Anatomy of the Face and Neck

2
Peter M. Prendergast

2.1 Introduction Following a description of the hard tissue foundation,

the soft tissues of the face will be described, from
Safe and effective cosmetic surgical practice relies on a superficial to deep, in the following order:
clear knowledge and understanding of facial anatomy. 1. Superficial fat compartments
Techniques evolve and improve as the complex, lay- 2. Superficial musculoaponeurotic system (SMAS)
ered architecture and soft tissue compartments of the 3. Retaining ligaments
face are discovered and delineated through imaging, 4. Mimetic muscles
staining techniques, and dissections both intraopera- 5. Deep plane, including the deep fat compartments
tively and in the research laboratory on cadavers [1]. To
create a more youthful, natural-looking form, the sur-
geon endeavors to reverse some of the changes that 2.2 Facial Skeleton
occur due to aging. These include volumetric changes
in soft tissue compartments, gravitational changes, and Facial appearance is to a large extent determined by
the attenuation of ligaments. Whether the plan of reju- the convexities and concavities of the underlying facial
venation includes rhytidectomy, platysmaplasty, autol- bones (Fig. 2.1). The “high” cheekbones and strong
ogous fat transfer, implants, or endoscopic techniques, chin associated with attractiveness are attributable to
a sound knowledge of facial and neck anatomy will the convexities and projection provided by the zygo-
increase the likelihood of success and reduce the inci- matic bone and mental protuberance of the mandible,
dence of undesirable results or complications. respectively (Fig. 2.2). The facial skeleton consists of
This chapter describes the anatomy of the face in the frontal bone superiorly, the bones of the midface,
layers or planes, with some important structures or and the mandible inferiorly. The midface is bounded
regions described separately, including the facial nerve, superiorly by the zygomaticofrontal suture lines, infe-
sensory nerves, and facial arteries. The superficial riorly by the maxillary teeth, and posteriorly by
layers and topography of the neck are also described. the sphenoethmoid junction and the pterygoid plates.
The facial skeleton forms the hard tissue of the face and The bones of the midface include the maxillae, the
provides important structural support and projection zygomatic bones, palatine bones, nasal bones, zygo-
for the overlying soft tissues, as well as transmitting matic processes of the temporal bones, lacrimal bones,
nerves through foramina and providing attachments for ethmoid bones, and turbinates. The facial skeleton
several mimetic muscles and muscles of mastication. contains four apertures: the two orbital apertures, the
nasal aperture, and the oral aperture. The supraorbital
foramen (or notch) and the frontal notch are found at
the superior border of each orbit and transmit the
supraorbital and supratrochlear nerves, respectively.
P.M. Prendergast
Venus Medical, Dublin, Ireland The maxillary bones contribute to the nasal aperture,
e-mail: [email protected] bridge of the nose, maxillary teeth, floor of the orbits,

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 29

DOI 10.1007/978-3-642-21837-8_2, © Springer-Verlag Berlin Heidelberg 2012
30 P.M. Prendergast

Fig. 2.1 Frontal view of the facial skeleton

and cheekbones. The infraorbital foramen lies in the The mandible forms the lower part of the face. In
maxilla below the inferior orbital rim and transmits the midline, the mental protuberance gives anterior
the infraorbital nerve. The zygomaticofacial foramen projection to the overlying soft tissues. Laterally, the
transmits the zygomaticofacial nerve inferolateral to ramus of the mandible underlies the masseter muscle
the junction of the inferior and lateral orbital rim. and continues superiorly to articulate with the cranium
2 Anatomy of the Face and Neck 31

Fig. 2.2 Convexities of the facial skeleton

Temporal process of
zygomatic bone

Zygomatic bone

Zygomatic process
of maxilla

Mental protruberance of
mandible

through the coronoid process and condylar process from one another by delicate fascial tissue and septae
of the mandible. The mental nerve emerges from that converge where adjacent compartments meet
the mental foramen on the body of the mandible in to form retaining ligaments. The superficial fat com-
line vertically with the infraorbital and supraorbital partments of the face comprise the following: the naso-
nerves. labial fat compartment; the medial, middle, and lateral
As well as providing structural support, projection, temporal-cheek “malar” fat pads; the central, middle,
and protection of sensory organs such as the eyes, and lateral temporal-cheek pads in the forehead; and
the facial skeleton provides areas of attachment for the superior, inferior, and lateral orbital fat pads
the muscles of facial expression and the muscles of (Fig. 2.4). Nasolabial fat lies medial to the cheek fat
mastication (Fig. 2.3). pad compartments and contributes to the overhang of
the nasolabial fold. The orbicularis retaining ligament
below the inferior orbital rim represents the superior
2.3 Superficial Fat Compartments border of the nasolabial fat compartment and the
medial cheek compartment (Fig. 2.5). The middle
The pioneering work of Rohrich and Pessa [2], using cheek fat compartment lies between the medial and
staining techniques and cadaver dissections, has lateral temporal-cheek fat compartments and is
revealed a number of distinct superficial fat compart- bounded superiorly by a band of fascia termed the
ments in the face. These compartments are separated superior cheek septum. The borders of the middle
32 P.M. Prendergast

