almost
all of this circulation is based on the external carotid artery and its branches, with
a small contribution to the eyelid, brow, forehead, and scalp through the palpebral
supratrochlear and supraorbital branches of the ophthalmic division of the internal
carotid artery.
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In each of the three major scalp and face regions, the pattern of arterial vasculariza-
tion is distinct. The anterior face is supplied by a large number of small, densely
populated musculocutaneous perforating branches; the lateral face by a small num-
ber of large, sparsely populated fasciocutaneous perforators with predictable loca-
tions; and the forehead and scalp region by a large number of small, densely popu-
lated fasciocutaneous perforators.
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Chapter 40  Applied Anatomy of the Face and Neck
Vascular Territories of the Face and Scalp
Anterior Face
Lateral Face
Scalp and Forehead
Facial
Transverse
Superficial temporal
Superior labial
Submental
Frontal branch of superficial temporal
Inferior labial
Zygomaticoorbital
Temporal branch of superficial temporal
Supratrochlear
Anterior auricular
Posterior auricular
Supraorbital
Occipital
Supratrochlear artery
Zygomaticoorbital
artery
Frontal branch
of superficial
temporal
artery
Parietal branch
of superficial
temporal
artery
Occipital
artery
Transverse
facial artery
Submental
artery
Posterior auricular artery
Inferior
labial artery
Superior
labial artery
In their exhaustive study of the blood supply of the face and scalp, Whetzel and
Mathes described 11 vascular territories based on 14 individual arteries. They fur-
ther subdivided the face into an anterior region supplied by five vessels, a lateral re-
gion supplied by four vessels, and a scalp and forehead region supplied by five vessels.

External Carotid Artery
The external carotid artery contributes to the facial soft tissue blood supply through
its facial, occipital, posterior auricular, superficial temporal, and maxillary branches.
The facial artery takes origin from the front of the carotid artery in the carotid tri-
angle above the lingual artery and just above the greater cornu of the hyoid bone. It
runs medial to the ramus of the mandible, arching upward and grooving the poste-
rior surface of the submandibular gland. Between this gland and the medial ptery-
goid it runs downward to the border of the mandible where the submental artery
branches off. The facial artery then hooks around the lower border of the mandible
at the anterior edge of the masseter muscle insertion. It is superficially located here
just under the platysma and is crossed by the marginal mandibular branch of the fa-
cial nerve. It may even groove the mandible as it curves around the mandible and as-
cends to the angle of the mouth over the buccinator and deep to the mimetic mus-
cles. At the angle of the mouth the superior and inferior labial arteries branch off
and the facial artery ascends along the nasofacial line to end in an anastomosis with
the dorsal nasal branch of the ophthalmic artery. During this portion of its course
it runs deep to or within the levator labii superioris alaeque nasi. Branches of the fa-
cial artery contribute to the blood supply of soft tissue and skin of the face and in-
clude the submental artery, inferior labial artery, superior labial artery, and lateral
nasal vessel. Most of the contribution from the facial artery and its branches to the
overlying skin is through densely populated multiple musculocutaneous vessels.
The submental artery takes origin from the facial artery just as it turns upward over
the inferior border of the mandible. It runs forward below the body of the mandible
lying on the mylohyoid muscle. It supplies the surrounding muscles, then courses
over the mandible at the chin where its branches anastomose with branches of the
inferior labial and mental arteries to supply the skin of the chin through musculo-
cutaneous perforators. The inferior and superior labial arteries arise at the angle of
the mouth. The superior labial artery is the larger of the two vessels. The inferior
labial artery runs deep to the depressor anguli oris and then penetrates the orbicularis
oris muscle, running a tortuous course just deep to the vermilion border to form an
anastomosis with the inferior labial artery from the other side. Similarly, the supe-
rior labial artery runs deep to the levator anguli oris and then enters the orbicularis
oris, and through musculocutaneous perforators these two vessels supply the skin
and mucosa of the lip and chin.
The labial vessels run within the orbicularis oris muscle just deep to the vermilion
border, where they may be at risk during injection of filler materials for lip aug-
mentation.
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The occipital artery takes origin from the posterior aspect of the external carotid ar-
tery opposite the origin of the facial artery and runs posteriorly along the deep bor-
der of the posterior belly of the digastric muscle to the posterior scalp. It supplies
the posterior scalp and eventually forms an anastomosis with the supratrochlear and
supraorbital vessels.
The posterior auricular artery is a small branch that takes origin from the posterior
aspect of the external carotid artery just above the digastric and the stylohyoid mus-
cles. It runs upward between the parotid gland and the stylohyoid process of the
temporal bone to the groove between the ear cartilage and the mastoid process. It
then divides into an auricular branch supplying the cranial skin (medial surface) of
the ear and an occipital branch that supplies the retroauricular skin and will even-
tually form an anastomosis with branches of the occipital artery.
The superficial temporal artery is the smaller of the two terminal branches of the
external carotid artery. It takes origin within the parotid gland and courses upward,
crossing the zygoma, and approximately 5 cm above the zygoma it divides into its
two terminal branches—the frontal and parietal. Within the parotid gland it is crossed
by the temporal and zygomatic branches of the facial nerve and in the scalp it is ac-
companied by the auriculotemporal nerve that lies deep to it. The five branches of
the superficial temporal artery that supply the face and scalp are the transverse fa-
cial, anterior auricular, zygomatic orbital, and its two terminal branches—the frontal
and parietal.
The transverse facial artery takes origin from the superficial temporal artery within
the parotid gland and runs forward through the gland. It crosses the masseter below
the zygomatic arch and above the parotid duct accompanied by the zygomatic and
buccal branches of the facial nerve. It supplies a large area of the lateral midface and
has a large number of terminal branches that form an anastomosis with branches of
the facial and infraorbital arteries. The transverse facial artery supplies the overly-
ing skin through large fasciocutaneous perforators. The most prominent of these per-
forators is usually located at the junction of the lateral third and medial two thirds of
the line drawn from the auditory canal to the nasal spine.
The zygomaticoorbital artery may sometimes take origin from the middle tempo-
ral rather than the superficial temporal artery. It runs along the upper border of the
zygomatic arch accompanied by a vein to the lateral orbital rim and within the two
layers of the temporal fascia. It supplies the overlying skin through three or four
fasciocutaneous perforators, the largest of which is usually located at the junction of
the lateral third with the medial two thirds of the line from the auditory canal to
the nasion.
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Chapter 40  Applied Anatomy of the Face and Neck

