Anatomía para Cirugía Plástica de Cara, Cabeza y Cuello

Anatomy for Plastic Surgery of the
Face, Head, and Neck
Koich i Wat an ab e, MD, Ph D
Assist an t Professor
Depar t m en t of An atom y
Ku ru m e Un iversit y Sch ool of Medicin e
Fukuoka-Prefect u re, Jap an
Moh am m ad ali M. Sh oja, MD
Research Scien t ist
Sect ion of Pediat ric Neu rosurger y
Ch ildren’s Hospit al
Birm ingh am , Alabam a, USA
Mar ios Lou kas, MD, Ph D
Dean of Basic Scien ces
Professor an d Ch air
Depar t m en t of An atom ical Scien ces
St . George’s Un iversit y
Gren ada, West In dies
R. Sh an e Tu b bs, MS, PA-C, Ph D
Professor an d Ch ief Scien t i c O cer
Seat tle Scien ce Fou n dat ion
Seat tle, Wash ington , USA
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Nam es: Wat an abe, Kåoich i, 1968– au th or. | Sh oja,
Moh am m adali M., au th or. | Lou kas, Marios, au th or. | Tu bbs,
R. Sh an e, au th or.
Title: An atom y for plast ic su rger y of th e face, h ead, an d n eck /
Kåoichi Watan abe, Moh am m adali M. Sh oja, Marios Lou kas,
R. Sh an e Tu bbs.
Descript ion : New York : Th iem e, [2016] | In clud es
bibliograph ical referen ces an d in dex.
Iden t i ers: LCCN 2015031107| ISBN 9781626230910 (alk. pap er)
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Subject s: | MESH: Head—an atom y & h istology—Atlases. |
Neck—an atom y & h istology—Atlases. | Recon st ruct ive Su rgical
Procedu res—Atlases.
Classi cat ion : LCC RD119 | NLM W E 17 | DDC 617.9/52—dc23
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Contents
List of Videos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Con t ribu tors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
1
Neuro cranium and Facial Skeleto n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
David Kahn, Toom as Arusoo, and Eric J. W right
2
Anterio r Skull Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Surjith Vat toth and Philip R. Chapm an
3
Middle Skull Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Philip R. Chapm an and Surjith Vat toth
4
So ft Tissue of the Scalp and Tem po ral Regio ns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Noriyuk i Koga
5
Arterial Supply o f the Facial Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Nobuak i Im anishi
6
Arteries o f the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Yelda Atam az Pinar, Figen Govsa, and Servet Celik
7
Veins o f the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Yusuke Shim izu
8
Facial Nerve and Tem po ral Bo ne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Orlando Gunt inas-Lichius
9
Pe ripheral Branches o f the Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Andrew P. Trussler
10
Se nso ry Ne rves o f the Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Ibrahim Khansa, Jenny C. Barker, and Jef rey E. Janis
11
Super cial Musculo apo ne uro tic Syste m and the Facial So ft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Yoko Tabira, Joe Iw anaga, Tsuyoshi Saga, and Koichi W atanabe
12
Mim etic Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Hee-Jin Kim
13
Orbital Anato m y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Sw apna Vem uri and Jerem iah P. Tao
14
Orbital So ft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Sw apna Vem uri and Jerem iah P. Tao
15
Eyelid Anato m y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Catherine Y. Liu, Sw apna Vem uri, and Jerem iah P. Tao
16
Nasal Cavity and Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Joe Iw anaga, Tsuyoshi Saga, and Koichi W atanabe
17
External No se . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Hideak i Rikim aru
18
Auricle and External Aco ustic Meatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Noritaka Kom une, Junichi Fuk ushim a, and Albert L. Rhoton, Jr.
19
Mandible and Masticato ry Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Kyung-Seok Hu and Yang Hun Mu
Content s
20
Oral Cavity and Pharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Joe Iw anaga, Shinya Mik ushi, and Haruk a Tohara
21
Ne ck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Sherine S. Raveendran and Lucian Ion
In dex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
vi
List of Videos
Video 1. Facial m uscles and facial nerve o n the anterio r face
Low er face
Middle face
Video 2. Dissectio n o f the external no se
Mu scles on th e extern al n ose
Bony an d car t ilagin ou s st r uct u re
Video 3. Main trunk o f the facial ne rve and its branches
Lan dm arks of th e facial n er ve t r u n k
Tem poral bran ch
Zygom at ic bran ch
Buccal bran ch
Margin al m an d ibu lar bran ch
Cer vical bran ch
Video 4. Se nso ry ne rves o f the face
Supraorbital n er ve
In fraorbital n er ve
Zygom at icofacial n er ve
Men t al n er ve
Video 5. Layers o f the tem po ral regio n
Super cial tem poral fascia
Deep tem p oral fascia
Tem poralis m u scle
vii
Preface
Th is book w as plan n ed as a h ead an d n eck surgical an atom y
book for plast ic surgeon s, h ead an d n eck surgeon s, an d surgeon s w h o pract ice in related elds. Un fort u n ately, few su rgical
textbooks em ph asize an atom y, especially textbooks in th e eld
of plast ic surger y. In m ost su rgical textbooks, th e procedures
are d escr ibed on ly in m in u te d et ail. Conversely, t rad it ion al an atom ical text books d o n ot p rovid e ad equ ate in for m at ion on
t h e region al an atom y, preven t ing surgeon s from obtain ing th e
kn ow ledge n ecessar y to exper tly perform various surgical procedures. On e reason for th is is th at alth ough th e basic an atom y
of th e h um an body w as alm ost com pletely described m ore th an
100 years ago, th e an atom y in th e h ead an d n eck region , especially th at applicable to plast ic surger y, is st ill developing. Addit ion ally, an atom ical textbooks often do n ot provide th e m ost
u p -to-date in form at ion . Th erefore, w e h ave at tem pted to in clude th e latest an atom ical un derstan ding of th e h ead an d n eck
an atom y from a p last ic su rgeon’s p ersp ect ive.
In w rit ing th is p reface, I (KW) discu ssed h ead an d n eck an atom y w ith m y m en tors in t w o specialt ies: gross an atom y an d
plast ic surger y. Th is allow ed m e to con sider an atom y from t w o
di eren t view poin t s.
First , m y m en tor in gross an atom y m ade th e follow ing ob ser vat ion s: Th e an atom y of t h e h ead an d n eck is ext rem ely
com plicated an d th e det ails di er am ong in dividuals an d during
di eren t st ages of life. Th ese di eren ces in clude th e th ickn ess
of th e t issues, th eir ch anges in respon se to aging, an d even an atom ical variat ion s in vessels, n er ves, an d m uscles. Each organ in
th e h ead an d n eck region h as a ver y dist in ct fun ct ion . Con sequen tly, path ologies involving th e h ead th at require surger y
w ill be operated on by surgeon s specializing in n eurosurger y,
otorhinopharyngolaryngology, ophthalm ology, den tal m edicin e,
an d p last ic su rger y. W h ile in -depth kn ow ledge in th e an atom ical area of specializat ion is ext rem ely im por tan t in t reat ing pat ien t s, th e su rgeon as w ell as th e m edical st a m ust also be
h igh ly fam iliar w ith n ot ju st related region s of th e body bu t also
w ith unrelated regions. In m edical education, unfort unately, the
im portance of anatom ical education has been dow nplayed glob ally in recen t years. Th is m ay be becau se n ow adays m edical st u -
dents have less tim e to study anatom y, given the m any new elds
of m edicin e th at th ey are expected to be fam iliar w ith . Apparen tly, som e m edical sch ools n o longer o er an atom ical dissect ion . Th us, n ot surprisingly, th e n um ber of an atom ist s, especially
gross an atom ist s, is decreasing. Th is ten d en cy h as crit ical, n egat ive im p licat ion s for su rger y. Gross an atom y is t h e basis of
know ledge for ever y surgeon. Surgeons m ust be experts in gross
an atom y if th ey h op e to acqu ire th e su rgical skills to becom e
exp ert s in su rger y.
My secon d m en tor, a specialist in p last ic su rger y, o ered th e
follow ing: Th e m ost im p or tan t asp ect of p erform ing p last ic su rger y is kn ow ledge of th ree-dim en sion al region al an atom y. For
exam ple, each n er ve an d blood vessel takes u p space th ree dim en sion ally. It is im port an t to recogn ize h ow th ese st ru ct u res
t ravel on t h e su r face p lan e, bu t it is m ore im p or t an t for t h e
su ccess of t h e act u al su rger y to kn ow w h ich t issu e layers t h ese
st r u ct u res r u n t h rough . An atom ical at lases an d text books p ro vid e det ailed im ages of t h ese st r u ct u res, bu t t h e kn ow ledge
gain ed from th em is t w o-dim en sion al. Novice su rgeon s t yp ically m em orize th e t w o-dim en sion al im age of th eir surgical
eld . Becau se of th is, su rgical resu lt s are som et im es u n sat isfactor y, or un expected surgical com plicat ion s m ay occu r. To perform su rgeries w ith a h igh degree of di cu lt y, a su rgeon h as to
be able to vividly visu alize th e th ree-dim en sion al region al an atom y of th e surgical eld. Plast ic surger y residen ts h ave to st udy
t h e region al an atom y in an atom ical at lases an d text books, an d
con r m t h eir an atom ical kn ow ledge in p ract ical op erat ion s.
By repeat ing th is p at tern m any t im es, a residen t is able to est ablish an d pract ice th ree-dim en sion al an atom ical kn ow ledge.
By having surgical training based on accurate anatom ical know ledge, a su rgeon w ill be bet ter equ ip p ed to p erform h igh -degree
operat ion s.
We h ope th at our textbook w ill n ot on ly h elp to im prove th e
su rgical skill of in dividu al su rgeon s, bu t w ill also prom ote th e
d evelop m en t of h ead an d n eck su rger y. I w ou ld like to t h an k
Dr. Koh -ich i Yam aki, Professor of An atom y, an d Dr. Ken su ke
Kiyokaw a, Professor of Plast ic Su rger y, for kin dly con t ribu t ing
th e above com m en t s to th e preface.
ix
Contributors
To o m as Aruso o , MS
Med ical St u den t , Year 2
Mich igan St ate Un iversit y College of Hu m an
Med icin e
Gran d Rapids, Mich igan , USA
No buaki Im anishi, MD
Associate Professor
Dep ar t m en t of An atom y
Sch ool of Medicin e, Keio Un iversit y
Tokyo, Japan
Jenny C. Barker, MD, PhD
Residen t
Dep ar t m en t of Plast ic Su rger y
Oh io St ate Un iversit y Wexn er Medical Cen ter
Colu m bus, Oh io, USA
Lucian Io n, FRCS(Plast)
Con sult an t Plast ic Su rgeon
Director, Aesth et ic Plast ic Su rger y Ltd
Lon don , UK
Hon orar y Con su lt an t
Ch elsea an d West m in ster Hospit al
Lon don , UK
Servet Celik, MD
Assist an t Professor
Dep ar t m en t of An atom y
Facult y of Medicin e
Ege Un iversit y
Izm ir, Tu rkey
Philip R. Chapm an, MD
Ch ief, Neu roradiology
Associate Professor, Neuroradiology Sect ion
Un iversit y of Alabam a at Birm ingh am Sch ool of
Medicin e
Birm ingh am , Alabam a, USA
Junichi Fukushim a, MD, PhD
Depart m en t of Otorh in olar yngology
Gradu ate Sch ool of Medical Scien ce
Kyu sh u Un iversit y
Fukuoka, Japan
Figen Govsa, MD
Professor
Depart m en t of An atom y
Ege Un iversit y, Facu lt y of Medicin e
Izm ir, Tu rkey
Orlando Guntinas-Lichius, MD
Professor an d Ch airm an
ENT Depart m en t
Jen a Un iversit y Hospit al
Dean of St u den t s
Medical Facu lt y
Friedrich -Sch iller Un iversit y
Jen a, Germ any
Kyung-Seo k Hu, DDS, PhD
Associate Professor
Depart m en t of Oral Biology
Division in An atom y & Develop m en tal Biology
Yon sei Un iversit y College of Den t ist r y
Seou l, Repu blic of Korea
Jo e Iw anaga, DDS
Assist an t Professor
Dep ar t m en t of An atom y
Ku ru m e Un iversit y Sch ool of Medicin e
Fuku oka, Japan
Je rey E. Janis, MD, FACS
Professor an d Execut ive Vice Ch airm an
Ch ief of Plast ic Surger y
Un iversit y Hospit als
Dep ar t m en t of Plast ic Su rger y
Oh io St ate Un iversit y Wexn er Medical Cen ter
Colum bu s, Oh io, USA
David Kahn, MD
Clin ical Associate Professor Plast ic Surger y
Sect ion Ch ief, Cosm et ic Su rger y
Division of Plast ic Su rger y
St an ford Un iversit y
Palo Alto, Californ ia, USA
Ibrahim Khansa, MD
Residen t
Dep ar t m en t of Plast ic Su rger y
Oh io St ate Un iversit y Wexn er Medical Cen ter
Colum bu s, Oh io, USA
Hee-Jin Kim , DDS, PhD
Professor
Division in An atom y & Developm en t al Biology
Dep ar t m en t of Oral Biology
Yon sei Un iversit y College of Den t ist r y
Seou l, Korea
Ke nsuke Kiyo kaw a, MD, PhD
Professor an d Ch airm an
Dep ar t m en t of Plast ic & Recon st ru ct ive Su rger y &
Maxillofacial Su rger y
Ku ru m e Un iversit y Sch ool of Medicin e
Fuku oka, Japan
xi
Contributors
No riyuki Ko ga, MD, PhD
Assist an t Professor
Dep ar t m en t of Plast ic Su rger y, Recon st ru ct ive an d
Maxillofacial Su rger y
Ku ru m e Un iversit y Sch ool of Medicin e
Ku ru m e, Japan
No ritaka Ko m une, MD, PhD
Fellow
Dep ar t m en t of Otorh in olar yngology an d Head an d Neck
Su rger y
Kyu sh u Un iversit y Hospit al
Fukuoka-ken , Japan
Catherine Y. Liu, MD, PhD
Residen t , Oph th alm ology
Gavin Herbert Eye In st it ute
Un iversit y of Californ ia, Ir vin e
Ir vin e, Californ ia, USA
Mario s Lo ukas, MD, PhD
Dean of Basic Scien ces
Professor an d Ch air
Dep ar t m en t of An atom ical Scien ces
St . George’s Un iversit y
Gren ada, West In dies
Shinya Mikushi, DDS, PhD
Nagasaki Un iversit y Hospital
Dep ar t m en t of Sp ecial Care Den t ist r y
Clin ic for Oral Care an d Dysp h agia Reh abilitat ion
Nagasaki, Japan
Yang Hun Mu, DDS, PhD
Assist an t Professor
Dep ar t m en t of An atom y College of Medicin e
Dan kook Un iversit y
Ch u ngn am , Korea
Yelda Atam az Pinar, MD
Professor
Dep ar t m en t of An atom y
Facult y of Medicin e
EGE Un iversit y, Facult y of Medicin e
Izm ir, Tu rkey
Sherine S. Raveendran, FRCSEd, EBOPRAS, MSc, MS, MBBS
Director
Toron to Medical Aesth et ics
Markh am , On t ario, Can ada
xii
Tsuyo shi Saga, PhD
Associate Professor
Depart m en t of An atom y
Ku ru m e Un iversit y Sch ool of Medicin e
Fukuoka, Japan
Yusuke Shim izu, MD, PhD
Associate Professor
Depart m en t of Plast ic an d Recon st ru ct ive Su rger y
Keio Un iversit y, Sch ool of Medicin e
Tokyo, Japan
Mo ham m adali M. Shoja, MD
Research Scien t ist
Sect ion of Pediat ric Neu rosu rger y
Ch ildren’s Hospital
Birm ingh am , Alabam a, USA
Yo ko Tabira, PhD
Research Associate
Depart m en t of An atom y
Ku ru m e Un iversit y Sch ool of Medicin e
Ku ru m e, Jap an
Jerem iah P. Tao , MD, FACS
Ch ief, Oculoplast ic & Orbital Surger y
Am erican Societ y of Oph th alm ic Plast ic an d Recon st ru ct ive
Su rger y Fellow sh ip Director
Op h th alm ology Residen cy Director
Associate Professor
Gavin Herber t Eye In st it ute
Un iversit y of Californ ia, Ir vin e
Ir vin e, Californ ia, USA
Haruka To hara, DDS, PhD
Gerod on tology an d Oral Reh abilit at ion ,
Depart m en t of Geron tology an d Gerodon tology
Gradu ate Sch ool of Medical an d Den t al Scien ces
Tokyo Medical an d Den tal Un iversit y
Yu sh im a, Bu n kyo
Tokyo, Japan
Andrew P. Trussler, MD, FACS
Plast ic Su rgeon , Private Pract ice
Au st in , Texas, USA
R. Shane Tubbs, MS, PA-C, PhD
Professor an d Ch ief Scien t i c O cer
Seat tle Scien ce Fou n dat ion
Seat tle, Wash ington , USA
Albert L. Rhoton, Jr., MD
R. D. Keen e Fam ily Professor an d Ch airm an Em erit u s
Dep ar t m en t of Neu rological Su rger y
Un iversit y of Florida
Gain esville, Florida, USA
Surjith Vatto th, MD, FRCR
Sen ior Con su tan t , Neu roradiologist
Ham ad Medical Corp orat ion
Doh a, Qat ar
Hideaki Rikim aru, MD, PhD
Dep ar t m en t of Plast ic Recon st ru ct ive Su rger y an d
Maxillofacial Su rger y
Ku ru m e Un iversit y Sch ool of Medicin e
Fukuoka, Japan
Sw apna Vem uri, MD
Fellow, Oculoplast ic an d Orbital Surger y
Gavin Herber t Eye In st it ute
Un iversit y of Californ ia, Ir vin e
Ir vin e, Californ ia, USA
Contributors
Ko ichi Watanabe, MD, PhD
Assist an t Professor
Dep ar t m en t of An atom y
Ku ru m e Un iversit y Sch ool of Medicin e
Fu kuoka-Prefect ure, Japan
Koh-ichi Yam aki, MD, PhD
Professor an d Ch air
Dep art m en t of An atom y
Ku ru m e Un iversit y Sch ool of Med icin e
Ku ru m e, Jap an
Eric J. Wright, MD
Ch ief Residen t
Division of Plast ic & Recon st ru ct ive Su rger y
Stan ford Un iversit y Med ical Cen ter
Palo Alto, Californ ia, USA
xiii
1
Neurocranium and Facial Skeleton
David Kahn, Toom as Arusoo, and Eric J. W right
Introduction
Th e skull can be divided in to t w o part s: th e neurocranium ,
w h ich form s a protect ive case aroun d th e brain , an d th e viscerocranium , w h ich form s th e skeleton of th e face. Th is ch apter details th e viscerocran iu m an d bon es of th e n eu rocran ium th at
pert ain to th e viscerocran ium .
Neurocranium
Th e n eurocran ium in adult s is form ed by a series of eigh t bon es:
th e singular fron t al, eth m oid, sph en oid, occipit al bon es cen tered on th e m idlin e, an d th e tem poral an d pariet al bon es occurring as bilateral pairs.1 Th e p rim arily at fron tal, p ariet al,
an d occip ital bon es form th e calvaria (sku llcap ) by in t ram em bran ous ossi cat ion of h ead m esen chym e derived from th e
n eu ral crest . Th e p rim arily irregu lar, yet con siderably at , sp h en oid an d tem poral bon es con t ribu te to th e cran ial base via en doch on dral ossi cat ion of car t ilage or from m ore th an on e t ype
of ossi cat ion . Th e irregular eth m oid bon e sligh tly con t ributes
to th e n eu rocran iu m bu t is p rim arily part of th e viscerocran iu m . In realit y, th e at bon es an d at port ion s of th e bon es
form ing th e n eu rocran iu m con sist of convex extern al an d con cave in tern al cur ved surfaces.1
Fibrous in terlocking su t ures un ite m ost calvarial bon es in
adulth ood, alth ough du ring ch ild h ood, th e sp h en oid an d occip it al bon es are un i ed by syn ch on droses.2 Som e sut ures, com p rising n arrow closu res of con n ect ive t issue at bir th , rem ain
open un t il adulth ood. Th e sagit tal sut ure is derived from n eural
crest cells an d th e coron al sut ure from paraxial m esoderm .2 Th e
n ew born sku ll con t ain s fontanels, th e m ost p rom in en t being th e
an terior fon t an el, w h ich are w iden ed su t u res at p oin t s w h ere
m ore th an t w o bon es m eet . Th e an terior fon t an el, fou n d w h ere
th e t w o pariet al an d fron t al bon es m eet , closes in m ost cases by
18 m on th s of age, an d th e posterior fon t an el closes by 1 to 2
m on th s of age.2
Tw o prim ar y cen ters of ossi cat ion t raverse th e fron tal (m etopic) su t u re in th e secon d year, dividing th e fron t al bon e in to
h alves. Usu ally, th e fron tal su t u re disap p ears by age 6 years,
w h en t h e h alves fu se, bu t it can p ersist in to ad u lt h ood as a
m etop ic su t u re eith er tot ally, ru n n ing from th e m idlin e of th e
glabella to th e bregm a, or part ially.2 Th e glabella is a sm ooth
an terior project ing p rom in en ce on th e fron tal bon e su p erior to
th e root of th e n ose, an d th e bregm a is th e ju n ct ion of th e coron al an d sagit t al su t u res.
Th e m axillae an d m an dible provide th e socket s an d sup port ing bon e for th e m axillar y an d m an dibular teeth . Th e m axillae con t ribute th e greatest part of th e upper facial skeleton ,
form ing th e skeleton of th e u pp er jaw, w h ich is xed to th e cran ial base. (Th e m an dible is det ailed in Ch apter 19.)
On th e lateral aspect of th e sku ll is th e th in pterion . Th e pterion , located t w o nger breadth s su p erior to th e zygom at ic arch
an d a th u m b’s breadth p osterior to th e fron t al p rocess of th e
zygom at ic bon e, is form ed by th e art icu lat ion s of th e fron t al,
p ariet al, sph en oid, an d tem poral bon es.1 Th e pterion overlies
th e an terior bran ch of th e m iddle m en ingeal ar ter y. Th erefore,
an inju r y to th is region can dam age th e vessel, p rod u cing an
epidu ral h em atom a.1
Th e air- lled paran asal sin u ses, in cluding th e m axillar y,
fron t al, an d eth m oidal sin u ses, are d iscu ssed. Th e sp h en oidal
sin uses are d iscu ssed in Ch apters 2 an d 16. Th e bony ar t icu lat ions of th e n eu rocran ium an d viscerocran ium are described in
Table 1.1, an d th e gen eral processes of ossi cat ion are displayed
in Table 1.2.
Frontal Bone
Th e fron t al bon e form s th e foreh ead via its squ am ous, orbit al,
an d n asal part s an d t w o cavit ies, th e fron t al sin u ses.
Squamous Part
Th e at squam ous part is th e largest part of th e front al bon e
form ing m ost of th e foreh ead.3 Th e su praorbit al m argin of th e
fron tal bon e is th e angu lar boun dar y bet w een th e squ am ou s
an d th e orbit al p ar ts (Fig. 1.1).4
On th e extern al su rface of th e squ am ou s p ar t , abou t 3 cm
above th e m id poin t of th is m argin , are th e fron t al t u berosit ies.4
Th ese t u bercles are m ore prom in en t in ch ildren an d adult
w om en . Ven t rally, a sh allow groove sep arates th e fron t al t u berosit ies from th e paired an d cur ved superciliar y arch es.4 Th ese
arch es exten d laterally from th e m edially located, sm ooth , an d
elevated glabella an d are m ore prom in en t in m ales. Partly depen den t on fron tal sin us size, supercilliar y arch prom in en ce is
occasion ally associated w ith sm all sin uses.4
Th e supraorbit al n otch (or foram en ), w h ich t ran sm it s th e
su p raorbit al vessels an d n er ve, lies at t h e ju n ct ion bet w een
t h e sh ar p , lateral t w o-t h ird s an d t h e rou n d ed m edial t h ird of
t h e su p raorbit al m argin .4 Th e var iably occu r r ing fron t al n otch
(or foram en ) occurs m edial to th e supraorbit al n otch in 50% of
sku lls.4
Surgical Annotation
Recen t in terest in t h e su rgical t reat m en t of m igrain es h as led
to n u m erou s an atom ical st u d ies id en t ifying areas of n er ve
com p ression . Th e su p raorbit al n er ve, as it em erges from t h e
1
Anatom y for Plastic Surgery of the Face, Head, and Neck
Table 1.1 Neurocranium and viscerocranium articulations
Bone
Single
Paired
Articulates w ith
Frontal
X
Parietal, sphenoid, zygom atic, maxilla, ethmoid, nasal, lacrim al
Ethm oid
X
Frontal, sphenoid, m axilla, palatine, vom er, nasal, lacrim al, inferior nasal concha
Temporal
X
Parietal, occipital, sphenoid, zygomatic, m andible
Nasal
X
Frontal, m axilla, nasal
Vom er
X
Sphenoid, m axilla, ethm oid, palatine
Inferior nasal concha
X
Maxilla, ethm oid, palatine, lacrim al
Maxilla
X
Frontal, sphenoid, zygom atic, m axilla, ethm oid, palatine, vom er, nasal, lacrimal,
inferior nasal concha
Palatine
X
Sphenoid, m axilla, ethm oid, palatine, vom er, inferior nasal concha
Zygom atic
X
Frontal, temporal, m axilla, sphenoid
Lacrim al
X
Frontal, m axilla, ethm oid, inferior nasal concha
Source: Data from Norton NS. Net ter’s Head and Neck Anatomy for Dentistry. 1st ed. Philadelphia, PA: Elsevier Saunders; 2006.
su p raorbit al foram en or n otch , h as been id en t i ed as a m igrain e
trigger area.5 Th e supraorbital n er ve can h ave com pression from
both a foram en as w ell as a n otch as a result of th e associated
fascial ban d s. In ad dit ion to th e soft t issu e p rocedu re, a su p raorbital foram inotom y or fascial ban d release h as been sh ow n to
im prove postop erat ive outcom es.6 A t ran sp alpebral in cision can
be used to access the supraorbital ner ves to perform the decom pression . An in cision is m ade in th e upper t arsal crease, w ith
su bsequ en t dissect ion iden t ifying th e su p raorbital n er ve. Mu scles such as th e corrugator supercilii are resected, an d th e foram in otom y is perform ed. En doscopic tech n iqu es h ave also been
described.7 With th e u se of th e en doscopic tech n iqu e, release of
th e zygom at icotem poral bran ch can also be perform ed.
The supraorbital m argin extends laterally, form ing the prom in en t zygom at ic process, w h ich art iculates w ith th e zygom at ic
bon e. A posterosuperiorly cur ving lin e, w h ich con t in u es on to
th e squam ous part of th e tem poral bon e, divides in to superior
an d in ferior tem poral lin es.4 Th e tem poral su rface of th e fron tal
bon e is in ferior an d posterior relat ive to th ese tem poral lin es.
Th e an terior surface of th e tem poral su rface form s th e an terior
part of th e tem poral fossa. The rough in ferior surface of th e posterior m argin of th e squam ous par t art iculates w ith th e greater
w ing of th e sph en oid.4
Th e n asal par t of th e fron t al bon e is discu ssed in th e Nasal
Bone: Nasal Bridge and Bony Sept um sect ion of th is ch apter. Th e
in terior su rface of th e fron tal bon e is det ailed in Ch apter 2.
Orbital Parts of the Frontal Bone
Th e t w o orbit al par ts of th e fron t al bon e are th in , cur ved, an d
t riangular lam in ae, con sist ing en t irely of com pact bon e (Fig.
1.2).4 Form ing th e largest part of th e orbit al roofs, the orbit al
par ts are sep arated by a w ide, qu adrilateral eth m oidal n otch
th at is occupied by th e cribriform plate of th e eth m oid bon e.4
Th e labyrin th s of th e eth m oid bon e, w h ich con t ain th e eth m oidal air cells, ar t icu late w it h t h e in fer ior su r face of t h e lateral
m argin s of th e eth m oidal n otch . Th is ar t icu lat ion conver t s t w o
t ran sverse grooves across each m argin in to an terior an d posterior eth m oidal can als. Th ese can als t ran sm it th e an terior an d
posterior eth m oidal n er ves an d vessels in to th e m edial orbit .4
Th e posterolaterally ascen ding fron t al sin uses open an terior
to th e eth m oidal n otch an d lateral to th e n asal spin e (Fig. 1.3).
De ect ing from th e m edian p lan e, th ese rarely sym m et rical sin u ses ascen d bet w een th e fron t al lam in ae an d are sep arated by
a th in sept u m .4 Each sin us com m un icates w ith th e ipsilateral
n asal cavit y’s m idd le m eat u s via th e fron ton asal can al.4
Table 1.2 Neurocranium and viscerocranium ossif cation patterns
Bone
Parts
Ossif cation
Frontal
Squam ous, orbital, nasal portions
Intram embranous
Ethm oid
Perpendicular plate, cribriform plate, ethm oid labyrinth
Endochondral
Temporal
Squam ous part, t ympanic part
Intram embranous
petrom astoid part, st yloid process
Endochondral
Nasal
Intram embranous
Vom er
Intram embranous
Inferior Nasal Concha
Endochondral
Maxilla
Body; frontal, zygom atic, palatine, alveolar processes
Intram embranous
Palatine
Perpendicular plate, horizontal plate, pyram idal process
Intram em branous
Zygom atic
Frontal, temporal, m axillary processes
Intram embranous
Lacrim al
Intram embranous
Source: Data from Norton NS. Net ter’s Head and Neck Anatomy for Dentistry. 1st ed. Philadelphia, PA: Elsevier Saunders; 2006.
2
1 Neurocranium and Facial Skeleton
Frontal bone
Parietal bone
Frontal
incisure
Supraorbital
foram en
Supraorbital
m argin
Sphenoid bone,
greater wing
Nasal bone
Tem poral bone
Sphenoid bone,
lesser wing
Orbit
Ethm oid bone,
perpendicular
plate
Sphenoid bone,
greater wing
Zygom atic bone
Infraorbital
m argin
Piriform (anterior
nasal) aperture
Middle nasal
concha
Maxilla
Infraorbital foramen
Vom er
Inferior nasal
concha
Anterior nasal
spine
Mandible
Fig. 1.1 Anterior view of the skull. The boundaries of the viscerocranium in relation to the neurocranium can be appreciated in this view.
Visible features include the anterior nasal aperture, marking the start of
the bony respiratory tract; a metopic suture projects superiorly from
Teeth
Mental foram en
the nasion; and the supraorbital foramen, infraorbital foramen, and
mental foramen through which cutaneous nerves pass, are visible.
(Reproduced from THIEME Atlas of Anatomy, General Anatomy and
Musculoskeletal System, © Thieme 2005, Illustration by Karl Wesker.)
Fig. 1.2 Inferior view of the frontal bone. From this
view, the ethmoidal notch and ethmoidal air sinuses can
clearly be appreciated. Additional visibilit y of the orbital
part surface features, including the fossa for the lacrimal
gland, the sphenoidal articulating surface, and the
zygomatic process, is obtained from this view.
3
Anatom y for Plastic Surgery of the Face, Head, and Neck
a
Fig. 1.3 (a) Superior view of the ethmoid bone. This view of the
ethmoid bone provides a bet ter appreciation for the ethmoidal
labyrinth and air cells, the cribriform plate, and the crista galli and it s
associated alae. (b) Inferior view of the ethmoidal bone. Viewing the
ethmoid bone from below allows bet ter appreciation of the nasal
conchae, uncinate process, and the perpendicular plate.
Frontal Sinus Fractures
Cribriform Plate
Surgical Annotation
Fron tal sin us fract ures can ser ve as a source of in fect ion an d
cosm etic deform it y. Approxim ately 10%of facial fractures involve
th e fron t al sin uses.8 W h en ou t ow of th e sin us is blocked as a
resu lt of inju r y to the n asofron tal duct , fron t al sin u s m ucoceles
can develop. In accessing th e injur y, m an agem en t depen ds on
w hich w all of th e sinus is fract ured, th e exten t of fract u re displacem en t , an d th e involvem en t of th e n asofron t al du ct . Correct ion of th e an terior table of th e sin u s, w h ich is d on e m ain ly
to cor rect t h e cosm et ic d efor m it y, can be p er for m ed t h rough
an exist ing lacerat ion or coron al in cision . W h en th e p osterior
table is displaced, the coron al in cision allow s access to perform
a cranialization, w hich involves rem oving the posterior w all and
allow ing for th e sin us to be part of th e in t racran ial cavit y. Th e
sin u s m u cosal su rface m u st be rem oved an d th e ou t ow t ract
an d dead sp ace obliterated to p reven t p ost inju r y in fect ion .
Di eren t tech n iqu es for p erform ing th e obliterat ion h ave
been described.8 Man agem en t of sin u s p reser vat ion can also be
perform ed w ith few com plicat ion s depen ding on th e fract ure
pat tern .9
Each sm ooth an d con cave orbit al surface con tain s a sh allow
an terolateral fossa for th e lacrim al glan d . Th e p osterior bord er
of th e orbit al p late ar t icu lates w it h t h e lesser w ings of t h e
sph en oid .4
Ethmoid Bone
Th e fragile cu boidal eth m oid bon e lies an teriorly in th e cran ial
base, contributing to the m edial orbital walls, nasal sept um , roof,
an d lateral w alls of th e n asal cavit y. Th e eth m oid is com p osed of
a h orizon t al, p erforated cribriform plate, a m edian perpen dicu lar p late, an d th e t w o lateral labyrin th s.3
4
b
As m en t ion ed, th e h orizon t al cribriform plate lls th e eth m oidal n otch of th e fron t al bon e (Fig. 1.3a). Pen et rated by n um erous foram in a th at con t ain olfactor y n er ve bran ch es, th e plate
form s a large p art of th e n asal roof.3 Th e t riangu lar an d m edian
crist a galli projects superiorly from th e plate an d join s th e fron t al bon e an teriorly via it s t w o alae.3 Dep ression s in th e cribriform p late on eith er sid e of th e crist a galli exist for th e overlying
olfactor y bulb an d gyru s rect us. An tero an d lateral to th e crist a,
foram in a exist to t ran sm it t h e an ter ior et h m oidal n er ve an d
vessels from th e n asal cavit y to th e foram en cecu m .4
Perpendicular Plate
Th e perpen dicu lar plate is discussed in th e Nasal Bon e: Nasal
Bridge an d Bony Sept u m sect ion of th is ch apter.
Ethmoidal Labyrinths
On average, th e eth m oidal labyrin th s con sist of 20 th in -w alled
air cells arranged as an terior, m idd le, an d p osterior grou p s con t ain ing 11, 3, an d 6 air cells, respect ively.4 Th e lateral orbit al
plate form s par t of th e m edial orbit al w all (Fig. 1.4). Adjoin ing
art icu lat ion s, save th ose th at op en in to th e n asal cavit y, close all
air cells. Th e air cells of th e su p erior an d posterior su rfaces are
closed by th e eth m oidal n otch of th e fron t al bon e an d both th e
sp h en oidal con ch ae an d orbit al process of th e p alat in e bon e,
respect ively.4
Th e orbit al plate covers th e m iddle an d posterior eth m oidal
air cells articulating superiorly w ith the orbital plate of th e fron t al bon e, an teriorly w ith th e lacrim al bon e, in feriorly w ith th e
m axilla an d orbit al p rocess of th e p alat in e bon e, an d posteriorly
w ith th e sph en oid bon e.4 An terior to th e orbital plate, th e lacrim al bon e an d fron t al p rocess of th e m axilla com p lete th e w alls.
1 Neurocranium and Facial Skeleton
Anterior
cranial fossa
Cribriform
plate
Superior
m eatus
Crista galli
Frontal bone
Sphenoid bone, lesser wing
Frontal sinus
Middle cranial fossa
Nasal bone
Hypophyseal fossa
Lacrimal bone
Sphenoid sinus
Frontal process
of maxilla
Superior concha,
(ethm oid bone)
Body of
sphenoid bone
Anterior nasal
aperture
Pterygoid process,
m edial plate
Choana
Middle
m eatus
Pterygoid process,
lateral plate
Inferior
concha
Palatine process
of m axilla
Palatine bone,
horizontal plate
Inferior
m eatus
Middle concha
(ethm oid bone)
Fig. 1.4 Medial view of the right nasal cavit y. This view of the nasal
cavit y allows bet ter appreciation of the conchae, meatuses, portions of
the hard palate, the frontal sinus, ethmoidal contributions to the nasal
cavit y, and the anterior nasal aperture. (Reproduced from THIEME Atlas
of Anatomy, Head and Neuroanatomy, © Thieme 2010, Illustration by
Karl Wesker.)
Project ing posteroin feriorly from th e labyrin th , th e th in u ncin ate p rocess crosses th e ost ium of th e m axillar y sin us to join
th e eth m oidal process of th e in ferior n asal con ch a.4
Descen ding from th e in ferior su rface of th e cribriform plate,
th e m edial surface of th e labyrin th form s part of th e lateral
n asal w all as th e th in , lam ellated, an d convolu ted m id dle n asal
conch a (Fig. 1.3b). It s an teron in ferior lateral surface form s part
of th e m iddle m eat us (Fig. 1.4).4 On th e lateral w all of th e m idd le m eat u s, m idd le eth m oidal air cells p rodu ce th e eth m oidal
bulla an d open eith er on th e bulla or above it . Posterior eth m oidal air cells open in to th e superior m eat us, w h ich is boun ded by
th e superior n asal con ch a of th e eth m oid.4 A cu r ved in fu n dibu lu m exten ds an teriorly an d superiorly from th e m id dle m eat us,
com m un icat ing w ith th e an terior eth m oidal sin uses an d in h alf
of sku lls con t in u es su p er iorly as t h e fron ton asal d u ct , w h ich
drain s th e fron t al sin us.4
as th e st yloid p rocess.3 The tem poral bon e also h as t w o associated can als. On it s lateral surface, th e extern al acoust ic m eat us
conveys soun d w aves to th e t ym pan ic m em bran e. On it s m edial
su rface, th e in tern al acou st ic m eat u s conveys th e facial an d vest ibulococh lear n er ves.4
Temporal Bone
Th e paired tem poral bon es h elp form th e base an d lateral w alls
of th e skull an d are discussed in fu rth er det ail in su bsequen t
ch apters (Fig. 1.1). Th e tem poral bon e h ouses th e au ditor y an d
vest ibu lar app arat u ses an d con t ain s m astoid air cells.3 Each
bon e h as eigh t cen ters of ossi cat ion th at give rise to th e th ree
m ajor cen ters obser ved before bir th .2 Th e tem poral bon e com prises th e squam ous, pet rom astoid, and t ym pan ic par t s, as w ell
Squamous Part
Th e largest , squam ous part lies an terosu periorly an d con t ain s
th e th in an d largest tem poral por t ion , a zygom at ic process an d
a m an dibular fossa (Fig. 1.5).3 Its external tem poral surface form s
p ar t of th e tem poral fossa. Th e con cave, in tern al cerebral surface of th e squ am ou s part is grooved by th e m idd le m en ingeal
vessels.3 Th e low er border, fused to th e an terior pet rous par t
often contains traces of a petrosquam osal suture. Posteriorly, the
squ am ous part fu ses w ith th e m astoid part . Th e an teroin ferior
border ar t iculates w ith th e greater w ing of th e sph en oid, an d
th e superior border art icu lates w ith th e in ferior pariet al bon e at
th e squam osal sut ure.4
The zygom atic process extends anterolaterally from the squam ou s port ion . It form s th e zygom at ic arch via an art icu lat ion
bet w een it s obliqu ely posteroinferiorly sloping, deeply serrated
an terior en d, an d th e tem poral p rocess of th e zygom at ic bon e.3
It s in ferior su rface form s a sh ort ar t icu lar t u bercle, w h ich con t act s th e art icular disc of th e tem porom an dibular join t an d
form s th e an terior lim it of th e m an dibu lar fossa.4
5
Anatom y for Plastic Surgery of the Face, Head, and Neck
Mandibular
fossa
St yloid
process
p et rou s p ar t an d p oster iorly fu sed w it h t h e squ am ou s p ar t
an d m astoid p rocess, th e t ym p an ic p ar t form s a th in , in com p lete ring.4 Th e p osterior su rface form s t h e an terior w all, oor,
an d p osterior w all of th e extern al acou st ic m eat u s. Th e an terior su rface form s th e p oster ior w all of t h e m an d ibu lar fossa.3
Th e p oin ted, slen der st yloid process project s an teroin feriorly
from t h e in ferior su rface of th e tem p oral bon e. Fu r th er exp lan at ion of tem p oral bon e relat ion sh ip s is covered in su bsequ en t
ch apters.
Squam ous
part
Viscerocranium
Petrous
part
Th e viscerocran ium con sists of 15 irregular bon es. Th ese are th e
singu lar m idlin e-cen tered m an dible, eth m oid, an d vom er, an d
th e six bilateral pairs of bon es, in clu ding th e m axillae, in ferior
n asal con ch ae, an d th e zygom at ic, p alat in e, n asal, an d lacrim al
bon es.
Tym panic
part
Fig. 1.5 Left temporal bone: inferior view. The squamous part, which
bears the mandibular fossa; the petromastoid part, which contains the
auditory and vestibular apparatus; and the t ympanic part, which forms
much of the external auditory canal, are best appreciated from this
inferior view. (Reproduced from THIEME Atlas of Anatomy, Head and
Neuroanatomy. © Thieme 2010, Illustration by Karl Wesker.)
Th e m an dibu lar fossa p resen t s an an terior ar t icu lar area
an d a p osterior n on ar t icu lar area, form ed by t h e t ym p an ic elem en t . Th is sm oot h , con cave ar t icu lar su rface, form ed by t h e
squ am ou s p ar t , con t act s t h e m an d ibu lar con dyle’s tem p oro m an d ibu lar join t ar t icu lar d isc. Th e squ am ot ym p an ic ssu re
separates th e p osterior m an d ibu lar fossa from th e t ym p an ic
p ar t .4
Nasal Bone : Nasal Bridge and Bony
Septum
Th e n asal bon es, placed side by side bet w een th e fron t al processes of th e m axillae, join tly form th e n asal bridge an d in tern asal su t u re. Each sm all, oblong, an d variable bon e h as extern al
an d in tern al su rfaces an d su p erior, in ferior, lateral, an d m edial
borders.4 Th e t ran sversely convex extern al su rface is cen t rally
perforated by a vein -t raversing foram en . A longit udin al groove
for th e an terior eth m oidal n er ve t raverses th e t ran sversely con cave in tern al surface (Fig. 1.6).4
Th e th ick, serrated superior border ar t iculates w ith th e
n asal part of th e fron t al bon e, form ing th e fron ton asal su t u re
(Fig. 1.7).4 Th e n asion is a cran iom et ric poin t on th e cran ium
w h ere th e fron ton asal an d in tern asal sut ures m eet . Th e m edial
border art iculates w ith th e con t ralateral n asal bon e an d pro-
Petromastoid Part
Th e pet rom astoid part is relat ively large an d bet ter described as
t w o p art s. Th e t rabecu lar m astoid par t , w h ich in tern ally con tain s th e m astoid air cells an d m astoid an t rum , con st it utes th e
posterior region of the tem poral bone. The posteriorly projecting
m astoid process, w h ich is larger in adu lt m en , at tach es th e stern ocleidom astoid, sp len iu s capit is, an d longissim u s capit is to it s
lateral surface an d th e p osterior belly of th e digast ric on it s m edial surface.4
Th e pet rous part form ed of com pact bon e in clin es superiorly
an d an terom edialy from th e cran ial base.4 It h ouses th e auditor y an d vest ibular apparat uses an d separates th e tem poral an d
occipit al lobes of th e brain .3 Th e m ass of th e p et rou s p ar t is
w edged bet w een th e sp h en oid an d occip it al bon es.4 Th e pet rous
p ar t ’s base, ap ex, t h ree su r faces, an d t h ree bord ers are d escribed in su bsequ en t ch apters.
Th e pet rous pot ion exten ds an teriorly an d m edially, form ing
th e foram en lacerum via sph en oid art iculat ion . On th e m edial
side lies th e in tern al acou st ic m eat u s an d su p erior an d in ferior
pet rosal sin us grooves.3
Th e t ym p an ic p ar t is located below t h e squ am ou s p ar t an d
an ter ior to t h e m astoid p rocess. In ter n ally fu sed w it h t h e
6
Fig. 1.6 Left nasal bone: internal view. The four articulating borders
and the groove for the anterior ethmoidal nerve are appreciated from
this view.
1 Neurocranium and Facial Skeleton
Anterior
cranial fossa
Cribriform
plate
Crista galli
Sphenoid
sinus
Frontal sinus
Nasal bone
Hypophyseal
fossa
Ethm oid bone,
perpendicular
late
Sphenoid
crest
Vom er
Septal
cartilage
Choana
Major alar
cartilage,
m edial crus
Posterior process
Nasal crest
Palatine bone
Incisive canal
Palatine process
of m axilla
Fig. 1.7 Nasal septum. Parasagit tal section viewed form the left side.
The lateral wall of the left nasal cavit y, including adjacent bones, has
been removed. The contributions of the frontal, nasal, vomer, and
ethmoid bones to the bony nasal septum can be appreciated from this
view. (Reproduced from THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustration by Karl Wesker).
ject s cau dally as a vert ical crest . Th is crest form s part of th e
bony n asal sept um an d fur th er ar t iculates w ith th e n asal spin e
of t h e fron t al bon e d orsally, t h e p er p en d icu lar p late of t h e
eth m oid bon e, an d th e n asal septal cart ilage.4
Th e n asal par t of th e fron tal bon e lies bet w een th e supraorbit al m argin s. A n asal n otch in feriorly ar t icu lates w ith th e n asal
bon es an d laterally ar t icu lates w ith th e fron tal processes of th e
m axilla an d th e lacrim al bon es.4 Th is n otch support s th e n asal
bridge via an an teroin ferior project ion from it s posterior surface. Th is p roject ion ru n s beh in d th e n asal bon es an d th e fron t al processes of th e m axillae, en ding in a sh arp n asal spin e.4 Th e
n asal sp in e laterally form s part of th e n asal cavit y an d m akes a
sm all contribution to the nasal sept um via an terior articulat ion s
w ith th e crest of th e n asal bon e an d posterior ar t iculat ion s w ith
th e perpen dicular plate of th e eth m oid.4
The at, m edian, and quadrilateral perpendicular plate of the
eth m oid bon e descen ds from th e cribriform p late. Th is p late
u sually deviates sligh tly to form th e upper part of th e n asal sep t u m . It ar t icu lates via it s an ter ior bord er w it h t h e n asal sp in e
of th e fron t al bon e an d th e crest s of th e n asal bon es.4 Posteriorly, th e plate art iculates w ith th e crest of th e sph en oid body
su periorly an d th e vom er in feriorly. Th e broad in ferior border
at tach es to th e n asal septal car t ilage. Th e su perior surface con t ain s grooves an d can als for m edial cribriform plate foram in a;
all oth er su rfaces are sm ooth .4
Surgical Annotation
Nasoet h m oidal orbit al fract u res involve inju r y to n u m erou s
osseous st ruct ures in th e upper m idface. Th e fron t al process of
th e m axilla is isolated from th e abut t ing osseous st ruct ures.
Th is fract ure pat tern allow s for displacem en t of th e m edial can th al ten don , leading to t raum at ic telecan th us. Th is t ype of in jur y is com m on ly seen after direct im pact to th e u pper n asal
area. Th e fract u re can p resen t a su rgical ch allenge to obtain adequ ate exp osu re of th e n u m erou s an atom ical st ru ct u res w ith in
th is area. An exist ing lacerat ion can be used to obtain access;
h ow ever, a coron al in cision , low er eyelid in cision , an d gingival
buccal in cision are n eeded to allow for access.10 Re-est ablish m en t of th e m edial can th al ten don p osit ion is essen t ial du ring
t h is p roced u re an d can be accom p lish ed by d irect p lat ing or
t ran sn asal w iring, d ep en ding on t h e exten t of com m in u t ion
of th e area.11 Use of bon e graft ing is depen den t on th e n eed to
re-establish th e n asal h eigh t . Lacrim al system inju r y can occur
given its close p roxim it y an d w ill requ ire repair.
Th e n otched in ferior border is con t in uou s w ith th e upper
lateral n asal cart ilage at its ceph alic m argin . Th e lateral border
art icu lates w ith th e fron t al p rocess of th e m axilla, form ing th e
nasom axillar y su t u re lin es.
Vomer
Th e th in, m edially sit uated vom er bon e form s th e posterior, in ferior part of th e n asal sept u m . Both su rfaces of th e vom er con t ain a prom in en t groove for th e n asopalat in e n er ve an d vessels
th at ru n s obliquely an teriorly an d in feriorly (Fig. 1.8).4
7
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 1.8 Vomer: lateral border. The four articulating borders and the
groove for the nasopalatine nerve and vessels are realized from this
view.
Th e superior border is th e th ickest of th e vom er’s four bord ers. Presen t in g as a d eep fu r row , ar t icu lat ing w it h t h e rost r u m of t h e body of t h e sp h en oid , it is bou n d on eit h er sid e
by h or izon t ally p roject ing alae.4 Th e alae ar t icu late w it h t h e
sp h en oidal con ch ae an d w it h bot h t h e sp h en oidal p rocesses
of t h e p alat in e bon es an d t h e vagin al p rocesses of t h e m ed ial pter ygoid p lates of t h e sp h en oid rost rally an d cau dally,
resp ect ively.4
Th e rost ral an d in feriorly sloping an terior border fuses w ith
th e perpen dicular plate of th e eth m oid in it s upper h alf. Th e
low er h alf is grooved to art iculate w ith th e in ferior m argin of
th e n asal sept al cart ilage. Th e an terior ext rem it y descen ds bet w een th e in cisive can als, art iculat ing w ith th e posterior m argin of th e m a xillar y in cisor crest .4 Median n asal crest s of th e
palat in e an d m axillae bon es art iculate w ith the in ferior vom er
border. The dorsally bi d, concave posterior border separates the
nasal apert ures and does not articulate w ith any other bones.3
Inferior Nasal Concha
Con sist ing of a lam in a of can cellous bon e, th e cur ved in ferior
n asal con ch a form s p art of th e lateral w all of th e n asal cavit y.
Th e perforated, convex m edial surface in cludes longit udin al
grooves for t raversing vessels. Th e con cave lateral su rface form s
part of th e in ferior m eat us (Fig. 1.9).4 Th e su perior border, d ivided in to th ree region s, ar t icu lates w ith th e con ch al crest s of
th e m axilla an teriorly an d th e palat in e posteriorly.4
Th e m iddle of th ese th ree region s com prises th ree art icu lating p rocesses. As discussed h erein , th e rost ral lacrim al process
h elps form th e n asolacrim al can al via ar t icu lat ion s w ith th e lacrim al bon e an d m axilla. Th e ascen ding eth m oidal p rocess join s
th e un cin ate process of th e eth m oid. In term ediately, th e ven t ral
an d laterally cu r ving m axillar y process ar t icu lates w ith th e m edial m axilla at th e open ing of th e m axillar y sin us.4 Th e an terior
an d p osterior en d s of th e in ferior n asal con ch a tapering an d th e
in ferior border are free, th ick, an d cellular.3
Maxilla
Th e m axilla join tly form s m ost of th e upper jaw an d face. Each
bon e form s th e bulk of th e oor an d lateral w all of th e n asal
8
Fig. 1.9 Left inferior nasal concha: lateral view. Forming part of the
inferior meatus, the superior border and its three processes and the
free inferior border can be appreciated from this view.
cavit y an d th e orbital oor. It also con t ribu tes to th e in fratem poral an d pter ygopalat in e fossae. Th e m axilla com p rises a body
an d fron t al, zygom at ic, p alat in e, an d alveolar processes.3
Body
Anterior Surface
En closing th e m axillar y sin us, th e pyram idal body of th e m axilla has anterior, infratem poral (posterior), orbital, and nasal surfaces (Fig. 1.10a).4 Th e an terolaterally facing an terior su rface
con t ain s in ferior elevat ion s an d th e alveolar processes dorsal to
th e roots of teeth . Th e can in e em in en ce overlies th e can in e
tooth socket an d separates th e sh allow in cisive fossa, posterior
to th e in cisors, from th e deeper, m ore lateral can in e fossa. Dorsal to th e can in e fossa lies th e in fraorbital foram en , w h ich
t ran sm its th e in fraorbital vessels an d n er ve.4 Th e an terior m edian in term axillar y sut ure is form ed bet w een th e t w o m axillae,
th e in ferior border of th e n asal aper t ure, an d th e cen t ral in cisor
teeth .
Posterior Surface
Th e con cave posterior (in fratem poral) surface form s th e an terior w all of th e in fratem poral an d pter ygop alat in e fossae.4 Sep arat ing th e p osterior an d an terior m axillar y body su rfaces are
th e ascen ding zygom at icoalveolar ridge (jugal crest) an d th e
zygom at ic process (Fig. 1.10b).4 Posteroin feriorly located is th e
m axillar y t u berosit y, w h ich art icu lates w ith th e pyram idal p rocess of th e palat in e bon e.4
Orbital Surface
Th e orbital surface form s m ost of th e orbit al oor. Along it s m edial border, th e orbital surface ar t icu lates w ith th e lacrim al
bon e, th e orbit al plate of th e eth m oid, an d th e orbit al processes
of th e palat in e bon e. It also form s th e in fraorbital groove, part of
th e in fraorbit al can al, an d th e an terior edge of th e in ferior orbit al ssure.4
1 Neurocranium and Facial Skeleton
a
b
Fig. 1.10 (a) Medial view of the left maxilla. Much of the body; the
palatine, frontal, and alveolar process; and the maxillary sinus can
be realized from this view. Additionally, the emerging incisive canal,
greater palatine groove, and the conchal and nasal crests can be
appreciated via this medial view. (b) Lateral view of the left maxilla.
The remainder of the body and it s associated jugal crest and orbital and
infratemporal surfaces are viewed best laterally. Additionally, the lateral
frontal zygomatic process can be appreciated via this lateral view.
Nasal Surface
m al bon e com bin e to com p lete th e lacrim al fossa.4 Th e m ed ial
su rface of th e fron tal p rocess form s p art of th e lateral n asal
w all. Su bap ical ar t icu lat ion s w ith th e eth m oid close th e an terior eth m oidal air cells, an d an obliqu e eth m oidal crest , w h ich
form s th e su p erior border of th e m iddle m eat u s, posteriorly art icu lates w ith th e m iddle n asal con ch a.4
Th e large m axillar y h iat us, w h ich leads to th e m axillar y sinu s,
de n es th e posterosuperior n asal surface. Th e aerated sin us is
part ially closed by eth m oid an d lacrim al bon e ar t icu lat ion s. In ferior to th e sin u s is part of th e in ferior m eat u s an d p osteriorly
a rough en ed su rface for ar t icu lat ion w ith th e perpen dicu lar
plate of th e palat in e bon e.4 An terior to th e h iat u s is th e n asolacrim al groove, com prising abou t t w o-th irds of th e circu m feren ce
of th e n asolacrim al can al; th e rem ain der is con t ributed by th e
descen d in g p ar t of t h e lacrim al bon e an d t h e lacr im al p rocess
of t h e in fer ior n asal con ch a.4 Th is can al lead s t h e n asolacr im al
du ct to t h e in fer ior m eat u s. An ter iorly, t h e obliqu e con ch al
crest ar t icu lates w it h t h e in fer ior n asal con ch a, sep arat ing t h e
in fer ior m eat u s from t h e m ore su p er ior at riu m of t h e m id d le
m eat u s.4
Zygomatic Process
Th e an terior, infratem poral an d orbit al surfaces converge at th e
laterally p roject in g zygom at ic p rocess. Th is ser rated p rocess
ar t icu lates w ith th e m axillar y p rocess of th e zygom at ic bon e.
Th e t h ick, arch ed , an d in fer iorly p roject ing alveolar p rocess
su p p or ts th e m axillar y teeth . Th ese socketed p rocesses var y in
depth , w idth , an d sept at ion according to th e tooth t ype.4
Frontal Process
Th e posterosuperiorly project ing fron t al process ar t iculates superiorly w ith th e n asal par t of th e fron t al bon e, an teriorly w ith
th e n asal bon e, an d posteriorly w ith th e lacrim al bon e.4 Th e
ver t ical lacrim al crest divid es th e fron t al process; posterior to
th is crest , vert ical grooves of th e fron tal process an d th e lacri-
Palatine Process
Project ing from th e m ost in ferior par t of th e m edial m axilla is
th e th ick, h orizon tal palat in e process. Togeth er, th e ar t iculated
con t ralateral palat in e processes form m ost of th e n asal oor
an d th ree-qu arters of th e osseou s (h ard) palate.4 Th e h orizon t al
p late of th e palat in e bon e form s th e rem ain der, subsequ en tly
form ing th e t ran sverse p alatom axillar y su t u re. Posterolaterally,
t w o grooves in th e palat in e process t ran sm it the greater palat in e vessels an d n er ves. Th ese t w o lateral in cisive can als, each
ascen ding in to it s h alf of th e n asal cavit y, op en in to th e in fu n dibular in cisive fossa an d t ran sm it th e term in at ion s of th e
greater p alat in e ar ter y an d n asopalat in e n er ve.4
Occasion ally, th e m ed ian an terior an d p osterior in cisive foram in a are p resen t .4 Th e m edian in term axillar y palat al su t u re
ru n s posterior to th e in fu n dibu lar in cisive fossa.
Th e t h icker an terom ed ial bord er ar t icu lates w it h t h e con t ralateral p alat in e process, for m in g a raised n asal crest t h at
creates a groove for th e vom er. An teriorly, th is ridge rises as an
in cisor crest , w h ich art iculates con t ralaterally w ith th e paired
p rocess, form ing th e an terior n asal spin e.4
Maxillary Sinus
Th e pyram idal m axillar y sin us, located in th e body of th e m axilla, is th e largest of th e paran asal sin uses (Fig. 1.11). Th e m edial
9
Anatom y for Plastic Surgery of the Face, Head, and Neck
Cribriform
plate
Crista
galli
Frontal
sinus
Perpendicular
plate
Orbital plate
Superior
m eatus
Orbit
Superior
concha
Middle
m eatus
Middle ethm oid sinus
Ostium of
maxillary sinus
Middle
concha
Uncinate process
Inferior
m eatus
Inferior
concha
Maxillary sinus
Palatine process
of maxillae
Vom er
Fig. 1.11 Bony structure of the paranasal sinuses: anterior view. This
coronal section elucidates the relationship of the paranasal sinuses with
their associated structures to the viscerocranium. (Reproduced from
THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010,
Illustration by Karl Wesker.)
w all form s p ar t of th e lateral w all of th e n ose, an d th e roof
form s th e largest port ion of th e orbit al oor. Th e m axilla form s
the oor, anterior w all, and posterior w all of the sinus via its alveolar process and part of the palatine process, the facial surface,
an d in fratem p oral su rface respect ively. Th e ap ex of th e sin u s
exten ds in to th e zygom at ic p rocess of th e m axilla.4
High on th e p osterior m edial w all of th e m axillar y sin u s is
th e ost ium of th e sin us. Port ion s of th e perpen dicular plate of
th e palat in e bon e, th e un cin ate process of th e eth m oid bon e,
th e in ferior n asal con ch a, th e lacrim al bon e, an d overlying n asal
m ucosa lim it th e size of th e ost iu m .4 Th e ost iu m usually open s
in to th e posterior part of th e eth m oidal in fun dibu lum , w h ich
com m un icates w ith th e m iddle m eat us, alth ough an accessor y
ost ium is som et im es presen t posterior to th e m ajor ost ium .4
rior edge of th e vom er. Th e posterior bord er projects posteriorly
as th e p osterior n asal spin e. Th e lateral border, con t in u ou s w ith
the perpendicular plate of the palatine bone, contains the greater
palat in e foram en .3
Perpendicular Plate
Th e perpen dicu lar plate h as n asal an d m axillar y surfaces an d
an terior, p osterior, su p erior, an d in ferior borders.4 Th e n asal
su rface of th e perp en dicu lar p late in feriorly con t ribu tes to th e
in ferior m eat us. Superiorly, a h orizon tal con ch al crest ar t iculates w ith th e in ferior con ch a. Moving superiorly are a d ep res-
Palatine Bone
Th e paired palat in e bon es each com prise a h orizon t al an d perpen dicular plate, arranged as L-sh aped pyram idal, orbit al, an d
sph en oidal p rocesses (Fig. 1.12).3 Th e p alat in e bon es con t ribu te
to th e oors of th e palate, orbit , an d n asal cavit y; to th e lateral
w all of th e n asal cavit y; to th e pter ygop alat in e an d pter ygoid
fossae; an d to th e in ferior orbital ssu res. Th ese bon es are
placed in th e posterior n asal cavit y bet w een th e m a xillae an d
pter ygoid processes of th e sph en oid bon e.3
Horizontal Plate
Th e quadrilateral h orizon t al plate h as n asal an d palat in e surfaces an d an terior, p osterior, lateral, an d m ed ial borders. Th e
n asal su rface t ran sversely form s th e posterior n asal oor. Th e
palat in e surface form s th e posterior quarter of th e bony palate
via m idlin e art icu lat ion s w ith it s pair at th e m edial border an d
w ith th e palat in e process of th e m a xilla at it s an terior border.4
Th e m idlin e art iculat ing horizon tal plates form th e posterior
part of th e n asal crest , w h ich art iculates w ith th e posteroin fe-
10
Fig. 1.12 Posterior view of the left palatine bone. The palatine bone,
which comprises the horizontal and perpendicular plates, pyramidal,
orbital, and sphenoidal processes and som e of their articulating
surfaces, can be understood from this posterior view.