Fig. 2.3 Areas of muscle Procerus

attachments to the facial
skeleton Corrugator
supercilii

Orbicularis oculi
Temporalis
Upper orbital part
Palpebral part
Levator labii superioris
Lower orbital part
alaeque nasi
Levator labii superioris

Zygomaticus major
Zygomaticus minor Masseter
Levator anguli oris
Nasalis: transverse part
Depressor septi
Nasalis: alar part
Temporalis
Buccinator
Platysma Masseter

Depressor anguli oris Mentalis

Depressor labii inferioris

cheek compartment, the inferior, and the lateral orbital adheres to the depressor anguli oris muscle and is
fat pad compartments converge to form a tougher band bounded medially by the depressor labii and inferiorly
of tissue called the zygomatic ligament [3]. The con- by bands of the platysma muscle. Premental and pre-
densation of connective tissue at the borders of the platysmal fat abut the jowl fat compartment.
medial and middle fat compartments correlates with The compartmentalized anatomy of the superficial
the masseteric ligaments in the same location [4]. The subcutaneous fat of the face has implications in the
lateral temporal-cheek fat pads span the entire face aging process. Volume loss appears to occur at
from the forehead to the cervical area. Its anterior different rates in different compartments, leading to
boundary, the lateral cheek septum, is encountered irregularities in facial contour and loss of the seam-
during facelift procedures with medial dissection from less, smooth transitions between the convexities and
the preauricular incision. In the forehead, its upper and concavities of the face associated with youthfulness
lower boundaries are identifiable as the superior and and beauty.
inferior temporal septa. Medial to the lateral temporal-
cheek fat compartment in the forehead, the middle
temporal fat pad is bounded inferiorly by the orbicu- 2.4 Superficial Musculoaponeurotic
laris retaining ligament and medially by the central System
forehead fat compartment. Above and below the eyes,
the superior and inferior orbital fat compartments lie In 1976, Mitz and Peyronie [5] published their descrip-
within the perimeter of the orbicularis retaining liga- tion of a fibrofatty superficial facial fascia they called
ment. These periorbital fat pads are separated from the superficial musculoaponeurotic system (SMAS).
one another medially and laterally by the medial and This system or network of collagen fibers, elastic
lateral canthi, respectively. The lateral orbital fat fibers, and fat cells connects the mimetic muscles to
compartment is the third orbital fat pad and is bounded the overlying dermis and plays an important func-
superiorly by the inferior temporal septum and inferi- tional role in facial expression. The SMAS is central to
orly by the superior cheek septum. The zygomati- most current facelift techniques where it is usually dis-
cus major muscle attaches, through fibrous septae, to sected, mobilized, and redraped. In simple terms, the
overlying superficial fat compartments along its length. SMAS can be considered as a sheet of tissue that
In the lower third of the face, the jowl fat compartment extends from the neck (platysma) into the face (SMAS
2 Anatomy of the Face and Neck 33

Fig. 2.4 The superficial fat Lateral Temporal-Cheek Middle forehead

compartments of the face (forehead)

Central
Lateral orbital

Medial

Superior
orbital

Middle
Inferior
orbital

Nasolabial

Lateral
temporal-cheek
Jowl

Pre-platysma fat

proper), temporal area (superficial temporal fascia), mouth to the overlying skin and has an important role
and medially beyond the temporal crest into the fore- in transmitting complex movements during animation.
head (galea aponeurotica). However, the precise anat- Over the parotid gland, the SMAS is relatively thick.
omy of the SMAS, regional variations, and even the Further medially, it thins considerably making it diffi-
existence of the SMAS are debated [6]. Ghassemi et al. cult to dissect. In the lower face, the SMAS covers the
[7] describe two variations of SMAS architecture. facial nerve branches as well as the sensory nerves.
Type I SMAS consists of a network of small fibrous Dissection superficial to the SMAS in this region pro-
septae that traverse perpendicularly between fat lob- tects facial nerve branches [8]. Above the zygomatic
ules to the dermis and deeply to the facial muscles or arch, the SMAS exists as the superficial temporal fas-
periosteum. This variation exists in the forehead, cia, which splits to enclose the temporal branch of the
parotid, zygomatic, and infraorbital areas. Type II facial nerve and the intermediate temporal fat pad.
SMAS consists of a dense mesh of collagen, elastic, Dissection in this area should proceed deep to the
and muscle fibers and is found medial to the nasolabial superficial temporal fascia, on the deep temporal fas-
fold, in the upper and lower lips. Although extremely cia, to avoid nerve injury. Although considered as one
thin, type II SMAS binds the facial muscles around the “system” or plane, the surgeon should be mindful of
34 P.M. Prendergast