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Part VIII  Face Lift and Neck Lift
External carotid artery
Facial artery
Infraorbital artery
Superficial temporal artery
Mental artery
Supraorbital artery
Supratrochlear artery
External carotid artery
Facial artery
Infraorbital artery
Parietal branch of
superficial temporal artery
Mental
artery
Supraorbital artery
Supratrochlear artery
Angular artery
Frontal branch of
superficial temporal artery
Transverse facial artery
Maxillary artery
Submental artery
The frontal branch of the superficial temporal artery takes origin 5 cm above the zy-
goma and runs anteromedially. It forms multiple anastomoses with the vessel on the
opposite side and with branches of the supraorbital and supratrochlear vessels. It
supplies the overlying skin through musculocutaneous perforators. The parietal or
posterior branch of the superficial temporal artery is the larger of the two terminal
branches. It runs upward and backward, forming multiple anastomoses with the ves-
sel on the opposite side and with the postauricular and occipital arteries.

The internal maxillary artery contributes to the blood supply of the facial soft tis-
sues and skin through the mental and infraorbital branches. The mental artery is the
terminal branch of the inferior alveolar artery, which is a branch of the first or
mandibular portion of the internal maxillary artery. The small vessel emerges through
the mental foramen of the mandible accompanied by the mental nerve. Its branches
form an anastomosis with the inferior labial and submental branches of the facial
artery. Through musculocutaneous perforators it contributes to the blood supply of
the chin and lips.
The infraorbital artery is a branch of the third (pterygopalatine) portion of the max-
illary artery. It enters the orbit through the posterior part of the inferior orbital fis-
sure and runs along the infraorbital groove and canal with the infraorbital nerve to
emerge onto the face through the infraorbital foramen deep to the levator labii su-
perioris. It descends between the levator labii superior and levator anguli oris. Its
branches form an anastomosis with branches of the facial, superior labial, and trans-
verse facial artery to supply the overlying skin through musculocutaneous perforators.
Internal Carotid Artery
The internal carotid artery contributes to the blood supply of the forehead and scalp
through the supraorbital and supratrochlear branches of its ophthalmic division
and the eyelids through the palpebral branches. The supraorbital artery accompanied
by the supraorbital nerve leaves the orbit through the supraorbital foramen or notch
and divides into superficial and deep branches. It supplies the overlying muscle and
through musculocutaneous perforators the forehead skin. Its terminal branches form
an anastomosis with the supratrochlear and frontal branch of the superficial tem-
poral artery. The supratrochlear artery is one of the terminal branches of the oph-
thalmic artery and leaves the orbit accompanied by the supratrochlear nerve along
the superior and medial aspect of the orbit. There may be a definite notch in the or-
bit where the vessel and nerve exit. This vessel supplies musculocutaneous perfora-
tors to the overlying skin and forms an anastomosis with branches of the supraor-
bital artery.
The small paired palpebral arteries supply the eyelids. The medial palpebral arteries
(superior and inferior) take origin directly from the terminal portions of the oph-
thalmic artery below the trochlear head of the superior oblique muscle. They enter
the eyelids and then run along the tarsus to form an anastomosis with the lateral
palpebral vessels. The lateral palpebral arteries are branches of the lacrimal artery.
Functional Significance
The facial vessels lie primarily in the deepest plane of the face with the parotid duct
and buccal and zygomatic branches of the facial nerve. These vessels are avoided in
a subperiosteal face lift as well as in deep plane and composite face lifts. The contri-
bution of the facial vessels to the blood supply of the skin is through a network of
musculocutaneous perforators located along the oral commissures and the nasolabial
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Chapter 40  Applied Anatomy of the Face and Neck