1 Neurocranium and Facial Skeleton
sion th at form s p art of th e m iddle m eat u s, an eth m oidal crest
for th e m iddle n asal con ch a, an d a h orizon tal groove th at form s
part of th e superior m eat u s.4
Th e m axillar y surface art iculates w ith th e n asal surface of
t h e m a xilla. Posterosu p er iorly, it for m s a m edial w all to t h e
pter ygopalat in e fossa an d an teriorly form s part of th e m edial
w all of th e m axillar y sin u s. Th e p alat in e groove (i.e., can al on
m axillar y art icu lat ion ) d escen ds p osteriorly on th e m axillar y
su rface an d t ran sm its th e greater p alat in e vessel an d n er ve.4
Th e an ter ior bord er ar t icu lates w it h t h e m a xillar y p rocess
of th e in ferior con ch a, appearing in th e m edial w all of th e m axillar y sin u s. Th e p osterior border ar t iculates w ith th e m edial
pter ygoid plate. Th e sph en opalat in e foram en is form ed by th e
sph en opalat in e n otch on th e su perior border art icu lat ing w ith
th e body of th e sph en oid. Th is foram en provides con n ect ion s
from th e pter ygop alat in e fossa to th e p osterior p ar t of th e su p erior m eat u s.4
Pyramidal Process
Th e pyram idal process exten ds posterolaterally from th e h orizon t al an d perpen dicular palat in e plate jun ct ion to an angle
bet w een th e pter ygoid plates of th e sph en oid bon e.3 Th e poster ior su r face com p letes t h e low er p ar t of t h e pter ygoid fossa,
an d t h e an ter ior lateral su r face ar t icu lates w it h t h e m a xillar y
t u berosit y.4 Th e in fer ior su r face con t ain s t h e lesser p alat in e
foram in a.3
Orbital Process
Th e orbit al p rocess, exten ding su p erolaterally from t h e an terior p er p en d icu lar p late, h as t h ree ar t icu lat in g an d t w o n on articulating surfaces. The anterior (m axillar y) surface articulates
a
Fig. 1.13 (a) External view of the left zygomatic bone. The facial
surface of the zygom atic body displays the zygomaticofacial foramen
near the orbital surface. The frontal and temporal processes, as well
as the orbital, temporal, and m axillary margins, are visible from this
anterior view. (b) Internal view of left zygomatic bone. The internal
an terolaterally w it h t h e m a xilla. Th e p oster ior (sp h en oidal)
su rface bears th e op en ing of an air sin u s th at u su ally com m u n icates w ith th e sph en oid sin us, w h ich is closed by th e sph en oidal con ch a.4 Th e m edial (eth m oidal) su rface art icu lates w ith
th e labyrin th of th e eth m oid bon e, on w h ich th e sin us of th e
orbital process can form , th us com m un icat ing w ith th e posterior eth m oidal air cells. Rarely, th e sin u s of th e orbit al p rocess
can open on both th e eth m oidal an d sph en oidal surfaces. Separat ing th e n on art icu lat ing su p erior (orbit al) an d lateral su rfaces
is a roun ded border th at form s a m edial par t of th e low er m argin of th e in ferior orbit al ssu re.4
Sphenoidal Process
Th e superior surface of th e superom edially project ing sph en oidal p rocess ar t icu lates w it h t h e sp h en oidal con ch a an d con t r ibutes to th e palatovagin al can al form at ion . Th e su perior an d
lateral surfaces an d th e posterior border of th e sph en oidal p rocess ar t icu late w ith th e root of, th e m edial surface of, an d th e
vagin al p rocess of th e m edial pter ygoid plate, respect ively.4 Th e
m edial border of th e sph en oidal process art icu lates w ith th e ala
of th e vom er, an d th e in ferom edial surface form s par t of th e
roof an d lateral w all of th e n ose.4
Zygomatic Bone
Th e quadrangular zygom at ic (zygom a) bon es form th e prom in en ces of th e ch eeks an d rest s on th e m axillae. Th e zygom a
form s th e an terolateral rim s, w alls, oor, m u ch of th e in fraorbit al m argin s of the orbit s, an d th e w alls of th e tem poral an d
in fratem poral fossae.3 It in clu des lateral, tem p oral, an d orbit al
su rfaces; t w o p rocesses, th e fron t al an d tem poral; th ree foram in a; an d ve borders (Fig. 1.13).4
b
view provides a bet ter appreciation for the serrated maxillary and
sphenoidal margins and those surfaces that articulate with the frontal
bone, temporal bone, and maxilla. The zygomatico-orbital foramen on
the orbital surface is also viewed from this angle.
11
Anatom y for Plastic Surgery of the Face, Head, and Neck
Surfaces
Th e convex lateral (facial) surface con t ain s th e cen t rally located
zyom at icofacial foram en , allow ing p assage of th e zygom at icofacial n er ve an d vessels. Th is foram en is often dou ble an d occasion ally absen t . Th e zygom at icus m in or an d m ajor origin ate
in ferior to the foram en anteriorly and posteriorly, respect ively.4
Th e posterom edial (tem poral) surface ar t icu lates m edially
w ith the zygom atic process of the m axilla. This sm ooth, concave
su rface t ran sm it s th e zygom at icotem p oral n er ve via th e zygom aticotem p oral foram en n ear th e base of th e fron t al process.4
Th e orbital surface exten ds up on th e m edial aspect of th e
fron t al process an d form s th e an terolateral p ar t of th e orbit al
oor an d adjoin ing lateral w all. Th is sm ooth , con cave su rface
u su ally con t ain s th e zygom at ico-orbit al foram in a represen t ing
canal open ings leading to th e zygom at icofacial an d zygom at icotem p oral foram in a.4
Borders
Th e an teroin fer ior (m a xillar y) bord er ar t icu lates w it h t h e
m a xilla. It s m edial en d t ap ers to a p oin t th at provid es p ar t ial
at t ach m en t for th e levator labii superioris m uscle. Th e sin uou s
posterosu perior (tem poral) border is con t in uous w ith th e posterior border of the fron tal process an d, thus, the upper border of
th e zygom at ic arch .4 Th e tem poral fascia at t ach es to th is border.
The serrated posterom edial border articulates superiorly w ith the
greater w ing of th e sp h en oid an d in feriorly w ith th e orbit al su rface of th e m axilla. Th is su rface u su ally form s th e lateral edge of
th e in ferior orbit al ssure by th e presen ce of a n on -art icu lat ing
con cave in den t .4 A posteroin ferior border, rough en ed for m asseter at t ach m en t an d th e an terosu p erior (orbital) border, form s
th e in ferolateral circum feren ce of th e orbit al open ing.4
Processes
Th e th ick, serrated fron t al process art iculates w ith th e zygom at ic process of th e fron t al bon e su p eriorly an d w ith th e
greater w ing of th e sp h en oid bon e p osteriorly.4 Var ying in size
an d form , W h it n all’s t u bercle is u su ally p resen t on th e orbit al
asp ect , 1 cm below th e fron tozygom at ic su t u re.4 Th e zygom at ic
arch is form ed by art icu lat ion s bet w een th e long, n arrow, an d
Fig. 1.14 External view of the right lacrimal bone. This view elucidates
the orbital surface of the lacrimal bone with its associated lacrimal
groove, which lies anterior to the posterior lacrimal crest.
serrated tem p oral process of th e zygom a an d th e zygom at ic
process of th e tem poral bon e.3
Lacrimal Bone
Th e paired sm all, th in , fragile lacrim al bon es con t ribute to th e
an terior m edial w all of th e orbit .3 A ver t ical posterior lacrim al
crest divides th e lateral (orbit al) su rface of th e lacrim al bon e
(Fig. 1.14). Rost ral to th is crest , th e rost ral edge of a ver t ical
groove m eet s th e p osterior border of th e fron tal process of th e
m axilla, com p let ing th e fossa for th e lacrim al sac. Th e m edial
w all of th is groove join s th e n asolacrim al groove of th e n asal
m axilla an d th e lacrim al p rocess of th e in ferior n asal con ch a,
con t r ibu t ing to t h e for m at ion of t h e n asolacr im al can al. Th e
u p p er op en in g of t h e n asolacr im al can al is com p leted by t h e
m axilla and th e lacrim al ham ulus, caudal and ventral to th e p osterior lacrim al crest .4
Th e m ed ial (n asal) su r face for m s p ar t of t h e m id d le m eat u s
via it s an teroin fer ior region . Th e p osterosu p er ior p ar t of t h e
m ed ial su rface m eet s t h e et h m oid , com p let in g som e an ter ior
et h m oid al air cells. Th e lacr im al bon es con t ain an ter ior, p oster ior, su p er ior, an d in fer ior bord ers. Th ey ar t icu late w it h t h e
fron t al p rocess of t h e m a xilla, t h e orbit al p late of t h e et h m oid , t h e fron t al bon e, an d t h e orbit al su r face of t h e m a xilla,
resp ect ively.4
References
1. Moore KL, Dalley AF, Agur AMR. Clin ically Orien ted An atom y. 6th
ed. Balt im ore, MD, an d Ph iladelph ia, PA: Lippin cot t William s &
Wilkin s; 2010
2. Sadler TW. Langm an’s Medical Em brology. 12th ed. New York, NY:
Lippin cot t William s & Wilkin s; 2012
3. Nor ton NS. Net ter’s Head an d Neck An atom y for Den t ist r y. 1st ed.
Ph iladelph ia, PA: Elsevier Saun ders; 2006
4. St an dring S, Gray HFRS. Gray’s An atom y: Th e Anatom ical Basis of
Clin ical Pract ice. 39th ed. Ph iladelphia, PA: Elsevier Chu rch ill Livingston e; 2005
5. Fallucco M, Jan is JE, Hagan RR. Th e anatom ical m orph ology of th e
supraorbit al n otch : clin ical relevan ce to th e su rgical t reat m en t of
m igraine h eadach es. Plast Recon st r Surg 2012;130(6):1227–1233
PubMed
6. Ch epla KJ, Oh E, Guyuron B. Clin ical outcom es follow ing su praorbit al foram in otom y for t reat m ent of fron t al m igrain e h eadache.
Plast Recon st r Surg 2012;129(4):656e–662e Pu bMed
12
7. Kung TA, Guyuron B, Cedern a PS. Migrain e surger y: a plast ic surgery solut ion for refractor y m igraine headache. Plast Reconstr Surg
2011;127(1):181–189 Pu bMed
8. Tiw ari P, Higuera S, Th orn ton J, Hollier LH. The m an agem en t of
fron t al sin u s fract u res. J Oral Maxillofac Su rg 2005;63(9):1354–
1360 Pu bMed
9. Bell RB, Dierks EJ, Brar P, Pot ter JK, Pot ter BE. A protocol for th e
m an agem ent of fron t al sin us fract ures em ph asizing sin us preservat ion . J Oral Maxillofac Surg 2007;65(5):825–839 PubMed
10. Paw ar SS, Rh ee JS. Fron t al sin us an d n aso-orbit al-eth m oid fract ures. JAMA Facial Plast Su rg 2014;16(4):284–289 PubMed
11. Koch h ar A, Byr n e PJ. Su rgical m an agem en t of com p lex m id facial
fract ures. Otolar yngol Clin North Am 2013;46(5):759–778 PubMed
2
Anterior Skull Base
Surjith Vat toth and Philip R. Chapm an
Introduction
Th e sku ll base is t radit ion ally divided in to an terior, cen t ral, an d
posterior zon es based prin cipally on th e appearan ce of th e skull
base as view ed from above (Fig. 2.1). Th is approach suppor ts
th e gen eral delin eat ion of th e in t racran ial com part m en t in to
th e an terior, m iddle, an d posterior fossae. Th e an terior skull
base form s th e broad oor of th e an terior cran ial fossa, w h ich is
lled p red om in an t ly w it h t h e fron t al lobes of t h e brain . Th e
an terior sku ll base is t radit ion ally de n ed as th e region of th e
sku ll base lying an terior to th e lesser w ing of sp h en oid an d p lan u m sp h en oidale (Fig. 2.2). Th e lesser w ing of th e sph en oid
span s an terolaterally from th e an terior clin oid process. Th e p osterior an d superior m argin s of th e lesser w ing form a cu r vilin ear ridge th at takes on th e sh ap e of a w ing—h en ce its n am e. Th e
lesser w ing of th e sph en oid bon e fu ses an teriorly w ith th e posterior m argin of the orbital plate of the frontal bone. The planum
sph en oidale is t h e su p erom ed ial p late of sp h en oid bon e seen
p os ter ior to t h e cr ibr ifor m p late of et h m oid an d an ter ior to
t h e an ter ior w all of sella t u rcica (t u bercu lu m sellae). Med ially,
t h e an ter ior sku ll base for m s t h e roof of t h e n asal cavit y an d
eth m oid sin u s, in clu ding th e cribriform p late of th e eth m oid .
Laterally, th e orbit al p lates of th e fron t al bon es form th e orbit al
roof p or t ion of th e an terior sku ll base on eith er side. Posteriorly,
th e m idlin e or parasagit t al an terior skull base is con st it uted by
th e plan um sph en oidale an d laterally by th e lesser w ing of th e
sph en oid bon e.1 Th e m iddle or cen t ral skull base is separated
from th e an terior sku ll base by a h orizon t al lin e along th e an terior sellar m argin exten ding laterally along th e posterior m argin
of lesser w ing of th e sph en oid bon e bilaterally, w h ich in cludes
th e m edial an terior clin oid processes.2
Midline or Parasagittal
Anterior Skull Base Forming
the Roof of the Nasal Cavity
and Ethmoid Sinuses
Th e an terior skull base, especially in th e region of th e n asal
vau lt an d eth m oid roof, is on ly m in im ally ossi ed at bir th an d
ossi es gradu ally from car t ilage. Th e roof of t h e n asal cavit y
begin s to ossify by aroun d th e age of 3 m on th s an d is predom in an tly ossi ed at 6 m on th s. Th e crist a galli, a m idlin e t rianglesh ap ed , su p er iorly p roject in g bony p rocess of t h e et h m oid
bon e, begin s to ossify from th e t ip at 3 m on th s an d is usually
ossi ed by th e rst year. Th e n am e is derived from th e Lat in an d
m ean s crest of th e cock (rooster’s com b). Th e crist a galli provides at t ach m en t to th e an teroin ferior p art of th e falx cerebri
an d sh ou ld n ot be con fu sed w ith th e fron t al crest , a m ore an terior m idlin e bony ridge–like p or t ion of th e fron tal bon es, w h ich
also p rovides at t ach m en t to th e falx cerebri (Fig. 2.3). Th e crist a
galli is p n eu m at ized in 10 to 15% of p at ien ts as iden t i ed on
com pu ted tom ography (CT) scan s. Alth ough th e crista galli is
tech n ically par t of th e eth m oid bon e, pn eum at izat ion gen erally
occurs as an exten sion of th e left or righ t fron t al sin us.3 Th e
p erp en dicu lar plate of th e eth m oid, w h ich form s th e sup erior
p or t ion of th e bony n asal sept um an d is seen directly below th e
crist a galli, begin s to ossify at 6 m onth s an d fuses w ith th e
vom er, w h ich form s th e in ferior p ort ion of th e bony n asal sep t um by aroun d 2 years of age.1
Th e cribriform plate (lam in a cribrosa) of th e eth m oid in th e
adu lt is a h orizon t al perforated bony plate at th e m edial asp ect
of eth m oid bon e, w ith deep grooves lying on either side of th e
m idlin e crist a galli. It form s part of th e roof of th e n asal cavit y
an d con st it u tes t h e oor of t h e olfactor y fossa lodgin g t h e olfactor y bu lbs (Fig. 2.4). Th e olfactor y fossa is th e low est poin t in
th e an terior sku ll base. Th e perforat ion s an d foram in a in th e
m idd le of th e grooves are sm all an d t ran sm it th e a eren t olfactor y n er ve bers from th e n asal vault m ucosa to th e olfactor y
bu lbs in t racran ially. Th e larger foram in a at th e m edial aspect of
th e grooves t ran sm it n er ves to th e superior n asal sept um an d
th ose at th e lateral aspect to th e su perior t urbin ate region .
More th an t w o-th irds of th e p opu lat ion w ill h ave ossi ed posterior cribriform plates by 1 year of age, an d m ost of th e an terior sku ll base, in clu d ing th e cribriform plates, are ossi ed after
2 years; h ow ever, sm all gaps can be seen in th e n asal roof un t il
early in year 3 of life.
Th e eth m oid roof is form ed by th e vert ically orien ted lateral
lam ella of th e cribriform plate of th e eth m oid bon e m edially
an d th e m ore h orizon t al fovea eth m oidalis of th e orbit al p late of
fron t al bon e su perolaterally. Th e vert ical lateral lam ella lies ju st
lateral to th e h orizon t al cribriform plate prop er. Th e lateral
lam ella is 10 t im es th in n er th an th e fovea eth m oidalis.4 Th e
sku ll-base at t ach m en t of th e m iddle t u rbin ate of th e n asal cavit y to th e an terior cribriform p late is quite delicate, an d its det ach m en t at surger y can dam age th e dura m ater w ith resultan t
cerebrospin al uid leak.
Eth m oid air cells lie in ferior to th e plan e of cribriform plate
u n t il 3 m on th s of age. By 6 m on th s, th ey exten d above th e h orizon t al cribriform plate plan e, an d th e m ore su perolateral fovea
eth m oidalis p or t ion of eth m oid sin u s roof begin s to develop
from t h e orbit al p late of t h e fron t al bon e by 18 m on t h s an d
m at u res by 2 years of age. Kn ow ledge of th is lateral-to-m ed ial
slop e of th e an terior sku ll base is ext rem ely im p or tan t during
t ran seth m oidal surgical approach es to an terior skull-base lesion s. Using th e sam e axial plan e of su rgical dissect ion , w h ich is
safe along th e m ore lateral eth m oid roof, cou ld inju re th e brain
an d du ra m ater if exten ded m edially to th e region of cribriform
plate.5
13
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 2.1 View of the skull base from above. Traditionally, the skull base
is divided into anterior, middle, and posterior components.
A h orizon t al lin e draw n along th e roof of th e eth m oid sin us
passes th rough th e orbit superior to th e orbital vert ical m idpoin t in m ost cases (88%), w ith 10% crossing at th e m idpoin t
an d on ly 2% below th at plan e.6 Preoperat ive im aging sh ould be
crit ically review ed to assess for a low -lying skull base. Th e safest an atom y is w h en th e h orizon tal lin e draw n from th e roof of
th e eth m oid crosses th e upper th ird of th e orbit; precau t ion s to
avoid injur y to th e skull base sh ould be taken w h en th e h orizon t al plan e of th e eth m oid roof crosses below th e ver t ical m idpoin t of th e orbit .1
Th e skull base also slopes dow nw ard in an an terior to posterior direct ion in th e sagit t al p lan e from th e fron t al recess to th e
planum sph en oidale along th e eth m oid roof. Th e degree of
slope is h igh ly variable an d sh ou ld be assessed by preoperat ive
im aging. During en doscopic sin us su rger y, th e skull base could
be inju red w h ile using a fron t-to-back tech n ique. Skull-base in ju r y can be avoided by early iden t i cat ion using th e back-tofron t tech n iqu e of en doscopic su rger y w h ereby th e sku ll base is
easily located at th e roof of sp h en oid sin u s after iden t ifying th e
su perior m eat u s an d sp h en oid ost iu m .7–11
Th e Keros classi cat ion of th e eth m oid roof an d olfactor y
fossa in to th ree t ypes t akes in to accou n t th e ver t ical h eigh t of
th e lateral lam ella of th e eth m oid an d th e result an t depth of th e
olfactor y fossa (Fig. 2.5). An olfactor y fossa th at is on ly 1 to 3
m m deep becau se of a n early n on existen t lateral lam ella con st it utes a Keros t ype 1 (12%). Th e olfactor y fossa is 4 to 7 m m deep
in Keros t ype 2 (70%) an d 8 to 16 m m deep in t ype 3 (18%) w ith
progressively in creasing vert ical h eigh t of th e lateral lam ella.12
Asym m et r y of m ore th an 2 m m is seen in 8% of cases.13 During
en d oscop ic su rger y, Keros t ype 3 h as th e largest risk for iat ro-
14
Fig. 2.2 Magni ed view of the anterior skull base. The anterior clinoid
process (AC) merges anteriorly with the lesser wing of the sphenoid
bone (LWS). Medially, the lesser wing of the sphenoid merges with a
at portion of the sphenoid bone that serves as the ventral roof to the
sphenoid sinus, the planum sphenoidale (PS). The lesser wing of the
sphenoid is joined anteriorly with the orbital plate (OP) of the frontal
bone. The orbital plate of the sphenoid bone serves as the roof of the
orbit. The ethmoid bone (EB) is in the center of the anterior skull base
and contains the cribriform plate (CP) and the crista galli (CG).
gen ic inju r y to th e lateral lam ella. Also, th e an terior eth m oidal
arter y cou ld be iat rogen ically inju red in th e an terior eth m oidal
foram en (along w ith th e an terior eth m oidal vein an d n er ve)
(Fig. 2.6) lying bet w een th e eth m oid an d fron tal bon es just an terolateral to th e cribriform plate an d cau se cat ast roph ic bleeding in to th e orbit . Th e posterior eth m oidal foram en con tain ing
th e posterior eth m oidal ar ter y, vein , an d n er ve lies bet w een th e
eth m oid an d sph en oid bon es, ju st posterolateral to th e cribriform p late of th e eth m oid .
More Anterior Portions of
Midline/Parasagittal
Anterior Skull Base
Th e foram en cecum is a sm all m idlin e pit lying bet w een th e
fron tal an d eth m oid bon es, ju st an terior to th e crist a galli of th e
eth m oid (Fig. 2.7). It is close to 4 m m in diam eter at birth , an d
th e ossi cat ion is u sually com plete by 2 years bu t can som et im es be delayed un t il th e age of 5 years.14 Ossi cat ion defect s
in th e region of th e foram en cecum , n ose, and foreh ead can lead
to th e form at ion of th ree subt ypes of fron toeth m oidal (sin cipit al) ceph aloceles: fron ton asal (40–60%), n asoeth m oidal (30%),
an d n asoorbit al (10%) cep h aloceles. Associated ocu lar or in t racran ial abn orm alit ies are presen t in 80% of cases w ith fron toeth m oidal cep h aloceles.15
Du ring early in t rau terin e life, a sm all an terior sku ll base fon t an el at t h e an ter ior bou n dar y of t h e an ter ior sku ll base, called
2 Anterior Skull Base
a
b
c
d
e
f
Fig. 2.3 Serial high-resolution computerized tomography (CT)
coronal images through the anterior skull base, anterior to posterior.
(a) Pneumatized frontal sinus (FS) air cells are seen bilaterally. The
supraorbital notch (SON) marks the exit of the supraorbital nerve and
associated vessels from the orbit to the forehead. The paired nasal
bones (NBs) merge anteriorly at the nasal bridge and fuse superiorly
at the nasofrontal suture (NFS). The perpendicular plate (PP) of the
ethmoid bone forms the bony nasal septum superiorly. The inferior and
lateral bony support of the nose is provided by the frontal process (FP)
of the maxilla. (b) Frontal sinus (FS) air cells extend posteriorly above
the orbital roof. There is a depression, the lacrimal fossa (LF), in the
inferior and medial orbit that houses the lacrimal sac. The medial wall
of the lacrimal fossa is formed by the lacrimal bone (LB).The lacrimal
fossa is contiguous with the bony nasolacrimal canal (NLC). (c) More
posteriorly, the crista galli (CG) is seen as a thin bony protrusion in the
sagit tal plane. The perpendicular plate (PP) of the ethmoid bone forms
the bony nasal septum superiorly. The ethmoid sinus (ES) and maxillary
sinus (MS) are seen at this level. A sm all foram en can be seen at this
level as the anterior ethmoid artery (EA) pierces the lateral lamella of
the cribriform plate. (d) At this level, the anatomy of the cribriform
plate and ethmoid roof are well demonstrated. The crista galli (CG)
again seen as midline sagit tal bone projecting above the cribriform
plate (CP). The lateral margin of the cribriform plate is formed by a
vertical portion of bone called the lateral lamella (LL) of the cribriform
plate. The lateral roof of the ethmoid sinus is formed by a horizontal
projection of bone that arises from the medial orbit, called the fovea
ethmoidalis (FE). At this level, the proximal anterior ethmoid artery
(EA) can be seen leaving the orbit as it extends anteromedially toward
the cribriform plate. (e) More posteriorly, the cribriform plate and
ethmoid roof (ER) at ten. The orbital plate of frontal bone separates
the orbit from the frontal fossa. The posterior ethmoid (ES) and
maxillary sinuses (MS) are shown. (f) More posteriorly, through the
orbital apex (OA), the sphenoid sinus (SS) air cells are seen, along with
the at midline bony roof, the planum sphenoidale (PS). At this level, a
portion of the pterygopalatine fossa (PPF), as well as the sphenopalatine foramen (SPF), can be seen.
Fig. 2.4 Coronal T2-weighted magnetic resonance imaging through
the orbits demonstrates the relationship of the frontal lobes, olfactory
bulbs, and olfactory grooves. The olfactory bulbs (OBs) lie inferior to
the gyrus rectii (GR) of the frontal lobes. The olfactory grooves (OGs)
vary in depth in relationship to the ethm oid roof. The lateral aspect of
the ethmoid roof is the fovea ethmoidalis (FE).
15
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 2.5 Coronal computed tomography im ages in three di erent
patients depicts the variable depth of the olfactory fossa, corresponding to the Keros classi cation, I–III. The image on the left shows a depth
of 3 mm (I). The middle image demonstrates a depth of 5 mm (II); the
image on the right shows a depth of 8 mm (III).
th e fon t icu lus fron talis, lies bet w een th e superior part ially ossied fron t al bon e an d in ferior n asal bon es. At th is t im e, th ere is
also a sm all sp ace lled w ith du ra ju st posterior to th e develop ing n asal bon es an d an terior to th e car t ilage of th e developing
n asal capsu le, called th e p ren asal sp ace. W h en th e ch on drocran iu m begin s to ossify, th e fon t icu lu s fron talis closes, an d failu re
of it s closure leads to developm en t of a fron ton asal ceph alocele.
In th is con d it ion , a sm all port ion of m en inges w ith (m en ingoen cep h alocele) or w ith ou t (m en ingocele) brain h ern iates in to
th e foreh ead at th e region of th e glabella or dorsum of th e n ose
th rough a paten t fon t iculus fron t alis, bet w een th e fron t al bon e
su p eriorly an d th e n asal bon es in feriorly.16
As a resu lt of ossi cat ion of th e ch on drocran ium of th e an terior sku ll base from posterior to an terior, leaving a sm all p ort ion of cart ilage an teriorly for th e n asal capsule an d fur th er
ossi cat ion of n asal bon es, th e pren asal space lying bet w een
th ese becom es en cased in bon e an d obliterates, leaving a sm all
dural diver t icu lum called th e foram en cecu m just an terior to
th e site of th e fut ure crist a galli. Th e foram en cecum can con-
n ect an teroin feriorly to th e skin of th e n asal region t ran sien tly
th rough a dura-lin ed st alk called th e an terior n eu ropore, w h ich
later regresses. Defect s in regression lead to a n asoet h m oid al
ceph alocele th rough a m idlin e foram en cecum defect in to th e
pren asal sp ace an d n asal cavit y. Mass e ect by th e ceph alocele
m ay bow th e n asal bon es an teriorly. Th e crist a galli lies poster ior to t h e an ter ior sku ll base foram en cecu m d efect an d m ay
be bi d or even absen t , an d an associated cr ibr ifor m p late d efect or absen ce m ay be seen .17 Th e least com m on su bt yp e of an
fron toeth m oidal or sin cip ital cep h alocele, called a n aso-orbit al
ceph alocele, develops as a result of defect s in th e lacrim al bon es
or fron t al process of the m axilla w ith m en inges an d brain h ern iat ing in ferom edially in to th e orbit .
Fig. 2.6 Axial image through the level of the olfactory recess in patient
with acute right orbital fracture. The anterior ethmoidal (AE) artery
canals are demonstrated bilaterally. Superimposed illustration of the
left ophthalmic artery branches also demonstrates the posterior
ethm oid artery (PE) travelling m ore posteriorly.
16
Fig. 2.7 Midline sagit tal reform ation of CT scan through the sinuses
demonstrates midline structures from front to back. The residual
foram en cecum (FC) is identi ed anterior to the crista galli (CG). The
perforations along the cribriform plate (CP) can be seen. The planum
sphenoidale (PS) is the at, ventral roof of the sphenoid sinus, anterior
to the sella turcica (ST).
2 Anterior Skull Base
Nasal derm al sin u s w ith associated derm oid or epiderm oid
an d n asal cerebral h eterotop ia (so -called n asal gliom a), also
p re sen t as congen it al m idlin e n asal m asses, sh are com m on em br yologic pat tern s an d form th e m ajor di eren t ial diagn oses for
fron toeth m oidal cep h aloceles. Nasal derm al sin u s is lin ed by
ep ith elial derm is, variably exten ds in t racran ially, an d m ay be
seen as a sm all n asal d im p le. It does n ot con t ain brain or m en inges bu t can be con fu sed w ith a fron toeth m oidal cep h alocele
w hen associated w ith a derm oid or epiderm oid cyst som ew here along the tract. Nasal gliom a (a m isnom er because it cont ains n on n eoplast ic t issue) com prises of h eterotopic dysplast ic
glial t issu e w ith ou t any dem on st rable in t racran ial con n ect ion .
Approxim ately t w o-th irds are ext ran asal an d are located along
th e dorsum of th e n ose; th e rest are un der th e n asal bon es in an
in t ran asal locat ion .18
Anatomical Relationships
of the Remainder of the
Paranasal Sinuses w ith the
Anterior Skull Base
Th e an atom y of th e paran asal sin uses is given in det ail in Ch ap ter 17. On ly th e relevan t an atom y of th ose port ion s of th e paran asal sin uses associated w ith an terior skull base is discussed in
th is ch apter.
Th e fron t al sin uses are divided by a cen t ral sept um in to t w o
part s, an d m u lt iple sept a m ay be seen . Th e fron t al recess, w h ich
is th e drain age path w ay of th e fron t al sin us, drain s in to th e
m iddle m eat u s of th e n ose, w h ere th e an terior eth m oid an d
m a xillar y sin u ses also d rain (Fig. 2.8). Th e un cin ate process,
w h ich is at tach ed in feriorly to th e in ferior t urbin ate of th e n asal
Fig. 2.8 Parasagit tal reformation of CT scan through the sinuses
demonstrates the frontal sinus (FS), the frontal sinus ostium (FSO), and
the frontal sinus recess (FSR). The frontal sinus recess is conical shaped
and extends inferiorly into the medial meatus. Also identi ed is the
ethmoid bulla (EB), posterior ethmoid air cells (PE), and the sphenoid
sinus (SS).The middle turminate (MT) is labeled.
cavit y, form s th e upper m edial w all of m axillar y sin us. It also
form s th e bou n dar y of th e eth m oid in fu n d ibu lu m , w h ich is th e
com m on drain age path w ay of m axillar y an d an terior eth m oid
sin u ses in to th e m iddle m eat u s. It m ay be at tach ed su p eriorly,
orien t ing laterally to th e lam in a papyracea (lateral eth m oid
w all or m edial orbital w all) or orien t ing m edially to th e n asal
m id dle t u rbin ate or an terior sku ll base. If th e u n cin ate p rocess
at tach es to th e m iddle t u rbin ate of n asal cavit y or an terior sku ll
base or ien t ing m ed ially, t h e fron t al recess op en s in to t h e
eth m oid in fu n dibu lu m . Th e clin ical im p ort an ce of th is an atom ical relat ion sh ip is th at in fect ion in th e eth m oid in fun d ibulu m
can a ect th e fron tal sin us, resu lt ing in com bin ed involvem en t
of th e fron tal an terior eth m oid an d m axillar y sin uses. On th e
oth er h an d, if th e u n cin ate p rocess orien t s laterally an d in ser t s
in to th e lam in a papyracea, th e fron t al recess h as an isolated direct drain age in to th e an terior asp ect of th e m iddle m eat u s. In
th is case, th e eth m oid in fun dibulum is closed su periorly by a
blin d-en ding pouch kn ow n as th e recessus term in alis 19 ; h en ce,
eth m oid in fu n d ibu la in am m at ion resu lt s in an terior eth m oid
and m axillary sinusitis w ithout fron tal sinus involvem ent; how ever, th e p resen ce of a recessu s term in alis in creases th e in ciden ce of fron t al sin usit is, presum ably because of th e lack of an
an atom ical barrier bet w een th e fron t al recess an d m iddle m eat us again st th e ascen t of predisposing factors like allergen s, irrit an t s, an d in fect ion s from th e n asal cavit y.20
Th e p oster ior lim it of t h e fron t al recess is de n ed by t h e
u pw ard con t in u at ion of th e bu lla eth m oidalis (a p rom in en t an terior eth m oid cell form ing th e superolateral m argin of th e eth m oid infundibulum ) and the anterior ethm oidal arter y, a branch
of th e oph th alm ic arter y.21 Th e an terior eth m oidal arter y t ravels from th e orbit th rough a can al piercing th e lam in a papyracea
in to th e an terior eth m oid sin us im m ediately posterior to th e
fron tal recess, crosses th e sin u s, an d en ters th e an terior cran ial
fossa. As st ated p reviou sly, inju r y to t h e an ter ior et h m oid foram en lyin g ju st an terolateral to t h e cr ibr ifor m p late of t h e
eth m oid sh ou ld be avoided du ring su rger y in th is locat ion . It
gives o an an terior m en ingeal ar ter y to th e du ra an d also n asal
bran ch es, w h ich re-en ter th e n asal cavit y th rough th e cribriform p late.
Th e fron t al recess h as a som ew h at con ical or inver ted fun n el
sh ap e w ith it s su p erior apex at th e fron t al ost iu m .22 An terior
eth m oid cell p n eu m at izat ion is variable, an d both classic an d
accessor y cells m ay com p ress th e fron t al sin u s drain age p ath w ay. Th e agger n asi cells an d Ku h n’s fron t al recess cell t yp es 1 to
4 occur along th e an terior aspect of fron t al recess, w hereas sup rabu llar cells an d fron t al bullar cells are fou n d posteriorly an d
su praorbit al eth m oid cells posterolaterally.23 Agger n asi (Latin
for nasal m ound) cells are the m ost anterior of the anterior
eth m oid cells, lie an teroin ferior to th e fron tal recess an d in ferior to th e fron tal sin u s an d are alm ost alw ays presen t . Th ese lie
p osterior to th e fron t al process of th e m axilla, posterom edial to
n asal bon e, su p erom ed ial to th e lacrim al bon e, an d su p erolateral to th e u n cin ate p rocess. Th ey are seen in ferior to th e fron t al
recess an d lateral to th e m iddle t urbin ate on coron al CT scan s,
form im port an t su rgical lan dm arks, an d are op en ed du ring en doscopic surger y to gain access to th e fron t al recess. Agger n asi
cell in am m ator y disease m ay obst ruct th e fron tal recess, producing isolated opaci cat ion of th e fron tal sin u s w ith out in volvem en t of th e an terior eth m oid or m axillar y sin u ses.24 Th ere
is a st rong correlat ion bet w een agger n asi cells an d fron t al sin u s
17
Anatom y for Plastic Surgery of the Face, Head, and Neck
diseases on CT scan s in pat ien t s u n dergoing revision fu n ct ion al
en d oscop ic sin u s su rger y.25
Frontal recess (Kuhn’s) cells extend from the anterior ethm oid
in to t h e fron t al recess, an d t h ese are all seen p osterosu p er ior
to th e agger n asi cells. Th ey are sim ilar to agger n asi cells in th at
th eir posterior an d superior w alls appear as part it ion s w ith in
th e fron t al recess or w ith in th e th e fron tal sin u s in t ype 3 an d 4
cells.23 A t yp e 1 cell is a single fron t al recess cell su p erior to th e
agger n asi bu t below th e oor of th e fron t al sin u s. Typ e 2 cells
are m ult iple cells in th e fron t al recess above th e agger n asi th at
m igh t exten d in to th e fron tal sin u s. A t yp e 3 cell is a single large
fron t al recess air cell th at p n eu m at ize su p eriorly in to th e fron tal sin us. A t ype 4 cell is a single isolated cell w ith in th e fron t al
sin u s. An in tersin u s cell is seen bet w een th e fron tal sin u ses,
arises from th e fron t al sin u s, an d can som et im es n arrow th e
fron t al recess.26 Mucosal in am m at ion is presum ed to play a
m ore cru cial role th an agger n asi cells an d fron t al recess cells
1–3 in th e occurren ce of fron tal sin usit is.27
As n oted, accessor y air cells along th e posterior aspect of
fron t al recess in clu de th e fron tal bu llar cells, su p rabu llar cells,
an d su p raorbital eth m oid cells. Fron t al bu llar cells are form ed
by an terior skull base pn eum at izat ion in th e posterior fron tal
recess an d exten d th rough th e fron tal ost iu m in to th e t rue fron tal sin us. Suprabullar cells are seen above th e bu lla eth m oidalis
an d are also located in th e p osterior fron t al recess sim ilar to
fron tal bu llar cells, bu t th ey do n ot exten d in to th e fron t al sin u s.
Su p raorbital eth m oid cells are seen bet w een th e eth m oid roof
an d m edial orbit al w all an d arise from an terior eth m oid sin u s,
an d th ey m igh t op en in to th e lateral aspect of fron tal recess.
Th ey pn eum at ize th e orbit al plate of fron t al bon e posterior to
th e fron tal recess an d superolateral to fron t al sin us. Th ese cells
are fou n d lateral to th e fron t al sin u s in coron al CT scan im ages,
w h ereas th e fron t al bullar cells are m edial to th e sin us.28 Th e
presen ce of accessor y cells predispose on e to a h igh er in ciden ce
of frontal sinusitis by narrow ing the frontal sinus drainage pathw ay. Posteriorly, th e su prabu llar cells n arrow th e an teroposterior diam eter of th e fron t al recess, fron tal bu llar cells n arrow
th e fron t al recess an d also th e m ore superior fron t al ost ium ,
an d su praorbit al eth m oid cells n arrow th e fron t al ost iu m .27
An oth er im por tan t paran asal sin us st ruct ure at th e posterior
aspect of th e an terior skull base is the sphen oethm oid Onodi cell,
a p osterior eth m oid air cell th at exten ds su perior an d lateral to
th e an terior aspect of th e sph en oid sin u s an d abut s th e opt ic
n er ve. Deh iscen ce of th e adjacen t opt ic can al an d carot id can al
can be associated w ith an On odi cell,29 w h ich can be seen as a
bulge of th e opt ic can al at t ran sn asal endoscopy an d sh ou ld n ot
be breach ed so as to avoid opt ic n er ve injur y.
References
1. Harn sberger HR. An terior skull base. In : Harn sberger HR, Osborn
AG, Macd on ald AJ, Ross JS AJ, ed s. Diagn ost ic an d Su rgical Im aging An atom y: Brain, Head & Neck, Spin e. 1st ed. Ph iladelph ia, PA:
Am irsys; 2010:II12–II25
2. Ch apm an PR, Bag AK, Tubbs RS, Goh lke P. Pract ical an atom y of th e
cen t ral skull base region . Sem in Ult rasoun d CT MR 2013;34(5):
381–392 PubMed
3. Som PM, Park EE, Naidich TP, Law son W. Crist a galli pn eum at izat ion is an exten sion of th e adjacen t fron t al sin uses. AJNR Am J Neuroradiol 2009;30(1):31–33 PubMed
4. Kain z J. Hein z St am m berger. Th e roof of th e an terior eth m oid: a
place of least resist an ce in th e sku ll base. Am J Rh in ol. 1989;3:
191–199
5. Nuss DW, O’Malley BW. Surger y of th e an terior an d m iddle cran ial
base. In : Cum m ings CW, ed. Cum m ings Otolar yngology Head an d
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6. Meyers RM, Valvassori G. In terpret at ion of anatom ic variat ion s of
com pu ted tom ography scan s of th e sin uses: a surgeon’s perspect ive. Lar yngoscope 1998;108(3):422–425 PubMed
7. St an kiew icz JA, Chow JM. Th e low skull base: an invit at ion to disaster. Am J Rh in ol 2004;18(1):35–40 PubMed
8. Kim E, Russell PT. Preven t ion an d m an agem en t of sku ll base inju r y.
Otolar yngol Clin Nor th Am 2010;43(4):809–816 PubMed
9. Messerklinger W. [En doscopy techn ique of th e m iddle n asal m eat us] (auth or’s t ran sl). Arch Otorh in olar yngol 1978;221(4):297–
305 PubMed
10. Wigand ME. Transnasal, endoscopical sinus surgery for chronic sinusit is. II En don asal eth m oidectom y. HNO 1981;29:287–293 PubMed
11. Gray ST, Wu AW. Path ophysiology of iat rogen ic an d t rau m at ic skull
base injur y. In : Bleier BS, ed. Com preh en sive Tech n iques in CSF
Leak Rep air an d Sku ll Base Recon st ru ct ion . Adv Otorh in olar yngol.
2013;74:12–23
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12. Keros P. [On th e pract ical value of di eren ces in th e level of th e
lam in a cribrosa of th e eth m oid]. Z Lar yngol Rh in ol Otol 1962;41:
809–813 PubMed
13. Savvateeva DM, Gü ldner C, Mu r th um T, et al. Digit al volum e tom ography (DVT) m easurem en t s of the olfactor y cleft an d olfactor y
fossa. Act a Otolar yngol 2010;130(3):398–404 PubMed
14. Osborn AG. An om alies of th e skull an d m en inges. In : Osborn AG,
ed. Osborn’s brain : im aging, path ology, an d an atom y.1st ed. Salt
Lake Cit y, UT: Am irsys; 2013:1187–1208.
15. Hoving EW, Verm eij-Keers C. Fron toeth m oidal en ceph aloceles, a
st udy of th eir path ogen esis. Pediat r Neurosurg 1997;27(5):246–
256 PubMed
16. Hedlun d G. Congen it al fron ton asal m asses: develop m en t al an atom y, m alform at ions, an d MR im aging. Pediat r Radiol 2006;36(7):
647–662, qu iz 726–727 PubMed
17. Barkovich AJ. Congen it al m alform at ions of th e brain an d skull. In :
Barkovich AJ, ed. Pediat ric Neuroim aging. 4th ed. Ph iladelp h ia: Lip pin cot t William s & Wilkin s; 2005:308–313
18. Barkovich AJ, Van derm arck P, Edw ards MS, Cogen PH. Congenit al
n asal m asses: CT an d MR im aging feat ures in 16 cases. AJNR Am J
Neuroradiol 1991;12(1):105–116 Pu bMed
19. McLaugh lin RB Jr, Reh l RM, Lan za DC. Clin ically relevan t fron t al
sin us an atom y an d physiology. Otolar yngol Clin Nor th Am 2001;
34(1):1–22 PubMed
20. Turgut S, Ercan I, Sayin I, Başak M. Th e relat ion ship bet w een fron t al sin usit is an d localizat ion of th e front al sin us ou t ow t ract: a
com pu ter-assisted anatom ical an d clin ical st udy. Arch Otolar yngol
Head Neck Surg 2005;131(6):518–522 PubMed
21. Worm ald PJ. Th ree-dim en sional building block approach to un derst an ding th e an atom y of th e fron t al recess an d fron t al sin us. Oper
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2 Anterior Skull Base
23. Lee W T, Ku h n FA, Cit ardi MJ. 3D com puted tom ograph ic analysis of
fron t al recess anatom y in pat ien t s w ith out fron t al sin usit is. Otolar yngol Head Neck Su rg 2004;131(3):164–173 PubMed
24. Vat toth S, Sullivan JC. Face an d Neck Anatom y. In: Can on CL, ed.
McGraw -Hill Specialt y Board Review : Radiology. 1st ed. New York:
McGraw -Hill; 2010:99–114
25. Bradley DT, Koun t akis SE. The role of agger n asi air cells in pat ien t s
requiring revision en doscopic fron t al sin us surger y. Otolar yngol
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26. Coates MH, W hyte AM, Ear w aker JW. Fron t al recess air cells: spect rum of CT app earan ces. Aust ralas Radiol 2003;47(1):4–10
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27. Lien CF, Weng HH, Ch ang YC, Lin YC, Wang W H. Com pu ted tom ograp h ic an alysis of fron t al recess an atom y an d it s e ect on t h e
d evelop m en t of fron t al sin u sit is. Lar yngoscop e 2010;120(12):
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28. Zh ang L, Han D, Ge W, et al. Com puted tom ographic an d en doscopic an alysis of supraorbit al eth m oid cells. Otolar yngol Head
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1996;10(6):365–370
19
3
Middle Skull Base
Philip R. Chapm an and Surjith Vat toth
Introduction
Th e m iddle or cen t ral skull base h as custom arily been delin eated from th e an terior sku ll base by a h orizon t al lin e along th e
an terior sellar m argin (t u bercu lu m sellae), w h ich exten ds laterally along th e p osterior m argin of th e lesser w ing of th e sp h en oid bon e on both sides an d in clu des th e m edial an terior clin oid
processes. Th e posterior boun dar y of th e m iddle sku ll base is
form ed m edially by the dorsum sella and laterally by the petrous
ridges. Th e ap pearan ce of th e sku ll base, as view ed from above
an d th rough an open calvaria, n at u rally sep arates th e sku ll in to
it s th ree classic an atom ical division s. Th e an atom ical boun daries of th e sku ll base coin cide w ith th e bou n daries of th e p roposed in t racran ial spaces, producing th e an terior, m iddle, an d
posterior cran ial fossae. Th is arch et ypical approach does n ot
take in to accoun t th e pract ically im port an t , th ree-dim en sion al
(3D) con n ect ion s of th e m iddle sku ll base in th e curren t era of
advan ced cross-sect ion al im aging or th e availabilit y of soph ist icated surgical an d radiat ion t reat m en t m eth ods.1,2
Th e 3D an atom y of th e m iddle sku ll base sh ould en com pass
th e con t iguous an atom ical region s of th e orbit al apex an d opt ic
canal, in cluding th e opt ic n er ve leading posteriorly to th e opt ic
ch iasm , th e superior orbit al ssure, th e pter ygopalat in e fossa,
an d th e sella. In addit ion , th e su p rasellar an d p arasellar st ru ct ures, in clu ding th e pit uitar y glan d an d st alk, cavern ou s sin us,
in tern al carot id ar ter y, cran ial n er ves, Meckel’s cave, region al
skull-base foram in a, sphen oid sinus, clivus, petrous apex, petrooccipital ssure, foram en lacerum , an d par ts of th e n asoph aryn x sh ou ld also be in corp orated as p art of th e m iddle sku ll base.
Th is region can be con cept ualized as h aving a rough ly sph erical
sh ape w ith th e opt ic ch iasm at th e su perior p ole, n asop h ar yn x
at th e in ferior p ole, pter ygopalat in e fossa at th e an terior pole,
an d th e foram en ovale at th e lateral an d p rep on t in e cistern at
20
th e posterior poles, respect ively. At t ribut ing a 3D con gurat ion
to th e m iddle skull base allow s for com part m en t alizat ion of th e
an atom y, w h ich in t u rn h elp s to p redict p ath ology based on th e
kn ow ledge of in t rin sic st ru ct ures dw elling in th e par t icular locat ion . In addit ion , it sh eds ligh t on th e com plex an atom ical
con n ect ion s an d aids in assessing th e origin an d spread of various t ran s-spat ial disease processes. Th e lateral aspect of th e
m iddle sku ll base, con st it u ted predom in an tly by th e greater
w ing of th e sph en oid bon e, form s th e oor of th e m iddle cran ial
fossa, w h ich h ou ses th e tem p oral lobes of th e brain .1,3
Center of the Sphere :
Sphenoid Bone and
Sphenoid Sinus
Th e sph en oid bon e h as a cen t ral body an d is con st it uted on eith er side by th e lateral greater an d lesser w ings an d th e in ferior
pter ygoid process w ith th e m edial an d lateral pter ygoid plates.
Th e body of th e sph en oid con tain s th e sella t u rcica superiorly
an d th e sph en oid sin u s in feriorly. Posteriorly, it form s th e an terosu perior aspect of th e clivus, join ing th e posteroin ferior aspect from occipit al bon e at th e sph en o-occipit al syn ch on drosis.
Th e sph en o-occipital syn ch on drosis separates th e basisph en oid
from th e basioccipu t (Fig. 3.1). Ch ordom as can arise from n otoch ordal rem n an ts n ear th e syn ch on drosis, an d the presen ce of
vascu larized bon e m arrow p redisposes th e clivu s to path ologies
like m yelom a an d m et ast asis. Th e lesser w ing of th e sp h en oid
form s the posterior m argin of the anterior skull base—harboring
th e opt ic can al. Th e greater w ing of sph en oid form s th e oor of
m iddle cran ial fossa. Th e su perior orbit al ssu re lies bet w een
3 Middle Skull Base
Fig. 3.1 Three-dimensional illustrations of
the superior, anterior, and lateral views of the
sphenoid bone and the osseous foundation of
the central skull base. The outlined spherical
region denotes the central skull base region
and includes the adjacent endocranial structures including the pituitary gland and the
exocranial structures of the neck including
the nasopharynx.
th e lesser w ing of th e sph en oid superom edially an d th e greater
w ing of th e sph en oid in ferolaterally, separated by th e opt ic
st ru t , a sm all bony bridge th at p rojects from th e an terior clin oid
process of th e lesser w ing to th e sph enoid body.4,5 Th e osseous
arch itect u re of th e sp h en oid bon e, sp h en oid sin u s, an d associated relat ion sh ips w ith adjacen t osseou s sku ll base, can als, an d
foram in a is best st u died w ith h igh -resolu t ion com p u ted tom ography (CT) scan s u sing th in slices an d bon e algorith m s (Fig.
3.2, Fig. 3.3).
The extent of sphenoid sinus pneum atization (or lack thereof)
is classi ed as con ch al, presellar, an d sellar.6 In th e con ch al
form , th e sph en oid bon e is essen t ially solid w ith ou t develop m en t of an aerated sph en oid sin u s. With presellar pn eu m at izat ion , th e sph en oid sin us is pn eum at ized but does n ot exten d
p osteriorly to th e coron al level of th e an terior sellar. With sellar
p n eum at izat ion , th e sp h en oid sin u s exten ds posteriorly in ferior to th e sella an d can exten d to th e posterior clival m argin .
Th e an terior w all an d oor of sella are quite thin in th e lat ter
su bt ype, m easu ring less th an a m illim eter in th ickn ess. Sp h en oid sin u s p n eu m at izat ion m ay exten d in to th e opt ic st ru t an d
an terior clin oid p rocess, resu lt ing in th in n ing of th e bou n dar y
w ith th e opt ic can al an d superior orbit al ssure. Passage of th e
vid ian can al th rough th e body of sp h en oid bon e an d th e foram en rot u n du m , along th e lateral aspect of sp h en oid sin u s roof,
lies in close relat ion to sph en oid sin us.7 Th e sp h en oid sin u s lies
close to th e in tern al carot id arteries (ICAs) an d cavern ou s sin u ses. Th e ICA lies along a sh allow groove on th e in t racran ial
side of th e lateral w all of th e sph en oid sin u s. Th e variable in tercarot id dist an ce bet w een th e ICAs of both sides m akes pit u it ar y
surgery m ore risky. Sph enoid sinus septation also varies considerably. Alth ough it is u su ally single, sept at ion can be m u lt ip le
w ith septa deviat ing laterally, in ser t ing n ear th e carot id arter y.8
Cont iguous spread of path ology, bony dest ruct ion , an d poten t ial for iat rogen ic injur y to adjacen t crit ical st ruct ures during
su rger y sh ou ld be carefu lly est im ated du ring p resu rgical im aging evaluat ion of th e sphen oid sin u s.
21
Anatom y for Plastic Surgery of the Face, Head, and Neck
a
b
c
d
e
f
g
22
Fig. 3.2 Axial computed tomography (CT) anatomy (a–g ). Axial, unenhanced CT images
through the skull base, superior to inferior. (a) The posterolateral margin of the sella is marked
by the posterior clinoid process (PC).The anterior clinoid (AC) is a bony projection along the
anterolateral sella that is contiguous with the lesser wing of the sphenoid bone (LWS). Medialto-the-anterior clinoid process is the optic canal (ONC) that transmits the optic nerve and
ophthalm ic artery. The planum sphenoidale (PS) is a horizontal segment of bone just anterior
to the sella that forms part of the roof of the sphenoid sinus. (b) As the axial images move
inferiorly, the superior orbital ssure (SOF) becomes more conspicuous. The optic canal (ONC)
is intimately related to the sphenoid sinus (SS) medially and bony strut of the anterior clinoid
process (AC) laterally. (c) The posterior vertical margin of the sella is the dorsum sella (DS).
At this level, there is contiguous soft tissue densit y bet ween the middle cranial fossa (speci cally,
the cavernous sinus) and the orbital apex through the superior orbital ssure. The SOF transmits
the ophthalm ic vein; V1 segment of the trigeminal nerve; and cranial nerves III, IV, and VI. Please
note the greater wing of sphenoid (GWS). (d) In this example, there is a single sagit tal septum
in the sphenoid sinus. The natural sphenoid ostia are identi ed on either side of the septum,
allowing mucus to drain into the posterior nasal passage. The superior orbital ssure (SOF) is
noted (arrow). (e) At this level, the petrous apex (PA) can be seen as a pyramidal shaped, m edial
extension of the temporal bone. Along the superior and m edial margin of the petrous apex is a
shallow concavit y, the trigeminal impression (TI). The medial opening of the carotid canal (CC)
is seen, separated from the sphenoid sinus by thin cortical bone. The foramen rotundum (FR)
opens into the upper recess of the pterygopalatine fossa (PPF). (f) The foramen lacerum (FL) is
a triangular shaped, horizontal layer of cartilage bet ween the clivus and petrous apex. The
eustachian tube (ET) is seen just lateral to the carotid canal, extending lateral tomedial and
superior to inferior. The foram en ovale (FO) and foram en spinosum (FS) are seen in the lateral
sphenoid bone. The vidian canal (VC) contains the vidian nerve and travels from a point near
the foramen lacerum forward to the pterygopalatine fossa (PPF). The PPF connects with the
masticator space laterally through the pterygomaxillary ssure (PMF, large oval) and medially
through the sphenopalatine foramen (SPF, small oval) with the nasal cavit y. The infraorbital
nerve passes from the PPF into the inferior orbital ssure (IOF) on its way to the cheek. (g) At
this level, soft tissues that form the roof of the nasopharynx begin to show up ventral to the
clivus. Note that these soft tissues are directly contiguous with the region of the eustachian
tube and foramen lacerum.
3 Middle Skull Base
a
b
c
d
e
f
g
Fig.3.3 Coronal computed tomography (CT) anatomy, anterior to
posterior (a–h). Coronal, unenhanced CT images through the central
skull base. (a) Coronal image through orbital apices at the level of the
pterygoid process (PP) demonstrates the relationship bet ween the
pterygopalatine fossa and the orbital apex. (b) The pterygopalatine
fossa (PPF) contains fat, the distal branches of the internal maxillary
artery, veins, the pterygopalatine ganglion, and it s connections. The
PPF is contiguous with the inferior orbital ssure (IOF) and, ultimately,
the orbital apex. (c) Near the apex, the orbital roof is formed by the
lesser wing of the sphenoid bone (LWS). The m edial (MPP) and lateral
(LPP) pterygoid plates project posteriorly from the pterygoid process
(PP). (d) Near the apex, there is an obliquely oriented superolateral
ssure, the superior orbital ssure (SOF), which transmits the
ophthalm ic vein; V1 segment of the trigeminal nerve; and cranial
nerves III, IV, and VI. (e) The foramen rotundum (FR) opens into the
upper recess of the pterygopalatine fossa (PPF). In the coronal plane,
h
the foramen rotundum is seen superolateral to the vidian canal (VC).
(f) Coronal image through the sphenoid sinus demonstrates the
relationship bet ween the anterior clinoid process (AC) and the optic
canal (ONC). The roof of the sphenoid sinus is at and is referred to as
the planum sphenoidale (PS). The optic strut (OS) is a thin bridge of
bone de nes the lateral margin of the optic canal. At this level, the
foramen rotundum opens into the middle cranial fossa as V2 travels
toward the lateral wall of the cavernous sinus. (g) Coronal image
through sphenoid sinus demonstrates foramen ovale (FO) laterally,
which transmits V3 into the masticator space and more poorly de ned
foramen lacerum (FL) m edially. (h) Coronal image through the
posterior aspect of the sella. The posterior clinoid processes (PC) can
be seen as bilateral superolateral projections. The posterior wall of the
sella is the dorsum sella (DS). The upper one-half of the clivus is formed
from the sphenoid bone and is referred to as the basisphenoid (BS).
23
Anatom y for Plastic Surgery of the Face, Head, and Neck
Intracranial Structures
Superior to Center of the
Sphere
Sella Turcica and Suprasellar Region
Th e sella t u rcica (Turkish saddle) is a saddle-sh aped depression
in th e body of th e sph en oid bon e. Th e seat of th e saddle su p port s th e pit u it ar y glan d an d is kn ow n as th e hypophyseal fossa
(Fig. 3.4). It s an terior m argin is th e t uberculum sella, an d it s
posterior m argin is th e dorsum sella, w ith th e superolateral
posterior clin oid processes on eith er side. Th e dorsum sella is
con t in uous posteriorly w ith th e clivus. Th e ch iasm at ic sulcus
lies ju st an terior to th e t uberculum sella an d m edial to opt ic
can als. Th e plan um sph en oidale, a part of th e an terior cran ial
fossa, lies in fron t of th e t u bercu lu m sellae an d ch iasm at ic su lcu s. Th e m ed ial p rocesses alon g lesser w ings of sp h en oid bilaterally for m t h e sella’s an ter ior clin oid p rocesses. Th e oor of
t h e p it u it ar y fossa h as a w ell cor t icated , less t h an 1-m m -t h ick
bony w all kn ow n as th e lam in a dura. Th e diaph ragm a sellae is a
sligh tly in ferior, convex, th in du al fold covering th e su p erior aspect of sella an d is perforated cen t rally by th e pit uit ar y st alk.
Th e pit uit ar y stalk passes th rough th e cerebrospin al u id (CSF)
lled su p rasellar cistern on it s w ay to th e hyp oth alam u s. Th e
su p rasellar cister n also h ou ses t h e opt ic ch iasm an d circle of
W illis. Large sellar or su p rasellar lesion s, in clu d ing p it u it ar y
ad en om as an d cran ioph ar yngiom as, can p rodu ce opt ic ch iasm
com pression .
Cavernous Sinus
Th e cavern ous sin u ses, dural ven ous sin uses lying on eith er side
of t h e sella con n ected by in tercaver n ou s sin u ses, are fed by
m u lt ip le t r ibu t aries, in clu d in g t h e su p er ior op h t h alm ic vein s
Fig. 3.4 Sagit tal illustration through the central skull base demonstrates the bony anatomy of the sella trurcica (ST). The anterior wall of
the sella is very thin and separates the sella from the sphenoid sinus
(Sph). The clivus is formed by the basisphenoid (BS) superiorly and the
basiocciput (BO) inferiorly.
24
in th e orbits, sph en oparietal sin u ses seen along th e an terior aspect of m iddle cran ial fossa, basal vein of Rosen th al seen in th e
perim esen cep h alic cistern s drain ing tow ard th e vein of Galen ,
pter ygoid ven ous plexus seen in th e m ast icator space, an d th e
basilar ven ous plexus n ear th e pet rous apex. Th ey drain th rough
th e superior pet rosal sin us in to th e sigm oid sin us an d th rough
t h e in fer ior p et rosal sin u s in to t h e in ter n al jugu lar vein . In a
carot id -caver n ou s st u la, ven ou s ch an n els m ay be en gorged
w it h h igh p ressu re ar ter ialized ow an d ap p ear en larged on
m agn et ic reson an ce im aging (MRI) an d CT scan im ages.9
Th e cavern ous sin u s h as ve w alls.1,10 Th e m edial w all of th e
cavern ous sin us con sist s of an upper sellar com pon en t w ith a
single-layered, th in , du ral m em bran e separat ing it from th e lateral m argin of th e p it u it ar y glan d, an d a low er, th icker com pon en t adh eren t to th e carot id su lcu s. Tu m or obliterat ion of th e
m edial ven ou s com p art m en t of th e cavern ou s sin u s in ferior to
th e cavern ous ICA in a coron al MRI scan (called carot id sulcus
ven ou s com p ar t m en t of cavern ou s sin u s) h as been sh ow n to
h ave a 95% posit ive p redict ive valu e (PPV) for cavern ou s sin u s
invasion by a pituitary adenom a.11 Perim eter en casem en t of 67%
or m ore of th e cavern ous segm ent of th e ICA (100% PPV) an d
t um or spread beyon d th e border join ing th e lateral w all of th e
in t racavern ous an d su pracavern ous ICAs (85% PPV), as seen on
coron al MRI, both suggest cavern ous sin u s invasion . If th e percen t age of en casem en t of th e perim eter of th e in t racavern ou s
ICA is less th an 25%, or if aden om a invasion does n ot cross beyond the adjoin ing m edial w all of the intracavernous an d supracavern ous ICAs, cavern ous sin us invasion can th en be ru led out
w ith a n egat ive predict ive value of 100%.