Fig. 2.5 Ligaments and septa Superior temporal septum

between fat compartments of Interior temporal septum
the face
Orbicularis retaining Ligament

Medial canthus

Lateral canthus

Zygomatic
ligament

Lateral cheek
septum

Superior cheek septum

Masseteric
ligaments
Platysma-auricular ligament

Mandibular ligament

the regional differences in SMAS anatomy from supe- retaining ligament. The latter connects the periosteum
rior to inferior and lateral to medial. of the mandible just medial to the origin of depressor
anguli oris to the overlying dermis. This attachment
gives rise to the labiomandibular fold just anterior to
2.5 Retaining Ligaments the jowl. The masseteric ligaments are false retaining
ligaments that arise from the anterior border of the
True retaining ligaments are easily identifiable struc- masseter and insert into the SMAS and overlying
tures that connect the dermis to the underlying perios- dermis of the cheek. With aging, these ligaments atten-
teum. False retaining ligaments are more diffuse uate, the SMAS over the masseter becomes ptotic,
condensations of fibrous tissue that connect superficial and this leads to the formation of jowls [10]. Below
and deep facial fasciae [9] (Fig. 2.6). The zygomatic the lobule of the ear, the platysma-auricular ligament
ligament (McGregor’s patch) is a true ligament that represents a condensation of fibrous tissue where the
connects the inferior border of the zygomatic arch to lateral temporal-cheek fat compartment meets the pos-
the dermis and is found just posterior to the origin of tauricular fat compartment. During facial rejuvenation
the zygomaticus minor muscle [3]. Other true liga- procedures, true and false retaining ligaments are
ments include the lateral orbital thickening on the encountered and often released in order to mobilize
superolateral orbital rim that arises as a thickening of and redrape tissue planes. Extra care should be taken
the orbicularis retaining ligament, and the mandibular when releasing ligaments as important facial nerve
2 Anatomy of the Face and Neck 35

Fig. 2.6 The retaining

ligaments of the face
Orbicularis retaining ligament

Zygomatic ligament
Platysma-auricular (McGregor’s patch)
ligament

Masseteric ligament

Mandibular ligament

branches are intimately related to ligaments, such as Contraction raises the eyebrows and causes horizontal
the zygomatic and mandibular retaining ligaments. furrows over the forehead. Frontalis receives innervation
from the temporal branch of the facial nerve.
Orbicularis oculi acts as a sphincter around the eye.
2.6 Mimetic Muscles It consists of three parts, the orbital, preseptal, and pre-
tarsal parts. The orbital part arises from the nasal part of
The muscles of facial expression are thin, flat muscles the frontal bone, the frontal process of the maxilla, and
that act either as sphincters of facial orifices, as dila- the anterior part of the medial canthal tendon. Its fibers
tors, or as elevators and depressors of the eyebrows pass in concentric loops around the orbit, well beyond
and mouth. Frontalis, corrugator supercilii, depressor the confines of the orbital rim. Contraction causes the
supercilii, procerus, and orbicularis oculi represent eyes to squeeze closed forcefully. Superior fibers also
the periorbital facial muscles. The perioral muscles depress the brow. Preseptal orbicularis oculi arises from
include the levator muscles, zygomaticus major and the medial canthal tendon, passes over the fibrous
minor, risorius, orbicularis oris, depressor anguli oris, orbital septum of the orbital rim, and inserts into the
depressor labii, and mentalis. The nasal group includes lateral palpebral raphe. The pretarsal portion, involved
compressor naris, dilator naris, and depressor septi. In in blinking, overlies the tarsal plate of the eyelid and
the neck, the platysma muscle lies superficially and has similar origins and insertions to its preseptal coun-
extends into the lower face (Fig. 2.7). terpart. These muscles receive innervation from the
Frontalis represents the anterior belly of the occipito- temporal and zygomatic branches of the facial nerve.
frontalis muscle and is the main elevator of the brows. Corrugator supercilii arises from the superomedial
It arises from the epicranial aponeurosis and passes aspect of the orbital rim and passes upward and out-
forward over the forehead to insert into fibers of the ward to insert into the dermis of the middle of the
orbicularis oculi, corrugators, and dermis over the brows. brow. From its origin deep to frontalis, two slips of
36 P.M. Prendergast