folds. As noted by Whetzel and Mathes, the anterior region of the face receives its
blood supply through a dense network of musculocutaneous perforators, whereas
the lateral face is supplied through a network of sparsely populated fasciocutaneous
perforators. Skin undermining during rhytidectomy will divide these fasciocutaneous
perforators located laterally. The blood supply to the facial flap is then dependent on
the medially located musculocutaneous perforators. Further separation of skin from
subcutaneous tissue toward the nasolabial fold will divide these perforators. The deep
plane approach preserves these musculocutaneous perforators and thus enhances
and maintains skin flap circulation.
The forehead blood supply is plentiful, and ischemia of the forehead and scalp is rare
even following the transcoronal approach, because the blood supply to the overly-
ing skin is through musculocutaneous perforators, which are not disturbed except
with the subcutaneous brow-lift technique. The blood supply to the scalp hairs is
plentiful. However, it can be compromised by excess tension or by sutures that stran-
gulate the blood supply to incision margins. Since the length of skin incisions is lim-
ited and the surrounding subdermal plexus is preserved, endoscopic approaches
should help to prevent or limit hair loss.
Injection of filler materials should be performed with caution in the glabellar region
and lips. Intraarterial injection, especially under pressure, may lead to vascular com-
promise and in the periorbital area may lead to visual problems through forceful ret-
rograde flow into the central retinal artery. The safer and preferred method is to push
the syringe plunger while withdrawing the needle.
V enous Drainage of the Face and Neck
Although not as critical to the survival of soft tissues and flaps during facial rejuve-
nation, knowledge of the venous drainage of the head and neck is essential, because
some of the veins bear a close anatomic relationship to nerves we strive to protect
during facial dissection (for example, the frontal branches of the facial nerve and the
sentinel vein, great auricular nerve, and external jugular vein). Intraoperative injury
of the veins will lead to profuse bleeding. Although rare, postoperative hematoma
may be related to intraoperative venous injury. Knowledge of the venous drainage
will contribute to our understanding of postoperative facial swelling.
The following discussion of the venous drainage of the head and neck is not as de-
tailed as that of the arterial supply; only the significant anatomic points and rela-
tionships as they affect face and neck dissection are presented. The venous drainage
of the head and neck is divided into a superficial and a deep system. Aesthetic sur-
geons normally encounter only the superficial system.
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Part VIII  Face Lift and Neck Lift

1307
Chapter 40  Applied Anatomy of the Face and Neck
Internal jugular vein
Occipital vein
Transverse
cervical vein
Pharyngeal vein
Maxillary vein
Sternocleidomastoid muscle
Retromandibular vein
Submental vein
Superior thyroid vein
Lingual vein
External jugular vein
Posterior external jugular vein
Anterior jugular vein
Lower end of facial vein
Inferior labial vein
Superior labial vein
Facial vein
Supratrochlear vein
Supraorbital vein
Posterior auricular vein
Middle temporal vein
Frontal branch of
superficial temporal vein
Superficial temporal vein
Parietal branch of
superficial temporal vein
Internal jugular vein
Digastric muscle
Sternocleidomastoid muscle
External jugular vein
Anterior jugular vein
Cricothyroid muscle
Superior thyroid vein
Facial vein
Jugular arch
Internal jugular vein
Submandibular gland
Parotid gland
External jugular vein