Form ing th e m edial m argin of th e tem poral lobe, th e bilam in ar lateral w all of th e cavern ou s sin u s con sists of a th in ou ter
m eningeal layer an d a thicker inner dural layer that exten ds from
th e region of superior orbital ssure an d th e an terior clin oid
process an teriorly to th e pet rous apex posteriorly. Th e ocu lom otor n er ve (cran ial n er ve III, or CN III), th e t roch lear n er ve (CN
IV), and the oph thalm ic segm ent of th e trigem in al n erve (CN V1)
are con t ain ed w ith in th e lateral w all layers, an d th e on ly t ru ly
in t racavern ous n er ve, n am ely, th e abducen s n er ve (CN VI), lies
w ith in th e cavern ous sin us it self, along w ith th e cavern ous segm en t of ICA (Fig. 3.5). In feriorly, th e m edial an d lateral w alls
fu se alon g t h e lateral m argin of t h e body of sp h en oid bon e. It
is in terest ing to n ote th at th is fu sion occu rs ju st su p erior to th e
m axillary nerve (second division of the trigem inal n erve, CN V2)
an d th at th e CN V2 an d m an dibu lar n er ve (th ird division of th e
t rigem in al n er ve, CN V3) are n ot part of th e cavern ous sin us,
even th ough th ey are invested by th e con t igu ou s du ra.1,12
Th e cavern ou s sin us becom es con t iguous w ith th e in ferior
petrosal sin us (w h ich in t urn drain s th rough th e pet roclival ssu re in to in tern al jugu lar vein ) p osteriorly. Th e p osterior w all of
th e cavern ous sin us exten ds from th e lateral m argin of th e dorsu m sella to th e su perom edial asp ect of Meckel’s cave. Ju st posteroin ferior to th is is th e pet rous apex, over w h ich th e abducen s
n er ve (CN VI) t ravels u n dern eath th e pet rosp h en oid ligam en t ,
goes th rough th e Dorello’s can al, en ters th e posterior w all of th e
cavern ous sinu s, an d is seen w ith in th e subst an ce of th e cavern ous sin us lateral to th e cavern ous ICA (Fig. 3.6). Pet rou s ap icit is
can lead to Graden igo syn drom e w ith CN VI palsy (result ing
from involvem en t in Dorello’s can al) an d t rigem in al dist ribu tion pain from spread of in am m ation into the adjacent Meckel’s
cave, w h ere th e t rigem in al ganglion resides.13
3 Middle Skull Base
Fig. 3.5 Posterior view through the cavernous sinuses. The central
location of the cavernous internal carotid artery is noted. Cranial nerve
VI, the abducens, is the only nerve that is truly intracavernous. From
superior to inferior, the oculomotor, trochlear, ophthalmic, and
maxillary nerves are seen along the lateral margin of the cavernous
sinus. The lateral wall is divided into t wo layers, an outer meningeal
layer and an inner dural layer. The inner dural layer envelops the
oculomotor, trochlear, and ophthalmic nerves.
Th e rectangular an terior w all of th e cavern ous sin us exten ds
from the optic strut under the anterior clinoid process toward th e
su perior orbital ssu re, an d it s in ferior m argin form s th e su perior en d of foram en rot u n du m carr ying CN V2. Th e cavern ou s
sin us roof exten d s from th e opt ic st ru t an d su p erior orbit al ssure an teriorly to th e petrous apex an d the edge of th e tentorium
posteriorly. It is contiguous w ith the diaphragm a sellae m edially
an d is separated laterally from the lateral wall of cavern ous sinus
by th e an terior pet roclin oid fold. Th e an terior pet roclin oid fold
is a cord like th icken ing of th e dura exten d ing from th e an terior
clinoid process an teriorly to ten torial edge posteriorly. Th e posterior pet roclin oid fold is a separate fold exten ding from th e
posterior clinoid process to the tentorial edge, w hereas the interclin oid fold is a th in ban d of du ra th at exten ds from th e an terior
clinoid process to th e posterior clin oid process. Th e an atom ical
im port an ce of th ese th ree fold s is th at th ey form a lan dm ark
t riangle at th e cavern ous sin u s roof—th e ocu lom otor t riangle
(Fig. 3.7). CN III pierces th e ocu lom otor t riangle from a posterosu perior asp ect to p ass th rough a sh ort ocu lom otor cistern an d
en ters w ith in th e bilam in ar lateral w all of th e cavern ou s sin u s
n ear th e an terior clin oid process. CN IV en ters th e ocu lom otor
triangle posterolaterally, just posterior to the oculom otor nerve.14
Internal Carotid Artery
Th e ICAs are im port an t st ruct ures th at are in t im ately related to
th e m iddle sku ll base, except for th e proxim al cer vical an d distal com m un icat ing segm en t s. Th e w idely used Bou th illier system divides th e ICA in to a seven -segm en t n um erical scale along
th e superiorly orien ted direct ion of blood ow according to a
det ailed un derst an ding of th e surroun ding an atom y an d th e
com par t m en t s th rough w h ich it t ravels (Fig. 3.8),15 in cluding
th e follow ing segm ent s from it s origin in th e n eck to it s term ination at the circle of Willis: cervical (C1), petrous (C2), lacerum
(C3), cavern ous (C4), clin oid (C5), oph th alm ic (C6), an d com m u n icat ing (C7) segm en t s. Cer vical C1 segm en t of th e ICA h as
Fig. 3.6 The right cranial nerve (CN VI), the abducens nerve, enters
the posterior wall of the cavernous sinus, beneath the petrosphenoid
ligament, through Dorello’s canal, and travels within the cavernous
sinus, lateral to the cavernous internal carotid artery.
n o bran ch es, en ters th e carot id can al at th e sku ll base, an d t ravels m edially in th e carot id can al as th e pet rous C2 segm en t , su rroun ded by bon e at it s m ost solid posterom edial an d relat ively
th in n er an terolateral an d in ferior w alls, w ith th e roof being
covered by dura. Th e pet rous segm en t of ICA bran ch es are th e
sm all carot icot ym p an ic arteries, w h ich en ter th e m iddle ear
an d th e occasion ally p resen t vidian arter y th at u su ally arises
from th e m a xillar y ar ter y, w h ich in t u rn is a bran ch of th e extern al carot id arter y. Th e pet rou s carot id arter y en ds m edially
p art ially su rroun ded by brocart ilagin ou s t issu e con t igu ous
w ith th e car t ilage of th e foram en lacerum , over w h ich th e ICA
p asses as th e lacerum C3 segm en t . Th e foram en laceru m is n ot
w ith in a single bon e; rath er, it is act ually a cart ilage- lled gap
separating the petrous apex from the basisphen oid m edially and
th e basiocciput posteriorly. Men ingeal bran ch es of th e ascen ding phar yngeal artery pass through the cartilage- lled foram en.1
Th en th e ICA t urn s superiorly on its w ay to th e cavern ou s sin us,
p assing un der a brou s ban d called th e pet rolingual ligam ent
(w h ich exten ds from th e pet rous apex to th e lingula of th e carot id sulcus of th e sph en oid body), after w h ich th e cavern ou s
C4 segm en t begin s. Th e pet rosh en oid ligam en t or Gru ber’s ligam en t (w h ich exten ds from th e pet rou s ap ex to p osterior clin oid process) is sit u ated su perior to th e pet rolingu al ligam en t ,
an d t h e abd u cen s n er ve (CN VI) lies ju st lateral an d p arallel
25
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 3.7 Cranial nerve III, the oculomotor nerve, pierces the roof of
the cavernous sinus on the left. Marginal thickening of the dura forms
three distinct folds: the anterior petroclinoid fold (APcF), the posterior
petroclinoid fold (PPcF), and the interclinoid (IcF) fold; these folds form
the oculomotor triangle.
to th e h orizon t al por t ion of th e cavern ous ICA un dern eath th e
pet rosh en oid ligam en t .16–18
Th e cavern ous C4 segm en t t ravels superiorly an d th en t u rn s
an teriorly w ith a h orizon t al cou rse along th e cavern ou s sin u s.
Th is h orizon t al port ion of cavern ous ICA lies in a sh allow sulcus
along th e lateral aspect of body of sp h en oid, called th e carot id
su lcu s. Deh iscen ce of th e bon e in th is locat ion allow s th e ICA to
project in to th e sph en oid sin us, poten t ially posing a risk du ring
en d oscop ic t ran s-sp h en oidal su rger y. Th e ch aracter ist ically
d escr ibed t h ree n am ed bran ch es of t h e caver n ou s ICA are t h e
m en ingohyp ophyseal t ru n k, in ferolateral t ru n k, an d cap su lar
arter y. Th e m en ingohyp ophyseal t ru n k (dorsal m ain stem arter y) arises from th e cavern ous ICA at th e cen ter of th e ou ter
convexit y of its posterior gen u , w h ere th e in it ial ascen ding segm en t t u rn s an teriorly to becom e th e h orizon t al segm en t , an d
su bd ivid es in to t h ree vessels: t h e ten tor ial ar ter y (ar ter y of
Ber n ascon i an d Cassin ari), th e d orsal m en ingeal arter y, an d th e
inferior hypophyseal artery. The inferolateral trunk (lateral m ainstem ar ter y or arter y of th e in ferior cavern ou s sin u s) arises
from th e h orizon t al p or t ion of th e cavern ou s ICA segm en t it self
an d su p p lies sm all ar terial bran ch es to th e in t racavern ou s cran ial n er ves an d ten tor iu m . Th is ar ter y is clin ically im p or t an t
becau se it is an astom osed w it h t h e exter n al carot id ar ter y
bran ch es th rough th e foram en rot un du m , ovale, an d spin osum .
McCon n ell’s capsu lar ar ter y arises from th e m ost su perior segm en t of th e in t racavern ou s ICA an d su p plies th e in ferior an d
periph eral aspect of th e an terior lobe of th e pit u itar y glan d an d
th e diaph ragm a sellae.
Th e ICA th en t urn s ver t ically n ear th e an terior m argin of th e
cavern ous sin us an d con t in ues m edially to th e an terior clin oid
process, w h ere it passes th rough t w o du ral rings, th e proxim al
dural ring (w h ich form s th e t rue roof of th e cavern ous sin us
an teriorly), an d th e distal du ral ring (w h ich represen t s th e an atom ical border bet w een th e ext radural an d in t radural ICA). Th is
sh or t vert ical segm en t of ICA m edial to th e an terior clin oid p rocess bet w een th e proxim al an d dist al dural rings is called th e
clin oid C5 segm en t , an d it h as n o n am ed bran ch es. Di eren t iation of an ICA aneurysm , w hich has a neck in the proxim al intra-
Fig. 3.8 The seven-segment classi cation
system for the internal carotid artery. From
proxim al to distal, these include the (1) cervical
(not shown), (2) petrous, (3) lacerum,
(4) cavernous, (5) clinoid, (6) ophthalmic,
and (7) communicating segm ents. All but the
cervical segment are intimately related to the
central skull base region.
26
3 Middle Skull Base
dural segm ent that could produce a carotid–cavernous stula if it
bleeds, from on e w ith a n eck in th e dist al in t radural segm en t ,
w h ich can produce life-th reaten ing su barach n oid h em orrh age,
is ext rem ely im port an t . Alth ough th e dural rings are n ot seen at
im aging, th e locat ion of th e p roxim al dural ring can be assu m ed
by th e kn ow ledge th at (1) it form s th e superom edial m argin of
th e easily iden t i able opt ic st ru t , a t iny bony process con n ected
to th e an terior clin oid p rocess of th e lesser w ing of sp h en oid;
an d (2) it sep arates th e m edial opt ic can al from th e su p erior
orbit al ssure laterally.19 Th e dist al du ral ring, lying su p erior to
t h e p roxim al d u ral r ing, for m s t h e real lin e of dem arcat ion bet w een t h e ext rad u ral an d in t rad u ral ICA an d can be assu m ed
to be at th e ju n ct ion of th e CSF an d cavern ous sinu s on h igh resolu t ion coron al 3D CT cistern ography or 3D T2 MRI.20
After th is, th e ICA con t in u es in to th e in t radu ral su barach n oid sp ace as t h e op h t h alm ic C6 segm en t , givin g r ise to t h e
ophth alm ic arter y an teriorly an d superior hypophyseal ar ter y
project ing posteroin ferom edially in to th e sella. Th e term in al
com m un icat ing C7 segm en t of th e ICA begin s just before th e
origin of its bran ch called th e posterior com m un icat ing arter y
(PCOM) an d en ds by bifurcat ing in to th e an terior cerebral arter y an d m iddle cerebral arter y. Th e an terior ch oroidal ar ter y
arises from th e com m u n icat ing segm en t im m ediately distal to
th e origin of th e PCOM.
Structures Filling Posterior
Aspect of the Sphere
Petrous Apex and Petroclival
Junction
Th e pet rous apex, th e pyram idal obliquely orien ted an terom edial exten sion of pet rous tem poral bon e, m u st be con sidered a
part of the 3D con gurat ion of th e m iddle skull base. Pet rous
ap ex p n eu m at izat ion varies, being lled w ith bon e m arrow in
60%, pn eum at ized in 33%, an d sclerot ic in 7% (Fig. 3.9). A pn eum at ized pet rou s apex m ay com m u n icate directly w ith th e m astoid or m iddle ear cavit y an d provide direct pathw ays for disease
spread. Pn eu m at izat ion is asym m et ric in 5 to 10%, an d th e T1
hyperin ten se m arrow fat on th e n onpn eum at ized side h as th e
poten t ial to m im ic a lesion in MRI. Pn eum at ized pet rou s apices
are m ore p ron e to apical p et rosit is an d n onp n eu m at ized m arrow con tain ing apices to disease processes like m et ast asis.21–23
Th e clin ically im por tan t Dorello’s can al, pet ro-occipital ssure,
an d Meckel’s cave are in close relat ion to t h e p et rou s ap ex.
Dorello’s can al is a sm all ch an n el bet w een t w o layers of d u ra
overlying th e su p erom edial aspect of th e pet rou s ap ex, w h ere it
is fu sed to th e posterolateral sp h en oid body below th e p osterior
clin oid p rocess. Th is ch an n el t ran sm it s t h e abdu cen s n er ve
(CN VI) an d is surroun ded by th e in ferior pet rosal sin us, w h ich
in t u rn is con t in u ous w ith th e cavern ous sin u s an teriorly an d
drain s in to in ferior pet rosal sin us. Pet ro-occipit al (pet roclival
ssu re) ssu re is t h e obliqu e car t ilagin ou s ju n ct ion of in ferom ed ial p et rou s tem p oral bon e an d in ferolateral clivu s. Th is
car t ilage- lled ssure appears lucen t on CT scan s, but it can be
variably ossi ed an d den se an d is th e classic site of origin for
sku ll base ch on drosarcom a.24
Fig. 3.9 Axial computed tomography image through the petrous apex
demonstrates the variabilit y in pneumatization of the petrous apex.
The petrous apex on the right is well pneumatized and demonstrates
air densit y (PApneu); the contralateral petrous apex is nonpneumatized
and dem onstrates bone trabecular bone densit y (PAnon).
Meckel’s Cave
Meckel’s cave is a localized du ral ou t p ou ch ing over th e pet rosp h en oid ju n ct ion at th e p osterom edial aspect of m idd le cran ial
fossa. It h ou ses th e t rigem in al (Gasserian ) ganglion w ith in it s
an teroin ferior asp ect an d th e caval segm en t of t rigem in al n er ve
m ore p osteriorly. Im m ediately p osterior to Meckel’s cave, th e
t rigem in al n er ve lies in close relat ion to a sm all depression in
th e su perior aspect of th e pet rou s apex, just lateral to pet rosph enoid jun ction, called th e trigem inal im pression . The trigem in al n er ve th en t ravels in to th e p osterior fossa as th e cistern al
segm en t an d en ters th e p on s at th e root en t r y zon e. An terom edially, Meckel’s cave is closely opposed to th e posteroin ferolateral aspect of th e cavern ou s sin u s an d is ju st lateral to th e ICA
n ear th e laceru m or p roxim al cavern ou s segm en t , w h ere th e
ar ter y begin s to ru n an terosu p eriorly in to th e cavern ou s sin u s.
Th e th ree m ajor division s of t rigem in al n er ve arise w ith in th e
Meckel’s cave. Th e oph th alm ic division (V1) ru n s an terom edially to en ter th e lateral w all of cavern ou s sin u s, w h ereas th e
m axillar y d ivision (V2) ru n s an teriorly u n dern eath th e cavern ou s sin u s to en ter in to foram en rot u n dum , an d th e m an dibu lar
division (V3) extends inferolaterally along the foram en ovale into
th e m ast icator space.25
Extracranial Structures Lying
Anterior/ Inferior to Center
of the Sphere
Orbital Apex and Pterygopalatine
Fossa
Th e orbit al ap ex is con t igu ou s w it h t h e m id d le sku ll base
th rough th e opt ic can al in th e lesser w ing of th e sph en oid, sup erior orbit al ssu re bet w een th e lesser an d greater w ings an d
th e pter ygopalat in e fossa th rough th e in ferior orbit al ssure.
Orbit al t u m ors like opt ic n er ve sh eath m en ingiom a, in am m a-
27
Anatom y for Plastic Surgery of the Face, Head, and Neck
tor y lesion s like orbit al apex pseu dot um or, an d in fect ion s like
invasive fu ngal disease can exten d in to th e m iddle skull base
an d vice versa. Orbital ap ex syn drom e can produ ce vision loss,
oph th alm oplegia, an d m ult iple cran ial n eu ropath ies as a resu lt
of th e conn ect ion s w ith cavern ous sin us an d pter ygopalat in e
fossa. Superior oph thalm ic vein throm bosis, w hich usually arises
from in fect ion s in th e dangerou s t riangle of th e face, can lead to
cavern ous sin us th rom bosis. Despite classic assum pt ion s th at
th e absen ce of valves in th e facial an d superior oph th alm ic
vein s is th ough t to facilitate in fect iou s sp read from th e m idface
region to th e cavern ous spread, a recen t cadaveric stereom icroscopic st u dy h as d em on st rated valves in th ese vein s. Th e con sisten t com m u n icat ion s bet w een th e facial vein an d cavern ou s
sin u s an d th e d irect ion of blood ow are im port an t in th e
spread of in fect ion rath er th e th an absen ce of valves.26
Th e opt ic can al is th e path w ay of opt ic n er ve an d oph th alm ic arter y an d lies en t irely w ith in th e lesser w ing of sp h en oid.
Th e opt ic st rut (in ferior root of lesser w ing), along w ith th e an ter ior clin oid p rocess of t h e lesser w ing of sp h en oid , w h ich it
is con n ected to, separates th e opt ic can al from th e su p erior orbit al ssure laterally. Th e fat t y bon e m arrow in th e opt ic st rut
m ay h ave h igh T1 MRI sign al an d m ay be seen p roject ing in ferom edially from the anterior clinoid process, separating the optic
n er ve from th e ocu lom otor an d oth er cran ial n er ves. Th e an terolateral aspect of body of th e sph en oid bon e form s th e m edial
boun dar y of opt ic can al, an d a th in bony bridge called th e superior root of th e lesser w ing form s its roof.27 With in th e dural
sh eath in opt ic can al, th e oph th alm ic arter y lies in ferolateral to
opt ic n er ve. It later leaves th e dura an d crosses above th e opt ic
n er ve from lateral to m edial sid es, giving rise to th e cen t ral retin al arter y as it w in ds arou n d th e n er ve. Th e ciliar y ganglion
lies in th e p osterior orbit bet w een th e opt ic n er ve an d lateral
rect u s m uscle at th e lateral aspect of op h th alm ic ar ter y.
Th e superior orbit al ssure (SOF) is an oblique gap bet w een
th e lesser w ing of sph en oid su perom edially an d th e greater
w ing of sph en oid in ferolaterally (Fig. 3.10). It con n ects th e orbit
an d m id d le cran ial fossa via t h e caver n ou s sin u s. It is d ivid ed
by th e an n u lus of Zin n , a tough brous apon eurot ic ring at th e
orbital apex, in to a m edial in t racon al com part m en t (con t ain ing
CN III, CN VI, an d th e n asociliar y n er ve) an d a lateral ext racon al
com part m en t (con t ain ing CN IV, fron t al, an d lacrim al n er ves,
an d th e su p erior op h th alm ic vein ). Th e ext raocu lar m u scles
arise from th e an n u lu s of Zin n , except th e in ferior obliqu e m u scle, w h ich origin ates at an teroin ferior orbital rim . In addit ion to
th e m edial SOF com par t m en t , th e an n u lus also su rroun ds th e
opt ic can al, an d h en ce th e opt ic n er ve an d oph th alm ic arter y
becom e in t racon al st ruct u res.
Th e in t racon al m edial SOF is w ider, lies directly an terior to
the cavernous sinus, and contains the oculom otor nerve (CN III),
w h ich im m ediately divides in to th e superior division (to supply
su perior rect u s an d levator p alpebrae su perioris m u scles) an d
th e in ferior division (to supply th e m edial rect us, in ferior rectus, and inferior oblique m uscles). The m edial com partm ent also
con t ain s t h e abd u cen s n er ve (CN VI to su p p ly lateral rect u s
m u scle) lying im m ediately lateral to th e CN III su p erior division
an d th e n asociliar y n er ve fu r th er su p eriorly. Note th at th e n asociliar y n er ve is on e of th e th ree bran ch es of th e sen sor y oph th alm ic division of t rigem in al n er ve (CN V1 ) bran ch ing w ith in
th e dist al cavern ous sin us before en tering the orbit .
Th e oth er t w o bran ch es of th e oph th alm ic CN V1 , n am ely,
th e fron t al an d lacrim al n er ves, lie w ith in th e sm aller ext racon al lateral com par t m en t of SOF in feriorly an d superolaterally
respect ively. Th e t roch lear n er ve (CN IV to supply th e su perior
oblique m uscle) en ters th e orbit at th e ext racon al lateral SOF
com part m en t outside th e an n ulus of Zin n an d lies h ere above
t h e fron t al n er ve an d in ferom ed ial to t h e lacr im al n er ve. Th e
Fig. 3.10 Orbital apex. The superior, medial,
inferior, and lateral rectus m uscles converge
posteriorly and at tach to a dense brous ring, the
annulus of Zinn. The ring circumscribes the optic
canal and the inferomedial aspect of the superior
orbital ssure. The optic canal contains the optic
nerve and ophthalmic artery. The oculomotor
nerve (CN III) enters the medial superior orbital
ssure and divides into superior and inferior
divisions. The nasociliary and abducens (CN VI)
nerves also enter through the medial compartment. Laterally, the superior orbital ssure
contains the trochlear nerve (CN IV), the lacrimal
nerve, the frontal nerve, and the superior
ophthalmic vein (SOV).
28
3 Middle Skull Base
su p erior oph th alm ic vein lies fu rth er lateral to th e n er ves in th e
lateral SOF com p art m en t .
Th e in fer ior orbit al ssu re is an obliqu e gap sit u ated bet w een t h e oor an d lateral w all of orbit (greater w in g of sp h en oid). It com m u n icates w it h t h e pter ygop alat in e fossa an d
m ast icator sp ace an d con t ain s th e in fraorbital n er ve an d zygom at ic n er ve (bran ch es of th e m a xillar y division of th e t rigem in al n er ve CN V2), in ferior op h th alm ic vein d ivision , or em issar y
vein s bet w een th e in ferior op h th alm ic vein an d th e pter ygoid
plexus.28,29
Th e pter ygopalat in e fossa (PPF) is a fat- lled space bet w een
th e m axillar y sin us an teriorly an d pter ygoid process of sph en oid bon e p osteriorly. Medially, it is p ar t ially bou n d by a p ort ion of th e perpen dicu lar plate of th e palat in e bon e (Fig. 3.11).
Th e PPF con t ain s th e sm all pter ygopalat in e ganglion at it s m ed ial asp ect , th e m axillar y n er ve (V2) en tering via th e foram en
rot un du m , an d th e dist al in tern al m axillar y ar ter y en tering via
t h e pter ygom a xillar y ssu re. It is d i cu lt to d i eren t iate t h e
ganglion from n er ves an d vessels in t h e PPF, even w it h h igh resolu t ion CT/MRI. Alth ough it is qu ite sm all, th e PPF h as im p ort an t con n ect ion s w ith th e m iddle skull base, orbit , p alate,
an d n asal cavit y an d can act as a ju n ct ion al area for th e sp read
of in lt rat ing or perin eural t u m or an d in fect ion .
Masticator Space
Th e pter ygom axillar y ssure is th e lateral open ing of PPF in to
th e n asoph ar yngeal m ast icator space (in fratem poral fossa). Th e
sph en opalat in e foram en is it s m u cosa-covered m edial open ing
in to th e superior m eat us of th e n ose th rough a gap in it s m edial
boun dar y form ed by th e palat in e bon e. Nasoph ar yngeal angio brom as arise in th is region . Th e PPF com m un icates superi-
orly w ith th e SOF. Th e in ferior orbit al ssure is it s an terior
open ing in to th e orbit , w h ich t ran sm its th e in fraorbit al n er ve
(CN V2 continuation branch) and arter y. The foram en rot undum
is th e path w ay along w h ich th e in t racran ial m axillar y n er ve
(CN V2) passes in to th e PPF after t raveling in th e dura un dern eath th e lateral w all of th e cavern ou s sin u s. Th e can al can be
easily id en t i ed in a xial CT an d MRI con n ect in g t h e PPF to
m id dle cran ial fossa alongside th e lateral w all of th e cavern ou s
sin u s an d in coron al im aging su perior to an occasion ally p n eu m at ized lateral recess of t h e sp h en oid sin u s. Th e vid ian can al
is a ch an n el th at ru n s th rough th e body of th e sph en oid bon e
con n ect ing th e PPF to th e foram en lacerum , w h ich in t urn is th e
an teroin ferom edial cart ilagin ou s oor of th e h orizon tal p et rou s
ICA can al sit u ated bet w een th e sp h en oid an d tem poral bon es.
In coron al sect ion s, th e vidian can al is seen in ferom edial to th e
foram en rot u n du m w ith an occasion ally p n eu m at ized lateral
recess of th e sp h en oid sin us bet w een th em . Th e pter ygopalat in e can al is th e com m on in ferior can al leading from th e PPF
an d carr ying th e p alat in e n er ves, an d u lt im ately it divides in to
an an terior greater palat in e foram en an d p osterior lesser p alat in e foram en at th e h ard palate.30,31
Th e m ast icator sp ace, con t ain ing t h e m ast icat ion m u scles,
is in t im ately related to th e m iddle sku ll base th rough (1) th e
foram in a in th e greater w ing of sph en oid (e.g., foram en ovale
t ransm it t ing m an dibu lar division of t rigem in al n er ve, CN V3);
(2) t h e lesser p et rosal n er ve, accessor y m en ingeal bran ch of
m axillar y arter y an d em issar y vein ; an d (3) th e t iny foram en
sp in osu m , ju st posterolateral to it (t ran sm it t ing th e m idd le m en ingeal arter y an d vein an d m en ingeal bran ch of CN V3). Th ese
foram in a are easily id en t i ed on CT im ages ju st an terolateral to
the horizontal petrous carotid canal. As described already herein,
t h e m ast icator sp ace is con n ected w it h t h e PPF t h rough t h e
pter ygom a xillar y ssu re. Th ese con n ect ion s allow p er in eu ral
Fig. 3.11 Pterygopalatine fossa (PPF). The
posterior aspect of the lateral nasal wall has
been dissected, exposing the sphenopalatine
foramen and pterygopalatine fossa. The
pterygopalatine ganglion (PPG) has multiple
neural connections. The maxillary nerve (V2)
traverses the upper aspect of the PPF. The
vidian nerve (VN) is seen passing from the
ganglion into the vidian canal. The greater and
lesser palatine nerves (Pn) descend into the
palatine canal and into the submucosa of the
palate.
29
Anatom y for Plastic Surgery of the Face, Head, and Neck
t um or spread w ith in th e m iddle skull base. Aggressive m ast icator space lesion s can also erode bon e an d exten d in t racran ially.
Th e super cial layer of th e deep cer vical fascia splits to en close
th is space, w h ich exten ds in feriorly to th e at t ach m en t of m edial
pter ygoid an d m asseter m u scles on to t h e m an d ible an d su p erom ed ially abu t s t h e sku ll base, w it h t h e foram en ovale an d
foram en spin osu m in clu ded in th is sp ace. Su p erolaterally, th e
m ast icator sp ace exten ds along th e ou ter su rface of th e sku ll as
far as th e tem poralis m u scle.32
Nasopharynx
Th e n asoph ar yn x lies im m ediately in ferior to th e basisph en oid
an d clival region of th e m iddle sku ll base an d is an im p or tan t
area to evalu ate for con t igu ou s in t racran ial sp read of t u m or or
aggressive in fect ion (Fig. 3.12). It exten ds from th e posterior
n asal ch oan a an terosu p eriorly to th e ret roph ar yngeal an d prevertebral space posteriorly an d th e p araph ar yngeal sp aces lie
laterally. An teroin feriorly, th e soft palate separates it from th e
oroph ar yn x w ith th e posterior side of th e soft palate con sidered
p ar t of n asop h ar yn x an d it s an teroin fer ior sid e p ar t of oro p h ar yn x. Th e sep arat ion p oster ior to t h e soft p alate is arbit rar y, u sin g an im agin ar y h orizon t al lin e along th e h ard palate
or su p er ior edge of t h e an ter ior arch of C1 or t h rough t h e at lan toaxial ar t icu lat ion .33,34
Fig. 3.12 Illustration of the submucosal nasopharynx. The superior
constrictor muscle (SCM) at taches to the skull base via the pharyngobasilar fascia (PBF). The eustachian tube (ET) passes through a defect
in the PBF referred to as the sinus of Morgagni. The tensor veli palatini
(TVP) muscle is seen arising from the cartilaginous eustachian tube and
extending inferiorly to the lateral margin of the soft palate.
30
Th e m iddle visceral or ph ar yngeal m ucosal layer of th e deep
cervical fascia encloses the pharyn x; hence, th e oropharynx and
n asoph ar yn x are collect ively called th e visceral sp ace or ph aryngeal m u cosal sp ace (PMS). Th e n asop h ar yngeal su p er cial
m ucosa con sist s of ep ith eliu m of th e PMS an d can give rise to
n asop h ar yn geal squ am ou s cell carcin om a.5 Th e su bm u cosal
sp ace con t ain s lym p h oid t issu e, accessor y salivar y glan ds, an d
cellular n otoch ord rem n an t s, w h ich can give rise to ben ign an d
m align an t lesion s like lym p h om a, salivar y glan d t u m ors, an d
chordom a. Th e nasopharyngeal tonsils are called adenoids; they
lie at th e m idlin e roof of th e n asoph ar yn x an d are usu ally prom in en t in ch ildren .
Th e ph ar yngeal t ubercle of th e occipit al bon e provides poster ior at t ach m en t to t h e m idlin e p h ar yngeal rap h e an d t h e
paired superior con st rictor m uscles of th e ph ar yn x; h ow ever,
th e superior con st rictor m uscle of eith er side fan s for w ard to
at t ach to th e low er por t ion of th e m edial pter ygoid plate. Th is
exp oses a gap bet w een t h e m u scles an d t h e sku ll base, w h ich
is lled by th e p h ar yngobasilar fascia, a tough apon eu rosis th at
su r rou n d s t h e p h ar yn x an d at t ach es to t h e sku ll base. Th e
ph ar yngobasilar fascia at tach es to th e m edial pter ygoid plate
an teroin feriorly an d exten ds su p eriorly to th e sku ll base. It lls
th e gap bet w een th e m uscles an d skull base as it proceeds posteriorly, at t ach ing to th e body of sph en oid bon e, pet rous apex,
foram en laceru m , an d m ore p osteriorly as it p rocesses to th e
occipit al ph ar yngeal t u bercle an d prevertebral m uscles. Th erefore, th e foram en laceru m lies w ith in th e at t ach m en t of th is
fascia to th e sku ll base, w h ereas th e foram en ovale is seen lateral to th is fascia. Th e eu st ach ian t u be an d levator veli p alat in i
m u scle en ter th e n asoph ar yn x th rough a p osterolateral d efect
of th e ph ar yngobasilar fascia called th e sin us of Morgagn i. Protect ion from t um or spread from the n asoph ar yn x to th e m iddle
sku ll base an d vice versa by th e tough p h ar yngobasilar fascia is
de cien t at th e sin us of Morgagn i an d at th e foram en lacerum ,
even th ough brocar t ilage closes th is foram en .35
Th e ten sor veli palat in i an d levator veli palat in i m uscles reside in th e n asop h ar yn x. Th e toru s t u bariu s is th e prom in en t
m edial en d of th e cart ilagin ou s eu stach ian t u be, w h ich togeth er
w ith th e levator veli palat in i m uscle an d th e overlying m ucosa
form s a ridgelike p rot ru sion in to th e n asoph ar yn x.33 Th e eu st ach ian t ube ori ce is a m ucosa-lin ed recess in fron t of th e torus
t ubarius. Th e lateral ph ar yngeal recess or fossa of Rosen m ü ller
is an oth er m ucosa-lin ed recess located posterosup erior to th e
toru s t ubarius. Th e fossa of Rosen m ü ller is an im por tan t site of
origin of n asoph ar yngeal carcin om a an d appears to be posterior
to th e eust ach ian t u be ori ce on axial im ages an d superior on
coron al im ages ow ing to th e con guration of the torus t ubarius.
Th e eu stach ian t u be con n ect s th e m iddle ear to th e n asoph ar yn x (Fig. 3.13). Th e posterolateral bony port ion begin s
along th e an terior w all of th e t ym pan ic cavit y an d t ravels an teroin ferom edially tow ard t h e n asop h ar yn x an d is seen ju st
in ferolateral to th e prom in en t lan dm ark of p roxim al p et rou s
carot id can al in axial CT scan im ages. Th e bony por t ion of th e
t ube con t in ues as th e car t ilagin ou s por t ion at th e sph en opetrosal groove, w h ich is th e gap bet w een th e posterior m argin of
th e greater w ing of sph en oid an d th e an terior m argin of pet rous
tem poral bon e. Th e cart ilagin ous port ion can be seen as a soft
t issue den sit y im m ediately posterior to th e foram en ovale an d
foram en spin osu m on axial CT scan s an d con t in u es in to th e n asop h ar yn x as described already. Mass lesion s in th e n asoph ar-
3 Middle Skull Base
Fig. 3.13 Axial computed tomographic image through the skull base
demonstrates the relationships bet ween various foramina, ssures, and
canals along the lateral margin of the central skull base region. The
internal carotid artery passes obliquely through the carotid canal (CC)
and exits the canal just above cartilage- lled gap, the foramen lacerum
(FL). The eustachian tube (ET) consists of bony and cartilaginous
segments and passes both medially and inferiorly from the middle ear
to the nasopaharynx. Note the intimate relationship bet ween the
eustachian tube, the carotid canal and the foramen spinosum (FS).
yn x, esp ecially th ose in th e fossa of Rosen m ü ller, can com press
th e eustach ian t ube open ing an d lead to th e developm en t of
m iddle ear an d m astoid e u sion s. It is ext rem ely im p or tan t to
evalu ate for any n asoph ar yngeal m ass lesion w h en un ilateral
m iddle ear or m astoid e u sion is iden t i ed on a brain or p aran asal sin u s CT scan .
Th e ret roph ar yngeal space (RPS) lies beh in d th e ph ar yn x,
im m ediately posterior to th e m iddle (visceral) layer of deep
cer vical fascia an d an terior to deep (prever tebral) layer of deep
cer vical fascia. Th e n asoph ar yngeal RPS exten ds superiorly to
th e basiocciput an d th e th in h orizon t al alar fascia exten ding
from th e sku ll base to cer vicoth oracic region divides th e space
in to an an terior t rue RPS an d posterior danger space. Anyw h ere
bet w een t h e C6 an d T4 level, t h e alar fascia fu ses w it h t h e an ter ior m id d le (visceral) layer of t h e d eep cer vical fascia an d
ter m in ates at th e in ferior exten t of the t ru e RPS; h ow ever, th e
p osterior danger space con t in ues in feriorly as a poten t ial sou rce
of skull-base in fect ion spread in to the posterior m ediast in um .
Th e RPS h arbors n orm al fat an d ret roph ar yngeal lym ph n odes,
especially laterally. Th e ret roph ar yngeal lym ph n odes (RPLNs)
are divided in to a lateral grou p th at overlie th e p revertebral fascia at th e level of th e upper cer vical vertebral t ransverse processes an d are m ore com m on ly involved by path ology especially
from squ am ou s cell carcin om as of th e n asoph ar yn x, orop h aryn x, hyp op h ar yn x, an d n asal cavit y an d an in con sisten t sm all
m edial grou p. It is im p ort an t to n ote th at on ly th ose n odes lying
m ed ial to t h e ICA an d w it h in 2 cm of t h e sku ll base are classied as RPLN on im agin g-based classi cat ion . If a lym p h n od e
sit u ated w ith in 2 cm of th e sku ll base lies an terior, lateral, or
p osterior to th e carot id sh eath , it is classi ed as a level II n ode.
Nodes inferior to a level 2 cm below th e skull base are not n am ed
RPLN.36
Th e prevertebral space (PVS), w h ich lies im m ediately poster ior to t h e RPS, is su r rou n d ed by t h e d eep (p rever tebral) layer
of deep cer vical fascia. In th e suprahyoid n eck, th e PVS con tain s
p rever tebral m u scles lon gu s colli an d cap it is, ver tebral body,
cer vical in ter vertebral disk, spin al can al, ver tebral arteries, an d
th e ph ren ic n er ve. Speci cally, at th e n asoph ar yngeal level, th e
larger longus cap it is an d th e sm aller an terior rect us capit is
m uscles beh in d it reside in th is locat ion . Di eren t iat ion of PVS
lesion s from th e an terior RPS an d lateral carot id space lesion s is
som et im es ch allenging, especially if th e lesion s are large. Usefu l
h in t s for im aging in clu de th e fact th at a PVS abscess elevates th e
p rever tebral m u scles, w h ereas a RPS abscess does n ot . Likew ise,
bony erosion of adjacen t an ter ior p or t ion of ver tebral body
favors a PVS t u m or like rh abd om yosarcom a, w h ereas erosion
along the lateral aspect of a vertebra favors a carotid space t u m or
like n euroblastom a.1,29
References
1. Ch apm an PR, Bag AK, Tubbs RS, Goh lke P. Pract ical an atom y of th e
cen t ral skull base region . Sem in Ult rasoun d CT MR 2013;34(5):
381–392 PubMed
2. Borges A. Im aging of th e cen t ral skull base. Neuroim aging Clin N
Am 2009;19(3):441–468 PubMed
3. Moran i AC, Ram an i NS, Wesolow ski JR. Skull base, orbit s, tem poral
bon e, an d cran ial n er ves: an atom y on MR im aging. Magn Reson
Im aging Clin N Am 2011;19(3):439–456 PubMed
4. Lain e FJ, Nadel L, Brau n IFCT. CT an d MR im aging of th e cen t ral
skull base. Part 1: Techniques, em br yologic developm ent, and anatom y. Radiographics 1990;10(4):591–602 Pu bMed
5. Lain e FJ, Nadel L, Brau n IFCT. CT an d MR im aging of th e cen t ral
skull base. Part 2. Path ologic spect rum . Radiograph ics 1990;10(5):
797–821 PubMed
6. Rh oton AL Jr. The sellar region. Neurosurger y 2002;51(4, Suppl)
S335–S374 Pu bMed
7. Un al B, Badem ci G, Bilgili YK, Bat ay F, Avci E. Risky an atom ic variat ion s of sph en oid sin us for surger y. Surg Radiol An at 2006;28(2):
195–201 PubMed
8. Ham id O, El Fiky L, Hassan O, Kotb A, El Fiky S. An atom ic variat ion s
of th e sph en oid sin us an d th eir im pact on t ran s-sph en oid pit uit ar y
surger y. Skull Base 2008;18(1):9–15 PubMed
9. Vat toth S, Cherian J, Pan dey T. Magn et ic reson an ce angiograph ic
dem onst rat ion of carot id-cavernou s st ula using ellipt ical cen t ric
t im e resolved im aging of con t rast kin et ics (EC-TRICKS). Magn
Reson Im aging 2007;25(8):1227–1231 PubMed
10. Miyazaki Y, Yam am oto I, Sh in ozuka S, Sato O. Microsurgical an atom y of th e cavern ous sin us. Neurol Med Ch ir (Tokyo) 1994;34(3):
150–163 PubMed
11. Cot t ier JP, Dest rieu x C, Bru n ereau L, et al. Cavern ous sin us invasion
by pit uit ar y aden om a: MR im aging. Radiology 2000;215(2):463–
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12. Tubbs RS, Hill M, May W R, et al. Does th e m axillar y division of th e
trigem inal nerve traverse the cavernous sinus? An anatom ical study and
review of the literature. Surg Radiol Anat 2008;30(1):37–40 PubMed
13. Hardjasudarm a M, Edw ards RL, Gan ley JP, Aarst ad RF. Magn et ic
reson an ce im aging feat ures of Graden igo’s syn drom e. Am J Otolaryngol 1995;16(4):247–250 PubMed
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Anatom y for Plastic Surgery of the Face, Head, and Neck
14. Isolan GR, Krayenbü h l N, de Oliveira E, Al-Meft y O. Microsu rgical
anatom y of th e cavern ous sin us: m easurem en t s of th e t riangles in
and aroun d it . Skull Base 2007;17(6):357–367 PubMed
15. Bouth illier A, van Loveren HR, Keller JT. Segm en t s of th e in tern al
carot id arter y: a n ew classi cat ion . Neurosurger y 1996;38(3):425–
433 Pu bMed
16. Liu XD, Xu QW, Ch e XM, Mao RL. An atom y of th e pet rosph en oidal
an d pet rolingual ligam en t s at th e pet rous apex. Clin An at 2009;
22(3):302–306 PubMed
17. Ch apm an PR, Gaddam an ugu S, Bag AK, Roth NT, Vat toth S. Vascular
lesion s of th e cen t ral sku ll base region . Sem in Ult rasou n d CT MR
2013;34(5):459–475 PubMed
18. Tubbs RS, Han sasut a A, Loukas M, et al. Bran ch es of th e pet rous
an d cavern ous segm en t s of th e in tern al carot id ar ter y. Clin An at
2007;20(6):596–601 PubMed
19. Hash im oto K, Nozaki K, Hash im oto N. Opt ic st rut as a radiograph ic
lan dm ark in evaluat ing n eck locat ion of a paraclin oid an eur ysm .
Neurosu rger y 2006;59(4):880–895, discu ssion 896–897 Pu bMed
20. Wat an abe Y, Nakazaw a T, Yam ada N, et al. Iden t i cat ion of th e dist al dural ring w ith use of fusion im ages w ith 3D-MR cistern ography and MR angiography: applicat ion to paraclin oid an eur ysm s.
AJNR Am J Neuroradiol 2009;30(4):845–850 PubMed
21. Con n or SE, Leu ng R, Nat as S. Im aging of th e pet rous apex: a pictorial review. Br J Radiol 2008;81(965):427–435 PubMed
22. Isaacson B, Kut z JW, Rolan d PS. Lesion s of th e pet rous apex: diagn osis an d m an agem en t . Otolar yngol Clin Nor th Am 2007;40(3):
479–519, viii Pu bMed
23. Razek AA, Huang BY. Lesions of th e pet rous apex: classi cat ion an d
ndings at CT an d MR im aging. Radiograph ics 2012;32(1):151–
173 PubMed
24. Balbon i AL, Esten son TL, Reiden berg JS, Bergem an n AD, Lait m an JT.
Assessing age-related ossi cat ion of th e p et ro-occip it al ssu re:
laying th e fou n dat ion for un derst an ding the clin icopathologies of
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th e cran ial base. An at Rec A Discov Mol Cell Evol Biol 2005;282(1):
38–48 Pu bMed
25. Woolfall P, Coulth ard A. Pictorial review : Trigem in al n er ve: an atom y an d path ology. Br J Radiol 2001;74(881):458–467 Pu bMed
26. Zh ang J, St ringer MD. Oph th alm ic an d facial vein s are not valveless.
Clin Experim en t Oph th alm ol 2010;38(5):502–510 Pu bMed
27. Dan iels DL, Mark LP, Mafee MF, et al. Osseous anatom y of th e orbital apex. AJNR Am J Neuroradiol 1995;16(9):1929–1935 PubMed
28. Aviv RI, Casselm an J. Orbit al im aging: Par t 1. Norm al an atom y. Clin
Radiol 2005;60(3):279–287 PubMed
29. Vat toth S, Su llivan JC. Face an d n eck an atom y. In : Can on CL, ed.
McGraw -Hill Specialt y Board Review : Radiology. 1st ed. New York:
McGraw -Hill; 2010:99–114
30. Dan iels DL, Mark LP, Ulm er JL, et al. Osseous an atom y of th e pter ygopalat in e fossa. AJNR Am J Neuroradiol 1998;19(8):1423–1432
PubMed
31. Cu rt in HD, William s R. Com puted tom ograph ic an atom y of th e
pter ygopalat in e fossa. Radiographics 1985;5(3):429–440
32. Harn sberger HR. An terior sku ll base. In : Harn sberger HR, Osborn
AG, Macd on ald AJ, Ross JS AJ, ed s. Diagnost ic and Surgical Im aging Anatom y: Brain, Head & Neck , Spine. 1st ed. Ph iladelph ia, PA,
Am irsys; 2010:II26–II35
33. Siddiqu i A, Conn or SEJ. Im aging of th e ph ar yn x an d lar yn x. Im aging 2007;19:83–103
34. Dubrulle F, Souillard R, Herm ans R. Exten sion pat tern s of n asopharyngeal carcinom a. Eur Radiol 2007;17(10):2622–2630 PubMed
35. Som PM, Cu rt in HD. Fascia an d Spaces of th e Neck. In : Som PM,
Cu rt in HD, eds. Head and Neck Im aging. Vol 2. 3rd ed. St . Louis:
Mosby; 2003:1805–1827
36. Som PM, Cu rt in HD, Man cu so AA. Im aging-based n odal classi cat ion for evaluat ion of n eck m et ast at ic aden opathy. AJR Am J Roen tgen ol 2000;174(3):837–844 PubMed
4
Soft Tissue of the Scalp and Temporal
Regions
Noriyuk i Koga
Introduction
Th e scalp is th e soft t issue covering th e calvaria. It anatom ically
posit ion ed in th e cran ial side of th e lin e con n ect ing th e supraorbit al border of th e foreh ead, th e fron tal process of th e zygom at ic bon e, th e su p erior m argin of th e zygom at ic arch , th e
extern al acou st ic foram en , th e m astoid p rocess of th e tem poral
bon e, an d th e superior n uch al lin e of th e occipit al bon e.1 Th e
m ajor di eren ce bet w een th e scalp an d oth er skin in term s of
ap pearan ce is th at it h as h air in alm ost all areas, exclu ding th e
foreh ead. In a cross-section, the scalp reveals a layered structure,
usually divided in to ve layers, excluding the tem poral region ,
as follow s, from th e ou term ost layer dow n : skin , su bcu tan eou s
fat (den se con n ect ive t issu e), galea apon eu rot ica (apon eu rot ic
layer), loose connective tissue; and pericranium (Fig. 4.1). Am ong
th ese layers, th e skin , subcutan eous t issue, an d galea aponeu rot ica layer are closely con n ected, m aking it di cult to blun tly
separate each layer. Therefore, these layers from the skin to galea
ap on eu rot ica are lu m p ed togeth er an d also called th e sup ercial fascial layer, w h ereas loose con n ect ive t issu e is also called
th e deep fascial layer.2
Scalp (Skin) and
Subcutaneous Fat Layer
Th e st ruct ure of th e scalp is fun dam en tally sim ilar to th e skin in
oth er region s; h ow ever, th e d erm is is th ick com pared w ith th at
in oth er p ar ts of th e body an d is rich in blood vessels. Fur th erm ore, it h as an abu n dan ce of h air.
Su bcu t an eou s t issu e com p rises an abu n dan ce of h air follicles an d sw eat glan ds. Moreover, th ere are m any brous septa,
sim ilar to th at of th e p alm s of th e h an ds an d soles of th e feet ,
closely con n ect ing th e skin an d th e galea apon eu rot ica layer.
Th erefore, su bcut an eou s fat is separated in to sm all fat lobes by
th ese brous septa. In this layer are m any perforating arteries
an d veins h eading to th e skin from th e m ain vascu lar n et w ork of
th e scalp in side t h e galea ap on eu rot ica, along w it h t h e sm all
sen sor y n er ves t ran sm it t ing cu t an eou s sen sat ion .
Galea Aponeurotica
Th e galea apon eu rot ica is th e in term ediate apon eurosis of th e
occipitofron talis m uscle an d is con n ected to th e fron t alis m u scle at th e fron t as w ell as to th e occipitalis m uscle at th e rear
(Fig. 4.2). Th e fron t alis m uscle origin ates from th e galea apon eurot ica an d at t ach es to th e derm is of th e eyebrow after in ter-
sect ing w ith th e orbicu laris ocu li m u scle an d proceru s m u scle
n ear th e su p raorbital border. Gen erally, fron talis m u scles ru n
obliquely dow nw ard superolaterally to in ferom edially; th erefore, th ere is a V-sh aped area in th e cen ter of th e foreh ead bet w een th e bilateral fron tails m uscles an d th e galea ap on eu rot ica
th at exten ds to th e fron t in th is V-sh aped part of th e foreh ead.
Th e occipit alis m uscle origin ates from th e h igh est n uch al lin e of
the occipital bone, runs upward, and attaches to the galea aponeu rot ica. Th ese fron talis an d occipit alis m uscles are both in n ervated by th e facial n er ve; th e tem p oral bran ch in n er vates th e
fron talis m u scle, an d th e occipit alis m u scle is in n er vated by th e
p osterior auricu lar n er ve. It is th e role of th e fron t alis m u scle to
lift th e eyebrow s, th ereby form ing h orizon t al w rin kles on th e
foreh ead. Th e occipit alis m u scle h as a role of pu lling th e galea
ap on eu rot ica an d p lacing ten sion on th e scalp; h ow ever, it is
degen erat ive an d w eak, on ly h aving th e e ect of suppor t ing th e
fron talis m u scle. In th e tem p oral region , th e galea apon eu rot ica
t ran sit ion s to th e super cial tem poral fascia, w h ich is a part of
th e super cial m usculoapon eu rot ic system (SMAS).3,4 Th e sup er cial tem poral fascia con t ain s th e tem poropariet al m u scle
an d su perior au ricu lar m u scle in th e sam e p lan e. Major blood
vessels of th e scalp ru n in th e galea ap on eu rot ica layer an d give
o m u lt iple bran ch es tow ard th e skin an d su bcut aneou s fat
layer. Th erefore, m assive bleeding is com m on ly obser ved w h en
sep arat ing th e galea apon eu rot ica an d su bcu t an eou s fat layer.
Loose Connective Tissue
Th is layer is also kn ow n as th e subgaleal fascia an d subapon eurot ic plan e (Fig. 4.3). It is foun d bet w een th e galea apon eurot ica
or p er icran iu m , p rovid in g m obilit y to t h e scalp . It is ap p roxim ately 1 to 3 m m th ick an d is grossly obser ved as a sem it ran sp aren t , foam y layer. Ch ayen et al rep or ted t h at t h is loose
con n ect ive t issu e layer is a t h ree-layer st r u ct u re com p r ising
t w o loose areolar t issue layers an d a den se fascial layer bet w een
t w o loose areolar t issu e layers, an outer layer (loose areolar t issue), a dense fascial layer, and a deep layer (loose areolar tissue).5
Alt h ough blood vessels are n ot grossly obser ved in t h is layer, it
is m acroscop ically obser ved as layers h avin g blood vessels.
Th e blood circulat ion of th is layer is su pplied via t w o st rain s
w h erein th e rst is th e perpen dicular blood ow from th e vascular plexus in side th e galea apon eurot ica layer using perforatin g vessels; t h e secon d is t h e blood ow by t h e blood vessel
system d irect ly ow in g in from t h e m ain blood vessel of t h e
scalp to th e loose con n ect ive t issu e layer, su ch as a su per cial
tem poral ar ter y, supraorbit al arter y, an d suprat roch lear ar ter y.
Using th ese blood circu lat ion s, it is u sed as a ap w h en ver y
th in soft t issue aps are required during au ricular recon st ruct ion an d such procedures.6
33
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 4.2 Galea aponeurotica (cadaver dissection picture of the left
superior view.) Left frontalis muscle, galea aponeurotica, and super cial
temporal fascia are exposed. F, frontalis muscle; STA, super cial tem poral artery; STV, super cial temporal vein.
Pericranium
Th is soft t issue layer is posit ion ed in th e deepest su bcut an eous
t issue. Th e pericran iu m of th e h ead is con t in uous w ith th e tem poral fascia in th e tem poral region an d is n ot obser ved u n dern eath th e tem p oralis m u scle of th e tem p oral fossa.
Fig. 4.1 The layers of the scalp. The scalp is divided into ve layers
from the surface down: skin (S), subcutaneous fat (dense connective
tissue) (C), galea aponeurotica (A), loose connective tissue (L), and
pericranium (P).
Blood Circulation
Morphology of the Scalp
Regarding th e arterial blood supp ly to th e scalp, th e su praorbit al arter y an d suprat roch lear ar ter y, bran ch ing from th e
Fig. 4.3 Loose connective tissue layer (cadaver
dissection picture).
34
4 Soft Tissue of the Scalp and Tem poral Regions
Table 4.1 Blood circulation morphology of the scalp
Artery
Origin
Distribution
Supraorbital artery
Ophthalm ic artery (a branch of the internal carotid artery)
Anterior part of the scalp
Supratrochlear artery
Ophthalm ic artery (a branch of the internal carotid artery)
Anterior part of the scalp
Super cial temporal artery
External carotid artery
Lateral part of the scalp
Posterior auricular artery
External carotid artery
Posterior part of the scalp
Occipital artery
External carotid artery
Posterior part of the scalp
oph th alm ic arter y, supply blood ow to th e an terior scalp; th e
su p er cial tem poral arter y, p osterior au ricu lar arter y, an d occipit al ar ter y, bran ch ing from th e extern al carot id arter y, sup ply blood ow to th e lateral an d posterior sides of th e scalp,
respect ively (Table 4.1). Th ese ar teries are con n ected to each
oth er in th e pariet al region , form ing a den se vascu lar n et w ork.
Th ese blood vessels form th e vascular plexus in th e galea apon eurot ica layer, th ereby bran ch ing blood vessels vert ically tow ard th e su per cial layer (th at is, th e su bcu t an eou s fat layer) or
deep layer (loose con n ect ive t issu e layer an d th e pericran ium ).
Th ese m ain ar ter ies of t h e scalp for m t h e vascu lar p lexu s also
in th e loose con n ect ive t issu e, an d th is vascu lar n et w ork con n ect s w ith th e perforator vessels from th e n et w ork in th e galea
ap on eu rot ica.
Th e vein s m ain ly ru n parallel w ith th e arteries, ow ing in to
th e in tern al jugular vein via vein s w ith th e sam e n am es as th e
arteries, th at is, th e su p rat roch lear vein , su p raorbit al vein , su per cial tem poral vein , posterior auricular vein , an d occipital
vein . Th e su p rat roch lear an d su p raorbit al vein s ow in to t h e
in ter n al jugu lar vein via t h e facial vein ; h ow ever, som e ow
in sid e t h e orbit tow ard t h e in t racran ial caver n ou s sin u s. Moreover, t h e su p er cial tem p oral vein is con n ected to t h e su p er ior
sagit t al sin u s in t h e cran ial cavit y via t h e em issar y vein p assin g t h rough t h e p ar iet al foram en . Th is vein cau ses su st ain ed
bleeding from th e pariet al bon e during subperiosteal dissect ion
in th e parietal region .
Surgical Annotation
Scalp Flap
Th is skin ap is th e rst con sidered in cases requ iring various
recon st ruct ion s of th e soft t issue defect in th e h ead. Alth ough
kn ow n as a skin ap, it is act ually raised u n dern eath th e galea
ap on eu rot ica. Alth ough it is often fu n dam en t ally u sed as a ran dom pat tern ap, it m ay also be u sed as an axial pat tern ap,
in clu ding th e m ain arteries dist ribut ing th e scalp , such as th e
su p er cial tem p oral ar ter y.
Frontal Musculopericranial Flap
Th e fron t al m uscu lopericran ial ap is useful in th e recon st ruct ion of th e an terior cran ial base required after injur y or t u m or
excision becau se it provid es good blood circu lat ion in addit ion
to being st rong but th in an d exible (Fig. 4.4). A periosteal ap
in th e fron tal region is som et im es used for repairing an terior
sku ll-base defect s. W h en creat ing a large p eriosteal ap su ch as
covering th e en t ire an terior skull base, th e blood circulat ion in
t h e p er ip h eral region of t h e ap often becom es u n st able; t h en ,
in cases of large d efect s, t h e fron t alis m u scle ap sh ou ld be
raised w ith th e periosteu m .
Characteristics of the
Layered Structures of Soft
Tissue in the Temporal
Region
Th e layered st ruct ures of th e soft t issues in th e tem poral region
is greatly di eren t from th e layered st ruct u res of oth er p ar t s of
th e scalp. Th e follow ing are th e t w o m ain di eren ces: (1) th e
tem poralis m uscle is in th e deepest layer, an d (2) th e pericran iu m is n ot presen t u n dern eath th e tem p oralis m u scle, an d th e
p ericran ium of oth er part s of th e h ead is con t in uous w ith th e
deep tem poral fascia. From th ese di eren ces, th e layered st ruct ure of th e tem poral region is basically as follow s, from th e surface dow n: skin , subcutaneous tissue, super cial tem poral fascia,
su bgaleal fascia (also called in n om in ate fascia or loose areolar
t issue layer), deep tem poral fascia (divided in to t w o layers in feriorly: th e su per cial layer an d th e deep layer), tem poralis m u scle, an d subperiosteum (t issues below th e pericran ium ).
Th e super cial tem poral fascia is con t in uou s w ith th e galea
ap on eu rot ica layer in oth er part s of th e h ead u pw ard, in ad dit ion to being con t in u ous w ith th e SMAS in th e face an d con t in u ous w ith th e plat ysm a in th e n eck.3,4 Th e super cial tem poral
fascia layer an atom ically has th e superior auricular m uscle, tem p oropariet al m u scle, an d so forth , w hich are m im et ic m u scles
in relat ion to t h e au r icle; h ow ever, t h ese m u scles are d i cu lt
to appreciate during surger y an d to recogn ize as th e fascia of
th e super cial layer.
Th e subgaleal fascial layer con sist s of a loose con n ect ive t issu e covering th e en t ire calvarial region , as w ell as th e tem p oral
region , an d it h as a role of support ing th e m obilit y of th e scalp.
Blood circu lat ion of th is layer is rich in th e tem p oral region as a
result of th e abu n dan t a xial blood su pply from th e su per cial
35
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 4.4 Frontalis muscle-pericranial ap. A
case of anterior skull base tumor. The anterior
skull base reconstruction was perform ed by
using the frontal musclopericranial ap. After
frontal craniotomy and supraorbital bar
osteotomy, the frontalis muscle-pericranial
aps were raised and transplanted to the
anterior skull base tissue defect. FMP, frontalis
muscle-pericranial ap; DM, dura m ater; OF,
orbital fat; NC, nasal cavit y.
tem poral arter y. Th in fat t issue is obser ved bet w een th e sub galeal fascia layer an d th e d eep tem poral fascia. Regarding th e
st ru ct u re of th e layers arou n d th e su prazygom at ic arch region ,
Moss et al rep orted a brou s p ar t it ion called th e in ferior tem poral sept um , w h ich is located along a lin e con n ect ing th e external acoustic m eatus and tem poral ligam entous adhesion (near
th e forefron t edge of th e tem poral lin e an d th e lateral m argin of
the orbit) and connecting to the deep tem poral fascia and supercial tem poral fascia. In addit ion to report ing th at th ere is a t riangu lar brofat t y com p art m en t on th e cau dal side, th ey fou n d
th at th e tem poral bran ch of th e facial n er ve run s directly u n dern eath th e super cial tem poral fascia in th is fat t issue in th e
tem poral region above th e zygom at ic arch .7
Th e deep tem poral fascia is a fascia covering th e tem poralis
m uscle, w hich m ay be seen as a thick w h ite-colored fascial layer.