Fig. 2.7 The mimetic facial

muscles Frontalis (medial)
Frontalis (lateral)
Depressor supercilii
Procerus

Levator labii superioris

alaeque nasi Corrugator

Orbicularis oculi:
Pretarsal part
Preseptal part
Orbital part
Zygomatici
Compressor naris
Dilator naris
Orbicularis oris
Depressor septi

Depressor anguli oris

Mentalis

Depressor labii
Platysma

muscle, one vertical and one transverse, pass through and lateral aspect of the upper lip, respectively. They
fibers of frontalis to reach the dermis. The superficial receive their nerve supply on their deep surface from
and deep branches of the supraorbital nerve are inti- the zygomatic and buccal branches of the facial nerve.
mately related to corrugator supercilii at its origin and Zygomaticus major and minor lift the corners of the
are prone to injury during resection of this muscle. mouth.
Corrugator supercilii depresses the brow and pulls it Levator labii lies deep to orbicularis oculi at its origin
medially, as in frowning. from the maxilla just above the infraorbital foramen. It
Depressor supercilii is a thin slip of muscle that is passes downward to insert into the upper lip and orbicu-
difficult to distinguish from the superomedial fibers of laris oris. A smaller slip of muscle medial to this, levator
orbicularis oculi. It inserts into the medial brow and labii superioris alaeque nasi, originates from the frontal
acts as a depressor. process of the maxilla and inserts into the nasal cartilage
Procerus arises from the nasal bone, passes and upper lip. Both of these muscles are supplied from
superiorly, and inserts into the dermis of the glabella branches of the zygomatic and buccal branches of the
between the brows. It depresses the lower forehead facial nerve and elevate the upper lip.
skin in the midline to create a horizontal crease at the Levator anguli oris arises deeply from the canine
bridge of the nose. Chemodenervation of procerus and fossa of the maxilla below the infraorbital foramen and
corrugator supercilii to alleviate frown lines is one of inserts into the upper lip. It is innervated on its superfi-
the most common aesthetic indications for botulinum cial aspect by the zygomatic and buccal branches of
toxins. Procerus is sometimes debulked during endo- the facial nerve and elevates the corner of the mouth.
scopic brow lift procedures to reduce the horizontal Risorius is often underdeveloped and arises from a
frown crease. thickening of the platysma muscle over the lateral
Zygomaticus major and minor are superficial mus- cheek, the parotidomasseteric fascia, or both. It inserts
cles that originate from the body of the zygoma and into the corner of the mouth and pulls the mouth
pass downwards to insert into the corner of the mouth corners laterally.
2 Anatomy of the Face and Neck 37