Facial Vein
Anatomic Features
The supratrochlear and supraorbital veins drain the forehead and anterior scalp.
These vessels start in the anterior scalp and forehead and join each other along the
medial border of the orbit to form the facial vein. The facial vein then runs along the
medial border of the orbit and root of the nose, coursing downward and backward
with the facial artery. It passes under the zygomaticus major, descending obliquely
toward the mandibular border. Along this part of its course, it is related to the facial
artery and the branches of the facial nerve. It crosses the border of the mandible and
runs superficial to the submandibular gland, posterior belly of the digastric muscle
and courses posteriorly to join the internal jugular vein at the level of the hyoid bone.
Functional Significance
The facial vein has no valves, and through its tributaries, the supraorbital vein and
the superior ophthalmic vein, it communicates with the cavernous sinus. The clini-
cal relevance is that any infection involving the facial vein may extend into the in-
tracranial venous system. The facial vein lies deep to the zygomaticus major and
should be safe during deep plane dissections over the zygomaticus major muscle.
Superficial Temporal Vein
Anatomic Features
The superficial temporal vein drains the temporal and posterior scalp region and
communicates with the supratrochlear and supraorbital veins through tributaries.
This vein takes a more superficial route than the facial vein, crossing the zygomatic
arch and running across the superficial surface of the parotid gland. It receives nu-
merous tributaries and is eventually joined by the posterior auricular vein to become
the external jugular vein. The occipital vein drains the lateral and posterior scalp,
piercing the trapezius muscle at the junction of the head and neck to join the deep
cervical and vertebral veins, and through its tributaries communicates with the pos-
terior auricular vein.
Functional Significance
On rare occasions, extensive posterior dissection in the retroauricular area may ex-
pose the occipital vein.
The posterior auricular vein courses along the retroauricular area and is a commu-
nicating vein between the occipital and the external jugular, which is made up of the
union of the postauricular and superficial temporal veins. These are all superficial
veins and may be injured during facial dissections.
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Part VIII  Face Lift and Neck Lift

Veins of the Neck
The veins of the neck are divided into superficial and deep, depending on their rela-
tionship to the deep fascia of the neck. The superficial veins are tributaries of the ex-
ternal jugular and drain the subcutaneous structures of the neck. The deep veins all
drain into the much larger internal jugular vein and are rarely exposed during aes-
thetic surgery.
External Jugular Vein
The external jugular vein receives most of the blood from the face and scalp. It is made
up of the union of the superficial, temporal, and posterior auricular vein. It origi-
nates at the level of the mandibular angle and runs down the neck to the middle of
the clavicle, entering the subclavian vein just behind the clavicle. The external jugu-
lar is covered by the platysma muscle along most of its length, and it lies over the
deep cervical fascia. The great auricular nerve ascends along the vein toward the face.
Functional Significance
The external jugular vein is at risk during dissection deep to the platysma and is in
close relationship with the great auricular nerve, as the nerve courses upward toward
the ear.
Anterior Jugular Veins
Several small veins in the submandibular region join on each side to become the an-
terior jugular veins, which descend along the mylohyoid muscle and the sternohy-
oid muscles toward the sternal notch, draining eventually into the external jugular
vein or directly into the subclavian. These veins are of variable size.
Functional Significance
The anterior jugular veins are often at risk during subplatysmal dissection and may
bleed profusely. They are easily identified, running from above downward along the
medial border of the strap muscles.
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Chapter 40  Applied Anatomy of the Face and Neck

Sentinel Vein
Anatomic Features
1310
Part VIII  Face Lift and Neck Lift
Zygomatico-
temporal
nerve
Sentinel vein
(medial zygomatico-
temporal vein)
Lateral
zygomatico-
temporal vein
The zygomaticotemporal veins (two of them) are communicating veins between the
superficial and deep system. They connect the superficial system through the tempo-
ralis to the deep venous system of the face. These paired vessels are located above the
zygoma and lateral to the orbital rim. The more lateral of the two is usually smaller
in size and is accompanied by the zygomaticotemporal nerve. The larger, more me-
dial vessel is called the sentinel vein. It is a very useful anatomic landmark for iden-
tifying clinically, preoperatively and intraoperatively, the course of the frontal
branches of the facial nerve. When present, the vein is easily identified during a brow
lift, whether by an open or endoscopic approach. The branches of the facial nerve
usually course 1 cm above this vein. The name “sentinel vein” may be a misnomer,
because by the time the dissection has reached the vein, it has already passed deep
to the nerves.
Functional Significance
In most patients the location of the sentinel vein is visible when the patient is in the
recumbent position. A centimeter above the vein, a mark is made on the skin indi-
cating the course of the frontal branch of the facial nerve. Brow-lift dissection can
proceed rapidly up to that point, then slowly and carefully, under endoscopic or open
control, until the sentinel vein has been identified. This is a useful guideline for avoid-
ing possible injury to the frontal branches of the facial nerve that run in or just super-
ficial to the temporoparietal fascia.
Whenever possible, these communicating veins should be preserved. Cauterization or
tying off of these veins will lead to further prominence of veins in the periorbital area.