Th is layer is a single layer, th e upper t w o-th irds, an d it is con t in u ou s w ith th e pericran ium above th e tem poral lin e upw ard. It
split s in to t w o lobes: th e su p er cial layer an d deep layer dow n w ard above th e zygom at ic arch . Th en th ese t w o layers of th e
deep tem poral fascia are at tach ed so as to cover th e super cial
an d d eep su r faces of t h e zygom at ic arch (Fig. 4.5). Th e su p ercial tem p oral fat p ad can be fou n d in t h e sp ace su r rou n d ed
by th ese t w o layers of t h e d eep tem p oral fascia an d zygom at ic
arch . Opin ion s di er regarding th e con t in u at ion of th e tem p oral
fascia to th e p ericran iu m . Casan ova et al m en t ion ed th at th e
pericran ium of th e h ead t ran sit ion s to a m em bran e of a thin
conn ect ive t issue kn ow n as th e in n om in ate fascia, w h ich is th e
layer bet w een th e layer u n dern eath th e galea ap on eurot ica an d
th e tem poral fascia.8
Ben eath th e deep tem poral fascia, th e deep tem poral fat pad
can be foun d, an d th is fat t issue is con t in uou s w ith th e buccal
fat p ad passing u n der th e zygom at ic arch . Th e aforem en t ion ed
36
su p er cial tem p oral fat p ad is bou n d fat t issu e an d d oes n ot
con t in ue to th e deep tem poral fat pad.9
Th e tem p oralis m u scle can be fou n d in t h e su bst rat u m of
the deep tem poral fascia. The tem poralis m uscle is a m asticator y
m uscle; it arises from th e in fratem p oral fossa an d in ser ts in to
th e coron oid process of th e m an dible (Fig. 4.6). Th e tem poral
fossa does n ot h ave p eriosteu m as seen at th e extern al sku ll
base; th erefore, th e pericran ium is n ot presen t on th e un derside
of th e tem poralis m uscle, th is area being com posed of th in ,
coarse con n ect ive t issue.
Blood Circulation
Morphology of the
Temporal Region
The super cial tem poral artery, m iddle tem poral artery, and
deep tem poral arter y are m ain ly involved in blood circulat ion of
th e tem poral region (Table 4.2). Th e super cial tem poral ar ter y
is on e of t w o term in al bran ch es of th e extern al carot id arter y,
w h ich passes in side th e parot id glan d after th e m axillar y arter y
is separated below th e n eck of m an dible, ap pearing from th e
deep part to th e subcut an eous fat layer at th e in ferior border at
th e posterior en d of th e zygom at ic arch an d run n ing tow ard th e
vertex p erp en dicu larly in fron t of th e au ricle. Th e su per cial
tem poral ar ter y is dist ributed w idely from th e skin to th e su b galeal layer. Th e m iddle tem poral arter y is a bran ch of th e su per cial tem p oral arter y, w h ich t urn s to th e deeper layer an d
pierces the deep tem poral fascia just after arising at the superior
m argin of th e zygom at ic arch , en ters th e d eep er layer, an d is
4 Soft Tissue of the Scalp and Tem poral Regions
Fig. 4.5 Deep temporal fascia (cadaver
dissection; right temporal region). Deep
temporal fascia is cut, and the temporalis
muscle is exposed. Each super cial and deep
layer of the deep temporal fascia is held by
Kocher forceps. The fat tissue bet ween the
super cial and deep layer of the deep temporal
fascia is the super cial fat pad. DL, deep layer
of the deep temporal fascia; DTF, deep tem poral fascia; SL, super cial layer of the deep
temporal fascia and super cial temporal fat
pad; TM, temporalis muscle.
dist ributed m ain ly in th e deep tem poral fascia. Moreover, som e
bran ch es of th e m iddle tem poral arter y t ravel to th e tem poralis
m u scle an d are dist ribu ted in th e p osterior region of th e m u scle. Usually, t w o bran ch es arise from th e m axillar y ar ter y an d
lead to th e tem poralis m uscle. Th ese are th e posterior deep
tem poral arter y an d an terior deep tem poral arter y. Th ese deep
tem poral arteries run on th e surface of th e superior h ead of th e
lateral pter ygoid m u scle after arising from th e m axillar y ar ter y
an d en ter th e tem poralis m u scle on it s deep su rface, w ith th e
posterior deep tem poral arter y supplying th e in term ediate par t
of th e tem poralis m uscle; th e an terior deep tem poral arter y
su p p lies th e an terior p art of th e tem p oralis m u scle. Th ree kin ds
of an astom oses bet w een t h ese ar ter ies h ave been obser ved .
Nakajim a et al p rovide a detailed rep or t .10 Th ese an astom oses
in clude th e follow ing: (1) a con n ect ion bet w een th e vascu lar
plexus of the super cial tem poral arter y branching from the skin
to th e su per cial tem poral fascia an d th e su bgaleal vascu lar
p lexus via perforators, (2) a con n ect ion bet w een the term in al
bran ch of th e m iddle tem poral ar ter y bran ching in th e tem poral
fascia an d vascu lar p lexu s in side th e tem poralis m u scle, an d
(3) a con n ect ion n ear th e tem poral lin e bet w een th e vascu lar
p lexus of th e low er layer of th e galea apon eu rot ica an d th e vascular plexus in side th e tem poralis m uscle over th e tem poral
fascia. W h en form ing th e soft t issu e ap of th e tem p oral region ,
Fig. 4.6 Temporalis muscle (cadaver dissection; right temporal region). Deep temporal
fascia was cut in the middle part and opened.
The zygom atic arch was rem oved and the
stump of the zygomatic bone can be seen. Deep
temporal fat pad, which continues to the buccal
fat pad, lies on the temporalis muscle. DF, deep
temporal fat pad; DTF, deep temporal fascia;
TM, temporal muscle.
37
Anatom y for Plastic Surgery of the Face, Head, and Neck
Table 4.2 Blood circulation morphology of the temporal region
Artery
Origin
Distribution
Super cial temporal artery
One of the terminal branches of
the external carotid artery
Skin to subgaleal layer
Middle temporal artery
A branch of the super cial
temporal artery
Deep temporal fascia and posterior region of the temporalis
m uscle
Anterior deep temporal artery
Posterior deep temporal artery
Branches of the m axillary artery
Anterior part of the temporalis m uscle (anterior deep
temporal artery)
Interm ediate part of the temporalis m uscle (posterior deep
temporal artery)
su cien t con sid erat ion is requ ired regarding it s blood circu lat ion an d th e respect ive an astom oses.
Surgical Annotation
Superf cial Temporal Fascial Flap
(Temporoparietal Fascial Flap)
Th e super cial tem poral fascial ap is a th in m uscle ap w ith
super cial tem poral arteries as a vascular pedicle. These are used
for vascu larizat ion w h en recon st ru ct ing th e face, au ricle, an d
dura m ater and for the reconstructing the lim bs as a free ap.11,12
Deep Temporal Fascial Flap
Th is fascial ap involves th e m iddle tem poral ar teries as a vascu lar pedicle. It can be used n ot on ly as a single fascial ap but
also as a bilobed ap or com bin ed ap togeth er w ith th e su percial tem p oral fascial ap w ith th e su p er cial tem p oral ar ter y
as a vascu lar pedicle.13
Temporalis Muscle -Pericranial Flap
Th is th in , exible pericran ial ap uses th e tem poralis m uscle as
th e pedicle (Fig. 4.7). Th e vascular pedicle of th is ap is th e
deep tem poral ar teries supplying th e tem poralis m u scle. W h en
creat ing th e ap, th e parietal pericran iu m an d th e loose con n ect ing t issu e layers are raised along w ith th e tem p oralis m u scle so as n ot to det ach th e tem poralis m uscle an d the deep
tem poral fascia in an area th at is abou t 2 cm w ide from th e tem poral crest dow n because th ere is a vascular plexus con n ect ing
th e tem poralis m uscle an d subgaleal fascial layer. Th erefore,
blood ow from th e deep tem poral ar teries can reach th e pericran iu m in th e m idparietal region via th is vascu lar n et w ork.14
Creat ing th e bilateral pericran ial aps becom es possible by dividing th e pericran iu m at th e m idparietal region , w h ich is u sed
for recon st ru ct ing th e an terior cran ial base an d m idd le cran ial
base of th e skull.
Temporalis Muscle Flap
Th e tem poralis m uscle ap is usually used as a pedicle ap for
dyn am ic recon st r u ct ion of t h e eyelid s an d t h e lip for facial
palsy.15,16
Fig. 4.7 Temporalis muscle-pericranial ap.
Bilateral temporalis muscle-pericranial ap are
raised after bicoronal skin incision. Bilateral
pericranial aps were raised with the temporalis
muscles, and the deep temporal arteries, which
supply the temporalis muscle, provide the blood
circulation of this ap. TM, temporalis muscle;
TMP, temporalis muscle-pericranial ap.
38
4 Soft Tissue of the Scalp and Tem poral Regions
References
1. Tolh u rst DE, Carsten s MH, Greco RJ, Hu r w it z DJ. Th e su rgical
an atom y of t h e scalp . Plast Recon st r Su rg 1991;87(4):603–614
Pu bMed
2. Trem olada C, Can dian i P, Signorin i M, Vigan o M, Don at i L. Th e su rgical an atom y of th e subcut an eous fascial system of th e scalp. An n
Plast Surg 1994;32(1):8–14 Pu bMed
3. Mit z V, Peyron ie M. Th e su per cial m usculo-apon eurot ic system
(SMAS) in the parot id an d cheek area. Plast Recon st r Su rg 1976;
58(1):80–88 PubMed
4. St uzin JM, Baker TJ, Gordon HL. Th e relat ion sh ip of th e super cial
an d d eep facial fascias: relevan ce to rhyt id ectom y an d aging. Plast
Recon st r Su rg 1992;89(3):441–451 PubMed
5. Ch ayen D, Nathan H. An atom ical obser vat ion s on the subgaleot ic
fascia of th e scalp . Act a An at (Basel) 1974;87(3):427–432 Pu bMed
6. Carsten s MH, Greco RJ, Hu r w it z DJ, Tolhu rst DE. Clin ical applicat ion s of th e subgaleal fascia. Plast Recon st r Surg 1991;87(4):615–
626 Pu bMed
7. Moss CJ, Mendelson BC, Taylor GI. Surgical an atom y of th e ligam en tous at t ach m en t s in th e tem ple an d periorbit al region s. Plast
Recon st r Su rg 2000;105(4):1475–1498 Pu bMed
8. Casan ova R, Cavalcan te D, Grot t ing JC, Vascon ez LO, Psillakis JM.
Anatom ic basis for vascularized outer-t able calvarial bon e aps.
Plast Reconst r Su rg 1986;78(3):300–308 PubMed
9. St uzin JM, Wagst rom L, Kaw am oto HK, Baker TJ, Wolfe SA. Th e
an atom y an d clin ical applicat ion s of the buccal fat pad. Plast Recon st r Surg 1990;85(1):29–37 PubMed
10. Nakajim a H, Im an ish i N, Minabe T. Th e arterial anatom y of th e
tem poral region an d th e vascular basis of various tem poral aps.
Br J Plast Su rg 1995;48(7):439–450 PubMed
11. Bren t B, Upton J, Aclan d RD, et al. Exp er ien ce w it h t h e tem p oro p ar iet al fascial free ap . Plast Recon st r Su rg 1985;76(2):177–188
PubMed
12. Tegt m eier RE, Gooding RA. Th e u se of a fascial ap in ear recon st r u ct ion . Plast Recon st r Su rg 1977;60(3):406–411 PubMed
13. Hirase Y, Kojim a T, Bang HH. Double-layered free tem poral fascia
ap as a t w o-layered ten d on -gliding surface. Plast Recon st r Su rg
1991;88(4):707–712 Pu bMed
14. Kiyokaw a K, Tai Y, In ou e Y, et al. E cacy of tem poral m usculopericran ial ap for recon st ruct ion of the an terior base of th e skull.
Scan d J Plast Recon st r Surg Han d Surg 2000;34(1):43–53 Pu bMed
15. Gillies SH, Millard DR. Th e Prin ciples an d Ar t of Plast ic Surger y.
Lon don : But ter w orth s; 1957
16. Frey M, Giovan oli P, Tzou CHJ, Kropf N, Fried l S. Dyn am ic recon st r u ct ion of eye closu re by m u scle t ran sp osit ion or fu n ct ion al
m uscle t ran splan t at ion in facial palsy. Plast Recon st r Surg 2004;
114(4):865–875 Pu bMed
39
5
Arterial Supply of the Facial Skin
Nobuak i Im anishi
Introduction
Arterial supply of th e facial skin is ch ie y provided by th e facial
an d su p er cial tem poral arteries an d also by bran ch es of th e
m a xillar y an d op h t h alm ic ar ter ies, w h ich accom p any t h e cu t an eou s bran ch es of t h e t r igem in al n er ve. Bran ch es from t h e
sou rce ar ter ies r u n w it h in t h e su bcu t an eou s soft t issu e an d
reach th e d erm is an d th en form th e subderm al p lexus. In th is
ch apter, th e det ailed ar terial vascu larit y of each region of th e
face on th e basis of angiogram s I h ave p erform ed is described .
Becau se th e arterial supply of th e face is su bst an t ial, n ecrosis of
m ost local ap s h ere rarely occu rs; h ow ever, kn ow ledge of th e
ar ter ial an atom y of t h e face is im p or t an t w h en var iou s local
ap s of th e face are elevated.
Arteries of the Facial Skin
Th e super cial tem poral, facial, an d oph th alm ic ar teries are
three m ajor source arteries of the facial skin. The super cial tem poral arter y gives o th e t ran sverse facial an d zygom at icoorbital arteries and divides into the frontal and parietal branches.
The facial artery gives o the subm ental, inferior labial, superior
labial, an d lateral n asal ar teries an d th en becom es th e angular
artery. Th e oph thalm ic artery gives o the supratrochlear, supraorbit al, dorsal n asal, an d m edial an d lateral palpebral ar teries.
Th e bran ch es from th e source ar teries form an in t im ate vascu lar n et w ork in th e face (Fig. 5.1). In addit ion , th e in fraorbit al,
zygom at icofacial, an d m en t al arteries, w h ich are derived from
t h e m a xillar y ar ter y, accom p any cu t an eou s bran ch es of t h e
t r igem in al n er ve. Th e skin ter r itor ies su p p lied by t h e zygom at icofacial an d m en tal ar teries are sm all an d play on ly a su pplem en t al role in th e blood su p p ly of th e face.
Vasculature of Each Region
of the Face
Forehead
Blood supply to th e foreh ead is provided by th e suprat roch lear
an d su p raorbital arteries an d th e fron t al bran ch of th e su p er cial tem poral ar ter y (Fig. 5.2). An in t im ate vascular plexu s is
40
form ed by th e ar teries an d th eir bran ch es. Th e su prat roch lear
ar ter y is d om in an t in t h e m ed ian foreh ead . Th e m ain t r u n k of
t h e ar ter y p en et rates t h e orbit al sept u m above t h e m edial p alp ebral ligam en t an d t h en ascen d s bet w een t h e cor r ugator su p ercilii an d orbicu lar is ocu li m u scles after sen d in g vessels to
t h e loose areolar t issu e u n d er t h e cor r ugator su p ercilii m u scle.1,2 It p en et rates t h e fron t alis m u scle abou t 1 cm above t h e
eyebrow an d ru n s ap p roxim ately a few cen t im eters ju st above
th e m uscle to reach th e subderm al plan e (Fig. 5.3). During it s
cou rse, sm all vessels bran ch o tow ard th e derm is an d fron t alis
m u scle. Th e su p rat roch lear arter y does n ot t ravel far in to th e
fron talis m u scle. Th e foreh ead ap origin ally in clu ded th e fron t alis m u scle, bu t from t h e p oin t of view of ar terial an atom y, it
is n ot essen t ial to in clu de th e m u scle it self. Th erefore, th e foreh ead ap is n ot a m u scu locu t an eou s ap bu t rath er a fasciocut an eous ap.
Upper Eyelid
Blood su p p ly of t h e u p p er eyelid is p rovid ed by fou r ar ter ial
arcades—th e m argin al, periph eral, su p er cial orbit al, an d deep
orbit al arcades—an d by ascen ding an d descen ding bran ch es
from th ese arcades 3 (Fig. 5.4, Fig. 5.5). Am ong th ese arcades,
th e m argin al on e along th e m argin of th e upper eyelid an d th e
periph eral on e along th e u pper m argin of th e tarsu s are form ed
by vascular anastom oses of m edial an d lateral palpebral arteries
from th e op h th alm ic ar ter y.
Th e m argin al arcade ru n s along th e fron t low er edge of th e
t arsus, giving o bran ch es th at ascen d on the an terior an d posterior su rfaces of th e orbicularis oculi m uscle an d t arsus. Am ong
th ese ascen ding branch es, th e arteries on th e an terior surface of
th e orbicularis oculi m uscle an d on th e posterior surface of th e
t arsus pass un der the low er m argin of th e m uscle an d t arsus.
From th e ascen ding bran ch es, addit ion al sm all vessels reach th e
skin , orbicu laris ocu li m u scles, an d tarsu s. Th e m argin of th e
eyelid is also su p plied by sm all d irect vessels from th e m argin al
arcade.
Th e periph eral arcade run s along th e at t ach m en t of Mü ller’s
m u scle to th e t arsu s, giving o bran ch es th at descen d on th e
an terior an d posterior su rfaces of th e tarsu s. Th ese descen ding
bran ch es com m un icate w ith th e ascen ding bran ch es from th e
m argin al arcade.
Th e super cial and deep orbit al arcades ru n on th e an terior
an d p osterior su rfaces of th e orbicu laris ocu li m u scle along th e
su p erior m argin of th e orbit . Th e m ain blood su p p ly of th e ar-
5 Arterial Supply of the Facial Skin
Fig. 5.1 Angiogram of the face. (1) Super cial temporal artery.
(2) Facial artery. (3) Transverse facial artery. (4) Zygomatico-orbital
artery. (5) Frontal branch. (6) Inferior labial artery. (7) Superior labial
artery. (8) Lateral nasal artery. (9) Angular artery. (10) Supratrochlear
artery. (11) Supraorbital artery. (12) Dorsal nasal artery. (13) Medial
palpebral artery. (14) Lateral palpebral artery. (15) Infraorbital artery.
(16) Zygomaticofacial artery. (17) Mental artery.
cades is provided by th e suprat roch lear ar ter y. Th e su praorbit al
an d m edial palp ebral ar teries on th e m edial side of th e orbit
an d t h e zygom at ico -orbit al, t ran sverse facial, an d su p er cial
tem poral arteries on th e lateral side part icipate in form ing th e
su p er cial an d d eep orbit al arcades. Descen d ing vessels from
t h e su p er cial orbit al arcade on t h e an ter ior su r face of t h e
orbicu lar is ocu li m u scle an d from t h e d eep orbit al arcad e on
t h e p oster ior of t h e m u scle an astom ose w it h t h e ascen d ing
bran ch es of th e m argin al arcade.
Becau se th e blood su pp ly to th e skin dep en d s basically on
th e super cial orbital an d m argin al arcades an d th eir con n ect ing vessels, it is n ecessar y for a local ap on th e up per eyelid to
Fig. 5.2 Angiogram of the left forehead. Enlarged im age of Fig. 5.1.
DNA, dorsal palpebral artery; Fbr, frontal branch of the super cial
temporal artery; MPA, medial palpebral artery; SoA, supraorbital
artery; StA, supratrochlear artery.
be elevated ju st above th e orbicularis oculi m uscle, th ereby preser ving th ose vessels. Th ere are n o m ajor arteries w ith in th e
orbicularis oculi m uscle, an d blood supply of th e m uscle is provid ed by sm all bran ch es from th e ascen ding an d descen ding
vessels on the anterior and posterior surfaces of the m uscle. In
the case of a m usculocutaneous ap, such as a V–Y advancem ent
41
Anatom y for Plastic Surgery of the Face, Head, and Neck
ap, it s blood su pp ly dep en ds on th e d eep orbit al an d m argin al
arcad es an d th eir con n ect ing vessels. Accordingly, su rgical op erat ion s m u st n ot exten d beh in d th e orbicu laris ocu li m u scle.
Nose and Upper Lip
Fig. 5.3 Schematic sagit tal section showing the course of the supratrochlear artery. (1) Supratrochlear artery. (2) Main trunk ascending bet ween the corrugator supercilii and orbicularis oculi muscles. (3) Branch
to the loose areolar tissue. CS, corrugator supercilii muscle; FB, frontal
bone; FM, frontalis muscle; LAT, loose areolar tissue; OO, orbicularis
oculi muscle.
Th e facial ar ter y gives o t h e su p er ior labial ar ter y abou t at
t h e angle of m ou t h an d becom es t h e angu lar ar ter y tow ard t h e
m edial can th u s.4 In 12% of our cases, th e periph eral p or t ion of
th e facial ar ter y can cert ain ly be recogn ized as th e angu lar arter y w ith a slight decrease in its diam eter.5 In 88%, th e facial
arter y en ds at th e alar base, an d th e term in al p ort ion of th e facial arter y tow ard th e alar base is called th e lateral n asal arter y
(Fig. 5.6). In th ese cases, a th in vessel or a vascu lar plexu s con n ect s th e lateral n asal arter y w ith vessels from th e su p rat roch lear ar ter y n ear th e m edial can th us.
Th e lateral n asal ar ter y divides in to t w o vessels surroun ding
th e alar base. On e is called th e in ferior alar bran ch , an d it run s
tow ard th e colum ella along th e low er m argin of th e n ost ril, su p plying blood to th e alar base an d n ost ril oor. A few bran ch es
t ravel tow ard th e upper lip from th e in ferior alar bran ch . Th e
oth er vessel is called th e su p erior alar bran ch , w h ich ascen ds
along th e lateral side of th e alar, giving o bran ch es to th e lateral port ion of th e alar, n asal t ip, an d dorsu m of th e n ose.
Th e su perior labial ar ter y run s bet w een th e labial m ucosa
an d orbicu laris oris m u scle at th e level of th e u p per m argin of
th e red lip. Th e superior labial arter y does n ot alw ays con sist of
on e vessel; in 35%of cases, it con sists of t w o vessels. Th is ar ter y
ru n s m edially, giving o ascen ding bran ch es at both sides of th e
labial m u cosa an d skin , an d th en it an astom oses w ith th e con t ralateral ar ter y of th e sam e n am e.
Th e ascen ding vessels tow ard th e cut an eous side pen et rate
th e orbicularis oris m uscle at th e level of th e upper m argin of
th e red lip an d give o bran ch es to th e red lip, skin , an d orbicu -
Fig. 5.4 Angiogram of the left eyelid; enlarged
image of Fig. 5.1. DAR, deep orbital arcade;
LPA, lateral palpebral artery; MAr. marginal
arcade; MPA, medial palpebral artery; PAr.
peripheral arcade. SAr, super cial orbital
arcade; SoA, supraorbital artery; StA. supratrochlear artery.
42
5 Arterial Supply of the Facial Skin
Fig. 5.5 Schematic sagit tal section through the upper eyelid (1)
marginal arcade. (2) peripheral arcade. (3) Super cial orbital arcade.
(4) Deep orbital arcade. FB, frontal bone; M, Müller’s muscle; OO,
orbicularis oculi; OS, orbital septum; T, tarsus.
laris oris m u scle (Fig. 5.7). A few vessels at th e ph ilt rum am ong
th e ascen ding vessels are som et im es large an d are called th e
sept al arteries. Th e ascen ding vessels at th e m u cosal side give
o brach es to both th e orbicularis oris m uscle an d labial m u cosa. At th e base of th e colum ella, th e ascen ding vessels from
both sides of th e su perior labial arter y an d th e term in al port ion
of th e in ferior alar bran ch from th e lateral n asal ar ter y an astom ose w ith each oth er an d form a vascu lar n et w ork. At th e colu m ella base are t w o kin ds of vessels from th e vascu lar n et w ork
th at ascen d tow ard th e n asal t ip. On e is an arter y th at ascen ds
w ith in th e colu m ella an d reach es vascular n et w ork at th e n asal
t ip. Th e oth er is an arter y th at en ters in to th e n asal sept um an d
ascen d s along th e an terior m argin of th e n asal sept al car t ilage.
Th is arter y also reach es th e n asal t ip vascular n et w ork th rough
a sm all op en ing am ong th e alar an d lateral n asal car t ilages. Th is
arter y gives o bran ch es in both an terior an d p osterior directions. The anterior branches reach the m edial crus of the alar cart ilage an d colum ella bet w een th e m edial crura. Th e posterior
bran ch es reach th e n asal sept al car t ilage. Th e vasculat u re of th e
skin of th e u pp er lip an d m u scle is sim ilar to th at of th e u p p er
eyelid (Fig. 5.3).
Fig. 5.6 Angiogram of the left upper lip and nose. Enlarged image of
Fig. 5.1. FA. facial artery; IABr, inferior alar branch; LNA, lateral nasal
artery; SA, septal artery; SABr, superior alar branch; SLA, superior labial
artery. Artery: a thin vessel toward the m edial canthus.
Cheek
From th e poin t of view of ar terial an atom y, th e ch eek is rough ly
a region su rrou n ded by th e facial an d su per cial tem p oral arteries. Th erefore, th e blood supply of th e ch eek is ch ie y provid ed by bran ch es of th e facial ar ter y, t ran sverse facial ar ter y,
an d zygom at ico-orbit al arter y (Fig. 5.8). A com plem en t ar y relat ion sh ip can be seen am ong th ese arteries. For exam ple, w h en
th e zygom at ico-orbit al arter y is sm all, th e t ran sverse facial arter y is en larged (Fig. 5.1). In addit ion , th ere are in fraorbit al an d
zygom at icofacial arteries. Th e zygom at icofacial ar ter y plays th e
role of a supp lem en t ar y blood supply.
A subderm al plexus is vessels in both th e derm is an d su b derm al plan e.6 Th e su bderm al p lexu s is n ot alw ays ran dom , but
its vascular pattern show s som e axialit y.7 In the n asolabial fold
an d it s n eigh boring area, sm all bran ch es from th e facial or lateral n asal arteries ascen d ver t ically.8 Th e skin territor y of each
bran ch is also sm all (Fig. 5.9). Accordingly, a V-Y advan cem en t
ap on th e n asolabial fold is su it able based on th e vascu lat u re
by t h e sm all ver t ical vessels; h ow ever, bran ch es of th e t ran sverse facial an d zygom at ico-orbit al arteries an d th e p roxim al
43
Anatom y for Plastic Surgery of the Face, Head, and Neck
por t ion of th e facial arter y are com parat ively large, an d vascu lar
con t in uit y by th ese bran ch es is apparen t . In th is region , th e
su bd erm al plexu s ru n s a xially. In th e in fraorbit al region , th e in fraorbit al ar ter y radiates ju st after p assing th rough th e in fraorbit al foram en , but th e skin territor y su pplied by each bran ch
is sm all.
Low er Lip
Fig. 5.7 Schematic sagit tal section through the upper lip and nose.
(1) Terminal portion of the inferior alar branch. (2) Septal nasal artery.
(3) Superior labial artery. AC, medial crus of alar cartilage; M. maxilla;
OO. orbicularis oris muscle; SC, septal cartilage.
Th e blood supply of th e low er lip is provided by th e facial an d
su bm en t al ar teries. Th ere are t w o kin ds of bran ch es from th e
facial arter y. On e is th e in ferior labial ar ter y, an d th e oth er is a
bran ch th at t ravels h orizon t ally at a level bet w een th e low er lip
an d m en t u m .9 In addit ion , ascen ding bran ch es from th e su b m en tal arter y take p ar t in th is blood su p ply (Fig. 5.10).
Th e in ferior labial arter y is derived from th e facial ar ter y at
th e low er m argin of th e m an dible in 67% of cases an d at th e
corn er of th e m outh in 25%. It is som et im es derived from th e
su p erior labial ar ter y in 8%. Th e in ferior labial arter y ru n s bet w een th e orbicularis oris an d buccin ator m u scles an d th en
reach es th e low er lip. It passes t ran sversely bet w een th e orbicu lar is or is m u scle an d labial m u cosa at t h e level of t h e bou n d ar y of th e red an d w h ite p art s of th e lips giving o descen ding
bran ch es at both sides of th e skin an d labial m ucosa (Fig. 5.11).
Th e descen ding bran ch es of th e cutan eous side cross over th e
upper m argin of th e orbicularis oris m uscle or pen et rate th e
m u scle an d d escen d , givin g o sm all vessels to t h e skin an d
m u scle. Th e descen ding bran ch es of th e m u cosal side also give
o sm all vessels to th e m uscle an d m ucosa.
Th e h orizont al bran ch at th e level bet w een th e low er lip an d
m en t u m is derived from th e facial ar ter y an d arises at th e low er
Fig. 5.8 Angiogram of the left cheek. Enlarged
im age of Fig. 5.1. FA, facial artery; IoA, infraorbital artery; STA, super cial temporal artery;
TFA, transverse facial artery; ZoA, zygomaticoorbital artery.
44
5 Arterial Supply of the Facial Skin
Fig. 5.9 Subdermal plexus of the cheek
Angiogram shows the subdermal plexus of the
cheek region. There are comparatively small
vessels from the facial or lateral nasal arteries
in the green area. Each sm all artery that enters
the subdermal plane has a small skin territory.
In other cheek regions, vessels that enter the
subdermal plane are comparatively large, and
their vascular continuit y (arrows) is good.
Fig. 5.10 Angiogram of the left lower lip. Enlarged image of Fig. 5.1.
ABr, ascending branch from the submental artery; FA, facial artery; Hbr,
horizontal branch at the level bet ween the lower lip and mentum; ILA,
inferior labial artery.
45
Anatom y for Plastic Surgery of the Face, Head, and Neck
m argin of th e m an d ible. Th e arter y ru n s on th e m u cosal side
bet w een th e orbicularis oris an d depressor labii in ferioris m uscles. In 50%of cases, it an astom oses w ith th e arter y of th e sam e
n am e on th e con t ralateral side w ith ou t decreasing its diam eter.
In 33% of cases, it s diam eter d ecreases gradu ally, an d it is n ot
iden t i ed in th e m iddle of th e low er lip. In 17% of cases, its
p at h w ay ch an ges from a h or izon t al d irect ion to a ver t ical d irect ion an d it an astom oses w ith bran ch es of th e in ferior labial
arter y. Th e arter y is larger th an th e in ferior labial arter y in 50%
of cases. Th e arter y gives o ascen ding bran ch es on both sides
of th e skin an d labial m ucosa beh in d th e in ferior m argin of th e
orbicularis oris m uscle. Th e ascen ding bran ch es an astom ose
w ith th e descen ding bran ch es of th e in ferior labial ar ter y. Ascen ding ar teries from th e m en t um to th e low er lip arise from
th e subm en t al ar ter y. At th e begin n ing of th eir path w ays, th ey
ru n beh in d th e dep ressor labii in ferioris m u scle. Th ey bifu rcate
w h en th ey ascen d n ear the orbicularis oris m uscle. Th e bifurcat ing bran ch es an astom ose w ith th e ascen ding bran ch es from
th e h orizon tal bran ch of th e facial arter y. Blood supply of th e
low er lip an d m en t u m is provided by n ot on ly th e th ree dom in an t vessels, as m en t ion ed, bu t also by direct bran ch es from th e
facial arter y an d m en tal arter y. Blood su p p ly by th e m en tal arter y is on ly supplem en t al.
Fig. 5.11 Schematic sagit tal section through the lower lip. (1) Inferior
labial artery. (2) Horizontal branch at the level bet ween the lower lip
and mentum. (3) Ascending branch from the submental artery. (4) Submental artery. DL, depressor labii inferioris muscle; M, mandible; OO,
orbicularis oris muscle.
References
1. Nakajim a H, Im an ish i N. Nasal recon st r uct ion by th e m edian foreh ead ap. In : Ogaw a Y, ed. Facial Reconst ruct ion by Various Local
Flaps: Recent Advancem ent. 1st ed. Tokyo: Kokuseidou Co.; 2000:93
(in Japan ese)
2. Kish i K, Im an ish i N, Sh im izu Y, Sh im izu R, Okabe K, Nakajim a H.
Altern at ive 1-step n asal recon st r uct ion tech n ique. Arch Facial Plast
Surg 2012;14(2):116–121 Pu bMed
3. Kaw ai K, Im anish i N, Nakajim a H, Aiso S, Kakibuch i M, Hosokaw a K.
Arterial an atom ical feat ures of th e u pper palpebra. Plast Recon st r
Surg 2004;113(2):479–484 PubMed
4. Barr y KB. Face an d scalp. In : St an dring S, ed. Gray’s An atom y, 40 th
ed. Edin burgh : Ch urch ill Livingston e/Elsevier; 2008:467.
5. Nakajim a H, Im an ish i N, Aiso S. Facial ar ter y in th e upper lip an d
n ose: an atom y an d a clin ical applicat ion. Plast Recon st r Surg 2002;
109(3):855–863 PubMed
46
6. Im an ish i N, Nakajim a H, Min abe T, Aiso S. Angiograph ic st udy of
th e su bderm al p lexu s: a p relim in ar y rep or t . Scan d J Plast Recon st r
Surg Han d Surg 2000;34(2):113–116 Pu bMed
7. Ch ang H. Ar terial an atom y of subderm al plexus of th e face. Keio J
Med 2001;50(1):31–34 PubMed
8. Im an ish i N. Arterial an atom y of th e n asolabial ap. Jpn J Plast Surg
2014;57(3):223–230 (in Japan ese)
9. Kaw ai K, Im an ish i N, Nakajim a H, Aiso S, Kakibuch i M, Hosokaw a
K. Ar terial an atom y of th e low er lip. Scan d J Plast Recon st r Surg
Han d Surg 2004;38(3):135–139 Pu bMed
6
Arteries of the Face and Neck
Yelda Atam az Pinar, Figen Govsa, and Servet Celik
Introduction
Safe an d e ect ive recon st ru ct ive su rgical p roced u res rely on a
clear kn ow ledge of facial an d n eck arterial an atom y. Cadaveric
angiographic an d dissection studies have dem onstrated that the
extern al an d in tern al carot ids are th e m ain arterial sou rces for
th e h ead an d n eck region s.
Th e skin an d soft t issue of th e face receive th eir ar terial sup ply from th e bran ch es of th e facial, m axillar y, an d super cial
tem poral ar teries, all of w h ich are bran ch es of th e extern al carot id. Th e except ion is a m asklike area th at in clu des th e cen t ral
foreh ead, th e eyelids, an d th e u p p er p ar t of th e n ose an d is su p plied via th e in tern al carot id ar ter y system via th e oph th alm ic
ar teries. Th e op h th alm ic ar ter y gives o bran ch es to th e face,
including the lacrim al, supraorbital, supratrochlear, dorsal nasal,
an d extern al n asal arteries.
Becau se t h ere are com m u n icat ion s bet w een t h e exter n al
an d in ter n al carot id ar ter y system s arou n d t h e eye, exter n al
n ose, an d foreh ead t h rough several an astom oses, kn ow ledge
of t h e ar ter ial ter r itor ies is im p or t an t in ap an atom y. Most
ap s are based on vascu lar izat ion of t h e ar ter ies, an d an atom ical var iat ion s m u st be con sid ered w h en in d ivid u al ap s are
p lan n ed for p at ien t s. To elevate an ar ter ial ap safely, rou t in e
u se of a Dop p ler p robe p reop erat ively an d in t raop erat ively is
recom m en d ed .
Th e p r im ar y ar terial ter r itor ies of t h e h ead an d t h e n eck
h ave been d e n ed by m ap p in g t h eir t h ree-d im en sion al ter r itor ies in t h e skin , t h e d eep soft t issu es, an d t h e bon es.1 –3 Th e
exter n al carot id ar ter y su p p lies t h e exter ior of t h e h ead , t h e
face, an d m u ch of t h e n eck. Th e in ter n al carot id ar ter y su p p lies t h e cen t ral face, w h ich con t ain s t h e eyes, t h e u p p er t w o t h ird s of t h e n ose, an d t h e cen t ral foreh ead 4 (Fig. 6.1, Fig. 6.2,
Fig. 6.3).
Th ere is a rich an astom ot ic n et w ork bet w een th e bran ch es
of t h e in ter n al carot id an d op h t h alm ic ar ter y system s (su p raorbit al or su p rat roch lear vessels) (Fig. 6.4a) an d t h e an gu lar
ar ter y an d su p er cial tem p oral arter y via th e t ran sverse facial
arter y to th e facial ar ter y (Fig. 6.4b). Th ere are also m ult iple
an astom oses bet w een th e facial an d m axillar y arter y territories
via th e in fraorbital an d m en t al ar teries (Fig. 6.4c).3,5
Recon st ruct ion m eth ods for facial defects in clude skin grafts,
local aps, pedicled aps, an d m icrovascu lar t issu e t ran sfers 6 ;
h ow ever, rem ote t issu es d o n ot p rovid e id eal t issu e con tou r,
t h ickn ess, text u re, or sh ap e for t h e facial st r u ct u res; h en ce,
t h ey often require m ult iple revision s an d result in don or-site
m orbidit y.1,7 Mu scles an d oth er t issu es h ave a vit al role becau se
t h ey p rovide an astom ot ic n et w orks for p reven t ing vascu lar
com prom ise.
Th e m any ch anges u n d ergon e by em br yon ic ar ter ies, su ch
as regression or reap p earan ce, can resu lt in var iat ion s of t h e
or igin p oin t s, t h e cou rses, an d t h e an astom ot ic feat u res of t h e
vessels. Ar terial variat ion s can be exp lain ed by th e persisten ce
of ch an n els th at n orm ally disappear or by th e disappearan ce of
n orm ally p ersist ing vessels. Th ese an atom ical variat ion s arising
from em br yologic developm en t can be sign i can t .8,9 Dop pler
u lt rasoun d h elps to de n e arterial feat u res an d p rovides in form at ion abou t back ow an d th e poten t ial for reverse ow in th e
ar ter y.7,10
External Carotid Artery
Th e cer vical par t of th e com m on carot id is usually divided in to
th e extern al an d th e in tern al carot id ar teries at th e level of th e
u pper border of th e thyroid car t ilage. Th e carot id bifurcat ion is
located 13.2 ± 5.6 m m below th e t ip of th e greater h orn of th e
hyoid bon e. Th e extern al carot id arter y is covered by skin , sup er cial fascia, p lat ysm a, deep fascia, an d th e an terior m argin
of th e sternocleidom astoid m uscle. It begins by taking a slightly
cu r ved cou rse an d t h en p asses u pw ard an d for w ard .11 After
bran ch ing on it s an ter ior (su p er ior t hyroid , lingu al, facial arter ies) an d posterior (ascen ding ph ar yngeal, occipital, posterior
au ricu lar arteries) sides, th e arter y in clin es backw ard to th e
sp ace beh in d th e n eck of th e m an dible, w h ere it is divided in to
it s term in al branch es, th e super cial tem poral an d m axillar y
ar teries (Fig. 6.1, Fig. 6.2).
47
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 6.1 The super cial arteries of the head and neck regions in
anterolateral oblique view. Regions: Arterial territories include
(1) frontal: Str, So, MP (O territory); (2) nasal: DN, AE, An (F-O territory);
(3) orbital: MP, LP, Io (O-Max-Zo territory); (4) oral: SL, IL (F territory);
(5) mental: Me, IL (Max-F territory); (6) buccal: Io, TF (Mx-ST territory);
(7) parotid: TF, Ms (ST territory); (8) temporoparietal: Fb, Pb, MT (ST
territory); (9) auricular: AA, PA (ST-ECA territory); (10) occipital: O
(ECA territory); (11) anterior cervical: STh (ECA territory). AA, anterior
auricular artery, AE: anterior ethmoidal artery; An, angular artery; C,
columellar artery; DN, dorsal nasal artery; ECA, external carotid artery;
F, facial artery; Fb, frontal branch of the super cial temporal artery;
HLm, horizontal labiomental artery; IA, inferior alar artery; IL, inferior
labial artery; Io, infraorbital artery; MP, medial palpebral artery; Ms,
masseteric artery; Me, mental artery; Mx, maxillary artery; MT, middle
temporal artery; L, lingual artery; LN, lateral nasal artery; LP, lateral
palpebral artery; P, parotid branch; PA, posterior auricular artery; Pb,
parietal branch of the super cial temporal artery; SA, superior alar
artery; Sh, suprahelical artery; SL, superior labial artery; So, supraorbital artery; Sp, septal artery; ST, super cial temporal artery; STh,
superior thyroid artery; Str, supratrochlear artery; TF, transverse facial
artery; VLm, vertical labiomental artery; Zo, zygomatico-orbital artery.
Fig. 6.2 The deep arteries of the head and
neck regions in anterolateral oblique view.
Regions: arterial territories: (1) frontal: Str, So,
MP (O territory); (2) nasal: DN, AE, An (F-O
territory); (3) orbital: MP, LP, Io (O-Max-Zo
territory); (4) oral: SL, IL (F territory); (5) mental: Me, IL (Max-F territory); (6) buccal: Io, TF
(Mx-ST territory); (7) parotid: TF, Ms (ST territory); (8) temporoparietal: Fb, Pb, MT (ST
territory); (9) auricular: AA, PA (ST-ECA
territory); (10) occipital: O (ECA territory);
(11) anterior cervical: STh (ECA territory). AE,
anterior ethmoidal artery; B, buccal artery;
DN, dorsal nasal artery; DT, deep temporal
artery; ECA, external carotid artery; F, facial
artery; IA, inferior alveolar artery; Io, infraorbital artery; L, lingual artery; Ms, masseteric
artery; Mx, maxillary artery; N, nasopalatine
artery; PA, posterior auricular artery; PE, posterior ethmoidal artery; Op, ophthalmic artery;
SAA, superior alveolar artery; SPA, superior
posterior alveolar artery; Sph, sphenopalatine
artery; So, supraorbital artery; Str, supratrochlear artery; STh, superior thyroid artery.
48
6 Arteries of the Face and Neck
a
b
c
Fig. 6.4 Schematic representation of the arterial anastomoses in three
pat terns. (a) Intercarotid anastomoses (angular and dorsal arteries).
(b) Transfacial anastomoses (radix, lateral nasal, marginal, and subnasal
arteries). (c) Polygonal system (intercarotid and transfacial). Red:
intercarotid; orange: transfacial interconnected arteries.
Surgical Annotation
Fig. 6.3 Branches of the external carotid artery, posterolateral view.
Regions: Arterial territories (5) mental: Me (Mx), Shy, SuL (L), SuMe (F)
territory; (7) parotid: TF, Ms (ST territory); (8) temporoparietal: Fb, Pb,
MT (ST territory); (9) auricular: AA, PA (ST-ECA territory); (10) occipital:
O (ECA territory). APh, ascendening pharyngeal artery; ECA: external
carotid artery; F, facial artery; Fb, frontal branch of the super cial
temporal artery; L, lingual artery; PA, posterior auricular artery; Pb,
parietal branch of the super cial temporal artery; O, occipital artery;
Sc, sternocleidomastoid branch; SHy, suprahyoid artery; Sh, suprahelical artery; ST, super cial temporal artery; STh, superior thyroid artery;
SuL, sublingual artery; SuMe, submental artery; TF, transverse facial
artery; Zo, zygomatico-orbital artery.
Surgical Annotation
Th e su p er ior t hyroid , lingu al, an d facial ar ter ies or igin ate as
sep arate bran ch es in 50 to 80%; a lingu lofacial t ru n k exist s in 18
to 31%, a thyrolingu al t ru n k in 1 to 18%, an d a thyrolingu lofacial
t run k in about 2.5% (Fig. 6.5).8,9,11,12 Th e carot id bifu rcat ion is
com m on ly located at th e superior border of th e thyroid cart ilage. Th e dist an ce from th e origin of th e su perior thyroid arter y
to t h e carot id bifu rcat ion is 3.3 ± 4.3 m m , from t h e or igin of
t h e superior thyroid arter y to th at of th e lingual arter y is 10.5 ±
5.2 m m , an d from th e origin of th e superior thyroid arter y to
th at of th e facial arter y is 18.2 ± 8.8 m m .8,9,12
Superior Thyroid Artery
Th e superior thyroid arter y t ypically arises from th e an terior
su rface of th e extern al carot id ju st below th e level of th e greater
cor n u of t h e hyoid bon e, alt h ough t h ere are var iat ion s (Fig.
6.6).8,9,11,12 Th e su p er ior t hyroid ar ter y u su ally h as a sh ar p
dow nw ard angle at its origin . From it s origin un der th e an terior
border of th e stern ocleidom astoid m uscle, it run s u pw ard an d
forw ard for a short distance in the carotid triangle; it then arches
dow nw ard ben eath th e in frahyoid m uscles (Fig.6.5a). It dist rib utes t w igs to th e adjacen t m uscles an d n u m erou s bran ch es to
th e thyroid glan d, an astom osing w ith its fellow on th e opposite
side an d w ith th e in ferior thyroid ar teries.
Th e origin of th e superior thyroid arter y can be iden t i ed 13 ±
4.5 m m below th e t ip of th e greater h orn of th e hyoid. Th e dist an ce from it s or igin to t h e t hyroid car t ilage’s u p p er edge is
7.1 ± 6.4 m m an d to t h e h or izon t al p lan e p assing t h rough t h e
u pper edge of th e thyroid glan d is 26.1 ± 12.1 m m .8,9,12
Lingual Artery
Th e lingual arter y arises from th e extern al carot id arter y bet w een th e origin of th e su perior thyroid an d facial arteries. It
rst ru n s obliqu ely u pw ard an d m edially to th e greater corn u of
th e hyoid bone (Fig. 6.5). It then curves dow nw ard and forw ard
and passes beneath the digastric and st ylohyoid m uscles. It runs
h or izon t ally for w ard , ben eat h t h e hyoglossu s m u scle, n ally
ascen ding as th e deep lingu al arter y.
Surgical Annotation
Th e bran ch ing pat tern s can var y. Th ese an atom ical variat ion s
arise from em br yological develop m en t an d can be sign i can t in
clin ical cases (Fig. 6.5, Fig. 6.6). Th e an atom ical ch aracterist ics
an d variat ion s of th e extern al carot id, su perior thyroid, lingu al,
an d facial arteries, su ch as th eir bran ch ing p at tern s, length s,
an d ou ter diam eters, are cru cial for safe im p lem en t at ion of in t ra-arterial cath eterizat ion for adm in istering an t ican cer drugs
to th e h ead an d th e n eck, surgical excision of ben ign an d m align an t t u m ors, an d m icrosu rgical ar terial im p lan tat ion s.8,9,12
Th e dist an ce from th e origin of th e lingual arter y to th e carot id bifurcat ion is 12 ± 5.9 m m , to th e origin of th e facial arter y
is 5.3 ± 5.2 m m , an d to th e thyroid cart ilage’s u pper edge is 15.6
± 7.7 m m .
Occipital Artery
Th e occipit al arter y arises from th e extern al carot id (89–95%)
or as a com m on t ru n k w ith th e posterior auricular arter y from
the external carotid artery (5–10%). From the m andibular angle,
th e origin of th e occipit al ar ter y is on average 13.4 m m (5–22
m m ) above in 29%cases, 17.6 m m (4–32 m m ) below in 57%, an d
49
Anatom y for Plastic Surgery of the Face, Head, and Neck
b
a
c
d
Fig. 6.5 The anterior branches of the external carotid artery. (a) Case
of thyrolingual trunk, (b) case of lingulofacial trunk, (c) case of separate branches, and (d) the branching t ypes of the anterior branches of
the external carotid artery. CC, common carotid artery; ECA, external
50
carotid artery; F, facial artery; L, lingual artery; LFT, lingulofacial trunk;
TLFT, thyrolingulofacial trunk; TLT, thyrolingual trunk; STh, superior
thyroid artery.
6 Arteries of the Face and Neck
a
b
c
Fig. 6.6 Origin of the superior thyroid artery. (a) From the external carotid artery, (b) from the carotid bifurcation, (c) from the common carotid
artery. CC, common carotid artery; ECA, external carotid artery; STh, superior thyroid artery.
at th e sam e level in 14%. From th e extern al carot id ar ter y, th e
arter y em erges from th e posterior side in 88%, from th e lateral
side in 8%, an d from th e m edial side in 4%. It t akes a tor t u ou s
course superiorly an d posteriorly tow ard th e base of th e scalp,
t raveling ben eat h t h e sp len iu s cap it is an d t h e ster n ocleid o m astoid m u scles.11,13,14 Th e m ean len gt h of t h e ar ter y is 9 cm
(3.4–12.5 cm ). It is divided in to descen ding, h orizon t al, an d
ver t ical bran ch es (Fig. 6.3). Th e h orizon t al bran ch run s along
th e n uch al ridge, con n ect ing across th e m idlin e to bran ch es of
t h e con t ralateral occip it al ar ter y. Th e ver t ical bran ch r u n s su p eriorly alon g t h e p osterior sku ll an d an astom oses w it h th e
p osterior au ricu lar, su p er cial tem p oral, an d su p raorbit al arteries (Fig. 6.7c,d). Th e descen ding bran ch is divided over t h e
t rap eziu s, an d it su pp lies th e t rapeziu s, splen iu s, an d stern ocleid om astoid m u scles. Th e d escen d ing bran ch an astom oses
w it h th e deep cer vical an d th e ascen ding bran ch of th e t ran sverse cer vical ar teries.2,15
Th e stern ocleidom astoid ar ter y gen erally arises from th e occipit al ar ter y, but som et im es it springs directly as a separate
bran ch from th e extern al carot id ar ter y (Fig. 6.3). Th e distan ce
from th e origin of th e stern ocleidom astoid bran ch to th e extern al carotid arter y is 14.4 m m . It passes dow nw ard and backw ard
over th e hyp oglossal n er ve an d su p p lies th e stern ocleidom astoid m uscle an d th e in tegu m en t .11
Surgical Annotation
Th e occipit al arter y is th e m ain arter y of th e su boccipit al region . Th e vascu lar n et w ork of th e cer vico-occipital ap con sists
of th e cutan eous an d m u sculocu tan eous perforators of th e descen ding bran ch of th e occip it al ar ter y an astom osing w ith th e
cer vical arteries an d th e cutan eous bran ch es of spin al arteries
in th e region arou n d th e n ape of th e n eck. Th e cer vico-occipit al
ap is u sed to recon st r u ct d efect s after resect ion of t h e m an -
d ible or t h e oor of t h e m ou t h an d t h e ton gu e or to close
p h ar yn goesop h ageal an d t rach eal st u lae. As t h e con ten t of
t h e cer vico-occipit al ap is rich ly vascularized an d as th e t w oh eaded stern ocleid om ast iod m u scle h as m in im al don or-site
m orbidit y, it is p referred as a m yocu t an eou s ap for st able an d
d u rable recon st r u ct ion . Th e u p p er t h ird of t h e ster n ocleid om astoid m u scle is su p p lied by bran ch es of th e occip ital ar ter y.
Th e m iddle th ird receives a bran ch from th e superior thyroid
ar ter y (42%), th e extern al carot id arter y (23%), or both (27%).
Th e low er th ird is supplied by a bran ch arising from th e su prascap u lar ar ter y.2,15 In th e su boccipit al region , th e m ean d ist an ce
bet w een th e poin t at w h ich th e occipit al ar ter y pierces th e stern ocleidom astoid m u scle an d th e in ion is 4.8 cm (3.9–6.5 cm ).
Th e m ean distan ce bet w een th e piercing poin t of th e arter y in
th e m uscle an d the low er par t th e m astoid process is 5.1 cm
(3.9–5.9 cm ). Classically, th e occipital ar ter y en ters th e stern ocleidom astoid m uscle 1.5 to 2 cm below th e an terior m argin .
Th e poin t w h ere th e occipit al arter y en ters th e stern ocleidom astoid an d th en com es ou t to th e su rface u p to 4 cm u n der th e
p rocess is determ in ed as th e referen ce poin t . St ud ies suggest
th at th e greater occipit al n er ve crosses the occipit al ar ter y lat eral to th e in ion . Occip it al ar ter y biop sy sh ou ld be p erform ed
bet w een 4 to 5 cm lateral an d 1 to 3 cm proxim al to th e in ion to
avoid injur y to th is ar ter y in vasculit is cases.2,4,15
Posterior Auricular Artery
Th e posterior auricular ar ter y arises from th e extern al carot id
ar ter y, above th e digast ric an d st ylohyoid m u scles, opp osite th e
ap ex of th e st yloid process.7,16,17 It h as a m ean distan ce of 0.29
cm an terior to th e m astoid t ip, just deep to th e lobule an d in th e
p osterior auricular sulcus. It ascen ds, u n der cover of th e parot id
glan d, on th e st yloid process of th e tem p oral bon e an d, im m edi-
51
Anatom y for Plastic Surgery of the Face, Head, and Neck
b
a
c
d
Fig. 6.7 Blood supply of the (a, b) forehead, (c) occipital, and
(d) retroauricular regions. Red latex is injected into the common
carotid arteries before dissection. Fb, frontal branch of the super cial
temporal artery; LP, lateral palpebral artery; MP, m edial palpebral
artery; O, occipital artery; PA, posterior auricular artery; Pb, parietal
branch of the super cial temporal artery; So, supraorbital artery; Str,
supratrochlear artery; *, anastomoses.
ately above th is poin t , divides in to its auricu lar an d occipit al
bran ch es (Fig.6.1, Fig. 6.2, Fig. 6.3, Fig. 6.7c,d). Th e occipit al
bran ch passes backw ard, over th e stern ocleidom astoid m uscle,
to th e scalp above an d beh in d th e ear. It an astom oses w ith th e
occipit al ar ter y (Fig. 6.7c,d).
th e post auricular sulcus. Th e m ean dist an ces from th e m astoid
t ip is 8.4 m m to t h e occip it al bran ch an d 6.8 m m to t h e au r icu lar bran ch . Th e arterial n et w ork of th e t riangu lar fossa an d
scap h oid fossa is provided by bran ch es of th e su p er cial tem p oral an d posterior au ricu lar arteries.
Surgical Annotation
Facial Artery (External Maxillary
Artery)
Th e arterial n et w ork in th e upper ear is form ed from the posterior au ricu lar ar ter y. Th e m ean length of th is ar ter y before it
pen et rates th e tem poroparietal fascia m easured from th e m astoid t ip is 75.6 m m . Th e posterior auricular ar ter y gives o a
ret roau ricu lar bran ch to th e p osterior surface of th e auricle an d
an occip it al bran ch to th e p ostau ricu lar skin , w h ich t ravels in
52
Th e facial ar ter y arises at th e level of th e greater h orn of th e
hyoid bon e a lit t le above t h e lingu al ar ter y’s or igin from t h e
exter n al carot id. It can arise from variou s t ru n ks from th e extern al carot id (Fig. 6.5). Hen ce, th e level of th e origin is sit u ated
6 Arteries of the Face and Neck
19.6 ± 8.7 (10–35 m m ) aw ay from th e bifu rcat ion of th e com m on carot id arter y. Th e dist an ce from th e origin of th e facial
arter y to a h orizon t al p lan e p assing over th e top side of th e thyroid car t ilage is 15.4 ± 8.4 m m . It ascen d s u n d er cover of t h e
p oster ior belly of t h e d igast r ic an d st ylohyoid m u scles an d
grooves t h e su bm an dibu lar glan d by m aking a loop . It cu r ves
u pw ard over th e body of th e m an dible at th e an tero in ferior
angle of th e m asseter m u scle. It th en p asses for w ard an d u p w ard across th e ch eek to th e labial com m issu re. Th e distan ces
from th e facial ar ter y are 13.5 m m (8–23 m m ) to th e labial com m issu re an d 45 m m (28–60 m m ) to th e m idlin e. It th en ascen ds
along th e side of th e n ose an d en ds at th e m edial com m issu re of
th e eye as th e angular arter y (Fig. 6.1, Fig. 6.8).
Th e course of th e ar ter y can var y.6,18–20 Bran ch es to th e face
in clu de th e ascen d ing palat in e, in ferior labial, ton sillar, sup erior
labial, glan d u lar, lateral n asal, su bm en t al, an gu lar, an d m u scu lar ar ter ies. Th e facial ar ter y an d it s bran ch es m ain ly su p p ly
t h e m en t al region , th e lips, th e in ferior part of th e parot idom asseteric region , an d th e bu ccal, orbital, in fraorbit al, an d n asal
region s (Fig. 6.1, Fig. 6.3).3–5,7,11
Submental Artery
Th e su bm en t al ar ter y is u su ally t h e largest of t h e cer vical
bran ch es (Fig. 6.3). Th e dist an ces of th e origin of th e su bm en tal
arter y are 27.5 m m (19–41 m m ) to th at of th e facial arter y an d
23.8 m m (1.5–39 m m ) to th e m an dibular angle.2,21 Th e arter y is
deep to th e an terior belly of th e digast ric m uscle in 70–80%. It
passes super cial to th e m ylohyoid n er ve, 16.8 m m (9–34 m m )
from its origin . A visible an astom osis bet w een th e t w o su bm en tal arteries is n oted in 92%.20 It an astom oses w ith th e su blingu al
arter y an d w ith th e m ylohyoid bran ch of th e in ferior alveolar
arter y; at th e sym p hysis m en t i, it t u rn s u pw ard over th e border
of th e m an dible an d th en is divided in to super cial an d deep
branches. The super cial branch passes bet ween the integum ent
a
b
Fig. 6.8 Course of the facial artery and its branches. Red latex is
injected into the common carotid arteries before dissection. (a) A
doubled facial artery, (b) nasal-t ype facial artery. The anastomoses
bet ween alar branches and branches of the superior labial artery, and
(c) septal branch are continued as the columellar artery. (d) Angular
t ype facial artery. The anastomoses bet ween the super cial ascending
an d dep ressor labii in ferioris an d an astom oses w ith th e in ferior
labial arter y; th e deep bran ch run s bet w een th e m u scle an d th e
bon e, supplies th e lip, an d an astom oses w ith th e in ferior labial
an d m en tal arteries.20
Surgical Annotation
Th e axial m yocutan eous plat ysm a ap using th e upper part of
th e m ylohyoid m u scle is supplied by th e subm en t al ar ter y.2,21
Dissect ion of th e p edicle back to th e origin of th e facial ar ter y
an d vein to exten d t h e arc of rot at ion of t h e ap is recom m en ded. Th e diam eter of th e su bm en tal ar ter y is su it able for
safe m icrovascu lar t ran sfer (1.7–2.2 m m ).5,21 Th e length of th e
su bm en t al ar ter y is 58.9 m m (35–108 m m ); it s length from th e
origin to th e an terior belly of th e digast ric m uscle is 31.5 m m
(26–38 m m ).21
Th e facial arter y crosses th e in ferior border of th e m an dible
obliquely to en ter th e face at th e an teroin ferior angle of th e
m asseter m u scle. Th e dist an ce bet w een th e m an dibu lar angle
an d th e poin t w h ere th e facial arter y crosses th e low er border
of th e m an dible is 26.6 m m (15.5–38 m m ).21 It is ext rem ely tort uous. It gives o sm all m uscular bran ch es to th e m asseter an d
th e depressor anguli oris m uscles (Fig. 6.8a).
Inferior Labial Artery
Th e in ferior labial arter y arises n ear th e angle of th e m outh ; it
p asses u pw ard an d for w ard ben eath th e depressor anguli m uscle or pen et rates th e orbicularis oris m uscle (Fig.6.1, Fig. 6.8a).
Th e dist an ce from th e origin of th e in ferior labial ar ter y from
th e labial com m issure is 19.3 ± 10 m m (4–35 m m ). It follow s a
tor t uous cou rse along th e edge of th e low er lip bet w een th e
m u scle an d th e m u cou s m em bran e. Th e length of th e in ferior
labial ar ter y is 34.5 ± 20.8 m m (29–67 m m ).18,20,21 It supplies
th e labial glan ds, th e m ucous m em bran e, an d th e m uscles of
c
d
artery and inferior alar branch. AE, anterior ethmoidal artery; An,
angular artery; C, columellar artery; DN, dorsal nasal artery; F, facial
artery; IA, inferior alar artery; IL, inferior labial artery; LN, lateral nasal
artery; SA, superior alar artery; SL, superior labial artery; Sp, septal
artery.
53
Anatom y for Plastic Surgery of the Face, Head, and Neck
th e low er lip. It an astom oses w ith th e arter y on th e opposite
side an d w ith th e m en t al bran ch of th e in ferior alveolar arter y.