Orbicularis oris acts as a sphincter around the mouth expression can move freely. Suborbicularis oculi fat
and its fibers interlace with all of the other facial mus- (SOOF) has two parts, medial and lateral [11]. The
cles that act on the mouth. The buccal and marginal medial component extends along the inferior orbital
mandibular branches of the facial nerve provide motor rim from the medial limbus (sclerocorneal junction) to
supply to orbicularis oris, which has various actions, the lateral canthus and the lateral component from the
including pursing, dilation, and closure of the lips. lateral canthus to the temporal fat pad. Between the
Depressor anguli oris arises from the periosteum of SOOF and the periosteum of the zygomatic process of
the mandible along the oblique line lateral to depressor maxilla, there is a gliding space, the prezygomatic
labii inferioris. Its fibers converge on the modiolus space [12]. This space is bounded superiorly by the
with fibers of orbicularis oris, risorius, and sometimes orbicularis retaining ligament and inferiorly by the
levator anguli oris. It is supplied by the marginal man- zygomatic retaining ligament (Fig. 2.8). The sublevator
dibular branch of the facial nerve and depresses the fat pad lies medial to the medial SOOF compartment
mouth corners on contraction. Depressor labii inferio- and represents the most medial of the deep infraorbital
ris arises from the oblique line of the mandible in front fat pads. This fat pad is an extension of the buccal fat
of the mental foramen, where fibers of depressor anguli pad, behind levator labii superioris alaeque nasi and is
oris cover it. It passes upward and medially to insert continuous below and laterally with the melolabial and
into the skin and mucosa of the lower lip and into fibers buccal extensions of the buccal fat pad [1]. The buccal
of orbicularis oris. fat pad is an aesthetically important structure that sits
Mentalis arises from the incisive fossa of the man- on the posterolateral part of the maxilla superficial
dible and descends to insert into the dermis of the chin. to the buccinator muscle and deep to the anterior part
Contraction elevates and protrudes the lower lip and of masseter. Functionally, it facilitates a free gliding
creates the characteristic “peach-pit” dimpling of the movement for the surrounding muscles of mastication
skin over the chin. Motor supply arises from the mar- [13]. As well as the medial extensions described
ginal mandibular nerve. above, it continues laterally as the pterygoid extension
Nasalis consists of two parts, the transverse part (Fig. 2.9). Buccal branches of the facial nerve and the
(compressor naris) and alar part (dilator naris). parotid duct travel along its surface within the parotido-
Compressor naris arises from the maxilla over the masseteric fascia after leaving the parotid gland.
canine tooth and passes over the dorsum of the nose to The galea fat pad lies deep to frontalis in the fore-
interlace with fibers from the contralateral side. It head and extends superiorly for about 3 cm [14]. It
compresses the nasal aperture. Dilator naris originates envelops corrugator and procerus and aids gliding of
from the maxilla just below and medial to compressor these muscles during animation. The retro-orbicularis
naris and inserts into the alar cartilage of the nose. It oculi fat (ROOF) is part of the galea fat pad over the
dilates the nostrils during respiration. Depressor septi superolateral orbital rim from the middle of the rim to
is a slip of muscle arising from the maxilla above the beyond the lateral part. It lies deep to the superolateral
central incisor, deep to the mucous membrane of the fibers of preseptal and orbital orbicularis oculi and
upper lip. It inserts into the cartilaginous nasal septum contributes to the fullness (in youth) and heaviness (in
and pulls the nose tip inferiorly. Nasalis and depressor senescence) of the lateral brow and lid.
septi receive innervation from the superior buccal With aging, the retaining ligaments under the eye
branches of the facial nerve. attenuate. This, together with volume loss in the super-
ficial and deep fat compartments, results in visible
folds and grooves in the cheeks and under the eyes
2.7 Deep Plane Including the Deep (Fig. 2.10).
Fat Compartments The deep cervical fascia covering sternocleidomas-
toid in the neck continues upward to ensheathe the
The superficial fat compartments described above lie parotid gland between the mandible and mastoid pro-
above the muscles of facial expression in the subcuta- cess. The layer of fascia covering the parotid gland and
neous plane. In the midface, the suborbicularis oculi fat masseter, termed parotidomasseteric fascia, continues
and deep cheek fat represent deeper fat compartments superiorly to insert into the inferior border of the zygo-
that provide volume and shape to the face and act as matic arch. In the temporal area, the corresponding
gliding planes within which the muscles of facial fascia in the same plane is present as deep temporal
38 P.M. Prendergast

Fig. 2.8 The prezygomatic Sub-orbicularis oculi fat (SOOF)

space. This space extends
anteriorly to the infraorbital
area Orbicularis oculi

Prezygomatic space

Zygomatic retaining ligament

Fig. 2.9 The buccal fat pad

and its extensions

Sublevator extension
Buccal fat pad

Pterygoid extension

Parotid duct

Melolabial extension
Facial nerve
Buccal extension

fascia, which inserts into the superior border of the above the zygomatic arch and in the upper face, facial
zygomatic arch. In the lower face, branches of the nerve branches lie superficial to the deep fascia and are
facial nerve lie underneath the deep fascia, whereas susceptible to injury during superficial dissections.
2 Anatomy of the Face and Neck 39