Lymph Nodes of the Face and Neck
Anatomic Features
1311
Chapter 40  Applied Anatomy of the Face and Neck
Submental
lymph nodes
Superficial
parotid
lymph nodes
Retroauricular
lymph nodes
Superficial cervical
lymph nodes
ental
nodes
e
Submental
lymph nodes
Superficial
parotid
lymph nodes
During face and neck lifts it is not uncommon to encounter superficial lymph nodes.
The most commonly encountered lymph nodes are the retroauricular nodes lying be-
hind the ear over the sternomastoid, and the superficial cervical nodes on the super-
ficial surface of the sternomastoid. These lymph nodes may be encountered during
the retroauricular and neck dissections. Anteriorly on occasion the superficial parotid
nodes may be encountered during sub-SMAS dissection. The submental lymph nodes
are encountered during subplatysmal or interplatysmal dissections.

Functional Significance
If lymph nodes are encountered during the dissection for face or neck lifts, they should
be evaluated and dealt with appropriately. These lymph nodes are usually small and
normal. However, if they have an unusual appearance or are large in size, it would
be advisable to do an excisional biopsy. The presence of these lymph nodes or en-
countering them during the dissection should not affect the conduct of the opera-
tion in any way, nor will it affect the final result.
Sensory Nerve Supply
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Part VIII  Face Lift and Neck Lift
Ophthalmic nerve
Greater
occipital
nerve
(cervical
dorsal rami
2 and 3)
Supraclavicular
nerves
Mandibular
nerve
Maxillary
nerve
Lesser
occipital
nerve
(cervical
ventral
ramus 2)
Cervical
dorsal rami
3, 4, and 5
Greater
auricular nerve
(cervical
ventral rami
2 and 3)
Transverse
nerve of neck
(cervical
ventral rami
2 and 3)
cutaneous
The sensory innervation of the face and scalp is based on the trigeminal nerve and
cervical spinal nerves with a small contribution to the auditory canal through the
eighth and tenth cranial nerves. Each of the branches of the trigeminal nerve has its
own well-delineated skin territory. That of the ophthalmic division is supplied through
the supraorbital, supratrochlear, infratrochlear, lacrimal, and external nasal branches;
that of the maxillary through the zygomaticotemporal, zygomaticofacial, and in-
fraorbital branches; and the mandibular through its auricular temporal, buccal, and
mental branches.

Ophthalmic Division
Anatomic Features
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Chapter 40  Applied Anatomy of the Face and Neck
The frontal nerve is the largest branch of the ophthalmic division entering the orbit
through the superior orbital fissure above the muscles. It runs forward in the orbit
and divides into a small supratrochlear branch and a larger supraorbital branch. The
supratrochlear branch runs medially forward above the trochlea of the superior
oblique muscle emerging from the orbit medially. It curves upward accompanied by
the supratrochlear branch of the ophthalmic artery to innervate the central portion
of the forehead. The supraorbital is the larger of the two branches and passes for-
ward to the supraorbital notch or foramen to exit with the supraorbital branch of
the ophthalmic artery to innervate the forehead and scalp. The lateral branch of the
supraorbital nerve is the major sensory nerve of the scalp and enters the hair-bearing
scalp medial to the temporal crest.
The infratrochlear nerve is a small branch of the nasociliary nerve that runs along
the medial wall of the orbit near the pulley of the superior oblique muscle. It receives
a branch from the supratrochlear nerve and leaves the orbit to supply the medial eye-
lid and a small area on the upper medial side of the nose. The lacrimal nerve, the
smallest branch of the ophthalmic artery, innervates the lacrimal gland and leaves
the orbit to innervate the eyelids and a small area of the adjacent temporal region.
Supraorbital nerve
Greater
occipital
nerve
Mental
nerve
Dorsal rami
(C3-5)
Anterior
greater
auricular
nerve
(C2-3)
Auriculo-
temporal
nerve
Transverse
cervical nerve
(C2-3)
Lesser
occipital
nerve
Zygomatico-
temporal
nerve
Zygomatico-
facial
nerve
Buccal
nerve
Posterior
Posterior
greater
greater
auricular
auricular
nerve
nerve
(C2-3)
(C2-3)
Posterior
greater
auricular
nerve
(C2-3)
Infra-
orbital
nerve
Supratrochlear nerve
Lacrimal nerve
Infratrochlear nerve
External nasal nerve
Cranial nerve X
Cranial nerve VII