Surgical Annotation
Th e origin s of th e in ferior labial ar ter y var y bet w een th e labial
com m issure an d th e low er m argin of th e m an dible. Th e in ferior
labial artery can arise from the facial artery above the labial com m issure (8%), below the labial com m issure (22%), and at th e labial
com m issure (60%).10,18,20 Th e in ferior labial an d labiom en tal arteries com e o at th e level of th e in ferior border of th e bu ccin ator m uscle an d run an teriorly, passing deep to th e depressor
angu li oris. Di eren t arterial d ist ribu t ion s exist in th e low er lip
su ch as en d-to-en d an astom osis bet w een th e bilateral in ferior
labial arteries an d th e in ferior labial arteries an astom ose w ith
th e su bm en t al arter y. The vert ical an d h orizon t al labiom en tal
ar teries are sit u ated bet w een th e low er lip an d th e su bm en t al
region (t ran sfacial an astom osis). Th e dist an ces from th e labial
com m issure are 29.1 ± 24.2 m m (7–71 m m ) to th e origin of th e
h orizon t al labiom en t al arteries an d 28 ± 12.1 m m (10–52 m m )
to th e origin of th e vert ical labiom en tal ar teries. Th e length s of
th e h orizon tal labiom ental arteries are 26.8 ± 10.7 m m (16–49
m m ) an d th e ver t ical labiom en tal arteries are 13 ± 4 m m (1–17
m m ).10,18,20,21 The labiom en tal arteries, w hich form anastom oses
bet w een th e facial, in ferior labial, an d subm en t al arteries, var y
in their course in the labiom ental region (Fig. 6.1).10,18,20,21 To elevate a labiom en t al arterial ap safely, rout in e u se of a Doppler
probe preoperat ively an d in t raoperat ively is recom m en ded.7,10
Superior Labial Artery
Th e facial ar ter y passes deep to th e risorius an d zygom at icu s
m ajor m u scles bu t su p er cial to th e bu ccin ator m u scle. It gives
o on e of it s m ajor bran ch es, t h e su p er ior labial ar ter y. Near
t h e labial com m issu re, it gives o th ree to ve bran ch es to th e
an terior part of th e bu ccin ator an d zygom at icu s m ajor m u scles
(Fig. 6.8).20
Th e ar terial su pply to th e lips is based on th e superior an d
in fer ior labial ar ter ies at t h e level of t h e labial com m issu re,
w here it term in ates in th e form of a perilabial arterial n et w ork
(Fig. 6.4b, t ran sfacial an astom osis). Th e arterial su p ply to th e
u pper lip arises m ain ly from th e superior labial ar ter y an d from
th e su bsept al an d su balar ar teries. Th e ar terial su pply to th e
low er lip arises from th e in ferior labial ar ter y an d th e bran ch es
of th e m en tal arter y.11,18
Surgical Annotation
Th e superior labial ar ter y is larger an d m ore tor t uous th an th e
in ferior labial arter y. It origin ates as follow s: at th e level of th e
labial com m issu re in 5%of cases, sup erior to th e com m issure in
25%, an d in ferior to th e com m issure in 70%. It can be iden t i ed
u su ally 8 ± 4.4 m m (1–18 m m ) lateral to th e m edial labial com m issu re. It s length is 4.8 ± 12.2 m m (29–67 m m ). In 84.8%, th e
ar ter y t ravels exclu sively bet w een th e orbicu laris oris m u scle
an d th e oral m u cosa; in 15.2%, it t ravels p art ially invested by th e
orbicularis oris. It supplies th e upper lip an d gives o t w o or
th ree vessels th at ascen d to th e n ose: a septal bran ch ram i es
on th e n asal sept u m , an d an alar bran ch supplies th e ala of th e
n ose (Fig. 6.1, Fig. 6.8).10,18,20,21 A relat ively large bran ch th at
54
cou rses along t h e in fer ior m argin of t h e n ost r il on it s ascen t
tow ard t h e colu m ellar base is called t h e in fer ior alar bran ch ,
an d th e arter y ru n n ing to th e n asal t ip over th e ala n asi is called
th e su perior alar bran ch . Th e in ferior alar bran ch supplies th e
alar base, th e n ost ril oor, an d th e u p p er lip ; th e su p erior alar
bran ch par t icipates in th e vascu lar plexu s of th e n asal dorsum
an d th e t ip. Th e length of th e su p erior alar bran ch is 14.6 ± 5.9
m m (7–26 m m ), an d th at of th e sept al bran ch is 15.6 ± 6.2 m m
(10–27 m m ).10,18,20
Th e su perior labial ar ter y run s bet w een th e m ucosa an d orbicularis oris at approxim ately th e border bet w een th e w h ite
an d th e red part s of th e lip s an d an astom oses w ith th e opp osite
ar ter y in th e m id dle of th e lip.6,7 Th e dist an ces from th e sup erior labial arter y at m idlip are 6.9 ± 2.5 m m (0.7–11 m m ) to th e
inferior border of the red upper lip, 5.4 ± 1.8 m m (3–9 m m ) to its
an terior border, an d 3.2 ± 0.7 m m to it s p osterior bord er.10,18,20
Th ese bran ch es are n am ed as t w o groups: th ose ru n n ing bet w een th e skin an d th e m uscle are called su per cial ascen ding
bran ch es, an d th ose run n ing th rough th e m uscle or bet w een
th e m uscle an d th e m ucosa are called deep ascen ding branch es.
At th e colu m ellar base, th ere are an astom oses am ong th e super cial ascen ding an d in ferior alar ar terial bran ch es. Ram i cat ions of th e deep ascen ding an d in ferior alar bran ch es pass to
th e n asal sept um an d ascen d along th e an terior m argin of th e
sept al cart ilage. Colu m ellar bran ch es are th e con t in u at ion of
th e super cial ascen ding bran ch es an d becom e part of th e vascular plexu s of th e n asal t ip (Fig. 6.8b– d). The colu m ellar arter y
is obser ved as a single bran ch in 48.9% an d a double pat tern in
38.7%.20
Lateral Nasal Artery
Th e lateral n asal ar ter y arises from th e facial arter y at th e n asolabial su lcu s level. It ru n s 2 to 3 m m su perior to th e alar groove,
exten d s bet w een th e n ose an d th e ch eek, an d gives o th e su perior an d in ferior alar arteries to su p ply th e n ose (Fig. 6.1, Fig.
6.8). Th e lateral n asal arter y an astom oses w ith it s fellow, w ith
th e sept al an d alar bran ch es, w ith th e dorsal n asal bran ch of th e
oph th alm ic, an d w ith th e in fraorbit al bran ch of th e m a xillar y
arteries (Fig. 6.1). Th e facial ar ter y con t in ues as th e angular arter y an d proceeds to th e m edial palpebral com m issure.6,7
Surgical Annotation
Sm all d ist al bran ch es of th e lateral n asal arter y form several
an astom oses w ith con t ralateral h ave bran ch es an d w ith th e colum ellar arteries.5,6,18 Som e st udies dem on st rated th e existen ce
of an an astom ot ic system , sit u ated in th e su perior m usculoapon eu rot ic system plan e, con n ect ing th e extern al an d th e in tern al carot id arter y system s an d th e t ran sfacial n asal vascular
blood supply, w h ich gives rise to th e subderm al plexus. Th is
n et w ork exp lain s w hy m any di eren t p edicles can be safely
used for local aps in n asal recon st ru ct ion (Fig. 6.4c, polygon al
system an astom osis). Fu rth erm ore, after skin t u m or resect ion s,
th e presen ce of th ese an astom ot ic vessels en ables a large vessel
ligat ion to be perform ed w ith out skin n ecrosis; h ow ever, th e
presen ce of so m any an astom ot ic vessels in th e n asal area can
be easily injured during inject ion s, an d creates a risk of em bolism or m icroem bolism , especially w ith rh in oplast ies u sing llers (Fig. 6.4a, in tercarot id an astom osis).
6 Arteries of the Face and Neck
Angular Artery
Th e angular arter y is th e term in al part of the facial ar ter y; it
ascen d s to th e m edial angle of th e orbit an d is accom p an ied by
th e angular vein . It is easily foun d on a vert ical line about 6 to
8 m m m edial to th e m edial can th us an d 5 m m an terior to th e
lacrim al sac. In 60%of specim en s, th e term in al bran ch is form ed
by th e lateral n asal arter y, an d in 22%it is form ed by th e angu lar
arter y. It an astom oses w ith th e in fraorbit al arter y on th e ch eek
after supplying th e lacrim al sac an d the orbicularis oculi. The angular artery ends by anastom osing w ith th e dorsal nasal branch
of t h e op h t h alm ic ar ter y (Fig. 6.1, Fig. 6.8c).11 It s bran ch es
are a com m u n icat ing bran ch w ith th e d orsal n asal arter y (96%),
a com m u n icat ing bran ch w ith th e su p rat roch lear arter y (67%),
th e in frat roch lear arter y, an d th e paracen t ral arter y. Th e paracen t ral ar ter y origin ates from th e angu lar ar ter y as th e m ain
con t in uat ion in to th e foreh ead (71%) or from th e com m un icat ing bran ch w ith th e su prat roch lear arter y (30%).7,11,20,22
Surgical Annotation
Di cu lt oron asal m u cosal defect s, in clu ding defect s of th e palate, alveolu s, n asal sept um , an t rum , u pp er lip an d low er lip,
oor of th e m ou th , an d soft p alate, can be recon st ru cted u sing
an axial m u scu lom u cosal ap based on th e facial ar ter y an d it s
bran ch es. Th eir diam eters are su it able for m icrovascular an astom osis.6,7,11,20 Most of th ese aps are based on local axial vascularization via the labial arteries, but anatom ical variations can
lead to problem s; it s bran ch ing pat tern sh ow s great variabilit y
(Fig. 6.8a, Fig. 6.9). Th e dist ribut ion pat tern s of th e arter y are
categorized in to six t ypes, A–F (Fig. 6.9).6,7,11,20 In t yp e A (47–
78%) th e arter y bifurcates in to th e superior labial an d lateral
n asal ar teries (th e lat ter gives o th e in ferior an d su p erior alar
an d en d s as th e angu lar arter y). Typ e B (38–60%) is sim ilar to
t ype A except th e lateral n asal term in ates as th e superior alar
(th e angular arter y is absen t). In t ype C (8–12%), th e facial arter y term in ates as th e superior labial ar ter y. In t ype D (3.8%),
th e angu lar ar ter y arises directly from t h e facial ar terial t r u n k
rat h er th an as th e term in at ion of th e lateral n asal, w it h th e facial arter y en ding as th e superior alar. In t ype E (1.4–3%), th e
facial arter y term in ates as a ru dim en t ar y t w ig w ith ou t p roviding sign i can t bran ch es. Type F p resen t s a doubled facial arter y.23 On th e basis of an atom ical st u dies, th e degree of vascu lar
territor y lost as a result of vessel dam age du ring th e m yocutan eou s ap p roced u re can be est im ated. For exam ple, ligat ion of
th e su perior labial arter y in a pat ien t w ith t ype A, B, or C w ould
n ot resu lt in isch em ic inju r y to th e n ose, as th e blood su p p ly is
p rovided by a separate lateral n asal ar ter y. In con t rast , ligat ion
of th e superior labial ar ter y in a pat ien t w ith t ype D or E dist ribu t ion is m ore likely to result in loss of th e vascular supply to
th e lateral n ose.7,10
Th e facial m uscu lom u cosal ap is an a xial ap based on th e
su perior labial arter y in an an terograde fash ion or th e angu lar
ar ter y in a ret rograde fash ion .3,7,10 Th e n asolabial ap can be
based on th e angular arter y eith er in feriorly or superiorly in an
an terograde or ret rograde fash ion , respect ively. Dop pler u lt rasou n d h elps to locate th e facial vessels an d provid es in form at ion about back ow an d th e potent ial for inver ted ow in th e
facial ar ter y.7,10
Fig. 6.9 Schematic drawing of the t ypes of
facial artery. (a) Angular, (b) nasal, (c) alar,
(d) labial, (e) hypoplastic, (f) double t ype. An,
angular artery; DN, dorsal nasal artery; F, facial
artery; IA, inferior alar artery; IL, inferior labial
artery; Io, infraorbital artery; LN, lateral nasal
artery; SA, superior alar artery; SL, superior
labial artery; Sp, septal artery.
a
b
c
d
e
f
55
Anatom y for Plastic Surgery of the Face, Head, and Neck
56
Maxillary Artery
Surgical Annotation
Th e m axillar y arter y, th e larger of th e t w o term in al bran ch es of
th e extern al carot id ar ter y, arises beh in d th e n eck of th e m an dible (Fig. 6.2). It run s in th e in fratem poral fossa super cial to th e
lateral pter ygoid m u scle an d is easily fou n d about 6.64 ± 6.33
m m from th e in fratem poral crest . It su p p lies th e deep st ru ct ures of th e face an d can be divided in to m an dibular, pter ygoid,
an d pter ygopalat in e p ar t s.11 It s total length is 57.38 ± 7.1 m m .
It s rst , or m an dibu lar, p art lies deep beh in d th e m an dibu lar
ram u s. From th is p ar t , th e in ferior alveolar ar ter y arises. Th e
d ist an ce bet w een t h e or igin of t h e m a xillar y ar ter y an d t h e
in ferior alveolar arter y is 10.8 ± 6 m m .11 It descen ds w ith th e
in ferior alveolar ner ve to th e m an dibu lar foram en on th e m edial surface of th e ram u s of th e m an dible. As it en ters th e foram en , it ru n s along th e m an d ibu lar can al. Th e m en t al ar ter y is
th e term in al bran ch of th e in ferior alveolar ar ter y th at passes
w ith th e n er ve th rough th e m en t al foram en to supply th e ch in
an d th e low er lip . Th e m en t al bran ch an astom oses w ith th e
su bm en tal an d in ferior labial arteries.
Th e secon d, or pter ygoid, par t ru n s obliquely for w ard an d
u pw ard u n der th e cover of th e ram us of th e m an d ible. It run s
eith er su p er cially or deep to th e lateral pter ygoid to th e pter ygop alat in e fossa. Bran ch es of t h is secon d p ar t are t h e d eep
tem poral, th e m asseteric, th e pter ygoid, an d th e buccin ator arteries.7,20,21 Th e deep tem poral bran ch es (i.e., th ree bran ch es)
ascend anteriorly and posteriorly bet w een the tem poralis m uscle
an d th e p ericran iu m ; th ey su p p ly th e m u scle (Fig. 6.2). Th ese
ar teries an astom ose w ith th e m iddle tem poral arter y; th e an terior com m un icates w ith th e lacrim al arter y via sm all bran ch es
perforat ing th e zygom at ic bon e (polygon al an astom osis). Th e
m asseteric arter y passes laterally through the m an dibular n otch
to th e deep surface of th e m asseter m uscle.11 It su p p lies th e
m u scle an d an astom oses w ith th e m asseteric bran ch es of th e
facial ar teries an d w ith th e t ran sverse facial ar teries (Fig. 6.2).
The buccinator artery runs obliquely forward, between the pterygoid an d th e in ser t ion of th e tem poral m u scles, to th e ou ter su rface of th e bu ccin ator m u scle. It an astom oses w ith bran ch es of
th e facial an d w ith th e in fraorbital arteries (Fig. 6.2).
Th e th ird, or pter ygopalat in e, part lies in th e pter ygopalat in e
fossa n ear t h e pter ygop alat in e gan glion . Th e bran ch es of t h is
t h ird p ar t are t h e p oster ior su p er ior alveolar ar ter y; t h e ar ter y
of t h e pter ygoid can al; an d t h e in fraorbit al, p h ar yngeal, d escen d in g p alat in e, an d sp h en op alat in e ar ter ies (Fig. 6.2). Th e
in fraorbit al arter y app ears, from it s direct ion , to be a con t in uat ion of th e t run k of th e m axillar y arter y.11,24 It ru n s along th e
in fraorbit al groove an d can al w ith th e in fraorbit al n er ve. Th e
in fraorbit al arter y reach es th e face th rough the in fraorbit al foram en an d sup p lies th e low er eyelid, th e ch eek, an d th e lateral
n ose (Fig. 6.1, Fig. 6.2). On th e face, som e branch es pass upw ard
to th e m edial angle of th e orbit an d th e lacrim al sac. It an astom oses w ith th e angu lar bran ch of th e facial arter y (Fig. 6.2);
som e ru n tow ard th e n ose, an astom osing w ith th e d orsal n asal
bran ch of th e oph th alm ic ar ter y (Fig. 6.4a), and oth ers descen d
bet w een th e levator labii superioris an d th e levator anguli oris
an d an astom ose w ith th e facial, t ran sverse facial, an d bu ccin ator arteries (Fig. 6.4c).
Th e locat ion of th e m asseteric arter y is easily determ in ed in relat ion to th ree p oin ts in th e an terioposterior plan e bet w een th e
m an dibu lar con dyle an d th e coron oid p rocess: (1) th e an terosuperior aspect of th e con dylar n eck, (2) th e m ost in ferior aspect
of th e art icular t ubercle, an d (3) th e in ferior aspect of th e sigm oid n otch . Th e m ean d ist an ce of th e m asseteric ar ter y to th e
m ost an terosu p erior asp ect of th e con dylar n eck is reported as
10.3 m m ; to th e m ost in ferior aspect of th e ar t icular t ubercle,
11.4 m m ; an d to th e m ost in ferior aspect of th e sigm oid n otch ,
3 m m .25
Th e tem poralis m uscle ap h as been w idely used for surger y
of th e skull base an d th e recon st ruct ion of oral cavit y an d oropharyngeal defect. The vascular net w ork of the tem poralis m uscle ap com es from th ree m ain p ed icles: th e an terior deep
ar ter y, t h e p oster ior d eep ar ter y (bot h collateral bran ch es of
t h e m a xillar y ar ter y), an d t h e m idd le tem p oral ar ter y (a collateral bran ch of th e su per cial tem poral ar ter y).25 Th e distan ce
bet w een a tem poralis m uscle ap an d a tem poralis m uscle split
on it s su p er cial ar ter y is 57 m m . Th e ap allow s t h e m id lin e
to be crossed easily, th us broadening its in dication . The gain ob t ain ed is greater th an th at obt ain ed w ith a ap split on th e deep
tem poral pedicles, an d it can easily cross th e m idlin e; th is is an
im p or t an t poin t .
Superf cial Temporal Artery
Th e super cial tem poral arter y arises from th e extern al carot id
arter y deep to th e p arot id glan d . It ascen ds beh in d th e con dyle
of th e m an dible.25–27 Th e im por tan t bran ch es of th e super cial
tem poral artery are the tran sverse facial, anterior auricular, m iddle tem poral, fron tal an d pariet al arteries (Fig. 6.1, Fig. 6.3). Just
before it reach es th e zygom at ic arch , th e super cial tem poral
arter y gives o th e t ran sverse facial arter y.
Th e t ran sverse facial arter y arises from th e su per cial tem poral ar ter y in th e parot id glan d after branch ing o th e m axillar y ar ter y. It s n u m ber ran ges from on e to t h ree (m ean , 1.34).
It r u n s p arallel abou t a n ger’s bread t h in fer ior to t h e zygom at ic arch (Figs. 7.3, Fig. 6.10). It passes t ran sversely across th e
sid e of th e face, bet w een th e parot id du ct an d th e low er border
of th e zygom at ic arch, an d is divided in to superior an d in ferior
t r u n ks after cou rsing 1 to 11 m m w it h in t h e glan d . Th e su p er ior t ru n k is u su ally larger th an th e in ferior t ru n k. Th e su perior
t r u n k is located below t h e level of t h e glan d u lar bord er, 5.0
to 26.1 m m from t h e zygom at ic arch (m ean , 14.0 m m ). Most
p er forators (76.8%) arise from th e su perior t ru n k, w h ich can
be useful w h en th e st ruct ures are visible during surger y. Th e
t ran sverse facial ar ter y is crossed by th e tem poral an d zygo m at ic bran ch es of th e facial n er ve. It an astom oses w ith th e facial, m asseteric, buccin ator, an d in fraorbit al ar teries (Fig. 6.10,
t ran sfacial an astom osis).
The m iddle tem poral artery arises im m ediately above the zygom atic arch an d perforates the tem poral fascia. It gives bran ch es
to th e tem poralis m uscle an d an astom oses w ith th e deep tem poral bran ch es of th e m axillar y ar ter y.
6 Arteries of the Face and Neck
a
b
c
Fig. 6.10 Course of the super cial temporal artery and its branches.
Red latex is injected into the common carotid arteries before dissection. (a, b) Bifurcation of the artery above the zygomatic arch, the
anastom oses bet ween the zygomatico-orbital artery and transverse
facial artery; (c) bifurcation of the artery over the zygomatic arch; the
frontal branch is larger than the parietal branch. F, Facial artery; Fb,
frontal branch; G, parotid gland; H, helicial artery; Pb, parietal branch;
Sh, suprahelical artery; ST, super cial temporal artery; TF, transverse
facial artery; Zo, zygomatico-orbital artery; *, interfacial anastomosis.
Th e an terior auricular arteries run to th e h elix an d th e t ragu s. Th ey reach th e h elix by p assing u n der th e su p er cial tem poral vein at th e level of th e arch . Th e arteries are dist ribu ted to
th e an terior port ion of th e auricle, th e lobule, an d par t of th e
extern al m eat u s, an d th ey an astom ose w ith th e posterior au ricu lar ar ter y. Th e h elical ar ter y ar ises from t h e p ar iet al bran ch
of th e super cial tem poral arter y w h ere it bifu rcates over th e
arch (Fig. 6.10a, b).
th e ar ter y h as been obser ved above th e zygom at ic arch in 61 to
88% of cases, directly over th e arch in 3.8 to 26%, an d below th e
arch in 7 to 11.5%.11,26–28
Th e pariet al bran ch (posterior) exten ding posteriorly cur ves
u pw ard an d backw ard on t h e sid e of t h e h ead as t h e con t in u at ion of t h e su p er cial tem p oral ar ter y. Th e p ariet al bran ch
h as an astom ot ic con n ect ion s w ith th e ip silateral an d con t ralateral arteries w ith th e ep icran ial ap on eu rosis (Fig. 6.7, Fig. 6.10).
Th e sub -bran ch es coursing tow ard th e fron t an astom ose w ith
th e fron tal bran ch in th e tem poropariet al region . Th ose going
backw ard an astom ose w ith th e posterior au ricular ar ter y an d
occipit al ar ter y in th e back of th e h ead. It s perforat ing bran ch es
pass th e deep fascia.
Th e fron t al bran ch (an terior) run s tort uously upw ard an d
for w ard to th e foreh ead, parallel to th e u pp er corn er of th e orbicularis oculi m uscle. Its perforat ing bran ch es pass th e deep
fascia an d th e fron t alis m u scle. Th e fron t al bran ch su p plies th e
m u scles, t h e in tegu m en t , an d t h e p er icran iu m in t h is region .
It an astom oses w ith th e opp osite fron t al bran ch on th e galea,
w ith th e supraorbital an d suprat roch lear arteries on the foreh ead, an d w ith th e zygom at ico-orbital ar ter y arou n d th e orbit
an d th e foreh ead (Fig. 6.7, Fig. 6.10).
Surgical Annotation
An ar terial an astom osis form ed in th e sh ap e of an arcade h as
clinical im portan ce in providing a longer ap for reconstruction .
For in stan ce, th e an astom osis bet w een th e super cial tem poral
an d th e p osterior au ricu lar ar teries is u sed as th e Ish io ap
w h en post auricular skin is pedicled on th e super cial tem poral
vessels to recon st ru ct th e n ose.1,10
Th e zygom at ico-orbit al arter y is presen t in 78 to 92%, an d it
origin ates from th e su per cial tem poral ar ter y an d som et im es
from its frontal branch. It courses an teriorly parallel to th e upper
border of th e zygom at ic arch bet w een t w o layers of th e tem poral fascia to th e lateral orbital region .19,26 In th e lateral face, it
su p p lies th e p arot id glan d an d du ct , facial n er ve, facial m u scles,
an d skin of th e lateral can th u s.19,26 It an astom oses w ith th e lacrim al an d p alpebral bran ch es of th e op h th alm ic arter y (Fig. 6.1,
Fig. 6.3, Fig. 6.10).
En tering th e tem poral fossa, about 2 cm above th e zygom at ic
arch , th e su p er cial tem p oral arter y is divided in to fron tal an d
p ar iet al bran ch es. In var iou s st u d ies, t h e bifu rcat ion p oin t of
Surgical Annotation
Tem poroparietal, parieto-occipital, galeopericranial, or forehead
aps are p repared on th e su per cial tem poral ar ter y an d it s
branches. Face and neck reconstructions perform ed by using the
su per cial tem poral arter y w ith ap s h ave som e advan tages.
57
Anatom y for Plastic Surgery of the Face, Head, and Neck
First , an en d -to -en d m icroan astom osis tech n iqu e is p ract ical.
Dissect ing th e arter y d ist ally m akes it possible to t u rn it over
cran ially or caudally to facilit ate an astom osis. Th e diam eters of
the super cial tem poral arter y and its branches m ake them suitable for m icrovascu lar an astom oses.5,17,25,26 Th e diam eter of th e
su p er cial tem p oral arter y is 2.03 to 2.14 m m , th at of th e fron tal bran ch is 1.61 to 2.1 m m , an d th at of the parietal bran ch is
1.44 to 2.1 m m .5,17,25,26 An at roph ic fron t al bran ch is presen t in
2%, eith er th e parietal bran ch or th e fron t al bran ch is at roph ic in
4%, an at roph ic super cial tem poral ar ter y is presen t in 2%, an d
dou ble pariet al bran ch es are presen t in 4%.5,17,25,26 Secon d, even
if th e su p er cial tem poral arter y h as been ru pt ured du ring previous procedures, th e zygom atico-orbital artery m ay be available
an d is easily id en t i ed u sin g Dop p ler or u lt rason ograp hy an d
can read ily be accessed by follow ing t h e su p er cial tem p oral
ar ter y.19 Th ird, th e p reser ved su p er cial tem p oral arter y can be
u sed an oth er t im e.
Th e dist an ce bet w een th e super cial tem poral arter y an d
th e t ragus is im por t an t for design ing preauricu lar aps. A rotat ion of the ap is su ccessfully perform ed to in clude th e parietal
bran ch according to th e an terior h airlin e an d th e course of this
bran ch .25,26 Som e lan dm arks are ch osen on th e h ead: th e m iddle poin t to th e bony lateral can th us (A), th e t ragus (B), th e su perior at t ach m en t of th e ear to th e h ead (C), an d a poin t 2 cm
directly above th is at t ach m en t (D). Th ese poin t s are join ed to
th e bony lateral can th us by st raigh t lin es: AB, AC, an d AD. Th e
DF lin e, w h ich t akes Ju ri’s origin al ap as a base, begin s at th e
poin t 2 cm above th e ear an d is directed an terosuperiorly 45
degrees above th e AD lin e to th e an terior h air lin e. Th e F poin t
is over th e an terior h airlin e. W h eth er th e parietal bran ch h as
passed th e DF lin e is ch ecked. According to Juri’s design , th e DF
lin e bu ilds th e base of th e parieto-occipit al ap , an d th e parietal
bran ch h as to be located in th e ap.27 Lin e A–B is 80 ± 5 m m
(65–87 m m ), lin e A–C 81.8 ± 5.3 m m (66.2–88 m m ), lin e A–D
83.6 ± 4.7 m m (72–90 m m ), an d lin e D–F 11 ± 7.7 m m .
Kn ow ing th e locat ion of th e t ran sverse fron t al ar ter y can be
of value for design ing a galeal fron t alis ap. If it is low, th en a
h airlin e in cision w ou ld be adequ ate for th e t ran sverse foreh ead
ap . If it is h igh er in th e foreh ead, a su perior in cision in th e
h airlin e w ou ld be n eeded to capt u re th e vein s, w h ich are m ore
su perior or p osterior to th e ar teries, an d in order to avoid ven ou s congest ion in th is ap . Th e level at w h ich th e t ran sverse
fron t al ar ter y en ters th e foreh ead is often easily p alp able, an d
th e fron tal bran ch of th e su per cial tem poral ar ter y is often
easily seen w eavin g tor t u ou sly in t h e tem p oral area an d t h e
lateral foreh ead . Th e fron t al bran ch of th e su p er cial tem p oral
ar ter y an d th e t ran sverse fron tal ar ter y are alw ays an terior to
th e fron t alis m uscle.16,23,27 At th is p oin t , th e t ran sverse fron tal
ar ter y or th e fron t al bran ch of th e su p er cial tem poral arter y
often ben ds. Th e an astom osis of th e oblique bran ch of th e su praorbit al ar ter y is clin ically sign i can t; th erefore, th e dist in ct ion bet w een the transverse frontal arter y and the frontal branch
of th e su per cial tem poral arter y is im por tan t . Th is arcade is
crucial for plan n ing aps.
On th e basis of an atom ical st u dies, th e ret roau ricu lar free
ap p ed icled on th e su p er cial tem p oral vessels h as advan tages
over th e ret roau ricu lar free ap p edicled on th e p osterior au ricu lar ar ter y becau se th e su per cial tem p oral vessels are m ore
reliable in cou rse an d caliber w h en th e posterior auricular arter y an d its com it an tes are com pared.16,23,27
58
Ophthalmic Artery
Th e oph th alm ic arter y provides blood su pply to th e eyes, th e
upper t w o-th irds of th e n ose, an d th e an terior part of th e foreh ead. It s bran ch es in clu de th e lacrim al, eth m oid, su praorbit al,
su p rat roch lear, an d extern al n asal arteries (Fig. 6.2). It arises
from th e in tern al carot id arter y an d en ters th e orbit al cavit y
th rough th e opt ic foram en . It th en passes to th e m edial w all of
th e orbit , an d th en for w ard ben eath th e low er border of th e
obliquus superior m uscle, an d divides in to bran ch es.
Th e supraorbit al ar ter y exit s th e orbit w ith th e supraorbital
n er ve th rough th e su p raorbit al foram en , or n otch , to su p ply th e
skin an d th e m u scles of th e foreh ead an d scalp (Fig. 6.1, Fig. 6.2,
Fig. 6.7a,b). It s term in al bran ch es an astom ose to the opposite
side via th e su p rat roch lear an d th e fron tal bran ch of th e su p ercial tem p oral ar teries. Th e su prat roch lear ar ter y su pp lies th e
m edial foreh ead an d scalp as w ell as th e root of th e n ose. Th e
dorsal n asal ar ter y an astom oses w ith th e lateral n asal an d in fraorbit al ar teries. It p rovides blood su p ply to th e m ed ial eyelid s an d d orsal n asal skin . Th e exter n al n asal bran ch , a bran ch
of th e an terior eth m oidal arter y, su pplies th e skin of th e n asal
dorsum an d t ip.
Surgical Annotation
Th ere is sign i can t com m un icat ion bet w een th e extern al an d
in tern al carot id arter y system s aroun d th e eye th rough several
an astom oses. Th ese an astom oses ru n bet w een th e collateral
branches of the internal carotid—the ophthalm ic, supraorbital, supratrochlear, dorsal nasal, and lacrim al arteries (Fig. 6.4c, intercarot id an astom osis)—an d th e collateral an d term in al bran ch es
of th e extern al carot id—th e facial arter y (angular arter y), supercial tem p oral, t ran sverse facial an d m iddle tem p oral arteries,
an d t h e fron t al an d p ar iet al bran ch es (Fig. 6.4c, t ran sfacial
an astom osis).
Th e su p raorbit al an d su p rat roch lear vessels are d escr ibed
as an “in t r icate system of an astom osin g vessels” bet w een t h e
an gu lar, th e su p rat roch lear, an d th e su p er cial tem p oral arteries.13,29 In adver ten t in t ra-arterial inject ion of soft t issu e augm en t ation arou n d th e eye can lead to occlu sion of th e cen t ral
retinal vessels and potentially to blindness.7,19 To avoid th is com plicat ion , llers sh ould be injected in sm all volu m es via blu n t
can n ulas, im plem en t ing a careful ret rograde inject ion tech n iqu e (Fig. 6.4c, p olygon al an astom osis).10,30
Lateral Palpebral Artery
Th e lateral palpebral ar teries arise from th e lacrim al ar ter y an d
dist ribute to th e eyelids an d conjun ct iva. Th ey ru n m edially in
th e upper an d low er lids respect ively an d an astom ose w ith th e
m edial palp ebral ar teries, form ing an ar terial circle. Th e m edial
p alp ebral ar teries leave t h e orbit to en circle t h e eyelid s n ear
t h eir free m argin s, for m ing a su p er ior an d an in fer ior arch ,
w h ich lie bet w een th e orbicularis oculi an d th e t arsus (Fig. 6.1,
Fig. 6.11). Th e lacrim al arter y gives o on e or t w o zygom at ic
bran ch es, on e of w h ich passes th rough th e zygom at icotem poral
foram en to reach th e tem p oral fossa an d an astom oses w ith th e
deep tem poral ar teries. An oth er bran ch appears on th e ch eek
6 Arteries of the Face and Neck
th rough th e zygom at icofacial foram en an d an astom oses w ith
th e t ran sverse facial arter y.10,11,30
Medial Palpebral Artery
Th e m edial palpebral ar teries are usually divided in to bran ch es
for th e u pper an d low er lids as th e su perior an d in ferior m edial
palpebrals.10,30 Th e superior branch passes under the m edial palpebral ligam ent to en ter th e upper eyelid. Th e in ferior bran ch
courses dow nw ards beh in d th e m edial palpebral ligam en t to
en ter th e low er lid (Fig. 6.11b,c).
Th e m ain blood supplies to th e upper an d low er lids are pro vid ed by ar terial arcades. Th e su p erior p alp ebral arcade is sit uated at th e lateral angle of th e orbit w ith th e zygom at ico- orbital
artery and the upper two lateral palpebral branches from th e lacrim al arter y.11,24 Th e in ferior palpebral arcade is at th e lateral
angle of th e orbit , w ith th e low er of th e t w o lateral p alpebral
bran ch es from the lacrim al, t ran sverse facial ar ter y, an d at th e
m edial p ar t of th e lid, w ith a bran ch from th e angu lar ar ter y
(Fig. 6.11c).
Th e blood supply to th e u pper eyelid is com posed of th ree
arcades: m argin al, su p ratarsal, an d p reseptal, w h ich com m u n icate by an anastom otic net w ork of vertical branches. These sm all
ver t ical bran ch es ru n u n der th e orbicu laris ocu li m u scle in th e
su bm u scu lar broelast ic layer.30 Th e preseptal arcade is su p p lied by th e bran ch es of th e oph th alm ic arter y (su praorbit al,
su p rat roch lear, an d m edial p alpebral ar teries). Th e m argin al
arcade is su p p lied by an an astom ot ic n et w ork con n ect ing th e
su p ratarsal (60%) an d presept al (20%) arcad es. Sm all vert ical
bran ch es arising out of th ese arcades provide a rich er an d m ore
com plex an astom ot ic n et w ork.24
a
Surgical Annotation
Th e color m atch , con tour, th ickn ess, an d m obilit y of th e skin
ap m u st be sim ilar to t h e n or m al u p p er eyelid . Up p er eyelid
ap s, w h et h er t h ey h ave a m ed ial or lateral p ed icle or are bipedicled or w ith islan d aps, are cen tered on th e suprat arsal
arcade or th e p resept al arcade.
Hem atom as can ar ise becau se of inju r y to a p er forat in g
bran ch of t h e m argin al arcad e. Th e m argin al arcad e is easily
fou n d on th e tarsu s just 3 m m from th e lid m argin . Un expected
bleeding m ay be due to varian t s of an ar ter y com m un icat ing
bet w een th e periph eral an d m argin al arcades.30 If arter y varian t s are an t icip ated, bleeding can be preven ted du ring blep h arop last y by m ore carefu l dissect ion of th e eyelid arou n d 4.5 m m
from th e lateral can th u s.
Ethmoidal Artery
Th e t w o eth m oidal ar teries are posterior an d th e an terior. Th e
posterior eth m oidal arter y passes th rough th e posterior eth m oidal can al. It s bran ch es descen d in to th e n asal cavit y th rough
ap er t u res in t h e cr ibr ifor m p late, an astom osin g w it h t h e
bran ch es of th e sph en opalat ine arter y. Th e an terior eth m oidal
arter y accom p an ies th e n asociliar y n er ve th rough th e an terior
eth m oidal can al. It th en descen ds in to th e n asal cavit y, ru n n ing
along th e groove on th e in n er su rface of th e n asal bon e. It s ter-
b
c
Fig. 6.11 Arteries of the (a) medial canthus, (b) upper eyelid, and
(c) lower eyelid. Red latex is injected into the common carotid arteries
before dissection. An, angular artery; DN, dorsal nasal artery; ILP,
inferior lateral palpebral artery; IMP, inferior medial palpebral artery;
LP, lateral palpebral artery; M, marginal arcade; MP, m edial palpebral
artery; P, peripheral arcade; SMP, superior m edial palpebral artery; Str,
supratrochlear artery; V, variant artery; N, nasal side, T, temporal side.
m in al bran ch ap p ears on th e dorsu m of th e n ose bet w een th e
n asal bon e an d th e lateral cart ilage (Fig. 6.1, Fig. 6.2).
Th e fron t al ar ter y, on e of th e term in al bran ch es of th e oph th alm ic ar ter y, leaves th e orbit at it s m edial angle w ith th e su p rat roch lear n er ve an d, by ascen ding on th e foreh ead, su pp lies
th e in tegum en t , th e m uscles, an d th e pericran iu m by an astom osing w ith th e su p raorbital ar ter y an d w ith th e arter y of th e
opposite side.
59
Anatom y for Plastic Surgery of the Face, Head, and Neck
Supratrochlear Artery
Th e suprat roch lear arter y is relat ively con st an t aroun d th e m edial can th al ver t ical lin e an d appears from th e superom edial
orbit (Fig. 6.11a, Fig. 6.12). Th e suprat roch lear ar ter y exit s th e
orbit in a posit ion 1.7 to 2.2 cm lateral to th e m idlin e. Th e course
con t in ues vert ically in th e foreh ead 1.5 to 2.0 cm lateral to th e
m id lin e an d goes across a t ran sverse u n n am ed vessel to an astom ose w it h th e con t ralateral ar ter y (Fig. 6.1, Fig. 6.8d, Fig.
6.11a).11,29 Th e bran ch es visible in th e dissect ion are th e m edial
com m un icat ing bran ch in 60%, lateral com m u n icat in g bran ch
in 23%, su p er ior p alp ebral ar ter y in 26%, p er iosteal bran ch es in
7%, an d cu t an eou s bran ch es. Nu m erou s ad d it ion al m u scu lar
bran ch es are p resen t as obliqu e bran ch es in 19%, m ed ial an d
lateral vert ical bran ch es in 53%, an d a single vert ical bran ch in
47% (Fig. 6.11a).
Surgical Annotation
Th e suprat roch lear arter y t ravels un der th e orbicularis oculi
m u scle an d over th e corrugator m u scle an d th en becom es su per cial. Th e cu tan eous bran ch is easily foun d at a posit ion 11.8
to 3.6 m m superior to th e supraorbit al rim an d 13.5 to 3.4 m m
lateral to th e m idlin e (Fig. 6.12).29 Th e su p rat roch lear ar ter y
en ters a su bcu t an eou s p lan e at average dist an ces of 35 m m su perior from th e supraorbit al rim an d 56 m m from th e supraorbital arter y.5,14 Th e superior on e-th ird of th e cut an eous bran ch
t ravels un der th e derm is an d over th e fat layer.29 Th e in ferior
t w o-th irds p ort ion t ravels u n der th e fat layer an d over th e fron talis m uscle an d gradually becom es su per cial. Th e m uscular
bran ch t ravels th rough th e fron talis m uscle, bu t the cutan eous
bran ch t ravels subcut an eously. Th e cu tan eous bran ch anastom oses w ith th e m u scu lar bran ch or th e su praorbit al arter y an d
th e suprat roch lear arter y of th e opposite side (Fig. 6.12).5,29
Th e ar ter y can possibly h ave a periosteal course from th e
m iddle th ird of th e foreh ead su p eriorly, w h ich h as clin ical im portan ce in ap plan n ing. Th e param edian foreh ead ap is su p plied by th e su prat roch lear ar ter y.1,13 Th e com m on pract ice of
rem oving fat from th e superior th ird of th e param edian foreh ead ap cou ld be qu ite risky if n ot don e u n der d irect vision
because a variat ion h as been repor ted in w h ich th e suprat roch lear arter y dives to a periosteal level in th e m iddle th ird of th e
foreh ead an d con t in u es su p er iorly at t h e p er iosteal level. To
avoid any possible risk of t ip or dist al par t ial n ecrosis or epiderm olysis, th e distal th ird ap sh ou ld n ot be defat ted at th e rst
st age. Th e blood su pp ly to th e m edial foreh ead is p rim arily from
th e suprat roch lear and supraorbital ar teries, ign oring th e im por tan t con t ribu t ion from th e angular ar ter y (dorsal n asal, cen t ral an d paracen t ral arteries).13,29
Supraorbital Artery
Th e supraorbit al ar ter y appears over th e su praorbit al rim on a
vert ical lin e corresp on ding to th e m edial lim bu s of th e corn ea.
It r u n s from m ed ial to lateral over t h e su p raorbit al r im as it
exit s t h e orbit (Fig. 6.1, Fig. 6.12). Th e su p raorbit al ar ter y
passes th rough th e supraorbit al foram en an d th en divides in to
su p er cial an d deep bran ch es.5,28 Five bran ch es of th e supraorbit al ar ter y are seen : th e lateral rim (91%), oblique (91%), vert ical (100%), m edial, an d brow (5%) bran ch es. Th e m edial, obliqu e,
an d lateral rim bran ch es are alw ays deep (p eriosteal or su bm u s-
a
b
Fig. 6.12 Distribution of the neuroarterial structures on the orbitofrontal region (a, b, closer). Red latex is injected into the common
carotid arteries before dissection. Photograph showing anastomosis
of super cial temporal and supraorbital arteries; anastomosis of supercial temporal and supratrochlear arteries. AF, ascending frontal artery;
Ce, central artery; D, deep (muscular) branch of the supratrochlear
60
artery; DN, dorsal nasal artery; L, lateral communicating branch supratrochlear artery; M, medial comm unicating branch supratrochlear
artery; PC, paracentral artery; S, super cial (cutaneous) branch of the
supratrochlear artery; So, supraorbital artery; SoN, supraorbital nerve;
Str, supratrochlear artery; T, transverse frontal artery; *, transfacial
anastomosis.
6 Arteries of the Face and Neck
cular). Often m ore th an on e ver t ical bran ch is presen t , or it sub bran ch es soon after it s origin .7,13,29 Th e obliqu e bran ch run s on
th e periosteum tow ard eith er th e fron tal bran ch of th e supercial tem poral arter y or th e t ran sverse fron t al ar ter y at th e lateral orbital rim . Th e su p raorbit al arter y is accom p an ied by th e
su p raorbit al n er ve an d th e su praorbit al vein . It su p p lies th e in tegum en t , th e m uscles, an d th e pericran ium of th e foreh ead,
an astom osing w ith th e fron t al bran ch of th e su p er cial tem p oral an d th e ar ter y on th e opposite side.16,28
Surgical Annotation
Th e super cial arterial bran ch es of th e face can n ot be recom m en ded as th e basis for any plan n ed ap . Th e con sisten t presen ce of deep bran ch es of th e su p raorbital arter y m akes th em
su itable for p lan n ing su p raorbital ar ter y–based aps.7,13 Poten t ially, a vascularized fron tal bon e ap cou ld be developed using
th ese deep bran ch es. Th is ap could be useful for orbital roof or
m edial w all recon st ru ct ion .
Dorsal Nasal Artery
Th e dorsal n asal arter y, th e oth er term in al bran ch of th e oph th alm ic ar ter y, em erges from th e orbit above th e m edial palpebral ligam en t . It th en gives o a t w ig to th e upper par t of th e
lacrim al sac. Th e arter y is divided in to t w o term in al bran ch es,
on e of w h ich crosses th e root of th e n ose an d an astom oses w ith
th e angu lar arter y; th e oth er run s along th e dorsum of th e n ose,
su p p lies its ou ter su rface, an d an astom oses w ith th e ar ter y on
th e opposite side an d w ith th e lateral n asal arter y.29,31
Surgical Annotation
Th e d orsal n asal ar ter y can be id en t i ed u su ally 5 to 7 m m
above t h e m ed ial can t h al h or izon t al lin e. It gives o a su p er ior
cen t ral ar ter y 3 to 5 m m after it s or igin .32 It h as m any an astom oses w it h t h e an gu lar ar ter y, su p rat roch lear ar ter y, alar
bran ch of t h e facial ar ter y, an d su p erior labial ar ter y (Fig. 6.9,
Fig. 6.12). Tw o con st an t p aram ed ian longit u din al bran ch es
from t h e d orsal n asal ar ter y com m u n icate freely across t h e
m id lin e.1,28
Th e cen t ral arter y origin ates from th e dorsal n asal arter y. It
su pp lies th e glabella an d in ferior an d m iddle t ran sverse th irds
of th e cen t ral foreh ead. Th e cen t ral arter y also h as lateral an astom oses w ith th e suprat roch lear ar ter y.
W it h an exten sive su rgical d efect , su ch as eyelid t rau m a,
p eriorbit al can cer excision , cicat r icial secon d ar y h ealin g, con gen it al an om alies, or n er ve p aralysis, a ap can be con sidered
for eyelid recon st ru ct ion . Am ong th e p eriorbit al opt ion s, th e
goal of th e recon st ru ct ion is to obt ain fu n ct ion al an d esth et ic
results.31,33
Th e bran ch es of th e oph th alm ic arter y (e.g., th e dorsal n asal
an d su p rat roch lear ar ter ies an d t h e ter m in al bran ch of t h e
angu lar ar ter y) are resp on sible for t h e n u t r it ion of t h e in n er
can t h u s region .22,30 Dorsal n asal an d angu lar ar ter y ap s are
repaired w ith a m idlin e foreh ead ap, a p aram ed ian foreh ead
ap, a single-stage m idlin e foreh ead ap, an in terp olated m elolabial ap , or a local n asal ap.10,31–33
Du al p erfu sion at th e m idlin e is con sisten t in th e region s of
th e skin an d soft t issue of th e n asal dorsum , th e foreh ead, an d
th e lips. Th e vessels of th e face form a series of plexuses, such as
th e deep facial, su bcut an eous, an d subderm al plexus. Th e deep
facial p lexu s p rovides deep circu lat ion to th e an terior face lying
deep beh in d or passing th rough th e m im et ic m uscles.6 Th is
p lexu s com m un icates w ith th e su bderm al plexu s via a den se
p op u lat ion of sm all m u scu locu t an eou s p en et rat in g bran ch es
of t h e facial, in fraorbit al, an d su p rat roch lear ar ter ies. Th e fasciocu t an eou s p er forators of t h e t ran sverse facial, su bm en t al,
an d p oster ior au r icu lar ar ter ies reach t h e su bd er m al p lexu s by
p assing th rough th e deep facial plan es an d subcut an eous layers
(Fig. 6.4c).10
References
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10. Vasilic D, Barker JH, Blagg R, W h it aker I, Kon M, Gossm an MD. Facial t ran sp lan t at ion : an an atom ic an d su rgical an alysis of th e p eriorbit al fun ct ion al u nit . Plast Recon st r Surg 2010;125(1):125–134
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11. St an dring S. Gray’s An atom y, 40th ed. New York: Chu rch ill Livingston e; 2009
12. Ozgur Z, Govsa F, Celik S, Ozgur T. Clin ically relevan t variat ion s of
th e su p erior thyroid ar ter y: an an atom ic gu id e for su rgical n eck
dissect ion . Surg Radiol An at 2009;31(3):151–159 PubMed
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A cadaver invest igat ion of th e blood supply of th e galeal fron t alis
ap. Plast Recon st r Surg 1994;94(6):794–800 PubMed
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volu m es. Br J Plast Su rg 1996;49(8):519–528 PubMed
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Arch Surg 1999;134(2):144–147 Pu bMed
16. Cordova A, Pirrello R, D’Arpa S, Mosch ella F. Superior pedicle ret roau ricu lar islan d ap for ear an d tem p oral region recon st r u ct ion :
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an atom ic invest igat ion an d 52 cases series. An n Plast Surg 2008;
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17. Ulkü r E, Açikel C, Eren F, Celiköz B. Use of axial pat tern cer vicooccipit al aps in restorat ion of beard defect s. Plast Recon st r Su rg
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18. Al-Hoqail RA, Meguid EM. An atom ic dissect ion of th e ar terial sup ply of th e lips: an an atom ical an d an alyt ical ap proach . J Cran iofac
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29. Yu D, Weng R, Wang H, Mu X, Li Q. An atom ical st u dy of foreh ead
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31. Tu rgu t G, Ozcan A, Yeşiloğlu N, Baş L. A n ew glabellar ap m odi cat ion for th e recon st ruct ion of m edial canth al an d n asal dorsal
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7
Veins of the Face and Neck
Yusuke Shim izu
Introduction
In th is ch apter, th e ven ou s system of th e h ead an d n eck is categorized in to th e vein s of th e face, scalp , an d n eck. Th e m ain ven ou s drain age p ath w ay of th e face is th rough th e h em iloop -like
vein t h at su r rou n d s t h e orbit . Th e vein can be for m ed by t h e
su p raorbit al, an gu lar, or facial vein s, depen ding on its locat ion .
It collect s m ost of th e blood from th e face an d con n ect s m ain ly
to th e zygom at ico-tem poral, su perior op h th alm ic, deep facial,
an d in tern al jugu lar vein s. Th e m ain ven ous drainage pathw ay of
the super cial part s of th e scalp is th rough th e super cial tem poral, m iddle tem poral, occipital, an d posterior auricular vein s.
Th ese vein s drain in to th e extern al jugular vein . Th e in tern al
jugu lar vein is th e m ain ven ous drain age path w ay of th e h ead
an d n eck; th e extern al an d an terior jugu lar vein s are th e p ath w ays from th e su p er cial layers of th e region . Th e vertebral vein
collect s blood from th e prevertebral m uscles an d drains in to th e
brach ioceph alic vein .
Veins of the Face
Th e m ain ven ous drain age path w ay of th e face is prim arily th e
facial vein . In t h e m id d le of t h e face, t h e h em iloop -like vein
su rrou n d s t h e orbit .1 Th is vein can be con t r ibu ted to by t h e
su p raorbit al, angu lar, or facial vein s, d ep en d ing on it s locat ion
(Fig. 7.1). These veins are connected to the zygom atico-tem poral
vein in th e u pp er lateral region of th e orbit , to th e su p erior op h t h alm ic vein in t h e m ed ial can t h al area, to t h e deep facial vein
in t h e n asolabial area, an d to t h e in ter n al or exter n al jugu lar
vein s in th e low er lateral area (Fig. 7.2). As w ith m ost super cial
vein s, th ese vein s h ave m any variat ion s. Com m on p at tern s are
d iscu ssed h ere (Fig. 7.3).
Supraorbital Vein
Th e su p raorbit al vein p asses m edially above t h e orbit al r im
u n d er th e orbicu laris ocu li m u scle to con n ect to th e angu lar
vein in th e m edial can th al area. A bran ch of th e su p raorbital
vein also con n ect s to th e su p erior op h th alm ic vein at th e su p raorbit al n otch or foram en . Laterally, it con n ect s to th e zygom at ico-tem p oral vein arising from th e m idd le tem p oral vein
n ear th e zygom at ic process of th e fron t al bon e. Th ere, it also
con n ect s w ith radicles of th e su per cial tem poral vein s.
Surgical Annotations
Th e zygom at ico-tem p oral vein is kn ow n as a sen t inel vein. Th e
vein is located in a 10-m m zon e above w h ich t h e tem p oral
bran ch of th e facial n er ve passes.2
Supratrochlear Vein
Basically, on e or t w o large vein s arise from th e m edial can th al
area an d ru n tow ard th e foreh ead. Th e su p rat roch lear vein con n ect s to th e t ribu t aries of th e su p er cial tem poral vein s to form
a large ven ou s n et w ork in th e foreh ead. Both th e deep vein s
from th e p ericran ial layer an d th e su p er cial vein s from th e
galea fron t alis layer em pt y in to th e vein .3 Th e suprat roch lear
vein n ally join s th e angu lar or n asal root vein n ear th e m edial
can th us.1
Nasal Root Vein
Arising super cially from th e angu lar vein , th e n asal root vein
pierces the procerus m uscle and anastom oses w ith its contralateral cou n terpart to form a large com m u n icat ing vein u n der th e
skin of th e n asal root .1 Th e n asal root vein is convex tow ard th e
n asal t ip . It is a bridge of th e bilateral h em iloop -like vein s. Several t ribu t aries from th e extern al n ose con n ect to th e n asal root
vein (Fig. 7.4).
Angular Vein
Th e angular vein is form ed by th e un ion of th e suprat roch lear
an d su p raorbit al vein s. It ru n s in feriorly across th e m edial m argin of t h e m ed ial can t h al ten d on ap p roxim ately 8 m m from
t h e m ed ial can t h u s of t h e eye.4 It becom es t h e facial vein at it s
63
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 7.1 Fresh cadaver specimen with white
contrast medium inside the veins. The
hemiloop-like vein surrounds the orbit.
The vein can be formed by the supraorbital,
angular, or facial injected into veins, depending
on its location.
ju n ct ion w ith th e su perior labial vein .5 Th e t w o m ajor vein s
arise from it , n am ely, th e t ran sverse n asal root vein (su per cial)
an d a bran ch to form th e in ferior root of th e su perior op h th alm ic vein (deep). Several t ribu t aries from th e extern al n ose an d
low er eyelid also con n ect to th e angular vein (Fig. 7.5).
Superior Ophthalmic Vein
Th e superior oph th alm ic vein is form ed at the superom edial
m argin of th e orbit im m ediately p osterior to th e t roch lea by th e
un ion of t w o con t ribut ing roots, n am ely, a superior root from
th e supraorbit al vein an d an in ferior root from a bran ch of th e
angu lar vein . It ru n s w ith th e op h th alm ic arter y an d lin ks th e
facial an d in t racran ial vein s. It t raverses th e su perior orbit al ssure to end in the cavernous sinus. The superior oph th alm ic vein
h as ven ou s valves; th e blood ow s tow ard th e cavern ou s sin u s.6
Inferior Ophthalmic Vein
Th e in ferior oph th alm ic ven ous plexus is form ed by vein s w ith
abu n dan t in tercon n ect ion s.7 It origin ates in a n et w ork of m in ute vein s in th e an terior region of th e orbit al oor an d receives
vein s from th e in ferior rect us m u scle, in ferior obliqu e m u scle,
lacrim al sac, an d eyelids. It usually join s th e su perior oph th alm ic vein . Rarely, th e vein can drain directly in to th e cavern ou s
sin u s.8 It con n ect s w ith th e pter ygoid ven ous plexus by a sm all
bran ch th at passes th rough th e in ferior orbit al ssure.
Fig. 7.2 Arteriovenogram of the face. The hemiloop-like vein surrounds the orbit. The tributaries of the super cial temporal vein
connect to the vein in the forehead area. The supratrochlear vein
connects to the vein in the m edial canthal area. The vein drains into
the facial vein.
64
Facial Vein
Th e facial vein is th e m ain ven ous drain age path w ay of th e face.
It st ar t s from th e angu lar vein an d descen ds obliqu ely n ear th e
7 Veins of the Face and Neck
Fig. 7.3 A common pat tern of the facial veins.
The facial vein begins at the angular vein and
descends obliquely near the nasolabial fold.
side of th e n asolabial fold. Th e facial vein an d arter y lie in close
proxim it y at th e level of th e low er edge of th e m an dible. Th ereafter, h ow ever, t h e ar ter y t akes a tor t u ou s cou rse am on g t h e
facial m u scles, w h ereas th e vein h as a direct p ath from th e an gu lar vein to th e low er m an dibu lar bord er.9 It passes un der th e
facial m u scles an d crosses th e body of th e m an d ible an d ru n s
obliqu ely back un der th e plat ysm a but super cial to th e sub m an dibu lar glan d an d digast ric an d st ylohyoid m u scles. Th e
facial vein is join ed by th e an terior division of th e ret rom an dib u lar vein n ear th e m an dibu lar angle an d n ally d rain s directly
or in directly in to th e in tern al jugu lar vein .
Cran ial to th e m an d ible, th e d eep facial vein from th e pter ygoid ven ou s p lexu s an d th e in ferior p alp ebral, su p erior an d
in ferior labial, bu ccin ator, parot id, an d m asseteric vein s join
th e facial vein . Cau dal to t h e m an dible, t h e su bm en t al, ton sillar, extern al palat in e, an d su bm an d ibu lar vein s join th e facial
vein .
Th e facial vein h as valves, par t icularly aroun d th e level of th e
m an d ible (Fig. 7.6).10 Th e dist ribu t ion of ven ou s valves in d icates th at th e blood ow is caudal tow ard th e in tern al jugular
vein in th e low er p ar t of th e facial vein an d n orm ally tow ard th e
cavern ous sin us in th e su perior oph th alm ic vein.6
Fig. 7.4 The nasal root vein. The nasal root
vein connects the bilateral hemiloop-like veins
at the nasal root. Several tributaries from the
external nose connect to the vein.
65
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 7.5 The angular vein. Several tributaries
from the external nose and lower eyelid
connect to this vein.
Surgical Annotations
Th e facial vein con n ects w ith th e cavern ous sin us by t w o m ajor
rou tes, th at is, th rough th e su perior oph th alm ic vein or th rough
th e deep facial vein to th e pter ygoid plexu s an d, n ally, th e cavern ou s sin u s. Th u s, in fect ion m ay sp read from th e face to th e
in t racran ial ven ous sin u ses.
Pterygoid Venous Plexus
Th e pter ygoid ven ous plexus is an exten sive n et w ork of sm all
vascu lar ch an n els th at are located bet w een th e tem poralis an d
lateral pter ygoid m u scles (Fig. 7.7). Th e sph en opalat ine, deep
tem poral, pter ygoid, m asseteric, buccal, alveolar, greater palat in e, an d m iddle m en ingeal vein s an d a bran ch from th e in ferior
oph th alm ic vein join th e plexu s. Th e plexus con n ect s w ith th e
facial vein th rough th e deep facial vein an d w ith th e cavern ou s
sin u s th rough th e sp h en oidal em issar y foram en , foram en ovale,
an d foram en laceru m . It s deep tem p oral bran ch often con n ect s
w ith t ribut aries of th e an terior diploic vein an d th u s w ith th e
m iddle m en ingeal vein s.
Surgical Annotations
In redu ct ion m alarp last y, w h ich is com m on in Asian p at ien t s,
osteotom y sh ould be perform ed caut iously an d n ot too deep in
reach ing th e periosteum of th e posterior side of th e m axillar y
sin u s to avoid inju ring th e deep facial vein , w h ich lies ju st beh in d th e p osterior side of th e m a xillar y sin u s.11
Maxillary Vein
Th e m axillar y vein con sist s of a sh or t t run k th at ser ves as th e
m ain drain age pathw ay of the pterygoid ven ous plexus. It passes
backw ard bet w een th e sph en om an dibular ligam en t an d n eck
of th e m an dible w ith th e m an dibu lar segm en t of th e m a xillar y
arter y.12 It form s th e ret rom an dibular vein by con n ect ing w ith
th e super cial tem poral vein .
Retromandibular Vein
Fig. 7.6 The valve in the facial vein. The facial vein commonly has
valves around the level of the mandible.
66
Th e ret rom an dibular vein is a deep drain age path w ay of th e
face form ed by th e u n ion of th e su p er cial tem p oral an d m axillar y vein s. It run s caudally in th e parot id glan d. It divides in to
t w o m ajor bran ch es: (1) an an ter ior bran ch t h at p asses forw ard to join t h e facial vein to for m t h e com m on facial vein an d
a (2) p osterior bran ch th at join s th e p osterior au ricu lar vein to
form th e extern al jugu lar vein .
7 Veins of the Face and Neck
Fig. 7.7 The pterygoid venous plexus. The
pterygoid venous plexus is an extensive
net work of sm all vascular channels that are
located bet ween the temporalis and lateral
pterygoid muscles. The sphenopalatine, deep
temporal, pterygoid, masseteric, buccal,
alveolar, greater palatine, and middle
meningeal veins and a branch from the
inferior ophthalmic vein join the plexus.
Veins of the Scalp
Th e m ain ven ous drain age path w ay of th e super cial par t of th e
scalp is th rough th e su per cial tem p oral, m iddle tem poral, occipit al, an d posterior au ricular vein s (Fig. 7.8).
cial tem p oral ar ter y, except for it s p roxim al p or t ion .13 Th e
p roxim al p or t ion of t h e vein crosses t h e zygom at ic arch an d
en ters th e parot id glan d to u n ite w ith th e m axillar y vein to
form th e ret rom an dibu lar vein . Th e su per cial tem poral vein
receives blood from th e parot id vein s, ar t icular vein s from the
tem p orom an d ibu lar join t , an ter ior au r icu lar vein s, an d t h e
t ran sverse facial vein from th e side of th e face.
Superf cial Temporal Vein
Th e super cial tem poral vein begin s in a w idespread n et w ork
of th e scalp. It join s th e correspon ding vein of th e con t ralateral
side, the ipsilateral supratrochlear, supraorbital, posterior auricular, and occipital veins. The vein divides into one, t wo, or three
m ajor bran ch es in t h e scalp . Th e p at h w ays are basically in d ep en d en t from t h e fron t al an d p ar iet al bran ch es of t h e su p er-
Middle Temporal Vein
Th e m id d le tem p oral vein lies ben eat h t h e su p er cial layer of
t h e deep tem p oral fascia an d is d ist r ibu ted in t h e su p er cial
tem poral fat pad bet w een th e super cial an d deep layers of th e
deep tem poral fascia.14 Th e vein con n ect s th e supraorbital vein
Fig. 7.8 The veins of the scalp. The main
venous drainage pathway of the super cial part
of the scalp is through the super cial temporal,
middle temporal, occipital, and posterior
auricular veins.