Tear trough Orbital septum

Orbicularis retaining ligment

Preperiosteal fat Orbicularis oculi

Sub-orbicularis oculi
Zygomatic retaining fat (SOOF)
ligament Prezygomatic space

Nasojugal groove

Nasolabial fold

Fig. 2.10 Frontal and lateral view of attenuated ligaments in the midface

2.8 Neck course, platysma covers the medial part of sterno-

cleidomastoid, transverse cervical and greater auricu-
Surgical rejuvenation of the neck is frequently lar nerves, cervical and mandibular branches of the
included in an overall plan of facial rejuvenation to facial nerve, the facial vessels, the submandibular
maintain harmony and enhance results. Cosmetic sur- gland, and inferior part of the parotid [17] (Fig. 2.12).
gical procedures in the neck typically address the Fibers insert into the border of the mandible, perioral
superficial structures: skin, subcutaneous fat, and plat- muscles, modiolus, and dermis of the cheek. Although
ysma. Occasionally, subplatysmal fat and even the variations exist [18], platysma usually decussates with
digastric muscles are partially resected to improve fibers from the other side 1–2 cm below the mandible.
neck contour [15, 16]. The aim of surgery is to As part of aging, its medial fibers attenuate or thicken
improve or restore the definition of the topographical to create platysmal bands. Functionally, platysma
landmarks of the neck. These include a sharp mento- depresses the mandible during deep inspiration but is
cervical angle, defined mandibular border, and promi- probably more important as a mimetic muscle to
nent anterior border of sternocleidomastoid. express horror or disgust. It is regarded as the inferior
The neck can be divided into anterior, posterior, most extension of the SMAS and is innervated by the
posterior cervical, and sternocleidomastoid regions cervical branch of the facial nerve.
(Fig. 2.11). Most cosmetic surgical intervention takes Between platysma and sternocleidomastoid, there
place in the anterior region or triangle. The contents of is a loose connective tissue layer termed the superficial
each region are described in Table 2.1. cervical fascia. This plane allows platysma to glide
Just beneath the skin in the anterior cervical triangle easily over sternocleidomastoid and enables effective
lies the platysma muscle. Platysma is a broad thin sheet minimally invasive suture lifting of platysma [19]. The
of muscle that arises from the fascia of the muscles of free edge of platysma is usually located about 3 cm
the chest and shoulders and passes upward over the below the border of the mandible just anterior to the
clavicles and neck toward the lower face. Along its anterior border of sternocleidomastoid.
40 P.M. Prendergast

Fig. 2.11 The triangles

of the neck

Submandibular Sternocleidomastoid

Submental
ANTERIOR
Carotid

Muscular
POSTERIOR

Table 2.1 Regions of the neck

Division Subdivision Contents
Anterior triangle Submandibular triangle Submandibular gland and nodes; facial and submental vessels;
hypoglossal, glossopharygeal, and mylohyoid nn.
Submental triangle Submental nodes and anterior jugular veins
Muscular triangle Sternothyroid and sternohyoid muscles, thyroid and parathyroid
glands
Carotid triangle Bifurcation of carotid, carotid body, hypoglossal, and vagus nn.
Sternocleidomastoid Sternocleidomastoid, carotid sheath with carotid a., internal jugular
v., vagus n., lymph nodes
Posterior triangle Supraclavicular triangle Part of brachial plexus, subclavian a., superficial cervical and
suprascapular vessels, termination of external jugular v.
Occipital triangle Accessory n., trunks of brachial plexus, occipital a., cutaneous
branches of cervical plexus
Posterior cervical Vertebral a., cervical plexus, nuchal muscles

The anterior cervical triangle is bounded posteriorly the temporal bone. It passes anteriorly and inferiorly
by the anterior border of sternocleidomastoid, anteriorly below the mandible toward the hyoid bone where it
by the median line of the neck, and superiorly by the becomes the digastric tendon. The digastric tendon
inferior border of the mandible. The triangle is further passes through the intermediate tendon and arises ante-
divided into submandibular, submental, muscular, and riorly as the anterior belly of digastric. The anterior
carotid triangles by digastric and omohyoid muscles belly inserts into the digastric fossa on the inferior bor-
(Fig. 2.11). An intermediate tendon, attached to the der of the mandible near the midline. Digastric muscle
greater horn of the hyoid bone, divides the digastric into serves to depress and retract the mandible and support
posterior and anterior bellies. The posterior belly arises the hyoid bone. It can be felt as a fleshy mass under the
from the mastoid notch behind the mastoid process of chin when the tongue is retracted.
2 Anatomy of the Face and Neck 41

Fig. 2.12 Neck region

showing platysma and
underlying structures

Greater auricular n.

Platysma
Transverse cervical n.

External jugular v.