Functional Significance
The supraorbital and supratrochlear nerves are important considerations when per-
forming a brow lift. These nerves course in a paramedial position upward in the fore-
head to the scalp and dividing them causes hypesthesia of the dome of the scalp.
There is slow return of sensibility after division of these nerves, and patients often
experience paresthesia, pruritus, and other annoying side effects. The supraorbital
nerves are usually spared during an endoscopic forehead lift. With midline and lateral
temporal incisions, the main branches of these nerves are left undisturbed. The en-
doscopic forehead approach benefits from the magnification by permitting the sur-
geon to remove the corrugator and procerus muscles while sparing the branches of
the supraorbital and supratrochlear nerves.
The supraorbital nerve is much larger than the supratrochlear nerve. It leaves the or-
bit through a definite notch or occasionally through a foramen located approximately
1 cm above the orbital rim. Whereas the supraorbital nerve is usually a single thick
nerve, the supratrochlear nerve may have several branches rather than a thick trunk.
The supraorbital nerve can be marked on the skin at the supraorbital rim above the
midpupillary line. This corresponds well with the skin markings for the infraorbital
nerve located 1 cm below the infraorbital rim in the midpupillary line. This same
midpupillary line, continued below the lip, marks the location of the mental nerve.
The lateral branch of the supraorbital nerve represents the main sensory innervation
of the scalp and runs along the temporal crest or medial to it. Incisions in the scalp
crossing medially past the temporal crest risk injury to the nerve and scalp numbness.
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Part VIII  Face Lift and Neck Lift
The supratrochlear nerve lies within or deep to the medial fibers of the corrugator
muscle, and its medial branches may be associated with the fibers of the procerus.
The supraorbital nerve is also associated with the lateral fibers of the corrugator.
During subperiosteal endoscopic or open myectomy, part of each muscle must usu-
ally be removed to fully expose these nerves. When these nerves lie deep to the mus-
cle, they are seen before muscle dissection, because the subperiosteal endoscopic ap-
proach allows visualization of these structures from their deep surface.
Supraorbital
foramen
Supraorbital
nerve

Maxillary Division
Anatomic Features
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Chapter 40  Applied Anatomy of the Face and Neck
The maxillary division innervates the skin of the midface through its zygomaticotem-
poral, zygomaticofacial, and infraorbital branches. The zygomatic nerve arises in the
pterygopalatine fossa and enters the orbit through the inferior orbital fissure. It
courses along the lateral border of the orbit and divides into two branches, the zy-
gomaticotemporal and zygomaticofacial nerves.
The zygomaticotemporal nerve passes along the inferior wall of the orbit and exits
through a foramen into the temporal fossa and ascends between the bone and the
temporalis, piercing the deep temporal fascia 2 cm above the zygomatic arch to in-
nervate the skin of the temple region. Along the terminal part of its course it is ac-
companied by one of the zygomaticotemporal veins, the lateral one. The zygomati-
cofacial branch passes along the inferolateral border of the orbit and exits through a
foramen in the zygomatic bone and then through the orbicularis oculi to innervate the
skin of the cheek below the zygoma. The maxillary nerve is a purely sensory nerve
when it enters the orbit through the inferior orbital fissure and becomes the infraor-
bital nerve. It runs along the infraorbital groove to exit through the infraorbital fora-
men accompanied by the infraorbital branch of the internal maxillary artery. It in-
nervates the skin of the cheek and upper lip.
Zygomaticofacial nerve
Zygomaticotemporal nerve
Mental nerve
Supraorbital nerve
Supratrochlear nerve
Infraorbital nerve
Auriculotemporal nerve
Infratrochlear nerve