67
Anatom y for Plastic Surgery of the Face, Head, and Neck
th rough th e zygom at ic tem poral vein n ear th e zygom at ic process of th e fron t al bon e. As th e vein passes back to th e proxim al
side, it p ierces an d ru n s several m illim eters over th e su rface of
th e super cial layer of th e deep tem poral fascia. Fin ally, th e vein
join s th e su p er cial tem poral vein ap proxim ately 1 cm below
th e upper aspect of th e zygom at ic root .
Surgical Annotations
Th e caliber of th e m iddle tem poral vein is sign i can tly greater
t h an t h at of t h e su p er cial tem p oral vein .14 Th e vein can be
safely u sed as a recip ien t vessel in case of free-t issu e t ran sfer.
Occipital Vein
au r icle an d also often receives a m astoid em issar y vein from
t h e sigm oid sin us.
Surgical Annotations
In adverten t inju r y of th e m astoid em issar y vein poses a sign i can t problem n ot on ly because of di cult y w ith h em ostasis but
also becau se of its bid irect ion al ow an d close p roxim it y to th e
sigm oid sin u s.15
Veins of the Neck
Th e vein begin s as a plexu s in th e posterior scalp at th e extern al
occipit al prot uberan ce. It pierces th e cran ial at t ach m en t of t h e
t rap eziu s m u scle, t u r n s in to a ven ou s plexus in th e suboccipital t riangle, an d join s th e deep cer vical an d vertebral vein s. It
n ally join s th e p osterior au ricu lar vein . Occasion ally, it accom pan ies th e occipit al ar ter y an d en ds in th e in tern al jugular vein .
Th e pariet al an d m astoid em issar y vein s lin k it w ith th e su perior sagit t al an d t ran sverse sin u ses.
Basically, th e in tern al jugu lar vein collect s m ost of th e blood
from t h e h ead an d n eck (Fig. 7.9, Fig. 7.10). It d rain s all bu t
th e subcut an eous st ru ct ures. Th e extern al an d an terior jugular
vein s collect blood from t h e su p er cial layer of t h e h ead an d
n eck. Th ey d rain a m u ch sm aller volu m e of t issu e t h an d o t h e
deep veins.16 Som e veins connect directly to the subclavian veins,
w h ich collect blood from th e u pper lim bs. Th e in tern al jugular
an d su bclavian vein s con n ect to form th e brach iocep h alic vein .
Th e bilateral brach ioceph alic vein s drain in to th e superior ven a
cava.
Posterior Auricular Vein
Subclavian Vein
Th e posterior auricular vein begin s from th e parieto-occipital
ven ou s n et w ork, w h ich com m u n icates w ith th e occipit al an d
su p er cial tem poral vein s. It descen ds beh in d th e au ricle to join
th e posterior bran ch of th e ret rom an dibular vein to form th e
extern al jugu lar vein . It collect s th e blood from th e st ylom astoid vein an d som e t r ibu t ar ies from t h e cran ial su r face of t h e
Th e subclavian vein is a con t in uat ion of th e axillar y vein th at
ru n s from th e ou ter border of th e rst rib to th e m edial border
of th e an terior scalen e m uscle. From h ere, it con n ect s w ith th e
in tern al jugular vein to form th e brach ioceph alic vein . Th e vein
follow s th e su bclavian arter y an d is sep arated from th e ar ter y
by th e in ser t ion of th e an terior scalen e m uscle. Hen ce, th e vein
Fig. 7.9 The veins of the neck (anterior view).
The internal jugular vein basically collect s most
of the blood from the head and neck. The
external and anterior jugular veins collect blood
from the super cial layer of the head and neck.
Some veins connect directly to the subclavian
veins.
68
7 Veins of the Face and Neck
Fig. 7.10 The veins of the neck (lateral view).
lies an ter ior to t h e m u scle, w h ereas t h e ar ter y lies p oster ior
to th e m uscle. Th e th oracic duct drain s in to th e left su bclavian
vein n ear it s ju n ct ion w it h t h e left in ter n al jugu lar vein (i.e.,
ven ou s angle), an d th e righ t lym ph at ic d u ct drain s in to th e
jun ct ion of th e righ t in tern al jugu lar an d righ t su bclavian vein s.
ner ves. The facial, lingual, phar yngeal, superior, and m iddle thyroid vein s, an d som et im es th e occipit al vein s, join th e in tern al
jugular vein. It m ay com m unicate w ith the external jugular vein.
Lingual Veins
Internal Jugular Vein
Th e in tern al jugular vein collect s blood from th e skull, brain ,
face, an d m ost of th e n eck. Th e in ferior pet rosal an d sigm oid
sin u ses u n ite to form th e in tern al jugu lar vein , w h ich begin s in
th e jugular foram en at th e cran ial base. At it s origin , th ere is th e
so-called su p erior bu lb. Th e vein ru n s cau dally in th e carot id
sh eath , lying ju st lateral to th e ar teries, u n it ing w ith th e su bclavian vein to form th e brach ioceph alic vein n ear th e stern al en d
of th e clavicle. At it s en d, th ere is th e so-called in ferior bulb,
w h ich con tain s a pair of valves above it . Gen erally, th e left vein
is th in n er th an th e righ t vein .
Th e posterior aspect of th e vein con sists of th e rect us capit is
lateralis m u scle, t ran sverse process of th e atlas, levator scapulae
m u scle, m idd le scalen e m u scle, cer vical p lexu s, an terior scalen e m u scles, ph ren ic n er ve, thyrocer vical t ru n k, ver tebral vein ,
an d rst p ar t of su bclavian arter y. Th e m edial asp ect of th e vein
is bord ered by t h e t h e in ter n al an d com m on carot id ar ter ies
an d vagu s n er ve. Th e vagu s n er ve is u su ally fou n d bet w een
t h e arter y an d vein . Super cially, th e vein is overlapped above
an d th en covered below by th e stern ocleidom astoid m u scle an d
crossed by th e posterior belly of th e digast ric m u scle an d superior belly of th e om ohyoid m u scle. Th e deep cer vical lym p h
n odes lie along th e vein , m ain ly on its super cial asp ect . At th e
root of the neck, the right internal jugular vein is separated from
th e com m on carot id arter y; th e left usually overlaps its arter y.
At t h e cran ial base, t h e in tern al carot id ar ter y is an ter ior an d
is sep arated from th e vein by th e n in th to th e t w elfth cran ial
Th e lingu al vein s begin on th e dorsum , sides, an d un dersurface
of t h e tongu e an d p ass back along t h e cou rse of t h e lingu al
ar ter y an d en d in t h e in ter n al jugu lar vein . Th e d orsal lin gu al
vein s drain th e dorsu m an d sides of th e tongu e an d join th e lin gu al vein s bet w een th e hyoglossu s an d gen ioglossu s m u scles.
Th e deep lingual vein begin s n ear th e t ip an d passes back n ear
th e m ucous m em bran e on th e in ferior surface of th e tongu e.
Near th e an terior border of th e hyoglossu s m u scle, it join s a
su blingu al vein th at drain s th e salivar y glan d to form th e ven a
com itan s of th e hypoglossal n er ve, w h ich passes back bet w een
th e m ylohyoid an d hyoglossus m uscles to join th e facial, in tern al jugu lar, or lingu al vein .
Pharyngeal Veins
Th e ph ar yngeal vein s begin in a ph ar yngeal plexu s posterolateral to th e ph ar yn x. After com m u n icat ing w ith th e pter ygoid
ven ou s plexu s an d receiving m en ingeal vein s, th ey en d in th e
in tern al jugu lar vein
Superior Thyroid Vein
Th e superior thyroid vein begin s in th e subst an ce of th e thyroid
glan d an d p asses cran ially along w ith th e su p erior thyroid arter y. Th e vein receives th e su perior lar yngeal an d cricothyroid
vein s an d en ds in th e u p per p ar t of th e in tern al jugu lar vein .
69
Anatom y for Plastic Surgery of the Face, Head, and Neck
Middle Thyroid Vein
Posterior External Jugular Vein
Th e m iddle t hyroid vein drain s th e low er par t of th e thyroid
glan d , th e lar yn x, an d th e t rach ea. It crosses an terior to t h e
com m on carot id ar ter y to join th e low er par t of th e in tern al
jugu lar vein .
Th e posterior extern al jugular vein begin s in th e occipital scalp
an d drain s th e skin an d su p er cial m u scles in th e u p p er an d
back part s of th e n eck, lying bet w een th e splen iu s an d t rapezius
m u scles. It descen ds at th e back part of th e n eck an d u su ally
join s th e m id dle p ar t of th e extern al jugu lar vein .
External Jugular Vein
Th e extern al jugu lar vein largely drain s th e scalp an d face. It lies
su p er cial to th e stern ocleidom astoid m u scle an d can be represen ted by a lin e th at st art s ju st below an d beh in d th e angle of
th e m an dible an d descen ds to th e clavicle n ear th e posterior
border of th e stern ocleidom astoid m uscle. Th e un ion of th e
posterior division of th e ret rom an dibular an d posterior au ricular vein s begin s n ear th e m an dibu lar angle. It run s cau dally in
th e direct ion of a lin e draw n from th e angle of th e m an dible to
th e m iddle of th e clavicle at th e posterior border of th e stern ocleidom astoid m uscle. It is covered by th e plat ysm a, super cial
fascia, an d skin , separated from th e stern ocleidom astoid m u scle
by deep cer vical fascia. Th e extern al jugular vein varies in size,
bearing an inverse proport ion to th e oth er vein s in th e n eck.
Th e vein is occasion ally doubled.16 It h as valves at it s en t ran ce
in to th e su bclavian vein approxim ately 4 cm above th e clavicle
bet w een w h ich it is often dilated. Th e extern al jugular vein receives th e posterior extern al jugular vein an d, n ear it s en d, th e
t ran sverse cer vical, suprascapular, an d an terior jugular vein s. In
th e parot id glan d, it is often join ed by a bran ch from th e in tern al jugu lar vein . Th e occipital vein occasion ally join s it .
Anterior Jugular Vein
Th e an terior jugular vein begin s n ear th e hyoid bon e by th e con u en ce of th e su p er cial vein s from th e su bm axillar y region . It
descen ds bet w een th e m idlin e an d an terior border of th e stern ocleidom astoid m u scle an d t u rn s laterally in th e low er p ar t of
th e n eck. It join s th e en d of th e extern al jugular or subclavian
vein directly. Th e size of th e vein is u su ally in inverse p rop ort ion to th at of th e extern al jugu lar vein . It com m un icates w ith
th e in tern al jugular vein s an d receives th e lar yngeal vein s an d
som et im es a sm all thyroid vein . Th ere are u su ally t w o an terior
jugu lar vein s an d th ey are un ited by a large t ran sverse jugu lar
arch above th e stern u m . Th e arch receives t ribu t aries from th e
in ferior thyroid vein s.
Deep Cervical Vein
Th e d eep cer vical vein accom p an ies it s ar ter y bet w een t h e
sem isp in alis cap it is an d colli m u scles. It st ar t s from vein s from
t h e occip it al an d su boccip it al m u scles an d from t h e p lexu ses
arou n d t h e cer vical sp in e. It p asses for w ard bet w een t h e seven t h cer vical t ran sverse p rocess an d n eck of t h e rst r ib to
join th e low er p ar t of th e ver tebral vein . It receives t ribu taries
from th e p lexu ses arou n d th e sp in ou s p rocesses of th e cer vical
vertebrae.
Vertebral Vein
Th e ver tebral vein is form ed in th e suboccipit al t riangle by n um erou s sm all t ribu taries from th e in tern al vertebral ven ou s
plexu ses, w h ich leave th e ver tebral can al above th e posterior
arch of t h e atlas. Th ey u n ite w ith sm all vein s from th e local
deep m u scles to form a vessel t h at en ters th e foram en in th e
t ran sverse process of t h e atlas to descen d arou n d th e ver tebral
ar ter y as a p lexu s. Th is p lexu s en d s as th e sin gle ver tebral vein ,
em erging from the sixth cervical transverse foram en. It descends
to join th e brach ioceph alic vein . A sm all accessor y ver tebral
vein u su ally d escen d s from th e ver tebral p lexu s. It t raverses
th e seven th cer vical t ran sverse foram en an d t u rn s for w ard bet w een th e su bclavian ar ter y an d cer vical p leu ra to also join t h e
brachioceph alic vein. The vertebral vein receives branch es from
t h e occip it al vein , p rever tebral m u scles, an d in ter n al an d exter n al ver tebral p lexu ses. It receives t h e an ter ior ver tebral an d
deep cer vical vein s an d som et im es th e rst in tercostal vein .
Anterior Vertebral Vein
Th e an terior vertebral vein begin s as a plexus aroun d th e upper
cer vical t ran sverse processes. It descen ds w ith th e ascen ding
cervical artery bet w een the attachm ents of the anterior scalenus
and capitis longus m uscles an d conn ects w ith the vertebral vein.
References
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71
8
Facial Nerve and Temporal Bone
Orlando Gunt inas-Lichius
Introduction
Th e facial n er ve h as a com plex course from th e brain stem to th e
periph er y. Th e n er ve crosses crit ical an d frequen tly accessed
su rgical st ru ct u res in cran ial-base su rger y, oton eu rologic su rger y, h ead an d n eck su rger y, an d cosm et ic su rger y. Du ring t ran stem p oral ap proach es, th e su rgeon h as to d rill th e tem p oral
bon e to avoid injur y to th e facial n er ve. W h en perform ing ap proach es to th e region s involving th e facial n er ve, it is m an dator y to un derstan d th e topograph ic an atom y of th e facial n er ve
from di eren t su rgical p ersp ect ives. Th is ch apter provid es an
over view of th e facial n er ve from th e brain stem th rough th e
tem poral bon e. Th e ext ratem poral course of th e facial n er ve is
presen ted in Ch apter 9. All por t ion s an d segm en t s of th e facial
n er ve, it s blood su p p ly, su rrou n d ing st ru ct u res, rad iologic an atom y, an d relat ion to t ypical surgical approach es are presen ted
in d etail to gu ide th e surgical m an agem en t of th is im port an t
st ru ct u re.
Segments of the Facial Nerve
Becau se of th e in t ricate course of th e facial n er ve from th e
brain stem to th e periph er y, th e course is divided in to th ree differen t p ort ion s. Topograph ically, th e p or t ion s of th e facial n er ve
are divided in to segm en t s. Th e port ion s an d segm en ts are su m m arized in Table 8.1. Th e facial n er ve is com posed of bran ch iom otor, p arasym p ath et ic, visceroa eren t , an d som at ic-e eren t
bers. Facial-n er ve bran ch es w ith di eren t ber qu alit ies are
leaving or en tering th e n er ve during its course to th e perip h er y.
Th e facial n er ve h as in tern al bran ch es leaving an d en tering th e
n er ve in th e tem p oral bon e, an d all extern al bran ch es leave th e
n er ve after its exit from th e st ylom astoid foram en .1 Table 8.2
gives an over view of th e facial n er ve bran ch es.
Intracranial Portion
Th ree prim ar y brain stem n uclei con t ribute to th e fun ct ion of
th e facial n er ve: (1) th e facial m otor n u cleus for som at ic m otor
fu n ct ion (in a st ricter sen se, th e facial n er ve is an exclu sive
m otor n er ve), (2) t h e su p er ior salivator y n u cleu s for secretom otor (au ton om ic) fu n ct ion , an d (3) th e n u cleu s of th e t ract u s
solitariu s for taste. All th ree n u clei are located in th e brain stem
72
(Fig. 8.1): (1) th e facial m otor n ucleus in th e low er th ird of
th e pon s in th e oor of th e fou rth ven t ricle, (2) th e super cial
salivar y n u cleu s directly n ext to th e facial m otor n u cleu s, an d
(3) th e n u cleus of th e t ract us solitarius lateral to th e dorsal
vagu s n u cleu s in th e m edu lla oblongata. It is im port an t , w h en
t reat ing a pat ien t w ith a brain stem lesion an d facial palsy, to
d i eren t iate t h e localizat ion of t h e n u clei of t h e facial n er ve.
Dep en d in g on t h e lesion site, t h e p at ien t can h ave a su p ran u clear, n u clear, or in fran u clear (p erip h eral) facial-n er ve palsy
or a com bin ed lesion ; th is con siderat ion is im port an t in th e
progn osis of th e palsy an d valuable in plan n ing facial-n er ve recon st ruct ion su rger y. Moreover, a lesion of th e superior salivator y n ucleus or of th e n ucleus of t ract us solitariu s can explain
n on m otor de cits of th e p at ien t related to th e facial n er ve.
Medullary Segment
Th e facial m otor n ucleus con t ain s th e facial m oton euron som a,
th e a xon s of w h ich form th e facial m otor n er ve. Here th e m edullar y segm en t begin s. Th e axon s leave th e n ucleus rst in a
dorsom edial direct ion , pass aroun d th e n u cleus of th e abducen s
n er ve to form th e in tern al facial gen u (kn ee) (cf. Fig. 8.1b), an d
leave th e brain stem from th e an terior pon s lateral to th e abdu cen s n er ve an d m edial to th e vest ibulococh lear n er ve. Th e facial
m otor n er ve is join ed by t h e in ter m ed iate n er vu s (n er vu s in ter m ed iu s, n er ve of Wr isberg) con t ain ing sen sor y an d p arasym p at h et ic bers. Th e p arasym p at h et ic bers of t h e n er vu s
interm edius arise from th e salivator y n uclei, an d th e taste bers
term in ate in th e n u cleu s t ract u s solit ar iu s. Th e n er vu s in term ed iu s is lateral to th e facial m otor n er ve w h en both leave th e
brain stem in th e cerebellopon t in e angle (CPA). Th e m edullar y
segm en t of th e facial n er ve en ds h ere, an d th e cistern al segm en t begin s.
Cisternal Segment
W it h in t h e CPA cister n , t h e facial n er ve is m ost an ter ior an d
su p erior, th e vest ibu lococh lear n er ve m ost posterior, an d th e
n er vu s in term ediu s— giving th e n er ve its n am e—bet w een th e
t w o. Th is is im por tan t w h en orien tat ing for vest ibular sch w an n om a su rger y or facial-n er ve rep air sh ou ld be p erform ed in th e
CPA. Th e cistern al segm en t en ds w h en th e facial n er ve en ters
th e porus acust icus of th e in tern al acoust ic m eat us. Th e facial
n er ve an d th e n er vu s in term ediu s resem ble th e n er ve root s of
th e spin al cord w ith in th e cistern .2
8 Facial Nerve and Tem poral Bone
Labyrinthine Segment
Table 8.1 Classi cation of the course of the facial nerve
Length
(mm)
Portion/segment
Intracranial portion
Medullary segm ent
3.5–6
Cisternal segm ent
18–21
Intratemporal portion
Meatal segm ent
8–12
Labyrinthine Segm ent
3–5
Geniculate ganglion segm ent
3–3
Tympanic segm ent
8–11
Mastoid segm ent
13–14
Extratemporal portion (see Chapter 9 for details)
As th e facial n er ve en ters th e fallopian can al, th e labyrin th in e
segm en t begin s (Fig. 8.2). Th e fallopian can al h ouses th e labyrin th in e, t ym pan ic, an d m astoid segm en ts. Th e n er ve takes an
an terolateral cou rse bet w een an d su p erior to th e coch lea (an ter ior) an d vest ibu le (p oster ior). Th en t h e n er ve t u r n s back p osteriorly at th e gen iculate ganglion . Th e labyrin thin e segm en t is
short an d is the narrowest segm ent. The facial n erve occupies up
to 83% of th e labyrin th in e can al cross-sect ion al area com pared
w ith on ly 64% of th e m ore distal m astoid segm en t .3 Th erefore,
it is said th at th e labyrin th in e segm en t is especially suscept ible
to vascular com pression , w h ich m igh t play a role in t reat ing pat ien ts w ith idiopath ic facial palsy (Bell’s palsy).
15–20
Geniculate Ganglion Segment
Intratemporal Portion
Meatal Segment
Th e facial n er ve en ters th e tem poral bon e via th e in tern al
acou st ic m eat u s. Th e m eat al segm en t is congru en t w ith th e in tern al acoust ic m eat u s. Th e facial an d vest ibulococh lear n er ves
pass th rough th e in tern al acou st ic m eat us on th e posterom edial
su rface of th e p et rou s ridge. Th e facial n er ve is join ed by th e
n er vus in term ediu s. Both are located in th e an terior superior
quadran t of th e in tern al acoust ic m eat us above th e falciform
crest an d an terior to Bill’s bar. Th ese are im por tan t lan dm arks
w h en ap p roach ing t h e facial n er ve via a t ran slabyr in t h in e,
t ran scoch lear, or m iddle cran ial fossa approach .
Th e gen iculate ganglion segm en t is equated to th e gen iculate
ganglion (Fig. 8.3, Fig. 8.4). Som e auth orit ies in clude th e gen icu late ganglion w ith th e labyrin th in e segm en t . Follow ing th is
de n it ion , th e gen iculate ganglion w ould reside w ith in th e dist al p ar t of t h e labyr in t h in e segm en t . Th e ganglion con sist s of
rst-ord er p seu dou n ip olar n er ve cells related to taste sen sat ion
from th e an terior tongu e via th e ch orda t ym pan i an d th e greater
p et rosal n er ve. Th e lat ter reach es th e ganglion from th e greater
p et rosal can al. At t h e gan glion , t h e n er ve h as to ben d d ow n to
reach t h e t ym p an ic segm en t; t h is ben d is called t h e exter n al
gen u .
Tympanic Segment
After th e gen iculate ganglion , th e n er ve becom es th e t ym pan ic
segm en t . Th e ju n ct ion to th e t ym pan ic segm en t is form ed by an
Table 8.2 Major branches of the facial nerve
Branch
Location
Function
Greater petrosal nerve
Geniculate ganglion segm ent
Parasympathetic bers for lacrim al gland and
salivary glands and visceroa erent bers for
sensation of palate
Nerve branch to the stapedius
m uscle
Mastoid segm ent
Branchiom otor bers innervating stapedius m uscle
Chorda t ympani
Mastoid segm ent
Visceroa erent taste bers from the anterior third
of the tongue
Posterior auricular nerve
Mastoid segm ent or extratemporal
portion
Branchiom otor bers innervating ear m uscle, m ay
contain also sensory bers
Nerve branch to st ylohyoid m uscle
Mastoid segm ent or extratemporal
portion
Branchiom otor bers innervating st ylohyoid m uscle
Nerve branch to posterior belly of
digastric muscle
Mastoid segm ent or extratemporal
portion
Branchiom otor bers innervating posterior belly of
digastric m uscle
Parotid plexus
Extratemporal portion
Branchiom otor bers innervating muscles of facial
expression (details in Chapter 9)
73
Anatom y for Plastic Surgery of the Face, Head, and Neck
Nucleus of the
abducent nerve
(CN VI)
Superior
salivatory
nucleus
Nucleus of the
abducent nerve (CN VI)
Pons
Nucleus of
solitary tract,
superior part
Superior
salivatory nucleus
Facial m otor
nucleus
Facial motor
nucleus
Nervus
intermedius
Facial nerve
Geniculate
ganglion
St ylomastoid
foram en
a
Branches of
the parotid
plexus
Internal genu
of facial nerve
b
Nucleus
of solitary
tract
b
Fig. 8.1 Nuclei and internal branches of the facial nerve (a) Anterior
view of the brainstem. (b) Superior view of cross section through the
pons. (From Head and Neck Anatomy for Dental Medicine, © Thieme
2010, Illustrations by Karl Wesker.)
acute angle, and shearing of th e facial nerve com m on ly occurs as
the nerve traverses this genu.4 The facial nerve runs posteriorly
ben eath th e lateral sem icircular can al in th e m edial w all of th e
m idd le ear cavit y (Fig. 8.5). The fallopian can al is often deh iscen t , especially in th e area n ear th e oval w in dow.5 Th is is im port an t during m iddle ear surger y because th e absen t bony
protect ion can allow for direct invasion of th e facial n er ve by
ch ron ic in fect ion an d because th e n er ve is at greater risk for
iat rogen ic injur y in su ch sit uat ion s. Duplicat ion of th e facial
Fig. 8.2 Relation of the meatal, labyrinthine, and geniculate ganglion
segm ents to the inner ear. As the facial nerve exits the internal acoustic
meatus at the fundus, it turns gently anteriorly and runs in the otic
capsule for 3 to 6 mm bet ween the cochlea and superior semicircular
canal.
74
Fig. 8.3 Course and branches of the facial nerve. (1) Internal acoustic
meatus. (2) External genu of facial nerve. (3) Proxim al mastoid
segment. (4) Distal mastoid segment. (5) Extratemporal portion.
(Reproduced from Head and Neck Anatomy for Dental Medicine,
© Thieme 2010, Illustration by Karl Wesker.)
8 Facial Nerve and Tem poral Bone
Facial nerve
(CN VII) in Geniculate Trigem inal Hiatus of greate r
petrosal canal
facial canal ganglion nerve (CN V)
Stapedial
nerve and
m uscle
Trigem inal
ganglion
CN V1
CN V3
Greater
petrosal nerve
CN V2
Fig. 8.4 Relation of the intratemporal course
of the facial nerve to the middle ear cavit y.
Lateral view of right temporal bone (petrous
part). Both the facial and vestibulocochlear
nerves (CN VIII, not shown) pass through the
internal acoustic m eatus on the posterior
surface of the petrous part of the temporal
bone. The facial nerve courses laterally in the
bone to the external genu, which contains the
geniculate ganglion. At the genu, CN VII bends
and descends in the facial canal. It gives o
three branches bet ween the geniculate
ganglion and the st ylomastoid foramen. (From
Head and Neck Anatomy for Dental Medicine,
© Thieme 2010, Illustration by Karl Wesker.)
Tym panic
cavit y
Chorda
t ympani
Posterior
auricular nerve
St ylom astoid
foram en
Petrot ym panic
fissure
Pterygopalatine
ganglion
Lingual nerve
(CN V3 )
St ylohyoid m uscle with nerve
Branchiomotor
fibers to
parotid plexus
Digastric m uscle,
posterior belly with nerve
n er ve is rare an d seen m ost often at it s t ym pan ic segm en t an d
associated w ith m iddle and inner ear anom alies.6 Next, the ner ve
passes posterior to th e coch leariform process, ten sor t ym pan i,
an d oval w in dow. Distal to th e pyram idal em in en ce, th e facial
n er ve m akes a secon d t u r n , t h e so -called secon d gen u , w h ich
p asses d ow nw ard . Here t h e m astoid segm en t of t h e facial
n er ve begin s. Th e t ym p an ic segm en t of t h e facial n er ve h as n o
bran ch es.
a
b
Fig. 8.5 Intraoperative view of extended mastoidectomy in patient
with right temporal bone fracture (*). Before (a) and after (b) extirpation of the incus (i) in order to explore the t ympanic segm ent (t) of
the facial nerve. The fracture has exposed and injured the facial nerve
in the t ympanic segment. Decompressed part of the mastoid segment
of the facial nerve (arrow), dura m ater of middle cranial fossa (d),
lateral semicircular canal (l), and sigm oid sinus (s).
75
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 8.6 Intraoperative view, translabyrinthine
approach during vestibular schwannoma surgery of the right ear showing the relation of the
second genu (g) and the mastoid segment (m)
of the facial nerve to the lateral sem icircular
canal (l), the posterior semicircular canal (p),
and the incus (arrow); dura mater of middle
cranial fossa (d); external acoustic meatus (o).
Mastoid Segment
Th e m astoid segm en t begin s at th e secon d gen u of th e facial
nerve and ends at the st ylom astoid foram en (Fig. 8.6). Rarely, the
secon d gen u is con sidered sep arately as th e pyram idal segm en t .
Th e facial n er ve gives o th ree bran ch es from it s m astoid segm en t . Th ese are, from p roxim al to dist al: th e bran ch to th e st apedius m uscle, th e ch orda t ym pan i, an d th e posterior auricular
n er ve. Th e ch orda t ym p an i p asses th rough th e t ym p an ic cavit y
an d th e pet rot ym p an ic ssu re to reach th e in fratem poral fossa.
Th e ch orda t ym pan i is an im port an t lan dm ark w h en a posterior
t ym pan otom y is being p erform ed so as to de n e th e level of th e
m astoid facial n er ve an d th e d ist al lim it of th e t ym p an otom y
w in dow to th e m iddle ear cavit y. Th e posterior auricular n er ve
u su ally arises from th e m astoid segm en t an d leaves th e tem poral bon e togeth er w ith th e facial ner ve at th e st ylom astoid foram en. Th e ner ve provides bran ch es to the st ylohyoid an d posterior
digast ric m uscles n orm ally distal to th e st ylom astoid foram en
(i.e., beyon d th e m astoid segm en t bu t before th e ext ratem p oral
part of th e facial n er ve en ters th e parot id glan d).
For facial n er ve recon st ruct ion surger y, it is som et im es n ecessar y to access th e m astoid segm en t of th e n er ve. For exam p le,
if a t u m or h as dest royed p art s of th e ext ratem poral facial n er ve
p lexu s, it m igh t be t h at su rgical exp lorat ion sh ow s t h at t h e
facial n er ve is in lt rated by th e t u m or u p to th e st ylom astoid
foram en . In su ch a sit u at ion , m astoidectom y is p erform ed an d
th e m astoid segm en t of th e facial n er ve exposed step -by-step
u n t il t u m or-free m argin s of th e proxim al facial n er ve st um p are
ach ieved.
Blood Supply of the Intracranial
and Intratemporal Portions
Th e blood supply to th e in t racran ial an d in t ratem poral part s of
th e facial n er ve is provided by th ree m ain arteries. During tem poral bone and m iddle cranial fossa surgery, these vessels should
be protected to en sure opt im al blood supply to th e in t ratem poral port ion of th e facial n er ve. A bran ch of th e an terior in ferior
cerebellar ar ter y (AICA), th e labyrin th in e ar ter y, supplies th e
76
m eat al segm en t . It m ay be ad dit ion ally su pp lem en ted d irectly
by sm all bran ch es from th e AICA. Furth erm ore, a bran ch of th e
m iddle m en ingeal ar ter y, th e su per cial p et rosal ar ter y, ru n s in
a ret rograde fash ion along th e greater p et rosal n er ve an d su p plies th is area. Th e pet rosal ar ter y is at risk of being dam aged
during th e m iddle cran ial fossa approach w h en th e du ra is elevated from th e oor of th e fossa.7 Fin ally, a bran ch of th e p osterior au ricu lar ar ter y, th e st ylom astoid arter y, ru n s ret rograde
in to th e st ylom astoid foram en to supply th e facial n er ve. Th e
labyrin th in e segm en t of th e facial n er ve is su pplied on ly by th in
con n ect ion s bet w een th e labyrinth in e ar ter y an d super cial
pet rosal arter y as en d arteries. Therefore, th e labyrin th in e segm en t is th e m ost vu ln erable to isch em ia, w h ich m igh t be w hy it
is frequ en tly a ected in cases of idiopath ic facial n er ve p alsy.
Radiologic Anatomy
Th e m eth od of ch oice to depict th e t ypical course of th e facial
n er ve from th e brain stem w ith it s rst gen u (m edu llar y segm en t) is by m agn et ic reson an ce im aging (MRI). With MRI, th e
facial n er ve is also iden t i ed in th e CPA an terior to th e vest ibulococh lear n er ve w ith in th e CPA cistern . Th e n er vu s in term edius can n ot alw ays be di eren t iated from th e facial m otor n er ve
using st an dard MRI. Now adays, 3 Tesla m agn et ic MRI (3T MRI)
allow s reliable d ep ict ion of t h e n er vu s in ter m ed iu s in m ost
cases.8 MRI can sh ow that both nerves an d the vestibulocochlear
n er ve are covered by a com m on du ral sh eath .9 Most n eu roradiologist s an d facial n er ve su rgeon s are fam iliar w ith com puted
tom ography (CT) as a m odalit y of st udying the in t ratem poral
por t ion of th e facial n er ve, especially w ith h igh -resolu t ion CT
(HRCT).9,10 Using HRCT, th e labyrin th in e segm en t is iden t i ed
on coron al an d axial plan es as lying bet w een th e in tern al acoust ic m eat us an d th e gen iculate fossa. It is located bet w een th e
coch lea and vest ibule. Norm ally, th is segm en t can alw ays be
seen w h en looking at th e sam e axial p lan e as th e lateral sem icircular canal. Here th e labyrin th in e segm en t is con cave on it s
an terom edial sid e as it ben ds arou n d th e coch lea. Th e t ym p an ic
segm en t is located bet w een th e lateral sem icircu lar can al an d
8 Facial Nerve and Tem poral Bone
a
b
Fig. 8.7 Magnetic resonance imaging (MRI) anatomy of the normal
intratemporal facial nerve. (a) parasagit tal T1-weighted view with
gadolinium contrast; (b) axial T1-weighter view with gadolinium
contrast. A, Anterior; g, geniculate ganglion; h, main trunk at the
st ylomastoid foramen; I, inferior; L, left; m, mastoid segment; NS,
stapedius nerve; P, posterior; pe, external petrosal nerve; pm a, greater
petrosal; pmi, lesser petrosal nerve; R, right; rd, digastric branch; rs,
st ylohyoid branch; S, superior; t , t ympanic segment. (Reproduced
courtesy of Dr. Hartmut Peter Burmeister, Institut für Radiologie,
Klinikum Bremerhaven-Reinkenheide, Bremerhaven, Germany.)
the t ym panic cavit y. Its position is 1–2 m m inferior to the lateral
sem icircu lar can al. Th e t ym p an ic segm en t is bet ter visu alized
on axial CT sect ion s. Th e secon d gen u de n ing th e begin n ing of
th e m astoid segm en t is iden t i ed by looking for th e posterior
sem icircu lar can al. Th e gen u n orm ally cou rses abou t 6 m m lateral to th e m ost in ferior p ar t of th e p osterior sem icircu lar can al.
Dist al to th e gen u , th e m astoid segm en t can be iden t i ed in th e
m astoid an d is seen w ell on t ran saxial sect ion s. Altern at ively,
th is m ost dist al in t ratem poral segm en t of th e facial n er ve can
be fou n d by follow ing th e can al up from th e st ylom astoid foram en on coron al sect ion s.10
MRI, esp ecially h igh -resolu t ion 3 T MRI w it h con t rast -en h an cem en t , can depict th e in t ratem p oral segm en t s of th e facial
n er ve an d even sm all bran ch es like th e n er ve to th e st ap es, th e
posterior au ricular branch , th e digast ric bran ch , an d st ylohyoid
bran ch (Fig. 8.7).11
m an d ibu lar sw ing ap proach es).12,13 To exam in e th e facial n er ve
in the CPA an d m eat al segm en t superiorly, an terior pet rosal ap p roach es o er good exp osures. The posterior pet rosectom ies
p rovide m ore direct visualizat ion w ith out th e n eed for cerebellar retraction. The lateral approach exposes parts of the posterior
an d th e en t ire in ferior qu adran ts of th e cistern al segm en t in th e
CPA. Th e ret rosigm oid approach best exposes part s of th e su perior an d in ferior qu adran t s an d th e en t ire p osterior qu adran t in
th e CPA. An terior an d an teroin ferior exposures of th e facial
n er ve can be ach ieved u sing t ran sfacial ap p roach es.13 During a
m idd le cran ial fossa ap proach , iden t i cat ion of th e greater p etrosal n er ve is an im por tan t step . Mean distan ces from th e arcu ate em in en ce to th e h iat u s of th e greater pet rosal n er ve in th e
m idd le cran ial fossa m easu re abou t 17.5 m m . Th e length of th is
n er ve w ith in th e m idd le cran ial fossa is app roxim ately 10 m m .
From t h e lateral w all of t h e m id d le cran ial fossa to a m id p oin t
of th e greater pet rosal n er ve, th e m ean dist an ce is 39 m m .14
Th e facial recess ap p roach via a p oster ior t ym p an otom y is
com m on ly p er form ed to facilit ate coch lear im p lan t at ion . Th e
facial recess app roach also allow s access to th e rou n d w in dow
for in sert ion of m iddle ear im p lan t s in p at ien ts w ith congen ital
ear at resia. Even in p at ien t s w ith n orm al ears, access th rough
th e superior open ing of th e facial recess is lim ited by th e presen ce of both th e m astoid segm en t of th e facial n er ve an d th e
ch orda t ym pan i.15 At resia surger y is ch allenging because of th e
altered an atom y of th e facial n er ve.16 Th e m astoid segm en t of
th e facial n er ve is m ore an teriorly posit ion ed in deform ed ears,
on average 3 to 7 m m m ore an teriorly, th an in ears w ith n orm al
an atom y. Fu r t h er m ore, m ost facial n er ves are located above
t h e roun d w in dow in th e deform ed ears.16 Hen ce, open ing th e
at ret ic p late to obtain subfacial access to the rou n d w in dow is
recom m en ded in deform ed ears to p rotect th e facial n er ve.
Surgical Approaches to
the Intracranial and
Intratemporal Portions of
the Facial Nerve
Th e m ost com m on approach es to th e facial n er ve are via an terior p et rosectom ies (m idd le cran ial fossa an d exten ded m idd le
cran ial fossa approach es), posterior pet rosectom ies (t ran slabyrin th in e [cf. (Fig. 7.6)], ret rolabyrin th in e, an d t ran scoch lear ap proach es), th e ret rosigm oid approach , th e far lateral approach ,
an d anterior tran sfacial approaches (extended m axillectom y and
77
Anatom y for Plastic Surgery of the Face, Head, and Neck
References
1. Baker EW. Head and Neck Anatom y for Dental Medicine. New York:
Th iem e; 2010
2. Myckat yn TM, Mackinn on SE. A review of facial n er ve an atom y.
Sem in Plast Surg 2004;18(1):5–12 PubMed
3. Fisch U, Esslen E. Tot al in t ratem poral exposure of th e facial n er ve.
Pat h ologic n d ings in Bell’s p alsy. Arch Otolar yngol 1972;95(4):
335–341 PubMed
4. May M. An atom y for th e Clin ician . In : May M, Sch aitkin BM, Hrsg.
Th e Facial Ner ve. New York: Th iem e; 2000
5. Di Mar t in o E, Sellh au s B, Haen sel J, Sch legel JG, West h ofen M, Presch er A. Fallopian can al deh iscen ces: a sur vey of clinical an d an atom ical n d ings. Eu r Arch Otorh in olar yngol 2005;262(2):120–126
PubMed
6. Glaston bur y CM, Fisch bein NJ, Harn sberger HR, Dillon W P, Ker tesz
TR. Congen it al bifu rcat ion of th e in t ratem p oral facial n er ve. AJNR
Am J Neuroradiol 2003;24(7):1334–1337 Pu bMed
7. El-Kh ou ly H, Fern an dez-Miranda J, Rh oton AL Jr. Blood supply of
th e facial n er ve in th e m iddle fossa: th e pet rosal ar ter y. Neurosurger y 2008; 62(5, Su p p l 2)ONS297–ONS303, d iscu ssion ONS303–
ONS304 PubMed
8. Burm eister HP, Balt zer PA, Diet zel M, et al. Iden t i cat ion of th e
n er vus in term edius using 3T MR im aging. AJNR Am J Neuroradiol
2011;32(3):460–464 PubMed
9. Ph illips CD, Bubash LA. Th e facial n er ve: anatom y an d com m on
pathology. Sem in Ultrasound CT MR 2002;23(3):202–217 PubMed
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10. Tü ccar E, Tekdem ir I, Aslan A, Elh an A, Deda H. Radiological an atom y of th e int ratem poral course of facial n er ve. Clin An at 2000;
13(2):83–87 PubMed
11. Burm eister HP, Hause F, Balt zer PA, et al. Im provem en t of visualizat ion of th e in term ediofacial n er ve in th e tem poral bon e using 3T
m agn et ic reson an ce im aging: par t 1: th e facial n er ve. J Com put
Assist Tom ogr 2009;33(5):782–788 Pu bMed
12. Sann a M, Kh rais T, Man cin i F, et al. The Facial Ner ve in Tem poral
Bone and Lateral Skull Base Microsurger y. St ut tgart: Thiem e; 2006.
13. Bernardo A, Evin s AI, Visca A, St ieg PE. Th e in t racran ial facial n er ve
as seen th rough di eren t surgical w in dow s: an extensive an atom osurgical st udy. Neurosu rger y 2013; 72(2, Su pp l Op erat ive)
on s194–on s207, discussion on s207 PubMed
14. Tubbs RS, Cust is JW, Salter EG, Sh eet z J, Zeh ren SJ, Oakes W J. Lan dm arks for th e greater pet rosal n er ve. Clin An at 2005;18(3):210–
214 PubMed
15. Ham am oto M, Mu rakam i G, Kat aura A. Topograph ical relat ion sh ips am ong th e facial n er ve, ch orda t ym pan i n er ve an d rou nd
w in dow w ith special referen ce to th e approach route for cochlear
im plan t surger y. Clin An at 2000;13(4):251–256 Pu bMed
16. Fu Y, Dai P, Zh an g T. Th e locat ion of t h e m astoid p or t ion of t h e
facial ner ve in pat ien t s w ith congen it al aural at resia. Eur Arch
Otorh in olar yngol 2014;271(6):1451–1455 PubMed
9
Peripheral Branches of the Facial Nerve
Andrew P. Trussler
Introduction
Facial Nerve
Navigat ion arou n d th e facial n er ve is im p ort an t in any facial
procedure, invasive or n on invasive. With th e adven t of a “less is
m ore” t ren d in facial aesth et ics, at ten t ion tow ard avoidan ce of
th e facial n er ve h as been falsely perpet uated. Less at ten t ion to
educating m edical residents on deeper-plane facelift techn iques
h as developed an “out of sigh t , ou t of m in d” at t it u de tow ard th e
facial n er ve an d it s bran ch es. At ten t ion is gain ed w h en an in adver ten t facial n er ve inju r y h ap pen s, w ith ou t th e kn ow ledge
of h ow or w h ere it could h ave occurred. It is h oped th at th is
ch apter on facial n er ve an atom y w ill sh ed ligh t on th e an atom ical lan dm arks an d fascial bou n daries of th e n er ve, as w ell as
h igh ligh t danger zon es of facial n er ve inju r y (Fig. 9.1).
Facial ner ve injur y during facelift surger y is a relat ively rare
but real occurren ce, w ith an in ciden ce ranging bet w een 0.5 an d
2.6%. Th is risk m ay be accept ably low in a prim ar y su per cial
facelift , w h ere th e risk of inju r y to th e facial n er ve m ay be con sidered less, alth ough th e act u al risk m ay be th e in t rod u ct ion of
scarring arou n d th e n er ve an d risk of con tort ing th e n er ve p osit ion , w h ich m akes it pron e to injur y in a secon dar y facelift procedure after a su per cial facelift h as failed. Th e m ore super cial
facelift tech n iqu es h ave been su bjected to longevit y issu es, alth ough th is topic h as been subject ively debated. A 2- to 5-year
longevit y of a su per cial lift is w ell docum en ted. If th e con t in u ed su p er cial p lan e is u sed , t h e r isk for inju r y m ay be w it h
su p er cial m u scu loap on eu rot ic system (SMAS)p licat ion or
SMASectom y, alt h ough if t h e d eep er p lan e is en tered , scarrin g m ay d istort th e facial n er ve bran ch es, m aking th em su scept ible to injur y. Even inject ables can cause en ough irritat ion
an d scarring w h ereby care sh ou ld be t aken to m ain t ain th e fascial boun daries of th e facial n er ve during SMAS dissect ion .
A sub -SMAS dissect ion is safe, an d th e facial n er ve does h ave
a p redictable locat ion , w h ich m akes n avigat ing arou n d it easy
for t h e exp er ien ced facelift su rgeon . Th ere are p red ict able lo cat ion s t h at t h e n er ve is tet h ered eit h er in fascia or w it h a
n eu rovascu lar ligam en tou s adh esion . Th ese are th e areas w h ere
caut ion is w arran ted w h en elevat ing th e facelift ap.
Un derst an ding of th e facial n er ve in th ree dim en sion s is
ben e cial w h en elevat ing t h e SMAS. Kn ow ledge abou t t h e cu t an eou s lan dm arks, t h e bony lan d m arks, an d t h e d ept h of t h e
n er ve as it t raverses th e face from p osterior to an terior m akes
th e abilit y to alter an d custom ize th e SMAS ap to m eet each
in dividu al’s rejuven at ion goals. Th e thickn ess of th e face an d
SMAS does var y in d i eren t p at ien ts, an d a th in -faced pat ien t
w ill likely h ave a t h in SMAS ap ; t h erefore, n u m er ical dept h
is less clin ically app licable w h ere an atom ical bou n daries w ith
fascial p lan es are m ore relevan t in facelift su rger y.
Th e facial n er ve is a m otor n er ve as it exit s th rough th e st ylom astoid foram en at t h e sku ll base. Th e m ain t r u n k is an ter ior
to th e m idport ion of th e earlobe an d lies approxim ately 2 cm
below t h e skin ; it is su r rou n d ed by den se fascia. Th e n er ve ascen d s from t h e st ylom astoid foram en in to t h e p arot id glan d
at an ap p roxim ate 45-d egree an gle. Th e m ain t r u n k bran ch es
w ith in 1 cm of en tering th e parot id glan d as t w o m ain t ru n ks
su perior an d in ferior. Th e n er ve t ru n ks bifu rcate th e parot id
glan d’s t w o lobes an d t ravel su per cial to th e d eep lobe at a
depth of 1 cm (Fig. 9.2a,b). Th e t w o m ain t run ks of th e facial
n er ve split in to th e form al t ru n ks of th e n am ed bran ch es of th e
face as th ey exit th e p arot id glan d (Fig. 9.2c).
Frontal Branch
Th e subcu tan eous course of th e fron t al (tem poral) bran ch w as
in it ially described in 1966 by Ram os an d Pit anguy (Fig. 9.3).1
Th eir n dings of an an atom ical st udy sh ow ed th at th e fron t al
bran ch cou rsed from 0.5 cm from t h e t ragu s to 1.5 cm lateral
to t h e su p raorbit al r im . Th eir n d ings h ave p rovid ed a top ograp h ic m ap for t h e n er ve, alt h ough it s d ept h in t h ree d im en sion s con t in u es to be con fu sin g. Nu m erou s st u d ies h ave
d escr ibed it s locat ion , bu t con sen su s h as n ot been at t ain ed as
to th e depth or it s fascial boun daries.
Th e fascial relat ion sh ips of th e fron t al bran ch of th e facial
n er ve var y rem arkably w ith in th e literat u re. It rem ain s am bigu ous in part because of th e lack of a st an dardized n om en clat u re
and in part because of the considerable variation in th e described
depth of th e n er ve at various levels across th e zygom at ic tem p oral region . As sh ow n by th e w orks of Furn as, Gosain et al, an d
St u zin et al, n o con sisten cy exist s as to th e exact fascial plan e
an d safe plan e of dissect ion in an d across th e zygom at ic arch .2–5
Confoun ding th e issue fur th er are th e n um erou s n am es at t ribu ted to th e variou s fascial layers. Th e tem poropariet al fascia,
w h ich is a con t in uat ion of th e SMAS, h as m u lt iple n am es an d
h as been referred to as th e su p er cial tem p oral fascia an d or th e
galea apon eu rot ica. Th e deep tem p oral fascia envelop s th e tem p oralis m uscle an d exten ds dow n to th e zygom at ic arch , fu sing
w ith th e periosteu m an teriorly an d posteriorly. Th is layer is
often broken dow n in to super cial an d deep port ion s, w h ich
are sep arated by th e tem p oral fat pad as described by St u zin et
al.4,5 With regard to th e su p er cial d eep tem poral fascia, several
n am es exist in th e literat u re an d in clu de th e in term ediate fascia
an d th e in n om in ate fascia.4–6 Fin ally, th ere are descript ion s of
th e loose areolar plan e bet w een th e tem poropariet al fascia an d
79
Anatom y for Plastic Surgery of the Face, Head, and Neck
Supratrochlear nerve
supraorbital nerve
(branch of CNV1 )
Auriculotem poral
nerve
Infratrochlear
nerve
Facial nerve,
tem poral
branches
Infraobital
nerve (branch
of CNV2 )
Occipital
artery
Facial nerve,
zygomatic branches
Greater occipital
nerve
Parotid duct
Posterior auricular
nerve (branch of
facial nerve)
Facial nerve,
buccal branches
Lesser
occipital nerve
Mental nerve
(branch of CNV3 )
Sternocleidom astoid m uscle
Masseter m uscle
Facial nerve,
m arginal
m andibular branch
Facial nerve,
cervical branch
Intraparotid
plexus
Facial nerve
Fig. 9.1 Overview of the facial nerve (left lateral view). (Reproduced from THIEME Atlas of Anatomy, Head and Neuroanatomy, © Thieme 2010,
Illustration by Karl Wesker.)
t h e d eep tem p oral fascia, an d som e au t h ors refer to t h is area
as a sep arate fascial plan e an d h ave referred to it as th e in n om in ate fascia or su bapon eurot ic p lan e. Th ese variat ion s an d discrepan cies are par tly to blam e for th e lack of con sisten cy w ith
respect to th e depth an d locat ion of th e fron t al bran ch of th e
facial n er ve across th e zygom at ic tem p oral region .
Th e th ough t th at th e n er ve bran ch t ravels w ith in th e SMAS
h as clin ically correlated w ith th e alterat ion of facelift tech n iqu e.
St u zin et al. d escribe a lateral low SMAS fasciotom y to protect
th e fron tal bran ch w ith a su perior exten sion to th e lateral can th us.7 In th e h igh SAMS tech n iqu e, th e SMAS is in cised t ran sversely at a level above th e zygom at ic arch . Th e advan t age of
th is tech n ique w ould be to provide a ver t ical vector to th e facelift w it h a com p osite ap con t ain in g SMAS an d su bcu t an eou s
ch eek t issue.8,9 Based on p reviou s st u dies, on e m igh t expect a
80
100% in ciden ce of fron tal bran ch injur y, but in realit y th e auth or h as n ot h ad any perm an en t n er ve injur y. Th e tech n ique to
preven t n er ve inju r y in th is tech n iqu e in cludes a su bcu t an eou s
tem poral dissect ion super cial to th e fron t al branch 2 cm above
th e arch at th e level of th e lateral can th us. Th e n er ve is isolated
on a tem poral m esenter y w ith deep dissection on the deep tem poral fascia. After the SMAS has been elevated, the level of SMAS
t ran sect ion is th en in cised w ith a push cu t across th e arch to th e
orbicu laris oculi w h ile m ain tain ing th e tem poral m esen ter y.
The high SMAS facelift uses a m ultiplanar sub-SMAS and subcut an eous dissect ion to m obilize th e ch eek an d th en a t ran sverse SMAS fasciotom y above th e zygom at ic arch to allow for a
vertical vector of repositioning. This direction of facelift replaces
th e facial soft t issu e as a com posite un it to a youth ful an d n at ural p osit ion . Th e t ran sverse SMAS in cision h as been on e p oin t of
9 Peripheral Branches of the Facial Nerve
Superficial tem poral
artery and vein
Parotid gland,
superficial
part
Parotid
plexus
Facial nerve
a
Parotid gland,
deep part
Sternocleidomastoid
b
Fig. 9.2 The facial nerve in the parotid gland (a) Main trunk of the
facial nerve and parotid plexus (left lateral view). The nerve ascends
from the st ylomastoid foramen into the parotid gland and bifurcates
into t wo main trunks: superior and inferior. (From THIEME Atlas of
Anatomy, Head and Neuroanatomy, Thiem e 2010, Illustration by Karl
Wesker.) (b) Operation ndings of a right parotid tumor. The super cial
layer of the right parotid gland was resected and parotid plexus of the
facial nerve was exposed.
con ten t ion in gain ing accept an ce of th is procedure secon dar y to
th e lack of con sen sus of th e course of th e fron t al bran ch an d th e
in h eren t risk of fron t al bran ch inju r y. Th e st u dy by Tr u ssler et
al h as dem on st rated th at if th e procedu re is p erform ed ap prop r iately, t h e fron t al bran ch is d eep to t h e SMAS above t h e zygom at ic arch an d h as an addit ion al layer of fascia, th e parot id
tem poral fascia, covering it .10 Th is fascia w as rst described in
1965 by Furn as as a lam in ated areolar t issue con t in uous w ith
th e galea.3 Addit ion al descript ion s h ave in cluded a super cial
tem poral fascia, tem poropariet al fascia, an d inn om in ate fascia. I
p ropose th at th e fascia be n am ed by its origin an d in sert ion , like
th at of th e parot id m asseteric fascia an d tem poraparietal fascia,
so t h at t h e ter m in ology is u n ifor m in t h is region . Th e p arot id
tem poral fascia is n ot a n ovel fascia, as dem on st rated by previou s descript ion s, alth ough th is term is a plea for con sisten cy so
th at th e cou rse of th e fron t al bran ch can be easily related to th e
fascial bou n daries over th e zygom at ic arch . Th is st u dy em ploys
both gross dissect ion s un der loop m agn i cat ion as w ell as h istologic evalu at ion of 1 cm in ter vals over th e arch . Th e fron tal
bran ch of t h e fascial n er ve can be easily id en t i ed by it s su b -
Fig. 9.3 Dissection of the right temporal
branch of the facial nerve.
81
Anatom y for Plastic Surgery of the Face, Head, and Neck
cu t an eou s cou rse over from t h e t ragu s to t h e lateral brow . Th e
cu t an eou s lan d m arks d e n ed by Pit an guy w ere con r m ed to
be accurate in th is st udy,1 alth ough th is w as n ot th e focu s of th e
st u dy. Th e fron t al bran ch w as id en t i ed in all cadaver d issect ion s via a p ret ragal in cision an d a su b -SMAS d issect ion w it h
elevat ion of th e p arot id an d iden t i cat ion of th e zygom at icofron t al t ru n k of th e facial n er ve. Th is t ru n k w as u n iform ly covered by th e invest ing fascia of th e p arot id, w h ich th en exten ded
su p eriorly as th e p arot id tem p oral fascia w h ere th e n er ve t raveled in a h eterogen eous fat pad. Th e SMAS w as easily elevated
o th is fascia as th ere w as an areolar plan e bet w een th em . Th is
plane w as easily elevated to above the arch, w ith the SMAS m ain tain ing it s in tegrit y; th e parot id tem poral fascia can be elevated
o of th e n er ve to above the zygom at ic arch as dem on st rated in
th e dissect ion video accom panying th is ch apter.
Th e h istologic evaluat ion rein forces th e dissect ion n dings
an d dem on st rates th at th ere are t w o in dep en den t fascial p lan es
below t h e arch ; t h ese p lan es are m ain t ain ed to ap p roxim ately
2 cm above t h e arch w h en t h e fron t al bran ch p en et rates t h e
tem poral-pariet al fascia an d t ravels w ith th e an terior bran ch of
th e super cial tem poral ar ter y.
Th e n dings of th e st udy by Trussler et al sh ow ed th at th e
fron t al bran ch h as a de n ed an atom ical cou rse an d u n iform fascial plan e w ith in w h ich it t ravels (Fig. 9.4).10 Th e n er ve does n ot
t ravel w ith in th e SMAS, w h ich is th e th ought an d teach ing th at
have been passed on in the anatom ical teaching in this area. This
in accu rate descript ion im poses a false sen se of secu rit y w h en
ap p roach ing th e arch an d m idface from a su p erior an d deep
plan e an d is ech oed in past descript ion s of th e subperiosteal
facelift h aving a h igh n u m ber of fron t al bran ch p alsies. In evaluating the histologic specim ens, the nerve closely abuts the periosteum of th e arch , an d if th e arch is to be accessed, it sh ould be
don e so by bilam in at ing th e deep tem poral fascia, elevat ing th e
periosteum o of th e arch , or both . Addit ionally, th e SMAS can
be elevated above th e arch an d exists as a layer on h istologic
evalu at ion , w h ich con t radict s a p reviou s st u dy dem on st rat ing
th at th e SMAS does n ot cross th e arch .
All th ese n dings are clin ically supported by th e fact th at I
h ave perform ed m ore th an 1,000 h igh SMAS facelifts w ith ou t
any perm anen t n erve injuries. This clin ical nding dem onstrates
th at th e h igh SMAS facelift is safe an d th e fron t al bran ch of th e
facial n er ve is p rotected by th e p arot id tem p oral fascia at th e
zygom at ic arch .
Zygomatic Branch
Th e zygom at ic bran ch of t h e facial n er ve h as clin ical im p licat ion s in low er eyelid fu n ct ion an d m id face m ovem en t . It is at
r isk as it exit s t h e p arot id glan d , alt h ough it t ravels w it h in
sim ilar bou n d s as t h e fron t al bran ch . It s ter m in al bran ch es can
be inju red in low er eyelid an d m id face p roced u res. Th is t yp e
of injur y is clin ically less severe secon dar y to its m ult iple ram i.
Th e zygom at ic bran ch of th e facial n er ve t ravels w ith in th e superior por t ion of th e parot id glan d. Th e n er ve bran ch es from
th e superior t run k in th e parot id glan d an d lies deep to th e parot id m asseteric tem poral fascia. It ru n s w ith th e t ran sverse facial arter y in lin e w ith th e parot id du ct as it t ravels an teriorly
in to th e bu ccal space. Th e n er ve t ravels ben eath th e zygom at ic
82
Fig. 9.4 The fascia plane where the temporal branch travels.
as m ajor m uscle but m ay give a bran ch super cial to th e m uscle,
w h ich in n er vates th e orbicularis oculi laterally. Th e zygom at ic
bran ch of th e facial n er ve gives o ram i to in n er vate th e deep
su rface of th e levator an d orbicu laris ocu li. Th ere is m edial
cross-in n er vat ion of th e bu ccal an d zygom at ic m edial bran ch es,
w h ich h as sign i can ce in th e blin k respon se, low er eyelid posit ion , an d ton e. Inju r y to th ese ram i du ring open low er eyelid
proced ures m ay result in an ect rop ion , w h ich can correct as
th ese sm all bran ch es rein n er vate th e m u scle (Fig. 9.5).
In th e ch eek, th e zygom at ic bran ch is covered by th e parot id
glan d . Th e area of vu ln erabilit y exist s at t h e or igin of t h e zygom at icu s m u scle or McGregor’s patch , w h ere th ere is a den se
ligam en tous adh esion w ith th e n eu rovascular bun dle, w h ich
in dicates th e t ran sit ion from deep to sup er cial plan es of t h e
n er ve.1 1 Scissor sp read ing in t h e su p er cial p lan e, as w ell as
p ressu re in stead of cau ter y for h em ost asis, can h elp elim in ate
injur y to th e bran ch . Th e perforator vessels from th e t ran sverse
facial ar ter y are t yp ically en cou n tered as w ell as th e zygom at ico-orbital sen sor y bran ch .
9 Peripheral Branches of the Facial Nerve
Fig. 9.5 Dissection of the right facial nerve.
B, buccal branch; C, cervical branch; M, m arginal mandibular branch; T, temporal branch;
Z, zygomatic branch.
Buccal Branch
Th e bu ccal bran ch ram i t ravel w it h in t h e m id p or t ion of t h e
p arot id glan d . Th e ram i exit t h e n er ve m ore p oster iorly t h an
t h e su p er ior t r u n k ram i becau se t h e p arot id glan d is n ar row er
as it d escen ds in to th e tail. Th e bu ccal ram i t ravel an teriorly on
th e m asseter m uscle an d below th e parot id m asseteric fascia. At
th e an terior border of th e m asseter, th e n er ve bran ch es t raverse
from th e d eep fascia to p erforate in to th e m ore su p er cial bu ccal fat com part m en t . Th e en d poin t is th e un dersurface of th e
facial levator m u scles (Fig. 9.6).
Elevat ion of th e SMAS ap o of th e p arot id is relat ively easy
as th e dissect ion p rogresses an teriorly. Th e dissect ion o of th e
Fig. 9.6 Dissection of the right buccal branch. BB, buccal branch of the
facial nerve; DAO, depressor anguli oris; LLS, levator labii superioris;
Ma, masseter; OOc, orbicularis occuli; OOr, orbicularis oris; ZM, zygom atic major; Zm, zygomatic minor.
p arot id an d on to th e parot id m asseteric fascia is a lan dm ark to
p reven t dam age to th e buccal bran ch es, w h ich are seen below
th e t ran sparen t fascia in an avascular plan e. Dissect ion in to th e
m asseter m u scle is in dicat ive of too deep of a dissect ion an d
p ossible inju r y to th e bu ccal bran ch es. Vert ical scissor spreading is all th at is n eeded to elevate th e SMAS o th e parot id m asseteric fascia. Previou s su rger y an d inject ion s m ay m ake th is
p lan e adh eren t an d di cult to elevate.