2.9 Facial Nerve lower orbicularis oculi. Smaller branches continue

around the medial aspect of the eye to supply depres-
The facial nerve (seventh cranial nerve) provides motor sor supercilii and the superomedial orbicularis oculi.
innervation to the muscles of facial expression. It The buccal branch exits the parotid and is tightly
begins in the face by emerging from the stylomastoid bound to the anterior surface of masseter within the
foramen 6–8 mm medial to the tympanomastoid suture parotidomasseteric fascia. It continues anteriorly over
of the skull. Before entering the substance of the the buccal fat pad, below and parallel to the parotid
parotid gland, the posterior auricular nerve and nerves duct, to supply the buccinators and muscles of the
to the posterior belly of digastric and stylohyoid branch upper lip and nose. A second branch is occasionally
from the main trunk. Within the parotid gland, the present, but this travels superior to the parotid duct in
facial nerve divides into its main branches: temporal its course anteriorly.
branch, zygomatic branch, buccal branch, marginal The marginal mandibular nerve exits the lower part
mandibular branch, and cervical branch (Fig. 2.13). of the parotid gland as one to three major branches. It
The temporal branch of the facial nerve leaves the usually runs above the inferior border of the mandible,
superior border of the parotid gland as three or four but may drop up to 4 cm below it. About 2 cm poste-
rami. They cross the zygomatic arch between 0.8 and rior to the angle of the mouth, the nerve passes upward
3.5 cm anterior to the external acoustic meatus, and and more superficially to innervate the lip depressors.
usually about 2.5 cm anterior to it. At the level of the Although it remains deep to the platysma, it is vulner-
zygomatic arch, the most anterior branch is always at able to injury during surgical procedures in the lower
least 2 cm posterior to the lateral orbital rim. The tem- face at this location.
poral branches pass in an envelope of superficial tem- The cervical branch of the facial nerve passes into
poral fascia with the intermediate fat pad, superficial to the neck at the level of the hyoid bone to innervate the
the deep temporal fascia. The temporal branch enters platysma muscle.
frontalis about 2 cm above the brow, just below the
anterior branch of the superficial temporal artery.
There are up to three zygomatic branches of the 2.10 Sensory Nerves
facial nerve. The upper branch passes above the eye to
supply frontalis and orbicularis oculi. The lower branch The sensory innervation of the face is via the three
always passes under the origin of zygomaticus major divisions of the trigeminal nerve (fifth cranial nerve):
and supplies this muscle, other lip elevators, and the ophthalmic nerve, maxillary nerve, and mandibular
42 P.M. Prendergast

Fig. 2.13 Branches of the

facial nerve. Note: The greater
auricular, zygomaticotemporal,
infraorbital, and mental nerves
are sensory nerves Zygomaticotemporal

Infraorbital

Temporal br.

Zygomatic br.
Posterior auricular
Buccal br.

Mental
Greater auricular nv.

External jugularv. Marginal mandibular br.

Cervical br.

nerve. The ophthalmic nerve supplies the forehead, periosteum of the forehead 0.5–1.5 cm medial to the
upper eyelid, and dorsum of the nose via the supraor- superior temporal crest line.
bital, supratrochlear, infratrochlear, lacrimal, and The supratrochlear nerve exits the orbit about 1 cm
external nasal nerves. The maxillary nerve supplies media to the supraorbital nerve and runs close to the
the lower eyelid, cheek, upper lip, ala of the nose, and periosteum under the corrugator and frontalis. Its sev-
part of the temple through the infraorbital, zygomati- eral branches supply the skin over the medial eyelid and
cofacial, and zygomaticotemporal nerves. The maxil- lower medial forehead. The infratrochlear nerve is a ter-
lary nerve also supplies the maxillary teeth and nasal minal branch of the nasociliary nerve that supplies a
cavity via the alveolar nerves and pterygopalatine small area on the medial aspect of the upper eyelid and
nerves, respectively. The mandibular nerve has motor bridge of the nose. The external nasal nerve supplies
and sensory fibers. Its branches include the inferior the skin of the nose below the nasal bone, except for the
alveolar nerve, lingual nerve, buccal nerve, and auric- skin over the external nares. The lacrimal nerve supplies
ulotemporal nerve. These supply the skin over the the skin over the lateral part of the upper eyelid.
mandible, lower cheek, part of the temple and ear, the The infraorbital nerve is the largest cutaneous
lower teeth, gingival mucosa, and the lower lip branch of the maxillary nerve. It enters the face through
(Fig. 2.14). The greater auricular nerve, derived from the infraorbital foramen 2.7–3 cm from the midline in
the anterior primary rami of the second and third men and 2.4–2.7 cm from the midline in women, about
cervical nerves, supplies the skin over the angle of the 7 and 6 mm inferior to the inferior orbital rim in men
mandible. and women, respectively. The nerve appears from
The supraorbital nerve emerges from the orbit at the the foramen just below the origin of levator labii supe-
supraorbital notch (or foramen) 2.3–2.7 cm from the rioris. It supplies the lower eyelid, ala of the nose,
midline in men and 2.2–2.5 cm from the midline in and upper lip. The zygomaticofacial nerve arises from
women [20]. It has superficial and deep branches that the zygomaticofacial foramen below and lateral to the
straddle the corrugator muscle. Sometimes, these orbital rim and supplies skin of the malar eminence. The
branches exit from separate foramina, the deep branch zygomaticotemporal nerve emerges from its foramen
arising lateral to the superficial one. The deep branch on the deep surface of the zygomatic bone and supplies
usually runs superiorly between the galea and the the anterior temple.
2 Anatomy of the Face and Neck 43