Functional Significance
The skin marking for the infraorbital nerve is in the midpupillary line 1 cm below
the infraorbital rim. The zygomaticotemporal nerve pierces the deep temporal fas-
cia 2 cm above the zygoma and 2 cm lateral to the orbit. It is easily identified and
just as readily injured during open or endoscopic subgaleal dissection in the lateral
brow–temporal region. Division of the nerve leads to some minor sensory loss in the
temporal region. The zygomaticofacial nerve exiting through a foramen in the zy-
goma just lateral to the orbit is located directly in the path of subperiosteal dissec-
tion. This nerve is easily identified and preserved. Division of the nerve will result in
a small area of sensory loss below the zygoma. The zygomaticotemporal nerve is of-
ten identified during endoscopic brow lifts, accompanied by the more lateral of the
two zygomaticotemporal veins.
Mandibular Division
Anatomic Features
The mandibular nerve innervates facial skin through the auriculotemporal, buccal,
and mental branches. The auriculotemporal nerve arises from two roots encircling
the middle meningeal artery. It runs backward under the lateral pterygoid muscle on
the surface of the tensor veli palatini to pass between the sphenomandibular liga-
ment and the neck of the mandible. The buccal branch of the mandibular nerve passes
forward between the two heads of the lateral pterygoid muscle and then deep to or
through the lower part of the temporalis muscle to emerge from under the mandibu-
lar ramus and anterior border of the masseter. It communicates with buccal branches
of the facial nerve and then innervates the skin of the cheek over the buccinator. The
mental nerve, the continuation of the alveolar nerve, exits the mandible through the
mental foramen to innervate the chin and lower lip.
Functional Significance
The auriculotemporal nerve courses with the superficial temporal artery and is eas-
ily and quite often injured or divided during open face-lift and brow-lift procedures.
The mental nerve exits through the mental foramen at the level of the second pre-
molar and the skin markings are 2 cm below the lip in the midpupillary line, making
it easily identified and preserved during open or endoscopic exposure for alloplas-
tic implant placement.
Nerves of the Cervical Spine
Anatomic Features
The cervical spinal nerves innervate the neck, ear, lower face, and posterior scalp.
The greater occipital nerve is the medial branch of the dorsal ramus of C2. It ascends
obliquely between the inferior oblique and semispinalis capitis, which it pierces. It
then pierces the trapezius and runs upward and forward to innervate the scalp up to
the vertex. The superficial ascending branches of the cervical plexus are branches of
the ventral rami; the lesser occipital C2, greater auricular C2-3, and transverse cu-
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Part VIII  Face Lift and Neck Lift

1317
Chapter 40  Applied Anatomy of the Face and Neck
The great auricular nerve is the most commonly injured nerve during open rhytidec-
tomy. It is at greatest risk in its superficial location on the sternocleidomastoid mus-
cle, 6.5 cm below the external auditory canal. Division of the nerve will lead to numb-
ness of portions of the ear. Although this numbness is a nuisance, the possibility of
a neuroma developing in the cut end of the nerve poses even greater problems. These
nerves can be blocked as they exit the posterior surface of the midsternocleidomas-
toid muscle.
Great auricular nerve
External jugular vein
Spinal
accessory
nerve
6.5 cm
McKinney’s
point
Great auricular nerve
External jugular vein
taneous C2-3 innervate the lower lateral face, upper neck, submental area, and most
of the ear. The lesser occipital nerve arising from C2-3 curves around the accessory
nerve ascending along the posterior border of the sternocleidomastoid and contin-
ues upward on the side of the skull behind the ear. It innervates a small portion of
the medial surface of the ear and the posterolateral neck and scalp.
The greater auricular nerve is the largest of the ascending branches of the cervical
plexus. It arises from the dorsal rami of C2-3, encircles the posterior border of the
sternocleidomastoid muscle, perforates the deep fascia 6.5 cm below the external au-
ditory canal, and then courses upward. At this point it may lie deep to the platysma
and is accompanied by the jugular vein. However, during its upward course toward
the parotid gland, it lies within the subcutaneous tissues. At the level of the parotid
it divides into anterior and posterior branches. The anterior branch innervates the
skin of the face over the parotid and the posterior branch and continues upward to
innervate the skin over the mastoid process and most of the medial and lateral sur-
faces of the ear, including the concha and lobule.
The transverse cutaneous nerve of the neck arises from the dorsal rami of C2-3 and
turns around the posterior border of the sternocleidomastoid muscle at about its
midpoint. It then runs obliquely forward and upward deep to the platysma and ex-
ternal jugular vein toward the anterior border of the sternocleidomastoid muscle
where it divides into an ascending and a descending branch. The ascending branch
innervates the submandibular and submental regions, and the descending branch in-
nervates the side and front of the neck.
Functional Significance