Mandibular Branch
Th e m an dibular glan d exits th e parot id at th e angle of th e m an dible. It is covered w ith th e t ran sit ion al fascia of th e parot id
m asseteric an d deep cer vical fasciae. Th e n er ve t ravels an teriorly above th e m an dibular border in m ost pat ien t s (Fig. 9.7). In
19% of cases, th e n er ve is located below th e border of th e m and ible an d can be fou n d 1 to 3 cm below t h e bord er before it
crosses th e an terior to th e facial vessels.12 In cases in w h ich th e
n er ve is below th e m an dible, it ru n s an teriorly an d crosses th e
su rface of th e posterior d igast ric m u scle an d th en th e capsu le of
th e subm an dibular glan d, lying deep to th e invest ing cer vical
fascia an d cu r ving a variable dist an ce below th e m an dible. Th e
n er ve p erforates th rough th e deep cer vical fascia at th e in ferior
bord er of t h e m idm an d ible n ear t h e an ter ior m argin of t h e
m asseter m u scle, w h ere it t h en crosses su p er cial to t h e facial
ar ter y to en ter t h e bu ccal sp ace lyin g ben eat h t h e p lat ysm a,
u lt im ately in n er vat ing th e m ajor lip depressors an d m en talis
m u scle.
Th e m argin al m an dibular n er ve can be injured in th e ch eek
an d in th e n eck. In adverten t inju r y can occu r w ith su bcu tan eou s dissect ion along th e m id-m an dibular border w ith push -cut
scissor dissect ion , blu n t inju r y w ith lip osuct ion or inject ion , as
w ell as elect rocau ter y after bleeding occu rs in th is area after
blin d dissect ion . Injur y to th e n er ve in th e n eck can occu r if th e
dissect ion t raverses th e plat ysm a an d en ters th e deep cer vical
fascia. Dissect ion of th e n eck plat ysm a sh ou ld st ar t several cen t im eters below th e angle of the m an dible in a relat ively loose,
83
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 9.7 Dissection of the right buccal,
mandibular and cervical branches. B, buccal
branch; C, cervical branch; M, marginal
mandibular branch.
avascular areolar plan e. In a revision n eck-lift procedure, adh eren ce of th e p lat ysm a to th e skin m ay direct th e dissect ion
th rough th e plat ysm a an d in adverten t injur y to th e n er ve if th is
dissect ion plan e is con t in ued.
In a su b -SMAS ch eek d issect ion , th e greatest risk of inju r y
for th e m argin al m an d ibu lar n er ve is in t h e low er an terior
ch eek as th e buccal space is approach ed. Vert ical spreading an d
blun t dissect ion over th e parot id m asseteric fascia adequately
elevate th e SMAS ap, w ith care t aken to avoid th e low er an terior border of th e m an dible w h ere th e n er ve crosses th e facial
vessels. Hem ostasis u n der th e exten ded SMAS ap in th e low er
ch eek sh ould be at t ain ed w ith pressure an d n ot elect rocau ter y.
Cervical Branch
Th e cer vical bran ch exit s th e parot id glan d at it s caudal border
below th e angle of th e m an dible. It im m ediately perforates
th rough brous adh esion s at th e t ail of th e parot id an d t ravels
above th e d eep cer vical fascia. Th e n er ve t ravels w ith in th e broareolar con n ect ive t issu e to th e un dersurface of th e plat ysm a, w h ere it divides an d sen ds ram i an teriorly an d in feriorly.
Dissect ion ben eath th e SMAS an d p lat ysm a can risk inju ring
th e cer vical bran ch an terior to th e angle of th e m an dible, w h ere
it em erges from th e parot id glan d. Dissect ion in fron t of th e
angle at a level deep to th e p lat ysm a sh ou ld be perform ed w ith
blun t dissect ion to elevate th e SMAS ap. Th is dissect ion can be
di cult secon dar y to th e den se fascial adh esion s over th is area;
freeing th e SMAS an d plat ysm a en ough for m ovem en t sh ou ld
be th e goal rath er th an an exten sive dissect ion .
Th e danger zon es for th e cer vical bran ch an d th e m an dibular
bran ch are adjacen t to each oth er an d can be t reated as a single
zon e during a SMAS-plat ysm a facelift , 1 cm above th e border of
th e m an dible to 2 cm below th e m an dible from th e angle to th e
oral com m issure (Fig. 9.7). Adequate m obilizat ion of th e SMASplat ysm a ap m ay en t ail th e release of th e fascial at t ach m en t s
in th is area. A dissect ion plan e above th is danger zon e in th e
ch eek an d below in th e n eck can be con n ected w ith blu n t dissect ion an d spreading, w h ich can create a m obile m esen ter y of
soft t issu e to h elp protect th e p ath of th e m an dibu lar an d cer vical n er ve bran ch es.
Conclusions
•
•
•
•
Kn ow th e variat ion s of th e n er ve bran ch es.
Un derst an d th e fascial bou n daries of th e n er ve bran ch es.
Use safe d issect ion tech n iqu es in t h e areas of fascial
ad h eren ce.
Hold p ressu re rath er th an cau terize bleeding in th e an terior
ch eek.
References
1. Pit anguy I, Ram os AS. Th e fron t al bran ch of th e facial n er ve: th e
im p or t an ce of it s var iat ion s in face lift ing. Plast Recon st r Su rg
1966;38(4):352–356 Pu bMed
2. Furn as DW. Lan dm arks for th e t r un k an d the tem porofacial division of th e facial n er ve. Br J Surg 1965;52(9):694–696 PubMed
3. Gosain AK, Sew all SR, You sif NJ. Th e tem poral bran ch of th e facial
n er ve: h ow reliably can w e predict it s path? Plast Recon st r Surg
1997;99(5):1224–1236 Pu bMed
4. St uzin JM, Wagst rom L, Kaw am oto HK, Wolfe SA. An atom y of th e
fron t al bran ch of th e facial n er ve: th e sign i can ce of th e tem p oral
fat p ad. Plast Recon st r Su rg 1989;83(2):265–271 PubMed
84
5. St uzin JM, Baker TJ, Gordon HL. Th e relat ion sh ip of th e su per cial
an d deep facial fascias: relevan ce to rhyt idectom y an d aging. Plast
Recon st r Surg 1992;89(3):441–451 Pu bMed
6. Abul-Hassan HS, von Drasek Asch er G, Aclan d RD. Surgical an atom y an d blood supply of th e fascial layers of the tem poral region.
Plast Recon st r Surg 1986;77(1):17–28 Pu bMed
7. St u zin JM, Baker TJ, Gordon HL, Baker TM. Exten ded SMAS dissect ion as an approach to m idface rejuven at ion. Clin Plast Surg 1995;
22(2):295–311 Pu bMed
8. Bar ton FE Jr. Th e SMAS an d th e nasolabial fold. Plast Recon st r Surg
1992;89(6):1054–1059 PubMed
9 Peripheral Branches of the Facial Nerve
9. Barton FE Jr, Hun t J. Th e h igh -super cial m u sculoapon eurot ic system tech n iqu e in facial rejuven at ion : an u p date. Plast Recon st r
Su rg 2003;112(7):1910–1917 Pu bMed
10. Trussler AP, Steph an P, Hatef D, Sch averien M, Meade R, Barton FE.
Th e fron t al bran ch of th e facial n er ve across th e zygom at ic arch :
an atom ical relevan ce of th e h igh -SMAS tech n iqu e. Plast Recon st r
Su rg 2010;125(4):1221–1229 Pu bMed
11. Fu rn as DW. The ret aining ligam en t s of th e ch eek. Plast Recon st r
Surg 1989;83(1):11–16 PubMed
12. Dingm an RO, Grabb WC. Surgical anatom y of the m an dibular ram us
of th e facial n er ve based on th e dissect ion of 100 facial halves. Plast
Recon st r Su rg Tran splan t Bu ll 1962;29(3):266–272 PubMed
85
10
Sensory Nerves of the Head and Neck
Ibrahim Khansa, Jenny C. Barker, and Jef rey E. Janis
Introduction
In t h e p ast t w o d ecad es, sign i can t advan ces h ave been m ad e
in th e descript ion of th e sen sor y an atom y of th e h ead an d n eck,
m ostly in th e cosm et ic su rger y literat u re. Th is p rogress w as
driven in large part by th e discover y th at com pression of sen sor y n er ves in th e h ead an d n eck m ay con t ribu te to th e path ogen esis of m igrain e h eadach es.
Migrain e h eadach es are a robu st clin ical ch allenge th at affect s 17.1% of w om en an d 5.6% of m en in th e Un ited St ates.1
Tradit ion al ph arm acologic t reat m en t is often in su cien t . New
su rgical opt ion s for th e t reat m en t of m igrain e h eadach e h ave
been developed based on th e n ding th at ext racran ial sen sor y
bran ch es of th e t rigem in al an d cer vical spin al n er ves can be irritated , en t rap ped, or com pressed at m u lt ip le poin t s along th eir
an atom ical cou rse, u lt im ately leading to a cascade of physiologic even t s th at results in m igrain e h eadach es.2–5
In ad d it ion to t h e abu n dan t clin ical st u d ies t h at h ave been
p u blish ed in su p p or t of t h e su rgical t reat m en t of m igrain e
h eadach es, com p lem en t ar y an atom ical st u d ies h ave been p erfor m ed t h at d escr ibe t h e d et ailed an atom y of t h e sen sor y
n er ves involved, as w ell as th e com p ression poin t s along th eir
course. Th ese in clude th e fron t al t rigger poin t (supraorbit al an d
su p rat roch lear n er ves, or STNs), t h e tem p oral t r igger p oin t
(zygom at icotem poral n er ve [ZTN] an d au riculotem poral n er ve
[ATN]), the occipital trigger point (greater occipital, th ird occipital, and lesser occipital nerves [LONs]), and the nasoseptal trigger
poin t . In th is ch apter, w e begin by sum m arizing th e hypoth eses
on th e path ogen esis of m igrain e h eadach es an d th en describe
th e det ailed an atom y of th e sen sor y n er ves involved, along w ith
th eir com pression poin t s.
Pathogenesis of Migraine
Headaches
Th e n al com m on path w ay in th e path ogen esis of m igrain e
h eadach es ap p ears to be hyperexcit abilit y of cerebral n eu ron s
resu lt ing from low er th an n orm al th resh old to excit at ion of th e
n eu ron al m em bran e,6 w h ich is believed to be du e to localized
dural in am m at ion and vasodilat ion of m en ingeal vessels th at
are su p p lied by t h e t rigem in al n er ve. Th e m ech an ism of au ra
is believed to be cor t ical sp reading dep ression , ch aracterized by
cort ical n eu ron al excitat ion , follow ed by depression of n orm al
n eu ron al act ivit y.6
Irrit at ion of th e t rigem in al n er ve, from eith er a cen t ral7 or
periph eral source, causes in am m at ion an d vasodilat ion in th e
region of th e dura m ater su pplied by th e t rigem in al n er ve via
release of n ocicept ive m ediators such as calciton in gen e-related
p ept id e, su bst an ce P, an d n eu rokin in A.6,8 Th e cen t ral t rigger
th eor y of m igrain e h eadach e post u lates th at cen t ral n eu rovas-
86
cu lar even t s cau se irrit at ion of th e t rigem in al n er ve, lead ing
to th e release of n ocicept ive su bst an ces from th e n er ve, t riggering d u ral in am m at ion an d th e m igrain e p ain cascad e. Th is
th eor y ascr ibes th e proven abilit y of bot u lin u m toxin A to redu ce th e frequ en cy an d severit y of m igrain e h eadach es 9,10 to
it s abilit y to be t aken u p by t h e t r igem in al n er ve p erip h erally,
t ravel dow n st ream t h rough th e a xon , an d block th e release of
n ocicept ive su bst an ces at th e syn apt ic in terface of th e t rigem in al n er ve w it h t h e d u ra. In an in vit ro st u dy, Du rh am et al
fou n d th at bot u lin u m toxin A d ecreased t h e am ou n t of calciton in gen e-related p ept ide released from act ivated rat t rigem in al n eu ron s.11
In con t rast , th e p eriph eral t rigger th eor y of m igrain e h eadach e p ost u lates th at irritat ion of th e t rigem in al n er ve occu rs
p erip h erally via com p ression of on e of t h e sen sor y bran ch es of
t h e t rigem in al or cer vical n er ves by m u scle, fascia, bon e, arter y, or m u cosa. Th is t h eor y at t r ibu tes t h e e cacy of bot u lin u m toxin A to its abilit y to w eaken tem porarily th e m u scles by
blocking acet ylch olin e release at th e n eurom uscular jun ct ion ,
th us reducing m u scular com pression of bran ch es of th e t rigem in al n er ve.12 Th is th eor y is also validated by th e e cacy of surgical t r igger-p oin t d ecom p ression . In d eed , su rgical release of
bran ch es of th e t rigem in al n er ve en t rapped in m uscle, fascia,
bon e, ar ter y, an d m ucosa h as been sh ow n to be e ect ive at reducing th e frequ en cy, in ten sit y, and severit y of m igrain e h eadach es in m ost p at ien t s w h o h ave been refractor y to m edical
m an agem en t th rough ret rospect ive ch art review s,5,13 prosp ect ive coh ort st udies,2,3 an d a prospect ive ran dom ized t rial using
sh am su rger y as a p lacebo con t rol.4 In ad dit ion , pat ien t s w ith
m igraine headach es often h ave ten derness to palpation that precisely localizes to th eir t rigger poin ts, w h ich fur th er len ds creden ce to th e periph eral t rigger th eor y.14
Th e cen t ral an d periph eral th eories of th e path ogen esis of
m igrain e h eadach es m ay n ot , in fact , be in com p at ible. A com bin at ion of p eriph eral an d cen t ral sen sit izat ion m ay act in syn ergy to p rodu ce m igrain e h eadach es,15 an d cu rren t th erapeut ic
st rategies—in clu d in g m e d icat ion s, b ot u lin u m , an d su rgical
d ecom p ression —m ay p rove to be m u ltim odal in th eir m ech an ism of act ion .
Peripheral Trigger Points in
Migraine Headaches
Frontal Trigger Point
Supraorbital Nerve
Origin and Course
Th e supraorbit al n er ve (SON) is on e of th e t w o term in al cut an eous bran ch es of th e fron t al n er ve, w h ich is a bran ch of th e oph -
10 Sensory Nerves of the Head and Neck
th alm ic division of th e t rigem in al n er ve (V1). Th e fron t al n er ve
Fig. 10.1 Sensory distributions of nerves involved in migraine trigger
points: AT, auriculotemporal nerve; GON, greater occipital nerve; LON,
lesser occipital nerve; SON-D, deep branch of the supraorbital nerve;
STN, supratrochlear nerve; TON, third occipital nerve; SON-S, supercial branch of the supraorbital nerve; V1, ophthalmic branch of the
trigeminal nerve; V2, maxillary branch of the trigeminal nerve; V3,
mandibular branch of the trigem inal nerve; ZTN, zygomaticotemporal
nerve.
passes th rough th e superior orbit al ssure an d divides in to t w o
bran ch es: th e SSTN an d th e SON, both of w h ich run ben eath th e
orbit al roof. Th e SON proceeds laterally an d m ost com m on ly
exit s th e orbit th rough a su praorbit al n otch located on th e supraorbit al rim , but it can also exit th rough a foram en located
ceph alad to th e supraorbit al rim .
After exit ing th e orbit , th e SON divides in to a deep (lateral)
bran ch an d a super cial (m edial) bran ch . Th e deep bran ch h as a
m ore con sisten t cou rse an d ru n s bet w een th e galea ap on eu rotica an d th e periosteum tow ard th e tem p oral fu sion lin e laterally 16 an d p rovides sen sat ion to th e fron toparietal scalp (Fig.
10.1). Cu zalin a an d Holm es described th e reproducible locat ion
of t h e d eep bran ch of t h e SON in a st u dy t h at exam in ed 75
p at ien t s u n d ergoin g en d oscop ic brow lift 17 an d fou n d t h e d eep
bran ch of th e SON to be located an average of 0.56 m m from a
ver t ical lin e draw n t angen t ially to th e m edial lim bu s of th e iris.
Th e super cial bran ch of th e SON is m ore variable in locat ion . It
pierces th e fron t alis m uscle in a fan like pat tern w ith n u m erous
bran ch es an d provides sen sor y in n er vat ion to th e foreh ead skin
an d an terior scalp.16
Points of Compression and External
Landmarks
Th e rst com pression poin t of th e SON con sist s of eith er th e
su p raorbit al n otch or foram en (Fig. 10.2, Table 10.1). W h en a
su p raorbit al n otch is presen t as th e SON exit s from th e su p erior
orbit al rim , th ere is frequen tly a fascial ban d th at com pletes th e
circular sh ape of th e n otch an d can com press th e SON again st
th e fron tal bon e, as obser ved by Jan is et al18 an d th en st u died
exten sively by Fallu cco et al,19 w h o foun d th at a supraorbit al
n otch w as p resen t 83% of th e t im e an d a foram en 27% of th e
t im e (10% of specim en s h ad both a n otch an d a foram en ). Th ey
fou n d th at 86% of su p raorbit al n otch es h ad a fascial ban d. Th e
fascial ban ds w ere fu rth er divided in to th ree classi cat ion s.
Type 1 ban ds, w h ich occurred in 51.2% of specim en s, w ere described as “sim ple” an d con sisted of a single fascial ban d. Typ e 2
ban d s, occu r r ing in 30.2% of sp ecim en s, con sisted of bony
sp icu les w ith a fascial ban d com plet ing th e bridge overlying th e
su praorbit al n otch . Typ e 3 ban ds, occu rring in 18.6% of specim en s, con t ain ed a sept u m th at allow ed for m ore th an a single
p assagew ay for th e n eurovascular bun dle th rough th e su praorbital n otch .
Th ese w ere fur th er divided in to t ypes 3A an d 3B classi cat ion , depen ding on w h eth er th e sept um w as h orizon t al or vert ical, w it h each occu r r ing 9.3% of t h e t im e (Fig. 10.2).19 W h en
p resen t , a su p raorbit al foram en can act as a bony com p ression
p oin t .20 Beer et al d escr ibed t h e SON exit from 507 Eu ropean
sku lls an d discovered th at in 74% of cases, th e locat ion of th e
exit w as asym m et ric bet w een sides in th e sam e p erson .21 Th e
average dist an ce from th e n asion to eith er a supraorbital notch
or foram en w as 31 m m . A single exit poin t exists in m ost circum stan ces, but in approxim ately 10 to 15% of people, m ore
th an on e exit poin t exists.21,22 Agth ong et al exam ined specim en s from 70 m en and 40 wom en in an Asian population and
noted that w hen m easured from the m idline, the nerve exit
t ren ded tow ard a m ore lateral locat ion in m en (25.1 m m ) th an
in w om en (24.1 m m ).22 In terest ingly, th is st u dy dem on st rated
an equ al rate of su p raorbital n otch versu s foram en in th is pop u lat ion . Conversely, Cu t righ t et al exam in ed 20 specim en s each
from w h ite versu s black an d m ale versu s fem ale pop u lat ion s
an d fou n d th at a n otch w as p resen t 92.5% of th e t im e an d a foram en p resen t in th e rem ain ing specim en s.23 Th ey also n oted a
m ore lateral locat ion in m en versu s w om en an d in blacks versu s
w h ites (24.1 m m in w h ite m en , 26.1 m m in black m en , 22.3 m m
in w h ite w om en , an d 25.5 m m in black w om en ). Saylam et al
described th e presen ce of a su praorbit al n otch in 71.6%of specim en s, w ith an average dist an ce of 25.2 m m from th e m idlin e.24
Webster et al exam in ed th e variabilit y in n er ve exit pat tern s
bet w een sides w ith in th e sam e person in a st udy w ith 111
sku lls.25 In ap proxim ately 50%of specim en s, a bilateral su p raorbit al n otch w as foun d, in 25% a bilateral supraorbit al foram en ,
an d in 25%, a n otch on on e side w ith a foram en on th e con t ralateral side. Ext rap olat ing d e n it ive con clu sion s abou t th e p resen ce of a n otch versu s a foram en as w ell as a p recise location of
ner ve exit from the data review ed here is lim ited by th e fact th at
n o t w o st u dies exam in ed com parable popu lat ion s in su cien t
n u m bers w ith com p arable referen ce poin t s to m easu re n er ve
exit; h ow ever, th e dat a h igh ligh t th e im p or tan ce of ap preciat ing
th e frequen t variabilit y w ith in di eren t people an d even w ith in
th e sam e pat ien t .
Th e secon d com pression poin t of th e SON is th e corrugator
su percilii m u scle (CSM), w h ere bran ch es of th e n er ve cou rse
directly th rough th e m uscle in 78%of people.18,26 In an an atom ical st u dy of 25 cadavers, Jan is et al described th e bran ch ing
p at tern s of th e SON in relat ion to th e CSM an d discovered fou r
u n ique pat tern s.18 In a t ype I bran ch ing pat tern , w h ich occu rred
in 40% of specim en s, th e deep bran ch of th e SON in teracted
w ith the CSM. In a t ype 2 pat tern, occurring in 34%of specim en s,
87
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 10.2 (a) Compression points of the supraorbital nerve. (Reproduced with permission from
Bindingnavele VK1, Bresnick SD, Urata MM, et al.
Superior results using the islandized hemipalatal
ap in palatoplast y: experience with 500 cases.
Reproduced from Plast Reconstr Surg 2008;
122(1):232.) (b) Supraorbital nerve course
through the corrugator supercilii muscle. Fascial
band classi cation at the supraorbital notch.
(Reproduced with permission from Fallucco M1,
Janis JE, Hagan RR. The anatomical morphology
of the supraorbital notch: clinical relevance to
the surgical treatment of migraine headaches.
(Reproduced with permission from Plast Reconstr
Surg 2012;130(6):1227–1233.)
a
b
bran ch es of bot h t h e su p er cial an d d eep bran ch es of t h e SON
in teracted w it h t h e CSM. In a t yp e 3 p at ter n , w h ich occu rred
in 4%of specim en s, on ly th e super cial bran ch of th e SON in teracted w ith th e CSM. Lastly, in a t yp e IV p at tern , occu rr in g in
22% of sp ecim en s, t h e bran ch ing of t h e SON occu r red m ore
cep h alad to t h e CSM, w it h ou t any in teract ion w it h t h e m uscle
(Fig. 10.2, low er left ).
Clinical Correlation
Th e supraorbital an d STNs con st it ute th e fron t al t rigger poin t ,
the m ost com m only described trigger point am ong m igraine patients. Patients w ith a frontal trigger point t ypically have a strong
CSM, as in dicated by deep frow n lin es. Th ey often h ave ten der-
88
n ess over th e SON, an d th ey exp erien ce h eadach es th at are “im ploding” an d are w orse in th e aftern oon an d w ith st ress.27
Th e rst com pression poin t is decom pressed via a supraorbit al foram in otom y (for a foram en ) or fasciotom y (for a n otch ).
Th e secon d t r igger p oin t is ad dressed by resect ion of t h e corr ugator m yofascial u n it th rough eith er su btot al resect ion of th e
CSMs or m ore e ect ively by resect ion of t h e en t ire glabellar
m u scle grou p , in clu d in g t h e CSM an d p or t ion s of t h e d ep ressor su percilii an d p roceru s m u scles. Th is resect ion is ach ieved
th rough eith er a t ran spalpebral approach or w ith an en doscopic
ap proach th rough sm all h airlin e in cision s,2 alth ough th e en doscop ic ap proach h as been sh ow n to visu alize m ore of th e m u scle and therefore m ay lead to m ore successful com plete resection
an d bet ter d ecom p ression .28,29
10 Sensory Nerves of the Head and Neck
Table 10.1 Compression points of the supraorbital nerve
Compression
point
1
2
Name
Type
Frequency
Supraorbital
notch
Fascial/
bony
Supraorbital
foram en
Bony
83.3%a (51.2% fascial
band, 30.2%
partial bony band,
9.3% horizontal
septum, 9.3%
vertical septum )
26.7%a
Corrugator
supercilii
Muscular
78% (40% deep
branch, 34% deep
and super cial
branch, 4%
super cial branch)
Horizontal location
(from midline)
Craniocaudal
location
At the superior
orbital rim
Fallucco et al19
Beer et al21
Agthong et al22
31 m m
25.1 mm in m en, 24.1 m m
in wom en
24.1 m m in white m en, 26.1
mm in black m en, 22.3
mm in white wom en, and
25.5 mm in black women
25.2 mm
2.9 –43.3 mm b
Reference
Cutright et al23
Saylam et al24
9.8–32.6 mm
cranial to
nasion b
Janis et al18
a 10% of
bThese
specim ens had both a supraorbital notch and a foram en.
m easurem ents indicate the extent of the corrugator supercilii m uscle.
Mu lt ip le clin ical st u dies h ave been com p leted th at address
m u scu lar, fascial or bony release of th e fron t al t rigger p oin t .5,13,30
Su ccess rates of m igrain e h eadach e im p rovem en t or m igrain e
h eadach e elim in at ion h ave been h igh w h en perform ed in depen den tly or con curren tly w ith decom pression of oth er t rigger
points. Interestingly, the proportion of patients w ho bene t from
su rgical decom pression (79.2%)5 closely m irrors th e p ercen t age
of pat ien t s w h o h ave in teract ion bet w een th e SON an d th e CSM
(78%).18
Supratrochlear Nerve
Origin and Course
Th e STN is on e of th e t w o term in al cut an eou s bran ch es of th e
fron tal branch of the oph th alm ic division of th e trigem inal ner ve
(V1). It p rovides sen sor y in n er vat ion to th e m id lin e foreh ead
(Fig. 10.1). Mu ch less h as been publish ed about th e an atom y of
th e sm aller STN com pared w ith th e larger SON. Th e STN proceeds m edially to exit th e superior orbit al rim via a n otch or a
foram en , th en t ravels cran ially th rough th e CSM. Miller et al exam in ed th e an atom y of th e STN in 10 cadavers an d fou n d th at
th e n er ve cou rsed bet w een 1.6 an d 2.3 cm lateral to th e m idlin e
at th e level of th e superior orbit al rim .31 After exit ing th e orbital
rim , th e STN cou rses th rough th e CSM as it t ravels ceph alad.
Points of Compression and External
Landmarks
Th e rst com pression poin t of th e STN occurs as it exit s th e
orbit via eith er a n otch or a foram en (Table 10.2). In a dissect ion
of 50 cadaver h em ih eads by Jan is et al, th e STN w as foun d to
exit the orbit via a notch in 72%of specim ens, located an average
of 1.75 cm from th e m idlin e.32 Th e oor of th e n otch con sisted
of a brou s ban d in all cases. In 68%of specim en s, th e n er ve w as
obser ved to pass directly th rough th e n otch ; h ow ever, in 8%, th e
n er ve p ierced th e fascial ban d an d cou rsed directly th rough th e
con n ect ive t issu e. In an oth er 8%, th e fascial ban d w as ver y
broad an d at ten ed th e n er ve again st th e bony surroun dings. A
t rue bony foram en occurred in 18% of specim en s an d w as located an average of 4 m m cran ial to th e superior orbit al rim .
Th e secon d com pression poin t occurs as th e STN in teract s
w ith th e CSM. Jan is et al found th at 84% of th e t im e, th e STN
Table 10.2 Compression points of the supratrochlear nerve
Compression
Point
Name
Type
1
Frontal notch
2
Frequency
Horizontal location
(from midline)
Craniocaudal
location
Fascial/bony
72%
17.5 m m
At the superior
orbital rim
Janis et al32
Frontal
foram en
Bony
18%
4 m m cranial
to superior
orbital rim
Janis et al32
Corrugator
supercilii
Muscular
88% (84% t wo branches,
4% one branch)
15 m m cranial
to superior
orbital rim
Janis et al32
Enters m uscle 18.7 m m ,
exits muscle 19.6 m m
Reference
89
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 10.3 Compression points of the supratrochlear nerve. (Reproduced with permission from Janis JE1, Hatef DA, Hagan R, et al.
Anatomy of the supratrochlear nerve: implications for the surgical
treatment of migraine headaches. Plast Reconstr Surg 2013;131(4):
743–750.)
d ivid ed in to t w o bran ch es w it h in t h e ret ro -orbicu lar is fat ,
w h ich t h en bot h en tered t h e CSM at an average of 18.7 m m
lateral to th e m idlin e, an d exited it 19.6 m m lateral to th e m idlin e an d 15 m m cran ial to th e sup erior orbit al rim (Fig. 10.3).32
In 4% of sp ecim en s, on ly on e STN bran ch en tered th e CSM, an d
th e oth er on e st ayed deep; in 12% of specim en s, n eith er bran ch
t raveled th rough th e CSM, but rath er both rem ain ed deep to th e
m u scle.
Clinical Correlation
Th e STN an d th e SON con st it ute th e fron tal t rigger poin t , an d
release of bot h n er ves is u su ally ach ieved sim u lt an eou sly. An atom ical st u d ies involvin g t h e STN h ave h igh ligh ted t h e im p or t an ce of exten d in g su rgical d issect ion m ed ially to fu lly
d ecom p ress it . It h as been hyp ot h esized t h at failu re to fu lly
d ecom press th e m ost m edial aspect of th e fron t al t rigger site
m ay h ave resu lted in early clin ical failu res.32
In a st u dy by Jan is et al, 30% of su bject s w ere fou n d to h ave
t w o ZTN bran ch es.33 Am ong th ose, 20% h ad bran ch ing of th e
ZTN w ith in th e orbit, w ith th e t w o bran ch es exit ing via t w o
separate zygom at icotem p oral foram in a. In th e rem ain ing 80%,
th e ZTN bran ch ed after exit ing th e orbit . Accessor y bran ch es of
th e ZTN w ere foun d in 50 to 55% of pat ien t s. Am ong th ose w ith
accessor y ZTN bran ch es, th e ZTN bran ch es w ere cran ial to th e
m ain bran ch in 30% on th e left (located an average of 16m m
lateral an d 12.2 m m cran ial to th e lateral palpebral com m issu re) an d in 55% on th e righ t (located an average of 15.7 m m
lateral an d 16.5 m m cran ial to th e lateral palpebral com m issu re). Th e ZTN bran ch es w ere im m ed iately adjacen t to th e m ain
bran ch in 30% on th e left (located an average of 17.7 m m lateral
an d 6 m m cran ial to th e lateral p alp ebral ssu re) an d in 9% on
th e righ t (located an average of 19.0 m m lateral an d 5.0 m m
cran ial to th e lateral palpebral com m issure). Th e ZTN bran ch es
w ere lateral to th e m ain bran ch in 40%, on th e left (located an
average of 34.2 m m lateral an d 6.7 m m cran ial to th e lateral
palpebral com m issu re), an d in 36% on th e righ t (located an average of 28.7 m m lateral an d 6.0 m m cran ial to th e lateral p alp ebral com m issu re). In all cases w ith a lateral bran ch , th is bran ch
travelled horizontally to join the ATN. Tubbs et al have con rm ed
th is com m un icat ion w ith th e ATN in 13%of h em ih eads.35 In ad dit ion , Odobescu et al foun d th at 82% of in dividu als h ad sm all
con n ect ion s bet w een th e ZTN an d th e fron tal division of th e
facial n er ve.36
Points of Compression and External
Landmarks
Th e rst com pression poin t occu rs as th e ZTN en ters th e tem poral fossa. Th e n er ve exit s th e lateral orbit via a bony can al an d
em erges in th e tem poral fossa via a bony foram en (Fig. 10.4,
Table 10.3) 34 ; 94% of in d ivid u als h ave on e zygom at icotem p oral
foram en , an d th e rem ain ing 6% h ave t w o foram in a.33 Th e foram en is located in th e fron t al bon e w ith in th e tem poral fossa an d
is fou n d an average of 6.7 ± 6.12 m m lateral to th e lateral orbit al
rim an d 7.88 ± 6.9 m m cran ial to th e n asion . In an an atom ical
st u dy of 400 h em isku lls, Lou kas et al fou n d th at th e locat ion of
th e zygom at icotem poral foram en varied w idely depen ding on
eth n ic backgrou n d an d th at u p to 50% of in d ividu als lacked a
zygom at icotem poral foram en .37
Temporal Trigger Point
Zygomaticotemporal Nerve
Origin and Course
Th e ZTN is on e of th e t w o term in al bran ch es of th e zygom at ic
n er ve, w h ich is a bran ch of th e m axillar y d ivision of th e t rigem in al n er ve (V2).33 Th e zygom at ic n er ve en ters th e orbit via th e
in fer ior orbit al ssu re, t ravels alon g t h e lateral orbit al w all,34
th en divides in to th e zygom at icofacial n er ve (ZFN) an d ZTN. Th e
ZTN provides sen sat ion to th e skin of th e tem ple (Fig. 10.1), as
w ell as p arasym p ath et ic in n er vat ion to th e lacrim al glan d.34
90
Fig. 10.4 Compression points of the zygomaticotemporal nerve.
10 Sensory Nerves of the Head and Neck
Table 10.3 Compression points of the zygomaticotemporal nerve
Compression
point
Name
Type
Frequency
Horizontal location
Craniocaudal
location
1
Zygom aticotemporal
foram en
Bony
100%
6.7 ± 6.12 m m lateral
to the lateral orbital
rim
7.88 ± 6.9 m m
superior to the
nasion
2
Temporalis m uscle
Deep temporal
fascia
Muscular
Fascial
50%
50%
16.9 m m lateral to
the lateral ocular
com m issure
10.1 ±1.5 m m lateral
to the zygomaticofrontal suture
6.5 mm superior to
the lateral ocular
com missure
22.2 ± 3.1 m m
superior to upper
margin of
zygom atic arch
23 m m cranial to the
zygom atic arch
Reference
Janis et al33
Janis et al33
Janis et al33
Totonchi et al34
Jeong et al38
Tubbs et al35
The second com pression point is the tem poralis m uscle/deep
tem poral fascia. After exit ing th e orbit , th e ZTN en ters th e deep
aspect tem p oralis m u scle an d t ravels in t ram u scu larly in 50% of
in dividuals.33 Am ong th ose w h ose ZTN h as an in t ram u scu lar
course, th is course is sh or t an d direct in 44% an d long an d tort uous in 56%. In th e 50% of in dividuals w h o h ave n o in t ram uscular course, th e ZTN t ravels bet w een th e tem poral periosteum
an d th e tem poralis m u scle before p iercing th e deep tem p oral
fascia. In an in t raop erat ive en d oscop ic an atom ical st u dy of 20
p at ien t s, Toton ch i et al foun d th at th e ZTN pierced the deep
tem poral fascia 16.9 m m lateral an d 6.5 m m cran ial to th e lateral p alpebral com m issu re,34 w h ereas Jeong et al fou n d th at it
pierced th e deep tem poral fascia 10.1 ± 1.5 m m lateral to th e
zygom aticofrontal suture and 22.2 ± 3.1 m m cranial to the upper
m argin of t h e zygom at ic arch .38 Th is w as con r m ed by Tu bbs
et al, w h o fou n d th at th e ZTN pierced th e deep tem p oral fascia
an average of 23 m m cran ial to th e zygom at ic arch .35
sign i can t im p rovem en t .41 In a p rospect ive evalu at ion of 71 p at ien ts w ith a tem poral t rigger site un dergoing surgical avulsion
of t h e ZTN, w it h a m ean 396-day follow -u p , Guyu ron et al
d em on st rated com p lete m igrain e elim in at ion in 63%, w it h at
least 50%im p rovem en t in m igrain e sever it y, d u rat ion , an d frequ en cy in an ad d it ion al 35%.3 In a single-blin d ed , ran dom ized
con t rolled t rial com paring act ual decom pression of th e ZTN in
19 pat ien t s w ith sh am su rger y in n in e pat ien t s, th ose un dergoing act ual decom pression h ad sign i can t im provem en t s in m igrain e in ten sit y, frequ en cy, an d du rat ion from baselin e, w h ich
w as n ot th e case for th ose u n dergoing sh am su rger y.4 In a review of 19 pat ien t s u n dergoing ZTN avu lsion for th e t reat m en t
of m igrain e h eadach es from a tem poral t rigger site, w ith a m ean
follow -u p of 661 days, Jan is et al dem on st rated com plete m igrain e elim in at ion in 52.6%of p at ien t s, w ith an ad dit ion al 36.8%
h aving at least 50% im p rovem en t .5
Clinical Correlation
Auriculotemporal Nerve
Pat ien t s w it h m igrain e h eadach es or igin at in g from t h e ZTN
ten d to h ave tem poral pain , usually in th e m orn ing, associated
w ith st ress, grin ding, clen ch ing, or tem porom an dibular join t
dysfun ct ion .27 Mu rillo rst described open resect ion of th e ZTN
an d of th e su per cial tem poral arter y (STA) for tem p oral m igrain e h eadach es in 34 p at ien ts in 1968 39 ; resu lt s w ere p osit ive
in 88.2% of p at ien ts. Th e tech n iqu e for ZTN decom pression h as
sin ce been re n ed by Guyu ron an d is n ow u su ally p erform ed
via an en d oscop ic ap p roach . Dissect ion is p er form ed ju st su p er cial to th e deep tem poral fascia u n t il th e ZTN is iden t i ed.
It is th en avu lsed, w ith resect ion of ap proxim ately 3 cm of th e
n er ve, allow ing th e p roxim al en d of th e n er ve to ret ract an d get
buried in to th e tem poralis m uscle.40 Avu lsion of th e ZTN m ay
cause tem porar y paresth esia an d an esth esia in th e tem poral region , w h ich are u su ally tem porar y.41 Th e m eth od of ZTN decom pression h as been exam in ed by Ch im et al.42 In an an im al
st u dy on rat su ral n er ves, th ey fou n d th at n er ve avu lsion an d
bur ying in m uscle led to th e low est rate of n eurom a form at ion .
In a st u dy of 246 p at ien t s u n dergoing en doscop ic decom pression of th e ZTN, Ku rlan der et al foun d th at at 1 year postop erat ively 55% of pat ien t s h ad com p lete elim in at ion of tem p oral
m igrain e h eadach es, w ith an addit ion al 30% of p at ien t s h aving
Origin and Course
Th e ATN is a bran ch of th e m an dibular division of th e t rigem in al n er ve (V3). It is a sen sor y n er ve th at provides sen sat ion to
th e t ragus an d an terior ear, as w ell as to th e posterior tem poral
region (Fig. 10.1). It also carries auton om ic n er vous bers, provid ing sym p at h et ic in n er vat ion to t h e scalp an d p arasym p ath et ic in n er vat ion to th e parot id glan d.
Th e ATN em erges w ith in th e super cial parot id glan d along
th e posterom edial aspect of th e tem porom an dibular join t 43 an d
t ravels cran ially w ith in th e tem poroparietal fascia, crossing th e
p osterior aspect of th e zygom at ic arch .44 It t ravels as a single
bran ch in 50%of people, an d u p to four bran ch es in th e rem ain der.45 As th e n er ve t ravels cep h alad, it p arallels an d ru n s lateral
to t h e STA.44 In t h e u p p er tem p oral area, t h e n er ve becom es
m ore super cial, lying super cial to the tem poroparietal fascia.
Points of Compression and External
Landmarks
In an an atom ical st u dy of 10 cadavers, Ch im et al fou n d th at in
all sp ecim en s th e ATN t raveled u n der a fascial com pression
91
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 10.5 Compression points of the auriculotemporal nerve.
band (com pression point 1), present an average of 13.1 ± 5.9 m m
an terior an d 5.0 ± 7.0 m m cran ial to th e m ost an terosu p erior
poin t of th e extern al acoust ic m eat us (Fig. 10.5, Table 10.4).46
Th ey also sh ow ed th at in 85% of specim en s, a secon d, m ore
cranial, fascial com pression ban d (com pression poin t 2) w as
presen t an average of 11.9 ± 6.0 m m an terior an d 17.2 ± 10.4
m m cran ial to t h e m ost an terosu p er ior p oin t of t h e exter n al
acou st ic m eat u s.
Th e th ird poten t ial com pression poin t con sists of th e in tersect ion w ith th e STA, fou n d in u p to 80%of specim en s; 81.2% of
those specim ens dem onstrated a sim ple intersection. Most com m on ly in this situation, th e arter y crossed super cial to th e n erve
(62.5%), at a poin t 19.2 ± 10.0 m m an terior an d 39.5 ± 16.6 m m
su perior to th e m ost an terosu p erior p oin t of th e extern al acou st ic m eat us. In th e rem ain ing 18.8% of th e sim ple in tersect ion
sp ecim en s, m u lt ip le bran ch es of t h e n er ve crossed su p er cial
to th e arter y at m ult iple poin t s, w ith variable an atom y am ong
t h e sp ecim en s. In 18.8% of t h e sp ecim en s w it h an AT-STA in tersect ion , h elical in ter t w in ing over an average distan ce of 10.3
± 0.4 m m w as n oted to exten d bet w een 20.0 ± 15.6 m m an d
24.7 ± 17.9 m m an terior an d 53.7 ± 4.7 m m an d 62.7 ± 3.8 m m
cran ial to th e m ost an terosuperior poin t of th e extern al acoust ic m eat us.46 In a st udy of 25 fresh cadavers, Jan is et al also described th e th ird com p ression p oin t of th e ATN in det ail44 : it
w as p resen t in 34% of sp ecim en s at a p oin t located an average
of 107.88 ± 17.73 m m lateral to th e facial m idlin e an d 37.53 ±
15.29 m m cran ial to a h orizon tal lin e passing th rough th e nasion . Am ong th e specim en s th at dem on st rated an in tersect ion
bet w een th e ATN an d STA, th e in tersect ion con sisted of a sim ple crossing in 88.2% an d a h elical in ter t w in ing in 11.8%. In
cases of a h elical in tert w in ing, th is exten ded from 123 m m to
117 m m lateral to th e m idlin e an d from 25 m m to 38 m m cran ial to a h orizon t al lin e th rough th e n asion .
Table 10.4 Compression points of the auriculotemporal nerve
Compression
point
Name
Type
Frequency
Horizontal location
Craniocaudal
location
1
Fascial band 1
Fascial
100%
13.1 ± 5.9 m m
anterior to
anterosuperior
EAC
5.0 ± 7.0 mm
superior to
anterosuperior
EAC
Chim et al46
2
Fascial band 2
Fascial
85%
11.9 ± 6.0 m m
anterior to
anterosuperior
EAC
17.2 ± 10.4 m m
superior to
anterosuperior
EAC
Chim et al46
3
Super cial
temporal
artery
Arterial
Simple
intersection: 65%
19.2 ± 10.0 m m
anterior to
anterosuperior
EAC
39.5 ± 16.6m m
superior to
anterosuperior
EAC
Chim et al46
Helical
intert wining: 15%
20.0 ± 15.6 m m to
24.7 ± 17.9 m m
anterior to
anterosuperior
EAC
53.7 ± 4.7 m m
to 62.7 ±3.8
m m superior
to anterosuperior EAC
Simple
intersection: 30%
107.88 ± 17.73 m m
lateral to m idline
37.53 ± 15.29
m m superior
to nasion
Helical
intert wining: 4%
123–117 m m lateral
to midline
25–38 m m
superior to
nasion
Abbreviations: EAC, external acoustic canal.
92
Reference
Janis et al44
10 Sensory Nerves of the Head and Neck
Clinical Correlation
Th e ATN h as been hypoth esized to be th e t rigger poin t in patients w ith persistent tem poral m igraine headaches w ho underw en t ZTN release.44 Pat ien t s w ith an ATN t rigger p oin t t ypically
h ave p ain along th e cou rse of th e ATN in th e h igh tem p oral region .27,46 Th is p ain m ay be p u lsat ile if n er ve com p ression is du e
to im p ingem en t of th e su p er cial tem p oral ar ter y on th e AT.44
Alth ough a su rgical tech n iqu e directly addressing th e rst
t w o fascial com pression p oin ts h as n ot been described yet , decom pression of th e ATN in tersect ion w ith th e STA involves
m aking a sh or t in cision over t th e p oin t of m axim al ten dern ess 46
or in th e tem poral h airlin e 44 an d exp osing th e ATN. If th e STA
arter y is fou n d to be crossing over th e n er ve, th e arter y is ligated . If th e ar ter y is n ot crossing over th e n er ve, th e n er ve is
t ran sected, an d it s en ds are buried in th e tem poralis m uscle.
Nasoseptal Trigger Point
Pathophysiology
Nasoseptal headaches are at tributed to intranasal m ucom ucosal
con tact poin t s th at are presen t in up to 4% of th e populat ion .47
Th e con t act areas are believed to cau se n eu ral ir r it at ion , lead in g to th e release of in am m ator y m ediators, sp eci cally su b st an ce P. Th is cau ses n ocicept ive sign als to be t ran sm it ted along
a eren t C bers to t h e d u ra m ater, w h ich t h en lead to vasod ilat ion an d p erivascu lar in am m at ion in th e d u ra, gen erat ing a
m igrain e h eadach e.
Points of Compression
In t ran asal con t act p oin t s can u su ally occu r bet w een t h e sep t u m an d t h e su p er ior t u rbin ate, m id d le t u rbin ate, or m ed ial
w all of th e eth m oid sin u s (Fig. 10.6). Cau ses of th ese con t act
p oin ts in clude sept al deform it ies, such as sept al deviat ion an d
septal sp u rs; t u rbin ate d eform it ies su ch as t u rbin ate hyper t rop hy; an d con ch a bullosa,48 w h ich refers to a pn eu m at ized t u rbin ate th at m ay im p inge on th e n asal sept u m .49
In p at ien t s w it h m igrain e h eadach es at t r ibu ted to a n asosept al t r igger p oin t , Fer rero et al fou n d t h at t h e frequ en cy of
in t ran asal m u cosal con t act p oin t s w as t h e follow in g: sept u m m id d le t u rbin ate p lu s sept u m -su p er ior t u rbin ate in 42.8%,
sept u m -m iddle t u rbin ate in 36%, sept al sp u r in 7.1%, sept al sp u r
p lus sept u m -m iddle t u rbin ate in 7.1%, sept al spur plu s sept u m m iddle t u rbin ate plu s sept u m -su p erior t u rbin ate in 7.1%.50
Fig. 10.6 Nasoseptal trigger point s: (a) Hypertrophic inferior turbinate. (b) Hypertrophic
middle turbinate with concha bullosa.
(c) Septal spur. (d) Deviated septum.
93
Anatom y for Plastic Surgery of the Face, Head, and Neck
Clinical Correlation
Pat ien ts w ith a n asosept al m igrain e t rigger p oin t t yp ically com plain of ret robulbar pain , usually w orse in th e early m orn ing,
an d related to w eath er, allergies, an d h orm on al cycles an d associated w ith rh in orrh ea.27 Con rm at ion of th e n asosept al t rigger
poin t as th e cau sat ive agen t in m igrain e m ay take th e form of
ap plicat ion of top ical local an esth et ic or inject ion of local an esth et ic in to th e con tact poin t du ring an act ive h eadach e. Im provem en t or elim in at ion of th e h eadach e con rm s th e con tact
poin t as a t rigger.51 An oth er m odalit y for diagn osis w ould be a
com bin at ion of con stellat ion of sym ptom s (as above) com bin ed
w ith com pu ted tom ograph ic scan n dings of an atom ical con tact poin t s (usually m ost easily seen on coron al im ages). Rh in osin u sit is m u st also be exclu ded.47
Surgical techn iques to address nasoseptal trigger points m ust
address th e u n derlying an atom ical abn orm alit y to elim in ate
th e m ucosal con t act point an d in clude septoplast y, m iddle t u rbinectom y, an d m edial eth m oidectom y.
In a st u dy of 12 p at ien t s w ith m igrain e h eadach es at t ribu ted
to th e n asosept al t rigger poin t , Beh in et al foun d th at surger y
redu ced h eadach e frequ en cy from 17.7 days per m on th to 7.7
days per m on th an d m ean h eadach e severit y from 7.8 to 3.6.47
Headach e severit y im p roved by 50% or m ore in 76.2% of su bject s an d w as elim in ated in 42.9%. In a st udy of 30 pat ien ts w ith
m igrain e h eadach es from a n asosept al t rigger p oin t , en d oscop ic
n asal su rger y ach ieved com plete h eadach e relief in 43%an d sign i can t im provem en t in 47%.52 Welge-Lu essen follow ed u p on
20 pat ien ts w ith m igrain e h eadach es from a n asosept al t rigger
poin t for a period of 10 years after en doscopic septoplast y, part ial eth m oidectom y, an d t urbinectom y (if in dicated) an d foun d
th at 30% had com plete h eadache resolut ion an d an addit ion al
35% h ad sign i can t im provem ent .53 In a st udy of eigh t pat ien ts
w ith a n asosept al t rigger poin t w h o un der w en t septoplast y or
in ferior an d/or m idd le t urbin ectom ies, eith er alon e or in con ju n ct ion w ith oth er t rigger sites, w ith a follow -u p of 661 days,
Jan is et al dem on st rated sign i can t overall im p rovem en t in
100%, w ith 62.5%having com plete elim ination of m igraine headach es.5 In a prospect ive evaluat ion of 62 pat ien t s w ith a n asosept al t rigger poin t u n dergoing su rgical t reat m en t , w ith a m ean
follow -u p of 396 days, Guyu ron et al dem on st rated com plete
m igrain e elim in at ion in 34% of p at ien t s, w ith an addit ion al 55%
exp erien cing at least 50% im p rovem en t .3
Occipital Trigger Point
Greater Occipital Nerve
Origin and Course
Th e greater occipit al n er ve (GON) is th e m edial bran ch of th e
dorsal ram us of th e C2 spin al n er ve. It m easures approxim ately
5 m m in diam eter as it en ters th e sem ispin alis capit is m uscle.54
Th e GON in it ially t ravels in a cau dal, p oster ior, an d lateral d irect ion u n t il it reach es th e low er border of th e obliqu u s cap it is
in ferior m u scle. It th en h ooks arou n d th is m uscle an d t ravels
cran ially, super cial to th e obliquus capit is in ferior m u scle, an d
deep to th e sem ispin alis capit is m uscle. Th e n er ve th en crosses
the sem ispinalis capitis m uscle from deep to super cial and ru n s
cran ially d eep to t h e t rap eziu s m u scle. It t h en p ierces t h e t ra-
94
p eziu s m u scle to becom e su bcu t an eou s an d provid es sen sor y
in n er vat ion to th e posterior scalp (Fig. 10.1).
Points of Compression and External
Landmarks
Jan is et al st u died th e p oten t ial com p ression p oin ts of th e GON
in 50 cadaver h em ih eads.55 Th ey iden t i ed six poten t ial poin t s
of com pression of th e GON as it t raveled cran ially th rough th e
posterior n eck (Fig. 10.7, Table 10.5). Th e rst com pression
poin t occu rred as th e GON crossed t igh t fascial ban ds bet w een
th e obliquus capit is in ferior an d sem ispin alis m uscles before
con t in uing its cran ial course. Th is poin t occurred at an average
20.13 m m lateral an d 77.38 m m cau dal to th e extern al occipit al
prot uberan ce (EOP).
Th e secon d com p ression p oin t occu r red w h en t h e GON
en tered t h e d eep su rface of t h e sem isp in alis cap it is 17.46 m m
lateral an d 59.71 m m cau dal to t h e EOP. Th e GON p ierced t h e
sem isp in alis cap it is m u scle in 90% of sp ecim en s by Bovim
et al.56
The third com pression point occurred w hen the GON em erged
from th e su per cial su rface of th e sem ispin alis cap it is 15.52
m m lateral an d 34.52 m m cau dal to th e EOP. Th is p oin t of com pression h as been st udied exten sively an d con rm ed by several
oth er au th ors. Mosser et al con du cted an an atom ical st u dy an d
foun d th at poin t of em ergen ce of th e GON from th e sem isp in alis cap it is m u scle cou ld be fou n d 29.1 m m (righ t) to 28.7 m m
(left ) cau dal to t h e EOP an d 14.1 m m (r igh t ) to 13.8 m m (left )
lateral to t h e EOP.54 Th is w as also con r m ed by Du cic et al,57
w h o foun d th e poin t of em ergen ce to be 14.9 m m lateral an d
30.2 m m in ferior to th e EOP an d w h o also n oted th at t h e cou rse
of t h e GON w as asym m et ric in 43.9% of in d ivid u als. Tu bbs et
al fou n d th at th e GON p ierced t h e sem isp in alis cap it is m u scle
2 cm cran ial to th e in term astoid lin e.58 Th e m ean in t ram u scu lar
cou rse in t h e sem isp in alis cap it is m u scle w as 7.6 m m (r igh t )
an d 8.9 m m (left ).
Th e fou r th com p ression p oin t , as dem on st rated by Jan is et
al,55 occurred as th e GON en tered th e t rapeziu s m u scle, 24.0 m m
lateral an d 21.0 m m cau dal to th e EOP. Th e fth com p ression
p oin t occu rred as th e GON p ierced t h e ten d in ou s in ser t ion of
th e trapeziu s in to th e n uch al lin e, 37.07 m m lateral an d 4.36 m m
cau dal to t h e EOP.
Th e sixth com p ression p oin t con sisted of th e in teract ion of
t h e GON w ith th e occip it al ar ter y,59 id en t i ed in 54% of sp ecim en s. Th is took th e form of a sim p le in tersect ion in 29.6%(w ith
t h e n er ve alw ays crossing su p er cial to th e ar ter y) an d of h elical in ter t w in in g in 7 0.4%. In cases w h ere t h ere w as a sin gle
p oin t of in tersect ion , th is occu rred 30.27 m m ± 6.83 m m lateral
an d 10.67 m m ± 8.25 m m cau dal to t h e EOP. In cases w h ere
t h ere w as a h elical in ter t w in in g, t h is occu rred bet w een 25.34
m m ± 12.16 m m an d 42.09 m m ± 25.61 m m lateral an d bet w een
24.91 m m ± 12.87 m m an d 0.97 m m ± 8.34 m m cau dal to th e
EOP, w ith a tot al len gt h of h elical in ter t w in in g of 37.6 m m ±
14.5 m m . Th e locat ion of t h e in teract ion bet w een t h e GON an d
t h e occip it al ar ter y is qu ite variable, as evid en ced by th e h igh
st an dard d eviat ion s rep or ted . In fact , alth ough it is referred to
as t h e sixth com p ression p oin t , it often occu rs p roxim al to p oin t
5 alon g t h e cou rse of t h e GON. It m ay be su p er cial or d eep to
t h e t rap eziu s m u scle. In a review of 272 p at ien t s u n d ergoin g
GON decom pression, Junew icz et al noted that the GON branched
in 7.4% of pat ien t s, m ost often in to t w o bran ch es.60 Th ey n oted
Fig. 10.7 Compression point s of greater occipital and third occipital nerves.
Table 10.5 Compression points of the greater occipital nerve
Compression
point
Frequency
Horizontal location
(from midline)
Craniocaudal location
Reference
20.1 m m
77.38 mm below EOP
Janis et al55
Name
Type
1
Bands bet ween
obliquus
capitis and
sem ispinalis
Fascial
2
Entrance into
sem ispinalis
Muscular
90%
17.46 m m
59.71 mm
Janis et al55
Bovim et al56
3
Exit from
sem ispinalis
Muscular
90%
11.5 m m
37.3 m m below EOP
Vital et al61
14.1 ± 4.4 m m on
right, 13.8 ± 4.3
m m on left
29.1 ± 7.8 m m on right,
28.7 ± 6.6 m m on left
below EOP
Mosser et al54
14.9 ± 4.5 m m
30.2 ± 5.1 m m
Ducic et al 57
15.52 m m
34.52 m m
Janis et al55
2 cm above interm astoid
line
Tubbs et al58
4
Entrance into
trapezius
Muscular
24 m m
21 m m
Janis et al55
5
Through
trapezius
insertion
Musculotendinous
37.07 m m
4.36 m m
Janis et al55
6
Occipital artery
Arterial
16%
Simple intersection:
30.27 ± 6.83 m m
Simple intersection:
10.67 ± 8.25 mm
Janis et al55
38%
Helical intert wining:
25.34 ± 12.16
m m –42.09 ±
25.61 m m
Helical intert wining:
24.91 ± 12.87 mm –
0.97 ± 8.34 m m
Abbreviations: EOP, external occipital protuberance.
95
Anatom y for Plastic Surgery of the Face, Head, and Neck
an in teract ion bet w een th e GON an d th e occip it al ar ter y in 64%
of pat ien t s
Clinical Correlation
Pat ien ts w ith m igrain e h eadach es from a GON t rigger p oin t
u su ally h ave u p per cer vical an d occipit al pain related to h eavy
exercise an d st rain . Th ey m ay also h ave cer vical m u scle t igh tn ess an d ten dern ess over th e GON.27
Th ere are m u lt iple repor ts of “occipit al n euralgia” occu rring
for variou s reason s,58 from w h iplash to C2 osteophytes an d arth rit is causing com pression of th e GON. GON com pression m ay
be static or dynam ic, as dem onstrated by Vital et al, w ho dem on st rated th at th e GON m ay be com p ressed by its m u scu lofascial
su rrou n dings du ring n eck exion an d rot at ion .61
Diagn osis of th e occipital t rigger p oin t as a cau se of m igrain e
headaches has traditionally focused on com pression point 3, the
poin t of em ergen ce of th e GON from th e sem ispin alis capit is
m uscle. An th ony fou n d th at inject ion of local an esth et ic arou n d
th e GON 1.5 cm lateral to th e m idlin e an d 3 cm in ferior to th e
EOP du ring a m igrain e at t ack led to m igrain e resolu t ion in 88%
of pat ien t s.62
Tradit ion al t reat m en t s h ave focu sed on n er ve ablat ion , in cluding C2 dorsal rhizotom y, C2 dorsal ganglionectom y, or radiofrequ en cy ablat ion of th e C2 dorsal root . An th ony et al. fou n d
th at greater occipital n eurectom y led to resolut ion of m igrain e
headaches in 70%of patients for a m ean duration of 8.1 m onths.62
Su ch ablat ive t reat m en t , h ow ever, often resu lted in sign i can t
n u m bn ess in th e occipit al region .
Mod ern n er ve-p reser ving t reat m en ts of m igrain e h eadach es
w it h an occip it al t r igger p oin t revolve arou n d decom p ression
of th e six poten t ial com pression poin t s. Eith er a m idlin e ver t ical or a h orizon tal in cision is perform ed in th e posterior n u ch al
area th rough th e skin an d su bcu t an eou s t issu e. Th e t rapeziu s
fascia is exp osed an d in cised ju st lateral to th e m idlin e. Th e
GON is exp osed an d dissected free from th e sem ispin alis capit is
m u scle. A segm en t of sem ispin alis cap it is m u scle is rem oved
m ed ial to th e n er ve, an d a t riangu lar segm en t of t rap eziu s m u scle an d fascia is rem oved lateral to th e n er ve. Fascial ban ds overlying th e GON are released. If th e occipital arter y crosses th e
n er ve, it is ligated.
Long-term ou tcom es of GON decom pression h ave been favorable. In a p rospect ive evalu at ion of 34 p at ien t s w ith an occipital trigger site undergoing GON decom pression, w ith a m ean
396-day follow -u p , Guyu ron et al. ach ieved at least 50% im p rovem en t in m igrain e in ten sit y, d u rat ion , an d frequ en cy in
100% of pat ien ts, w ith 62% of th em h aving com plete m igrain e
elim in at ion .3 In a single-blin ded, placebo-con t rolled, ran dom ized t rial, Guyu ron et al ran dom ized 18 p at ien ts w ith m igrain e
headaches stem m ing from a GON trigger point to act ual or sham
su rger y.4 Th ere w as a sign i can t im provem en t in m igrain e
h eadach e frequ en cy, in ten sit y, an d d u rat ion in th e act u al su rger y group , w h ich w as sign i can tly greater th an th e im p rovem en t exp er ien ced by t h e sh am su rger y grou p (P = 0.03). Jan is
et al st u died 16 p at ien t s w ith m igrain e h eadach es from an occipit al t rigger site w h o un der w en t GON decom pression , eith er
alon e or in com bin at ion w ith oth er t rigger sites.5 After a follow -u p p eriod of 661 days, 93.8% dem on st rated sign i can t im provem en t , w ith 56.3% h aving com plete m igrain e elim in at ion .
96
Du cic et al follow ed u p on 202 pat ien t s w h o u n der w en t GON
decom pression , eith er alon e or in conjun ct ion w ith CSM excision , w ith a m in im u m follow -u p of 12 m on th s 15 ; 80.5% of th e
pat ien ts h ad sign i can t im provem en t , w ith 43.4% h aving com plete m igrain e h eadach e relief.
Th e role of occipital ar ter y ligat ion is st ill unclear. Ch m ielew ski et al an alyzed 170 pat ien t s w h o u n der w en t GON decom pression .63 Am ong th em , 55 pat ien t s un der w en t occipit al ar ter y
resect ion , an d 115 did n ot . Pat ien ts u n dergoing occip ital arter y
resect ion had sign i can tly low er rates of surger y su ccess, den ed as 50% or m ore redu ct ion in m igrain e h eadach es (80.0%
vs. 91.3%, P = 0.047) an d m igrain e elim in at ion (38.2% vs. 64.3%,
P = 0.002), w h ich suggest s th at occip it al arter y resect ion m ay
n ot alw ays be ben e cial in pat ien t s u n dergoing GON decom pression . Fur th er st udies m ay be n eeded, but w h at can be st ated
is th at som e pat ien t s w h o h ave a h igh suspicion of sym ptom s
related to th is area (geograp h ic locat ion , pulsat ile n at u re, p osit ive Doppler sign al at th e poin t of m axim al pain ) likely w ould
ben e t from decom pression of th is t rigger poin t .