Fig. 2.14 Sensory innervation of the face

SO
SI
GO

LO

L
ZT
CZ IT

AT
EN
ZF IO

GA B

C2/C3 M

Green = ophthalmic nerve (V1) Red and Blue = Cervical nerves (C2/C3)
Supraorbital nerve (SO) Greater occipital nerve (GO)
Supratrochlear nerve (ST) Lesser occipital nerve (LO)
Infratrochlear nerve (IT) Greater auricular nerve (GA)
External nasal nerve (EN)
Latrimal nerve (L)
Oronge = Maxillary nerve (V2)
Zygomaticotemporal nerve (ZT)
Zygomaticofacial nerve (ZF)
Infraorbital nerve (IO)
Purple = Mandibular nerve (V3)
Auriculotemporal nerve (AT)
Buccal nerve (B)
Mental Nerve (M)

The mental nerve is a branch of the inferior alveolar upper one-third of the ear, the external acoustic meatus,
nerve that exits the mental foramen in line vertically with tympanic membrane, as well as the skin over the tempo-
the infraorbital foramen, between the apices of the pre- ral region. Secretomotor fibers also pass via the auricu-
molar teeth. It is often visible and easily palpable through lotemporal nerve to the parotid gland.
stretched oral mucosa. It supplies the skin over the lower
lip and mandible. The buccal branch of the mandibular
nerve supplies the buccal mucosa and skin of the cheek, 2.11 Arteries of the Face
and the lingual nerve provides sensory innervation to the
anterior two-thirds of the tongue and the floor of the The skin and soft tissue of the face receive their arterial
mouth. The auriculotemporal nerve emerges from behind supply from branches of the facial, maxillary, and
the temporomandibular joint to supply the skin of the superficial temporal arteries – all branches of the
44 P.M. Prendergast

Fig. 2.15 Arterial supply

to the face Internal carolid
Ophthalmic
Lacrimal

Supraorbital
Supratrochlear
Infratrochlear
Middle temporal

Superficial Infraorbital
temporal
Angular

Transverse facial

Intemal maxillary
Superior labial

Inferior labial

External carotid Facial

external carotid artery. The exception is a mask-like of the parotid, just before reaching the zygomatic arch,
area, including the central forehead, eyelids, and upper it gives off the transverse facial artery which runs
part of the nose, which are supplied through the internal inferior and parallel to the arch and supplies the parotid,
carotid system by the ophthalmic arteries (Fig. 2.15). parotid duct, masseter, and skin of the lateral canthus.
The facial artery arises from the external carotid The superficial temporal artery crosses the zygomatic
and loops around the inferior and anterior borders of arch superficially within the superficial temporal fas-
the mandible, just anterior to the masseter. It pierces cia. Above the arch, it gives off a middle temporal
the masseteric fascia and ascends upward and medially artery that pierces the deep temporal fascia and sup-
toward the eye. It lies deep to the zygomaticus and plies the temporalis muscle. Thereafter, about 2 cm
risorius muscles but superficial to buccinator and leva- above the zygomatic arch, the superficial temporal
tor anguli oris [21]. At the level of the mouth, the facial artery divides into anterior and posterior branches. The
artery sends two labial arteries, inferior and superior, anterior branch supplies the forehead and forms anas-
into the lips where they pass below orbicularis oris. tomoses with the supraorbital and supratrochlear ves-
The continuation of the facial artery near the medial sels. The posterior part supplies the parietal scalp and
canthus beside the nose is the angular artery. periosteum.
The maxillary artery is a terminal branch of the The ophthalmic artery is a branch of the inter-
external carotid with three main branches, mental, buc- nal carotid system (Fig. 2.15). Its branches include
cal, and infraorbital arteries. The mental artery is the the lacrimal, supraorbital, supratrochlear, infratro-
terminal branch of the inferior alveolar artery that chlear, and external nasal arteries. There is significant
passes through the mental foramen to supply the chin communication between the external and internal
and lower lip. The buccal artery crosses the buccina- carotid artery systems around the eye through several
tors to supply the cheek tissue. The infraorbital artery anastomoses. Inadvertent intra-arterial injection of
reaches the face through the infraorbital foramen and fillers for soft tissue augmentation around the eye
supplies the lower eyelid, cheek, and lateral nose. It can lead to occlusion of the central retinal vessels
anastomoses with branches of the transverse facial, and potentially blindness [22–24]. To avoid this com-
ophthalmic, buccal, and facial arteries. plication, fillers should be injected in small volumes
The superficial temporal artery is the terminal using blunt cannulas and a careful retrograde injection
branch of the external carotid artery. In the substance technique [25].
2 Anatomy of the Face and Neck 45

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