Lower buccal branch
Temporal branch
Zygomatic branch
Facial nerve
Marginal mandibular branch
Motor Nerve Supply
Facial Nerves
Anatomic Features
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Part VIII  Face Lift and Neck Lift
Surgeons performing facial aesthetic surgery must have a clear understanding of the
facial nerve. Damage to a single branch of this nerve causes a visible muscle palsy
and significant facial asymmetry, distressing to both patient and surgeon. Fortunately,
most postoperative facial muscle weakness is caused by reversible stretch injuries to
the facial nerve branches; however, division of the nerve, although rare, is always a
possibility.
The facial nerve emerges through the stylomastoid foramen and is immediately pro-
tected by the parotid gland. Within the parotid gland it divides into an upper and
lower portion and then into its five major branches: the temporal (frontal), zygo-
matic, buccal, marginal mandibular, and cervical. The branches then emerge medi-
ally from the parotid gland lying initially on the superficial surface of the masseter
and deep to the parotideomasseteric fascia (deep facial fascia). Beyond the masseter
muscle, the branches lie over the buccal fat pad, and at this level the facial nerve
branches, the parotid duct, and the facial vessels are all at the same depth. Facial
nerve branches proceed medially and innervate the mimetic muscles on their deep
surface, except for the deepest level muscles, the mentalis, levator anguli oris, and

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Chapter 40  Applied Anatomy of the Face and Neck
Although the facial nerve branches are deep and well protected during facial dissec-
tion, the frontal branches and marginal mandibular branch are most at risk. The
frontal branches, unlike the others that lie deep to the facial fascial layers, assume a
superficial course once they cross the zygomatic arch. They cross the zygomatic arch
at approximately the midpoint of a line drawn from the tragus to the lateral can-
thus. At this level they assume a superficial course running within the sub-SMAS fat
just deep to the temporoparietal fascia. More distally they pierce the temporopari-
etal fascia to innervate the frontalis on its deep surface.
Along the medial portion of its course, the marginal mandibular branch is well pro-
tected by the parotid gland. Beyond the parotid it is protected by the rather thick
SMAS platysma layer. Here it usually runs at or below the mandibular margin. As it
crosses the facial vessels deep to the platysma it courses upward and is usually lo-
cated well above the mandibular margin. At the level of the facial vessel, the platysma
and fascia are usually thinner.
Marginal mandibular
nerve
Frontal branches
Zygomatic
and
buccal
branches
Marginal
mandibular nerve
Lateral border of the
zygomaticus major
buccinator, which are innervated on their superficial surfaces. Dissection during deep
plane or composite face-lift procedures, either endoscopic or open, superficial to the
zygomaticus muscles will also be superficial to the facial nerve branches.

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Part VIII  Face Lift and Neck Lift
The marginal mandibular branch in its periph-
eral course follows the mandibular border. Be-
fore crossing the facial vessels it may extend 1 or
2 cm below the border of the mandible. However,
once it has crossed the facial vessels, it always
runs above the border of the mandible. It is deep
to the platysma throughout its course; however,
as the platysma thins, this nerve could be in jeop-
ardy. To prevent injury to the nerve, any sub-
platysmal dissection should begin at least 2 cm
below the angle of the mandible. Dissection above
the platysma laterally and deep to the platysma
centrally will avoid nerve injury.
Functional Significance
Injuries to the buccal and zygomatic branches of the facial nerve are extremely rare.
These branches of the facial nerve are located deep to the SMAS and the deep facial
fascia. For injury to occur during rhytidectomy not only must the SMAS layer be
penetrated but also the deep facial fascia. Since there are multiple interconnections
between the buccal and zygomatic branches, injury to one or more branches would
probably not result in a clinically noticeable deficit.
Dissection deep to the fixed or immobile portion of the SMAS (the portion adher-
ent to and overlying the parotid gland) is safe and best performed sharply with a
scalpel or scissors, but dissection deep to the mobile SMAS, beyond the parotid
gland, must be done cautiously and should be performed bluntly by spreading rather
than cutting.
The frontal and marginal mandibular branches are at greater risk. The frontal branch
assumes a superficial course after it crosses the zygomatic arch. In this area a viola-
tion of the SMAS or superficial fascial layer (temporoparietal fascia) may result in
nerve injury. Lower on the cheek, however, the SMAS and deep facial fascia must be
penetrated before the buccal or zygomatic branches are placed at risk. Therefore a
safe plane of dissection in the temporal region would be either deep or superficial to
the frontal branch. When combining an open coronal brow lift with a face lift, the
dissection above the zygoma is in the loose areolar plane deep to the temporopari-
etal fascia on top of the superficial layer of the deep temporal fascia and below the
temporoparietal fascia. Below the zygoma the dissection is in the more superficial
subcutaneous level, leaving an intervening “mesentery” to protect the nerve.
During an endoscopic brow lift, injury to the frontal branch can be avoided in sev-
eral ways. Lateral dissection in the plane immediately above the superficial layer of the
deep temporal fascia in the lateral brow must proceed cautiously in a medial to in-
Marginal
mandibular branch
of facial nerve