Lesser Occipital Nerve
Origin and Course
The LON originates from the ventral ram us of the C2, and som et im es C3, spin al ner ves. It is a cutaneous ner ve that inner vates
the superior ear, as w ell as the postauricular and lateral neck
areas (Fig. 10.1). It em erges from beneath th e posterior border of
the sternocleidom astoid (SCM).64 The LON th en travels superolaterally along the posterior border of SCM. Ducic et al fou nd
that in 85% of specim ens, th e LON can be located along the posterior border of the SCM, 3 cm inferior to occipital prot uberan ce.57 It is m ore variable in th e rem aining 15%. It then crosses
over the SCM an d travels superolaterally to th e postauricu lar
region at a point 7 cm lateral to the EOP and 3 cm m edial to m astoid.58 Th e n er ve th en bran ch es in to a m edial an d lateral com ponent at the m idpoint bet w een the EOP and the interm astoid lin e.
Points of Compression and External
Landmarks
Th e LON’s poin t of em ergen ce from ben eath th e posterior border of th e SCM is located an average of 61.3 ± 12.3 m m (righ t) or
68.9 ± 10.1 m m (left) lateral to th e posterior m idlin e an d 53.2 ±
16.1 m m caudal to a h orizon t al line draw n th rough the in ferior
aspect of the external acoustic m eatuses (Fig. 10.8, Table 10.6).64
Most of th e t im e, th e n er ve sim p ly em erges arou n d th e m u scle
edge, bu t in 13.3%of sp ecim en s, th e LON act u ally p ierces it . Th is
is th e rst poten t ial com pression poin t . Lee et al located th is
poin t of em ergen ce from th e SCM an average of 64 ± 14 m m
lateral to th e posterior m idlin e an d 50 ± 9 m m cau dal to a lin e
draw n th rough th e m ost an terosuperior aspect s of th e extern al
acou st ic m eat u ses.65 Un like Dash et al, Lee et al foun d n o com pression at th e poin t of em ergen ce from th e SCM. Th is m u scu lar
com pression poin t can be t reated w ith n eurom uscular blockade
or n er ve block. Dash et al suggest addressing th e LON w ith botulin um toxin in a region ap proxim ately 3 cm in diam eter cen tered at a poin t 6.5 cm from m idlin e an d 5.3 cm below th e lin e
bet w een th e extern al acoust ic m eat uses.64
10 Sensory Nerves of the Head and Neck
Fig. 10.8 Compression point s of lesser
occipital nerve.
In 55% of cadavers, th e LON h ad an in tersect ion w ith th e occipit al ar ter y, con st it ut ing th e secon d poten t ial com pression
p oin t .65 Th is in tersect ion w as located 51 ± 9 m m lateral to th e
m idlin e an d 20 ± 14.5 m m in ferior to a h orizon t al lin e th rough
th e m ost an terosuperior poin t s of th e extern al acoust ic m eat uses. In 82%of th ose cases, th e in tersect ion w as a sim ple crossing located 50.7 ± 10.9 m m lateral to th e m idlin e an d 22.5 ± 16.3
caudal to th e h orizon tal lin e th rough th e m ost an terosuperior
p oin ts of th e extern al acoust ic m eat u ses. In th e rem ain ing 18%,
th ere w as a h elical in ter t w in ing bet w een th e t w o st ruct u res,
th e m idpoin t of w h ich w as located 52.2 ± 6.8 m m lateral to th e
m id lin e an d 15.7 ± 11.2 m m cau dal to th e x-axis.
The third com pression point, observed in 20% of specim ens,
consisted of a fascial band located 47 ± 8.1 m m lateral to th e m idlin e an d 13.1 ± 15.2 m m in ferior to a h orizon tal lin e th rough th e
m ost anterosuperior points of th e external acoustic m eatuses.65
Table 10.6 Compression points of the lesser occipital nerve
Compression
point
1
2
3
Horizontal location
(from midline)
Craniocaudal location
Reference
61.3 ± 12.3 mm (right)
or 68.9 ± 10.1 m m
53.2 ± 16.1 mm caudal
to inferior EAC
Dash et
al64
64 ± 14 m m
50 ± 9 m m caudal to
anterosuperior EOP
Lee et al65a
Simple intersection:
45.1%
50.7 ± 10.9 m m
22.5±16.3 m m caudal
to anterosuperior
EAC
Lee et al65
Helical intert wining:
9.9%
52.2 ± 6.8 m m
15.7 ± 11.2 m m caudal
to anterosuperior
EAC
20%
47 ± 8.1 m m
13.1 ± 15.2 m m caudal
to anterosuperior
EAC
Name
Type
Frequency
Em ergence
from SCM
Muscular
13.3%
Occipital
artery
Fascial band
Arterial
Fascial
Lee 65
Abbreviations: EAC, external acoustic m eatus; EOP, external occipital protuberance; SCM, sternocleidom astoid.
a Did not nd com pression at this point.
97
Anatom y for Plastic Surgery of the Face, Head, and Neck
Table 10.7 Compression points of the third occipital nerve
Compression
point
1
Name
Type
Frequency
Em ergence from
sem ispinalis
Muscular
100%
Clinical Correlation
Pat ien t s w ith LON com pression t ypically h ave sym ptom s sim ilar to t h ose seen w it h GON com pression , bu t th e pain is m ore
lateral along th e cou rse of th e LON. Th e LON m ay be im plicated
in p at ien t s w ith m igrain e h eadach es resu lt ing from an occipit al t rigger poin t w h o u n dergo GON release w it h ou t com p lete
relief.5
To decom press th e LON, it is released from all m uscular an d
fascial at t ach m en ts, ligated, an d it s en ds are im p lan ted in to th e
SCM m u scle. Guyu ron et al also recom m en d inject ing t riam cin olon e in th e area in t raoperat ively in order to m in im ize th e risk
of neurom a form at ion .30
Few clin ical st u dies h ave reported th e ou tcom es of LON release, an d m ost p at ien t s in th ose st udies u n der w en t con com itant GON release, w h ich m akes quan t i cat ion of th e ou tcom es
of isolated LON release di cult .
Third Occipital Nerve
Origin and Course
Th e t h ird occip it al n er ve (TON), also kn ow n as t h e d orsal occip it al n er ve, origin ates from th e m edial bran ch of th e dorsal
ram u s of th e C3 spin al n er ve.64 It is a sen sor y n er ve th at in n ervates th e p osterior m edial scalp an d n eck (Fig. 10.1).
Th e TON alw ays em erges from th e sem ispin alis capit is m uscle by piercing it an d th en t ravels cran ially in th e subcut an eous
plan e tow ards th e posterior m edial scalp. Th e average diam eter
of th e TON is 1.3 m m .66 Each TON h as m u lt ip le in tercon n ect ion s
w ith th e ipsilateral GON an d th e con t ralateral TON.
Points of Compression and External
Landmarks
Dash et al fou n d th at th e TON pierces th e sem ispin alis capit is
m u scle at a p oin t 13.0 ± 5.0 m m (left) to 13.3 ± 5.8 m m (righ t)
lateral to th e p osterior m idlin e an d 60.7 ± 20.2 m m (left) to 63.4
± 20.8 ± m m (righ t) in ferior to a h orizon t al lin e draw n th rough
th e in ferior aspect of th e extern al acoust ic m eat uses (Fig. 10.7,
Table 10.7).64 Tubbs et al foun d th at poin t approxim ately 5 to
6 cm caudal to th e extern al occipital prot uberan ce, 3 cm caudal
to th e in term astoid lin e, an d 3 to 7 m m lateral to th e m idlin e.66
Th e vert ical locat ion of th e TON varies sign i can tly; th erefore, to reliably block th is n er ve, Dash et al suggest perform ing
t w o inject ion s 1.3 cm lateral to th e m id lin e, w ith on e inject ion
1 cm above a h orizon tal lin e draw n th rough th e in ferior aspect
98
Horizontal location
(from midline)
13.0 ± 5.0 m m (left),
13.3 ± 5.8 m m (right)
Craniocaudal location
Reference
60.7 ± 20.2 m m (left),
63.4 ± 20.8 ± m m
(right) caudal to inferior
external acoustic
m eatus
Dash et al64
of t h e exter n al acou st ic m eat uses an d a secon d inject ion 1 cm
below.64
Clinical Correlation
Sim ilar to th e lesser occipit al n er ve, th e th ird occipital n er ve
m ay be im p licated in som e pat ien t s w ith occip it al t rigger poin t s
w h o d o n ot fu lly resp on d to release of t h e GON.5,64 Cer vicogen ic h eadach es stem m ing from th ird occip ital n er ve irrit at ion
can be due to osteoarth rit is of th e C2-C3 zygapophysial join t or
w h iplash . Lord et al foun d th at 27% in ciden ce of TON-in duced
h eadach es in p ost-w h iplash p at ien t s.67
In t h e p ast , p at ien t s w ere su ccessfu lly t reated w it h t h ird
occipit al n er ve blockade,67,68 radiofrequ en cy ablat ion ,69 or n eu rectom y.66 Recen tly described su rgical release m eth ods of TON
release involve releasing it from th e surroun ding sem isp in alis
capit is m uscle an d th en avulsing th e n er ve. Avu lsion of th e TON
is p er for m ed by ap p lyin g t ract ion to it an d avu lsin g it , t h u s
allow in g it to ret ract in to t h e m u scu lat u re in stead of bein g
t rapped in th e scar of th e surgical eld.15
Like th e LON, few clin ical st u dies h ave clearly ou tlin ed th e
outcom es of isolated TON release in m igrain e decom pression
su rger y. Lee et al con du cted a ret rosp ect ive review of pat ien t s
un dergoing GON release an d com pared th ose in w h om th e TON
w as en cou n tered an d avu lsed w ith th ose in w h om it w as n ot 70 ;
n o di eren ce in ou tcom es bet w een th e t w o grou ps w as fou n d .
Summary
Th e periph eral t rigger th eor y post u lates th at com pression of
sen sor y bran ch es of th e t rigem in al an d cer vical n er ves in th e
h ead an d n eck gen erates t h e n ocicept ive sign als resp on sible
for m igrain e h eadach es. Su rgical d ecom p ression of t h ose
com p ression poin ts h as been proven , in m u lt iple st udies, to be
e ect ive at redu cing th e frequ en cy, severit y, an d du rat ion of
m igrain e h eadach es. In a system at ic review com paring variou s
n er ve decom p ression m odalit ies in m igrain e h eadach es, su rgical decom pression sh ow ed th e h igh est e cacy an d th e low est
com plicat ion rate.71 To p erform adequ ate an d safe su rgical decom pression , h ow ever, a th orough an d det ailed kn ow ledge of
th e an atom y of th ose com pression poin ts, th eir extern al lan d m arks, an d th eir an atom ical varian ts is essen t ial. Th is ch apter
su m m arizes th e p u blish ed an atom ical dat a on th e kn ow n m igrain e t rigger sites.
10 Sensory Nerves of the Head and Neck
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11
Superf cial Musculoaponeurotic
System and the Facial Soft Tissues
Yoko Tabira, Joe Iw anaga, Tsuyoshi Saga, and Koichi W atanabe
Introduction
Th e soft t issue layers of th e face from th e surface dow n are gen erally m ad e u p of th e skin , su bcu t an eou s fat , su per cial fascia
(super cial m usculoaponeurotic system [SMAS]), m im etic m uscles, an d d eep t issu e layers. St r u ct u rally, t h ese layers var y
am on g t h e d i eren t region s of t h e face. For exam p le, t h e su b cu tan eou s fat layer does n ot exist in th e eyelid, lip, or n ose. Th e
d eep t issu e layer is covered by deep fascia an d in clu d es t h e
p arot id glan d , m asseter m u scle, bu ccal fat p ad, deep tem poral
fascia, an d tem p oralis m u scle. Th e st ru ct u res w ith in th e deep
t issue layer also var y am ong th e di eren t facial region s. Each
layer is con n ected to adjacen t layers an d support s p roper an atom ical p osit ion ing of t h e facial soft t issu e again st gravit y.
Am ong th e soft t issu e layers of th e face, th e SMAS is th e key
st ru ct u re of th e facial fascial system . Th is ch apter describes th e
basic st ruct ure of each layer an d presen ts cadaver dissect ion s
an d m icroscop ic im ages.
Subcutaneous Fat Layer
Th e subcut an eous fat is located ben eath th e derm is an d is presen t th rough ou t m ost of th e en t ire body. In body region s oth er
th an th e face, th e subcut an eous fat layer is divided in to t w o layers by th e su p er cial fascia, an d each layer exh ibit s di eren t
ch aracterist ics. Th e super cial fat layer con t ain s m any brous
sept a an d is involved in protect ion from extern al forces. Nakajim a et al1 term ed this fat layer the protective adipofascial system .
In con t rast , th e deep fat layer p rovides exibilit y to m u scu loskelet al m ovem en t an d is term ed th e lu brican t ad ip ofascial system . Th e facial subcut an eous fat con t ain s m any brou s septa
an d h as a st ru ct u re sim ilar to th at of th e protect ive adipofascial
system . Th e su bcu t an eou s fat layer h as an in t im ate relat ion sh ip
w ith th e SMAS. Many con n ect ive t issue bers rise upw ard to
th e derm is an d provide a st rong con n ect ion bet w een th e derm is an d SMAS. Each lobu le of th e su bcu t an eou s fat is sm all an d
su rrou n d ed by den se brou s septa. In th e ch eek region , a th ick
fat t issu e layer lies on th e SMAS an d is d ist in ct from th e su bcu tan eous fat layer. Th is fat t issue is called th e m alar fat pad.
Malar Fat Pad
Th e m alar fat p ad is t h e fat t issu e t h at lies su p er cial to t h e
SMAS in t h e ch eek region . It is t r ian gu lar sh ap ed an d bou n d
m edially along th e n asolabial crease, su p eriorly along th e orbital rim , an d laterally along th e convex cur ved lin e con n ect ing
th e lateral can th us an d n asolabial crease aroun d th e corn er of
t h e m ou t h . At t h e locat ion of t h e m alar fat p ad , t h e u p p er h alf
of th e SMAS com prises th e orbicularis ocu li m uscle, an d th e
low er h alf com prises th e super cial upper lip elevator m uscles.
Th e low er h alf of th e SMAS is quite th in an d alm ost discon t in u ous an d h as n o m ech an ical bearing capacit y. Th e m alar fat pad
is rm ly xed to th e derm is an d relat ively loosely xed to th e
SMAS layer in th is region . Th e zygom at ic ligam en t , w h ich is an
osteocut an eou s ligam en t located on th e zygom a lateral to th e
origin of th e zygom at ic m in or m uscle, in ser t s in th e overlying
derm is an d pierces an d an ch ors th e m alar fat pad to con n ect it
to th e deeper t issue layers.
Cosm et ically, th e m alar fat pad slides dow nw ard an d inw ard
over th e SMAS w ith aging, d eep en ing th e n asolabial crease. Fat
t issue is also presen t ben eath th e orbicularis oculi m uscle. Th is
fat t issu e is called th e su borbicu laris ocu li fat p ad an d lacks con t in uit y w ith th e m alar fat pad.
SMAS
Th e SMAS is th e fascial t issu e layer located just ben eath th e
su bcu t an eou s fat layer. It con n ect s th e facial m u scles w ith th e
derm is, t ran sm its con t ract ion of th e facial m uscles to th e skin ,
an d assists in creat ing facial expression . Th e SMAS is th e key
st ru ct u re in su rgical t reat m en t of th e face, an d an accu rate
kn ow ledge of its an atom y is ext rem ely im port an t . Th e existen ce of su per cial fascia in th e h ead an d n eck region h as been
discovered in fragm en t s; for exam ple, th e super cial tem poral
fascia an d galea ap on eu rot ica w ere n ot or igin ally recogn ized
as a con t in u ou s layer. Th e con cept of a fascia layer th at sp read s
th rough out th e en t ire h ead an d n eck region in on e sh eet an d is
in tegrated w ith th e conven t ion al fragm en tal fascial st ruct u res
(i.e., th e con cept of th e SMAS) w as rst advocated by Mit z an d
Peyron ie in 1976.2 Th e SMAS is a fascial layer th at is con n ected
su periorly to th e fron t alis m u scle an d in feriorly to th e p lat ysm a
m u scle. Its th ickn ess d ecreases as it con t in u es to th e an terior
cheek area. Although som e opinions di er, th e generally prevailing th ough ts regarding th e SMAS are alm ost iden t ical to th ose
p rop osed by Mit z an d Peyron ie.2
Th e SMAS lies on th e sam e h orizon t al plan e as th e plat ysm a
m uscle an d exten ds su p eriorly to th e su per cial tem poral fascia, galea apon eurot ica, an d fron talis m uscle in it s upper region
(Fig. 11.1). How ever, som e au t h or it ies h ave qu est ion ed t h e
con t in u it y of t h e SMAS in t h e tem p oral region . Gosain et al3
rep or ted t h at t h e SMAS ter m in ates w it h in 1 cm below t h e zygom at ic arch an d is n ot con t in u ou s w ith th e tem p orop ariet al
fascia (su per cial tem p oral fascia). In t raop erat ively, th e area
over th e zygom at ic arch h as a com plicated st ru ct u re. Th e su percial tem p oral arter y passing from th e deep p lan e to th e su p ercial tem p oral fascia layer an d th e tem p oral bran ch of th e facial
n er ve also p asses from th e deep layer to th e in ferior su rface of
th e super cial tem poral fascia. Th e SMAS is also di cu lt to dissect as a un iform layer. It is quite th ick in th e parotid–m asseteric
101
Anatom y for Plastic Surgery of the Face, Head, and Neck
a
102
b
Fig. 11.1 Cadaveric dissection of the super cial m usculoaponeurotic
system (SMAS) in the parotid region. (a) The SMAS is seen as a white
brous layer under the subcutaneous fat. EL, Earlobe; T, tragus; S, SF,
subcutaneous fat. (b) The SMAS is elevated with Kocher forceps. The
parotid gland is observed in the sub-SMAS layer. P, Parotid gland;
S, SMAS.
an d zygom at ic areas an d is easily dissected in th is region u n der
gross visu alizat ion . Beyon d th e an terior border of th e m asseter
m u scle, h ow ever, th e SMAS becom es qu ite th in an d alm ost in visible, m aking it qu ite di cu lt to d issect , raising qu est ion s
abou t th e con t in u it y of th e SMAS. Gardet to et al4 st ated th at th e
SMAS can n ot be d etected in any facial region ot h er t h an t h e
p arot id region . Jost an d Levet 5 quest ion ed w h eth er th e SMAS
act u ally con t in u es to th e orbicularis ocu li m u scle from an em bryologic point of view. The orbicularis oculi originates from the
sp h in cter colli p rofu n du s; h ow ever, th e p lat ysm a m u scle, w h ich
lies on th e sam e plan e as does th e SMAS, origin ates from a differen t layer (i.e., th e p lat ysm a layer). Th u s, con fu sion resu lt s
from th e h istologic di eren ces am ong th e soft t issu e layers of
the lateral and central facial regions. Ghassem i et al6 claim ed that
th e SMAS can be h istologically classi ed as t ype 1 or t ype 2.
Type 1 SMAS describes th e com m on arch itect ure of th e posterior part of th e face an d is obser ved in th e foreh ead, parot id region , zygom at ic region , in fraorbit al region , an d lateral aspect of
th e n asolabial fold. Th e subderm al st ru ct ure com prises a m esh w ork of brous septa enveloping lobules of fat cells. Type 2 SMAS
is fou n d in th e u pp er an d low er lips, an d th e subderm al t issu e
com prises a m esh w ork of in term ingled collagen , elast ic bers,
an d m u scle bers.
With resp ect to th e relat ion sh ip of th e SMAS w ith m im et ic
m u scles, Mit z an d Peyron ie 2 rep orted th at th e SMAS invests
in an d exten ds in to th e extern al p ar t of th e sup er cial facial
m u scles involving th e risoriu s, fron talis, plat ysm a, an d orbicularis ocu li m u scles. St u zin et al7 rep orted th at th e SMAS invests
in t h e zygom at icu s m ajor an d zygom at icu s m in or, in ad d it ion
to th e m uscles described by Mit z an d Peyron ie.2 Th e m im et ic
m u scle layer is th ree-dim en sion al, an d each of its m u scles is
located at a di eren t depth from th e su rface. According to em br yologic hypoth esis, th ese facial m uscles origin ate from th ree
layers: th e sph in cter colli sup er cialis, sp h in cter colli profu n dus, an d plat ysm a, th e last of w h ich is located bet w een th e t w o
sph in cters. Th e sp h in cter colli p rofu n du s di eren t iates an d be-
com es th e bu ccin ators, orbicularis oris, levator angu li oris, levator labii superioris, depressor anguli oris, an d sim ilar m uscles.
Th e plat ysm a becom es oth er facial m uscles, an d th e sph in cter
colli super cialis degen erates in m any m am m als. Freilinger et
al8 repor ted th e th ree-dim en sion al st ruct u re of th e m im et ic
m uscles as com prising four layers: layer 1, depressor anguli oris,
zygom aticus m inor, and orbicularis oculi; layer 2, depressor labii
in ferioris, risorius, plat ysm a, zygom at icus m ajor, an d levator
labii sup erioris alaeque n asi; layer 3, orbicu laris oris an d levator
labii su perioris; an d layer 4, m en talis, levator angu li oris, an d
buccin ator. Th e SMAS is presum ed to h ave a close relat ion sh ip
w ith th e t w o super cial layers of th e m im et ic m uscles as described by Freilinger et al.8 According to Freilinger et al, h ow ever,
som e m u scles are su p er cial to th e SMAS (e.g., th e p lat ysm a).
Th us, th e descript ion s of th e SMAS are presum ed to be based
m ore on clin ical th eor y th an st rictly on em br yologic th eor y.
Th ere are m any opin ion s about th e em br yologic origin of
th e SMAS.2,9 For exam ple, som e research ers h ave reported th at
th e su per cial fascia (tela subcut an ea), w h ich is a loose brous
layer located ju st un der th e skin , is also obser ved in oth er part s
of t h e body.2 Ot h ers h ave d escr ibed brou s d egen erat ion of
t h e p lat ysm a,5 a d ist in ct brom u scu lar layer com p r ising t h e
p lat ysm a an d parot id fascia,10 a m u scu loap on eu rot ic layer con t in uous w ith th e plat ysm a,6 an d an evolut ion ar y form of th e
pan n icu lus carn osu s.11 Som e report s st ate th at th e SMAS con t ain s m uscle bers,2,8 w h ich in dicates th e em br yologic origin of
th e SMAS layer. On e an atom ical textbook also sh ow s th at th e
plat ysm a som et im es exten ds farth er upw ard th an usu al, in
som e cases as h igh as th e zygom a.12 Su ch a m arkedly u pw ardexten ding p lat ysm a is con sidered to rep resen t rem ain ing m u scle bers along th e plat ysm a layer. An oth er possibilit y is th at a
prim it ive m u scle rem ain s in th e SMAS layer.13 Lei et al14 term ed
the m u scle th at spreads over th e parot id glan d the t ransverse
nuchae m uscle an d assum ed that this m uscle is the SMAS m uscle
ber described by Mit z an d Peyron ie.2 Th is m u scle w as fou n d in
abou t 5% of ou r dissect ion s.
11 Super cial Musculoaponeurotic System and the Facial Soft Tissues
Fig. 11.2 Cross-section from the parotid gland to the upper lip (com posite photograph of three preparation specimens; Masson trichrome
stain, ×1). BF, Buccal fat pad; BM, buccinator muscle; MF, m alar fat pad;
MM, masseter muscle; OC, oral cavit y; OO, orbicularis oris muscle;
P, parotid gland; SMAS, super cial musculoaponeurotic system .
Histologic Findings of the SMAS
Temporal Region
Parotid Area to Cheek Region
In the tem poral region, the SMAS m eets the super cial tem poral
fascia (Fig. 11.3). Th e super cial tem poral fascia usually com p rises brous t issu e w ith out m uscle; h ow ever, it som et im es
con t ain s visible degen erat ive facial m uscles such as th e superior au ricu lar m u scle an d tem poroparietal m u scle. Th e SMAS
becom es som ew h at am bigu ou s bet w een t h ese t w o fasciae,
arou n d th e region of th e zygom at ic arch . Tow ard th e tem p oral
region , th e SMAS layer separates in to bers con t ain ing fat t issu e, n o longer con st it u t ing a sh eet of m em bran e. Th is n ding is
in con t rast to th e idea th at th e SMAS is con t in uou s. Th e bers
gradu ally converge as th ey cou rse u pw ard. Th e su bcu t an eou s
fat layer above th e SMAS also becom es th in n er tow ard th e h ead.
Th e SMAS is a th ick m em bran ous t issue th at lies on th e parot id
gland and extends anteriorly, m aintaining alm ost the sam e thickn ess u n t il reach in g t h e an ter ior bord er of t h e m asseter (Fig.
11.2). Som e bran ch ed m uscu lar bers of th e plat ysm a are presen t w ith in t h e SMAS layer. Th e su bcu t an eou s fat t issu e layer is
relat ively t h in in t h is area. Th e brou s sept a w it h in t h is layer
basically r u n p arallel to t h e SMAS an d d elin eate long, ovalsh ap ed fat t issu e in th e h orizon t al plan e. Th e SMAS becom es
dram at ically th in n er beyon d th e an terior border of th e m asseter as it en ters th e ch eek area; it can be barely t raced by th e
posit ion of split periph eral par t of th e plat ysm a. Th e th ick fat
t issue super cial to th e SMAS layer is th e m alar fat pad. Th is fat
t issue con t ain s brou s sept a th at run perpen dicular to th e
SMAS tow ard th e d erm is an d separate th e fat t issu e in to long
ovals in th e vert ical p lan e. Th e fat t issu e obser ved an terior to
th e m asseter is th e buccal fat pad, w h ich lls th e m ast icator y
space.
Fig. 11.3 Cross section from the parotid gland to the temporal region
(composite photograph of three preparation specimens, Masson
trichrome stain, ×1). BF, Buccal fat pad; DT, deep temporal fascia;
Low er Eyelid
It is gen erally recogn ized th at th e SMAS ru n s su p er cial to th e
zygom at icus m ajor an d m in or an d con t in ues to th e orbicularis
oculi; h ow ever, it is di cult to con rm th at th e SMAS con st it utes on e con t in u ous sh eet in th is area (Fig. 11.4). Th e th ick fat
P, parotid gland; SMAS, super cial musculoaponeurotic system ; ST,
super cial temporal fascia (in this case, the temporoparietal muscle);
TM, temporalis muscle; ZA, zygomatic arch (rem oved).
103
Anatom y for Plastic Surgery of the Face, Head, and Neck
on th e oor of th e lateral face du ring sub -SMAS dissect ion are
th e parot id glan d an d th e m asseter m uscles (Fig. 11.5a). Th e
parot id m asseteric fascia envelop s th ese st ruct u res. A part of
th e bu ccal fat pad exposed at th e an terior m asseteric m uscle
also con st it u tes th e oor of th e plan e. In th e an terior region of
th e face, th e deep layer of th e m im et ic m u scles in cludes st ruct ures such as th e levator labii superioris, levator anguli oris, an d
buccin ator m uscles (Fig. 11.5b). Th e m ost im por t an t st ruct ures
in th e su b-SMAS plan e are th e p eriph eral bran ch es of th e facial
n er ve. Th e facial n er ve ru n s th rough th e parot id glan d after
em erging from th e extern al sku ll base via th e st ylom astoid foram en , an d th e bran ch es of th e n er ve ru n along th e fascia after
em erging from th e superior, anterior, and in ferior borders of th e
parot id glan d. Th e periph eral bran ch es of th e facial n er ve (th e
tem poral, zygom at ic, buccal, m argin al m an dibular, an d cer vical
bran ch es, especially th e zygom at ic an d buccal bran ch es) run
along th e basal oor. In con t rast , th e tem p oral, m argin al m an dibu lar, an d cer vical bran ch es rise up to th e SMAS plan e from
th e base. Th ese bran ch es in n er vate th e SMAS m uscles, m ain ly
th e fron t alis m uscle, depressor angu li oris, plat ysm a, an d som e
oth ers. Th e su b -SMAS sp ace also con tain s som e ber bu n dles
th at support th e facial skin . These bers from a st ruct ure called
th e ret ain ing ligam en t , w h ich divides th e sub -SMAS space in to
sm all com part m en t s. Th e n ext sect ion of th is ch apter d escribes
th e m ain ret ain ing ligam en ts of th e face an d th e sub -SMAS
sp aces related to th e ligam en ts.
Mimetic Muscles and Facial Nerve
Th e det ails of th e m im et ic m uscles an d facial n er ve are addressed in oth er ch apters (Ch apters 9 an d 12).
Fig. 11.4 Cross-section of lower eyelid (Masson trichrome stain, ×1).
EO, extraocular muscle; MF, malar fat pad; OF, orbital fat; OOc, orbicularis oculi muscle; SO, suborbicularis oculi fat pad; ZM, zygomatic
muscles.
t issue overlying th e SMAS layer is th e m alar fat pad. It is th ick in
th e m iddle region of th e ch eek an d en ds at th e orbital rim . Th e
fat p ad is ver t ically long an d oval in sh ape, an d its brou s septa
are st rongly con n ected as th ey cou rse tow ard th e derm is. Th e
fat tissue beneath the orbicularis oculi is the suborbicularis oculi
fat p ad.
Facial Soft Tissue Layer Deep
To the SMAS (Mimetic
Muscle Layer and Deep
Tissue Layer)
Many st ru ct u res im p ort an t to facial fu n ct ion are located in th e
t issue layer deep to th e SMAS, in cluding th e m im et ic m uscles,
facial n er ve, p arot id glan d, m u scles of m ast icat ion , an d oth ers.
W h en perform ing surgical procedures involving th e sub -SMAS
plan e, accurate an atom ical kn ow ledge is required to preven t
dam age to th ese st ruct ures. Th e m ain st ruct ures en coun tered
104
Parotid Masseteric Fascia
Th e parot id m asseteric fascia is a deep fascia th at envelops th e
parot id glan d an d m asseter m uscle. Th is fascia also covers th e
parot id duct , th e periph eral bran ch es of th e facial n er ve, an d
th e su rface of th e bu ccal fat pad. In it s m ore an terior part , th e
fascia exten d s to th e deep layer, reach ing th e elevator m u scles
of th e upper lip. It con t in ues to th e deep cer vical fascia in feriorly beyon d th e m argin of m an dible. Fin ally, it con t in ues to th e
tem poral fascia (deep tem poral fascia) superiorly over th e zygom at ic arch .7
Retaining Ligaments of the Face
Som e brou s st ru ct u res arising from th e basal oor are ob ser ved in th e su b -SMAS plan e. Th ese st ru ct u res con n ect to th e
derm is an d play a role in an ch oring th e facial skin , resist ing
gravit y, an d p reven t ing droop ing of th e facial soft t issu e. Loosen ing of th is system cau ses aging ch anges of th e facial ap pearan ce. Th is an ch oring system is based on th e ret ain ing ligam en t s.
McGregor rst rep or ted t h e ret ain in g ligam en t of t h e face,
term ed the zygom atic ligam en t or McGregor’s patch. Furn as subsequ en tly su m m arized th e retain ing ligam en ts in 1989 15 an d
described four retain ing ligam en ts: th e zygom at ic (McGregor’s
patch ), m an dibu lar, plat ysm a–au ricular, an d an terior plat ysm a
11 Super cial Musculoaponeurotic System and the Facial Soft Tissues
a
b
Fig. 11.5 Sub-super cial musculoaponeurotic system (SMAS) plane
dissection. (a) Lateral part. Right lateral view of the right side of the
face. The left side of the picture is the cranial aspect, and the right side
is the caudal aspect. The area superior to the zygomatic arch was
dissected from the m ore super cial layer to keep the temporal branch
on the basal oor. The plat ysma was cut along the mandibular border.
The branches of the facial nerve were marked as follows: temporal
branches, orange string knot; zygomatic branches, dark blue; buccal
branches, green; marginal mandibular branches, dark brown; and
cervical branches, purple. A bar was inserted into the prezygomatic
space. (b) Medial part. Frontal view of the right side of the face. BF,
Buccal fat pad; FA, facial artery; LLS, levator labii superioris muscle; ML,
masseteric ligam ent; MM, masseteric muscle; OOc, orbicularis oculi
muscle; PD, parotid duct; PL, plat ysma; ZFN, zygomaticofacial nerve;
ZL, zygomatic ligament; ZM, zygomaticus major muscle.
105
Anatom y for Plastic Surgery of the Face, Head, and Neck
ligam en t s. Th ese fou r ligam en t s can be clas si ed in to t w o
t yp es based on t h e t issu es from w h ich t h e ligam en t s ar ise. Th e
zygom at ic ligam en t an d t h e m an d ibu lar ligam en t ar ise from
t h e facial skeleton an d in ser t in to t h e d er m is, w h ereas t h e
p lat ysm a–au ricu lar ligam en t an d an terior p lat ysm a ligam en t
con n ect th e plat ysm a an d derm is. St uzin et al7 also d escribed
t w o t ypes of ret ain ing ligam en ts, depen ding on w h eth er th ey
origin ate from th e bon e or from oth er st ruct u res. Th e ligam en t
arising from th e bon e, w h ich is com p at ible w ith th e zygom at ic
an d m an dibu lar ligam en ts d escribed by Fu rn as,15 w as classi ed
as a t ru e osteocu tan eou s ligam en t . Oth er ligam en ts p rovide coalescen ce bet w een th e d eep fascia an d su p er cial fascia. Th e
parot id cut an eou s an d m asseteric cut an eous ligam en t s are also
categorized in this group. Moreover, Moss et al16 described th ree
t yp e of ret ain ing ligam en ts: t rue ligam en t s, adh esion s, an d
sept a. Tru e ligam en t s are alm ost iden t ical to th e so-called t ru e
osteocu tan eous ligam en t described by St uzin,7 w h ich arises
from eith er th e deep fascia or th e p eriosteu m , p ierces th e SMAS,
an d dist ribu tes th e at t ach m en t of th e ligam en t to th e derm is by
sp reading like a bran ch ing t ree. It is located m ain ly on th e m edial m idface an d low er face, an d th e zygom at ic ligam en t an d
m asseteric ligam en t are in clu ded in th is categor y. Sept a are brous w alls passing bet w een th e deep fascia an d th e SMAS (super cial fascia) an d do n ot adh ere to th e derm is. Th is categor y
in clu des th e in ferior tem poral sept u m , th e sup erior tem poral
sept u m , an d th e p eriorbit al sept u m . Fin ally, ad h esion s are low den sit y areas of brou s or brofat t y con n ect ion s bet w een th e
deep fascia (or pericran ium ) an d th e su per cial fascia. Th ey also
con n ect th e basal t issu e an d SMAS an d do n ot adh ere to th e
derm is. Adh esion s are u sually obser ved in th e tem poral an d
foreh ead regions, excluding the preauricular and parotid regions.
Tem poral an d su praorbit al ligam en tou s adh esions are in cluded
in th is categor y.
Forehead and Temporal Region
A ret ain ing ligam en t in th e foreh ead an d tem poral region w as
rst rep or ted in det ail by Moss et al (Fig. 11.6, Table 11.1).16 It
in clu des on e adh esion an d t w o sept a exten ding radially in the
lateral direct ion . As previously m en t ion ed, all th ese st ruct ures
con n ect th e basal t issue an d th e SMAS.
Temporal Ligamentous Adhesion
Th e tem poral ligam en tous adh esion is located at th e lateral part
of th e supraorbit al rim , m edial to th e an terior en d of th e tem poral lin e. It is t riangular sh aped; th e base of th e t riangle lies on
a p arallel lin e app roxim ately 10 m m from th e su praorbit al rim
an d is ap proxim ately 15 m m in length , an d th e ap ex lies on th e
tem p oral lin e an d is 20 m m in h eigh t . Th ree ot h er ligam en t s in
th e foreh ead an d th e tem poral region converge at th is poin t: th e
su p erior tem p oral sept u m , in ferior tem poral sept u m , an d su praorbit al adh esion .16 Th e su perior tem p oral sept u m con t in u es
to th e superior apex of th e t riangular adh esion , an d th e in ferior
tem poral sept um con t in ues to th e lateral apex of th e base. Th e
su p raorbit al adh esion is located along th e su praorbit al rim m e-
106
Fig. 11.6 Temporal region. Lateral view of the right side of the face.
FN, temporal branches of the facial nerve; ITS, inferior temporal
septum; PS, periorbital septum; STS, superior temporal septum; TLA,
temporal ligamentous adhesion; ZTN, zygomaticotemporal nerve.
dial to th e tem poral ligam en tous adh esion an d con t in ues to th e
m edial apex of th e t riangle.
Superior Temporal Septum
Th is su perior tem poral sept u m st art s from th e tem poral ligam en tou s adh esion an d ru n s su p eriorly an d laterally along th e
su p er ior tem p oral lin e. It for m s t h e con n ect ion bet w een t h e
periosteu m an d th e t ran sit ion al zon e bet w een th e su p er cial
tem poral fascia an d th e galea apon eurot ica.16
Inferior Temporal Septum
Th e in ferior tem poral sept um st ar ts from th e lateral poin t of th e
base of th e tem poral ligam en tous adh esion an d run s in feriorly
an d laterally. It is located on an obliqu e lin e con n ect in g t h e
tem poral ligam en tou s adh esion an d extern al acoust ic m eat us.
In th e ver t ical sect ion , it arises from th e d eep tem poral fascia
11 Super cial Musculoaponeurotic System and the Facial Soft Tissues
Table 11.1 Retaining ligaments of the forehead and temporal region
Retaining ligament
Location
Type
Temporal ligam entous
adhesion
Lateral part of supraorbital rim , m edial to the anterior
end of the temporal line
Adhesion bet ween the pericranium and the
super cial fascia
Supraorbital ligam entous
adhesion
Supraorbital rim, m edial to the temporal ligam entous
adhesion
Adhesion bet ween the pericranium and the
super cial fascia
Superior temporal septum
On the superior temporal line
Septum , connecting bet ween the periosteum
and super cial fascia (super cial temporal
fascia and galea aponeurotica)
Inferior temporal septum
On the line connecting bet ween the temporal
ligam entous adhesion and external acoustic m eatus
Septum connecting bet ween the deep
temporal fascia and super cial temporal
fascia
an d in ser ts in to th e deepest layers of th e su p er cial tem poral
fascia over th e lin e. Th e tem p oral bran ch es of th e facial n er ve
ru n below th e sept u m .16
Supraorbital Ligamentous Adhesion
Th e su praorbit al ligam en tous adh esion arises from th e fron t al
bon e above th e orbit al rim an d exten ds in t w o direct ion s to th e
corrugator supercilii m uscle an d tem poral ligam en t .16
Periorbital Region (Tear Trough and
Orbicularis Retaining Ligament,
Periorbital Septum)
Th e ligam en t s in t h e p er iorbit al region cou rse along t h e orbit al rim , covering alm ost th e en t ire circu m feren ce of th e orbit
(Table 11.2). Th is ligam en tou s com plex is th e rst reported t rue
osteocut an eous ligam en t in th e low er eyelid an d w as described
by Wong in 2012.17 Th e tear t rough –orbicu laris retain ing ligam en t s com prise th e tear t rough ligam en t , w h ich is located m edially, an d th e orbicularis ligam en t , w h ich is located laterally.
Th e tear t rough ligam en t ar ises from t h e in fer ior orbit al r im of
t h e m a xilla an d con n ect s t h e bou n dar y of t h e p alp ebral an d
orbit al par t s of th e orbicularis oculi. Th e m edial par t of th is ligam en t is located at th e level of th e m edial can th al ten don , im m ediately in ferior to th e an terior lacrim al crest . It en ds arou n d
th e m edial pupil lin e an d con t in ues laterally to th e t w o orbicularis ret ain ing ligam en t s. Th e orbicu laris ret ain ing ligam en t
con t in ues to th e lateral orbit al th icken ing at th e level of th e lateral can t h u s an d t h e lateral brow t h icken in g at t h e su p er ior
lateral angle of th e orbital rim , n ally en d ing at th e origin of th e
corrugator supercilii at the superior m edial part of the orbital rim .
Middle and Low er Facial Region
Begin n ing w ith McGregor’s descript ion of th e zygom at ic ligam en t , th e retain ing ligam en t s in th e m id dle an d low er facial
region s h ave been reported in det ail by m any research ers (Fig.
11.7, Table 11.3). In th is region , th e zygom at ic ligam en t an d
m an dibu lar ligam en t are so-called t ru e osteocu t an eou s ligam en ts th at arise from th e p eriosteu m an d in ser t in to th e derm is. With resp ect to oth er ligam en t s, th e m asseteric cu t an eou s
ligam en t form s th e coalescen ce bet w een th e deep fascia an d
th e super cial fascia; th e bers of th is ligam en t do n ot reach th e
d er m is. Th e p lat ysm a au r icu lar ligam en t is an ad h esion on ly
located in th e super cial layer, an d it con n ect s th e plat ysm a an d
th e derm is. In th is area, m any bran ch es of th e facial n er ve run
Table 11.2 Retaining ligaments of the periorbital region
Retaining ligament
Location
Type
Tear-trough
Ligam ent
Inferior orbital rim from the m edial canthal tendon to m edial pupil line
Osteocutaneous
ligament
Orbicularis retaining ligam ent
Continuing to the tear-trough ligam ent
Two ligam ents run parallel on the inferior orbital rim and end at the lateral
canthus
Osteocutaneous
ligament
Lateral orbital thickening
Lateral canthus
Osteocutaneous
ligament
Lateral brow thickening
Superior lateral angle of the orbital rim and inferior to the temporal ligam entous
adhesion
The ligam ent continues to the m edial part of the orbital rim along the superior
orbital rim
Osteocutaneous
ligament
107
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 11.7 Prezygomatic space. LLS, levator labii superioris; ORN, orbicularis retaining ligament; Zb, zygomatic branch of the facial nerve; ZFN,
zygomaticofacial nerve; ZL, zygomatic ligament; ZM, zygomatic major muscle.
Table 11.3 Retaining ligaments of the middle and low er facial region
108
Retaining ligament
Location
Type
Zygom atic ligam ent
(McGregor’s patch)
Usually t wo bundles
About 4.5 cm from the tragus
Inferior border of the anterior end of zygomatic arch and behind
the insertion of the zygom atic m inor
Osteocutaneous ligam ent
Mandibular ligam ent
Mandibular bone along a line that is 1cm above the m andibular
border and which extends along the anterior third of the
m andibular body
Imm ediately in front of the m asseter m uscle’s anterior border.
Osteocutaneous ligament
Masseteric cutaneous
ligam ent
Serious of bers arising along the anterior border of the
m asseter m uscle
Coalescence bet ween the deep fascia and
the SMAS
Plat ysm a cutaneous
ligament
Middle and anterior cheek
Aponeurotic connection bet ween the
plat ysm a and the derm is
Plat ysm a auricular
ligam ent
Inferior auricular region
Connection bet ween the posterior border
of the plat ysm a and the dermis of the
inferior auricular region
11 Super cial Musculoaponeurotic System and the Facial Soft Tissues
along th e basal oor of th e su b -SMAS p lan e, an d som e bran ch es
ru n in th e vicin it y of th e ligam en t s.
Perforat ing vessels an d cu t an eou s n er ves also ru n w ith th e
ligam en t . Accu rate in t raop erat ive iden t i cat ion of th ese accom panying st ru ct ures is ver y im por tan t to preven t com plicat ion s.
Zygomatic Ligament
Th e zygom at ic ligam en t is a represen t at ive t rue osteocut an eou s
ligam en t . It arises from th e bon e or periosteum an d in sert s in to
th e derm is, exh ibit ing t reelike spreading. Th e origin of th is ligam en t is located arou n d th e in ferior bord er of th e an terior en d
of th e zygom at ic arch , beh in d th e in sert ion of th e zygom at icu s
m in or m u scle, an d abou t 4.5 cm an teriorly from th e t ragu s.
Tw o ligam en tous bun dles are usu ally presen t; both are sim ilar in size, m easuring approxim ately 3.0 m m w ide, 0.5 m m th ick,
an d 6.0 to 8.0 m m long.15 On e of th e u p per ram i of th e zygom at ic bran ch of th e facial n er ve an d a bran ch of th e t ran sverse
facial ar ter y u su ally lie d irectly ben eath th is ligam en t .15,18 Th e
zygom at ic ligam en t p ierces t h e m alar fat p ad as it cou rses tow ard t h e overlying d er m is an d p lays a role in su p p or t ing t h e
fat p ad . As t h e ligam en t loosen s w it h agin g, t h e m alar fat p ad
d escen d s an d t h e n asolabial crease d eep en s. Th e sp ace on t h e
zygom a an terior to th e zygom at ic ligam en t is term ed th e p rezy-
Fig. 11.8 Mandibular area. Frontal view of the left mandibular area.
The depressor anguli oris m uscle and depressor labii inferioris are
elevated. Linear adhesions parallel to the mandibular border are ob-
gom at ic sp ace. Th e su p erior bou n dar y of th is space is th e orbicularis ret ain ing ligam en t , an d th e roof of th e space is th e
orbicularis oculi m uscle. Th e prezygom at ic space is lled w ith
th e suborbicu laris oculi fat pad an d provides m obilit y to th e orbicularis oculi m uscle during facial expression . Th e zygom at icotem poral n er ve, w h ich is a cu t an eou s n er ve of th e face, ru n s
u pw ard tow ard th e derm is, an d part of th e zygom at ic bran ch of
th e facial n er ve to th e orbicularis ocu li m uscle run s along th e
roof side of th e space.
Mandibular Ligament
Like t h e zygom at ic ligam en t , t h e m an d ibu lar ligam en t is also
categorized as a t rue osteocut an eous ligam en t (Fig. 11.8). Furn as 15 reported th at th e m an dibu lar ligam en t origin ates from
th e m an dibular bon e along a lin e th at lies approxim ately 1 cm
above th e m an dibu lar border an d exten ds along th e an terior
th ird of th e m an dibu lar body. Th e m an dibular ligam en t usually
ap p ears as a lin ear series of parallel bers. A sen sor y n er ve an d
cutaneous arter y usually accom pany and run w ith the ligam ents.
Men d elson et al19 rep or ted t h at t h e m an d ibu lar ligam en t is
located im m ed iately in fron t of t h e an ter ior bord er of t h e m asseter m u scle; th is border is cu r ved an d exten ds an teriorly tow ard th e low er edge of the m andible. Th e m andibular ligam ent
served. DAO, depressor anguli oris muscle; DLI, depressor labii
inferioris, OO, orbicularis oris muscle.
109
Anatom y for Plastic Surgery of the Face, Head, and Neck
m aint ain s th e lateral facial fat in th e correct p osit ion . Loosen ing
of th e ligam en t w ith aging causes th e fat t issue to droop, form ing th e facial jow l.
Masseteric Cutaneous Ligament
St u zin et al7 st ated th at a series of bers arises along th e en t ire
an terior border of th e m asseter m u scle su p eriorly from th e
m alar region an d cou rses in feriorly to th e m an d ibu lar border.
Th ese bers play a role in suppor t ing th e soft t issu es of th e m edial ch eek region . Th is ligam en t is categorized as St uzin’s second
t ype (coalescen ce bet w een th e d eep fascia and th e SMAS). Th e
zygom at ic bran ch of t h e facial n er ve r u n s in close p roxim it y to
t h e m asseter ic cu t an eou s ligam en t .18 Th e sp ace located p osterior to th e m asseteric cu t an eou s ligam en t is term ed th e prem asseter space. Th is space is located bet w een th e m asseter an d
plat ysm a an d is delin eated posteriorly by th e posterior border
of th e m asseter an d in feriorly by th e m an dibular border. With
age, th e fat t issu e in th is space bulges on to th e m an dibu lar ligam en t an d form s th e jow ls.19
Platysma Cutaneous Ligament
Furn as 15 also rep or ted th at an ap on eu rot ic con n ect ion bet w een
th e an terior plat ysm a an d skin of th e m iddle an d an terior ch eek
is som et im es seen . Th e in ciden ce of th is ligam en t m ay n ot be
con st an t. Ozdem ir et al18 obser ved th is ligam en t in on ly a few
cases.
Platysma Auricular Ligament
Furn as 15 described th e plat ysm a au ricular ligam en t as follow s.
Th e posterior border of th e plat ysm a recedes in to an in t ricate
fascial con den sat ion th at often at tach es in t im ately to th e overlying skin. Th is st ruct ure provides rm an ch orage bet w een th e
plat ysm a an d th e derm is of th e in ferior auricular region .
References
1. Nakajim a H, Im an ish i N, Minabe T, Kish i K, Aiso S. Anatom ical
st u dy of su bcu t an eou s ad ipofascial t issu e: a con cept of th e p rotect ive ad ip ofascial system (PAFS) an d lu br ican t ad ip ofascial system
(LAFS). Scan d J Plast Recon st r Su rg Han d Su rg 2004;38(5):261–
266 Pu bMed
2. Mit z V, Peyron ie M. Th e super cial m usculo-apon eurot ic system
(SMAS) in th e parot id an d ch eek area. Plast Recon st r Surg 1976;
58(1):80–88 Pu bMed
3. Gosain AK, You sif NJ, Mad iedo G, Larson DL, Matlou b HS, Sanger JR.
Surgical an atom y of th e SMAS: a reinvest igat ion. Plast Recon st r
Surg 1993;92(7):1254–1265 Pu bMed
4. Gardet to A, Dabernig J, Rain er C, Piegger J, Piza-Kat zer H, Frit sch H.
Does a su per cial m u scu loap on eu rot ic system exist in th e face and
neck? An anatom ical study by the tissue plastination technique. Plast
Reconstr Surg 2003;111(2):664–672, discussion 673–675 PubMed
5. Jost G, Levet Y. Parot id fascia an d face lift ing: a crit ical evalu at ion of
the SMAS concept. Plast Reconstr Surg 1984;74(1):42–51 PubMed
6. Gh assem i A, Presch er A, Riediger D, Axer H. An atom y of th e SMAS
revisited. Aesth et ic Plast Surg 2003;27(4):258–264 PubMed
7. St u zin JM, Baker TJ, Gordon HL. Th e relat ion sh ip of th e super cial
an d deep facial fascias: relevan ce to rhyt idectom y an d aging. Plast
Recon st r Surg 1992;89(3):441–451 PubMed
8. Freilinger G, Gr uber H, Happak W, Pechm an n U. Surgical an atom y
of th e m im ic m uscle system an d th e facial n er ve: im port an ce for
recon st r u ct ive an d aest h et ic su rger y. Plast Recon st r Su rg 1987;
80(5):686–690 PubMed
9. Ferreira LM, Hoch m an B, Locali RF, Rosa- Oliveira LM. A st rat igraph ic ap p roach to th e su per cial m u scu loapon eu rot ic system
an d it s an atom ic correlat ion w ith th e super cial fascia. Aesth et ic
Plast Su rg 2006;30(5):549–552 PubMed
10. Th aller SR, Kim S, Pat terson H, Wildm an M, Dan iller A. Th e su b m uscular aponeu rot ic system (SMAS): a histologic an d com para-
110
t ive an atom y evalu at ion . Plast Recon st r Su rg 1990;86(4):690–696
PubMed
11. Fodor PB. From the panniculus carn osum (PC) to the super cial fascia system (SFS). Aesthetic Plast Surg 1993;17(3):179–181 PubMed
12. Bergm an RA, Th om pson SA, A
AK, Saadeh FA. Com pen d iu m of
h um an an atom ic variat ion : text , atlas, and w orld literat ure. Balt im ore: Urban & Schw arzen berg; 1988:30.
13. Wilh elm i BJ, Mow lavi A, Neum eister MW. Th e safe face lift w ith
bony an atom ic lan dm arks to elevate th e SMAS. Plast Recon st r Surg
2003;111(5):1723–1726 PubMed
14. Lei T, Cui L, Zh ang YZ, et al. An atom y of th e t ran sversus n uch ae
m u scle an d it s relat ion sh ip w ith th e super cial m usculoapon eu rotic system . Plast Reconstr Surg 2010;126(3):1058–1062 PubMed
15. Furn as DW. Th e ret ain ing ligam en t s of th e ch eek. Plast Recon st r
Su rg 1989;83(1):11–16 Pu bMed
16. Moss CJ, Men d elson BC, Taylor GI. Su rgical an atom y of t h e ligam en tou s at t ach m en t s in t h e tem p le an d p er iorbit al region s. Plast
Recon st r Su rg 2000;105(4):1475–1490, d iscu ssion 1491–1498
PubMed
17. Wong CH, Hsieh MKH, Men d elson B. Th e tear t rough ligam en t:
an atom ical basis for th e tear t rough deform it y. Plast Recon st r Su rg
2012;129(6):1392–1402 PubMed
18. Ozdem ir R, Kilin ç H, Un lü RE, Uysal AC, Sen söz O, Baran CN. An atom icoh istologic st udy of the ret ain ing ligam en t s of th e face an d
use in face lift: ret ain ing ligam en t correct ion an d SMAS plicat ion.
Plast Recon st r Su rg 2002;110(4):1134–1149 PubMed
19. Men delson BC, Freem an ME, Wu W, Huggin s RJ. Surgical an atom y
of th e low er face: th e prem asseter space, th e jow l, an d th e labiom andibular fold. Aesthetic Plast Surg 2008;32(2):185–195 PubMed
12
Mimetic Muscles
Hee-Jin Kim
Layers of the Face
Basic facial soft t issu es are com posed of ve layers: (1) skin ,
(2) su bcu t an eou s layer, (3) su p er cial m u scu loap on eu rot ic
system (SMAS), (4) retaining ligam ents and spaces, and (5) peri
osteum an d deep fascia (Fig. 12.1). Except for th e auricles an d
n ose alae su p ported by th e cart ilage un der th e skin , facial skin
glides over th e loose areolar con n ect ive t issu e layer. Facial skin
con tain s n um erous sw eat an d sebaceous glan ds.
Super cial fascia or subcutan eous connective tissue con tain s
u n equ al am ou n ts of fat t issue, an d th ese fat t issues m ake th e
facial con tou r sm ooth bet w een th e skin an d u n d erlying facial
m u scu lat u res. In som e areas, th e fat t issu es are broadly dist rib
u ted. Th e bu ccal fat pad form s th e bu lge over th e ch eek an d con
t in u es to th e scalp beh in d th e orbit . Facial vessels, t rigem in al
n er ve bran ch es, facial n er ve bran ch es, an d th e m u scles of facial
exp ression are con t ain ed w ith in th e su bcu t an eou s t issu e.
Th e super cial m uscu loapon eurot ic system (SMAS) is th e
su p er cial fascial st ru ct u re com p osed of m u scle bers an d su
per cial facial fascia. Th is m uscu lofascial un it is m an ipulated
during facial cosm et ic su rger y, especially rhyt idectom y, an d th e
SMAS exten ds from th e p lat ysm a to th e galea ap on eu rot ica an d
is con t in uou s w ith th e tem porop ariet al fascia an d galea. It con
n ect s to th e derm is th rough ver t ical sept a.
Forehead and Temporal
Region
The occipitofrontalis m uscle (OFM) is the w idest and largest con
st it u en t of th e com plex of m u scles u n derlying th e u p per face
an d occip it al area, covering from th e h igh est n u ch al lin e to th e
eyebrow s, bu t th e in ten sit y of con t ract ion s along th at w idth can
di er subst an t ially from person to person . Th e fron t al belly of
th e OFM is th e fron tal port ion of th is m uscle, an d it arises from
the galea aponeurotica and is inserted into the frontal skin above
th e eyebrow. Du ring an xiet y or surprise, th is m uscle con t racts
an d prod u ces th e t ran sverse w rin kles of th e foreh ead .
Th e OFM is rough ly rect angular an d h as bilateral sym m et r y;
it s m u scle bers are approxim ately ver t ically oriented an d at
t ach ed to th e super cial fascia of th e skin in th e region w h ere it
m eets th e m u scles above th e glabella an d brow ridges. Its at
t ach m en t is broader an d h as longer bers th an th e occipit alis.
Th e OFM lies at a u n ifor m d ept h ben eat h t h e skin of t h e fore
h ead (3–5 m m on average), alt h ough t h at d ept h can d i er con
sid erably (2–7 m m ) bet w een in d ivid u als an d is 1 m m greater
on average in m en t h an in w om en . Th e OFM d oes n ot at t ach to
Facial Expression Muscles
and their Actions
Facial m uscles are at tach ed to th e facial skeleton or m em bra
n ou s su per cial fascia ben eath th e skin (Fig. 12.2). Th e topography of th e facial m uscles varies bet w een m ales an d fem ales, as
w ell as bet w een in dividu als of th e sam e sex. It is im p or tan t to
de n e m uscle sh apes, th eir associat ion s w ith th e skin , an d th eir
relat ive fun ct ion alit y to explain th e un ique expression s people
can m ake. The face is divided into several distinct areas: (1) fore
head an d tem poral region , (2) periorbit al region covered by th e
eyelid , (3) exter n al n ose, (4) an ter ior ch eek region (u p p er lip
elevators), (5) perioral region , an d (6) ch in region an d su per
cial n eck.
Gen erally, th e facial m uscles are fou n d w ith in th e super cial
fascia or su bcu tan eou s t issu e layer of th e face. Th ese m u scles
are involved in t w o d i eren t roles: (1) con t rol of t h e op en in g
of th e ori ces as dilators or sph in cters an d (2) in th e form at ion
of variou s facial expression s by m oving th e overlying facial skin .
Most of th e facial exp ression m u scles origin ate from th e bon es
of th e face or fascia an d are in serted in to th e facial skin . Th ere
fore, facial skin by th e con t ract ion of th e facial m uscle produ ces
the various expressions, such as sadness, anger, joy, fear, disgust,
an d su rprise.
Fig. 12.1 Layers of the face. Facial soft tissues are composed of ve
layers: (1) skin, (2) subcutaneous layer, (3) super cial musculoapo
neurotic system (SMAS), (4) retaining ligaments and spaces, and
(5) periosteum and deep fascia.
111
Anatom y for Plastic Surgery of the Face, Head, and Neck
Galea aponeurotica
(epicranial aponeurosis)
Occipitofrontalis,
frontal belly
Depressor
supercilii
Corrugator
supercilii
Procerus
Levator
labii superioris
alaeque nasi
Orbicularis
oculi
Levator
labii superioris
alaeque nasi
Levator
labii superioris
Nasalis
Zygom aticus
m inor
Levator
labii superioris
Zygom aticus
major
Zygom aticus
m inor
Levator
anguli oris
Zygom aticus
major
Buccinator
Levator
anguli oris
Risorius
Depressor
anguli oris
Plat ysma
Depressor
labii inferioris
Masseter
Orbicularis
oris
Depressor
anguli oris
Depressor
labii inferioris
Mentalis
Fig. 12.2 Facial muscles. (a) Anterior view. The super cial layer of the muscle is shown on the right half of the face, and the deep layer is shown on
the left half.
a bony st r u ct u re. In stead , it s m ed ial bers con t in u e alon g p ro
cer u s, in term ediate bers along th e corr ugator su percilii (CS)
an d orbicu laris ocu li (OOc), an d lateral bers along th e OOc
over th e zygom at ic p rocess (Fig. 12.3). Th e tem poroparietalis is
located bet w een OFM an d th e an terior an d superior auricu lar
m u scles, an d it s develop m en t an d sh ap e var y.
Periorbital Region
Th e sh ape of th e eye is clearly fram ed by th e m oving m uscles
su rrou n ding it , w h ich th u s d eterm in e th e basic facial exp res
sion . Th e OOc m u scle is located arou n d th e orbit an d in to th e
112
eyelids, an terior tem poral region , in fraorbit al ch eek, an d su p er
ciliar y region . Th e OOc is a broad, at , ellipt ical m uscle com
posed of th ree por t ion s: (1) an orbit al port ion that con cen t rically
en circles th e orbit , in clu ding th e depressor su p ercilii; (2) a p al
p ebral p or t ion , w it h n er an d p aler m u scle bers t h an t h e
orbit al p ar t , t h at sw eep s across t h e eyelids an ter ior to t h e or
bit al sept um an d arises from th e m edial palpebral ligam en t;
an d (3) a lacrim al p or t ion th at arises from th e u p p er p art of th e
lacrim al crest an d passes laterally beh in d th e n asolacrim al sac
(Fig. 12.4).
Th e m ain fu n ct ion of th e OOc is to m ediate eye closure. Th e
OOc h as m any n eigh boring m u scles: th e corrugator su p ercilii
m u scle (CSM), proceru s, fron tal belly of th e OFM, zygom at icu s
m ajor (ZMj), an d zygom at icu s m in or (ZMi) m u scles) an d variou s
12 Mim etic Muscles
Galea
aponeurotica
Superior auricular
m uscle
Occipitofrontalis,
frontal belly
Tem poropariet al
Orbicularis
oculi
Anterior auricular
m uscle
Nasalis
Levator labii
superioris
alaeque nasi
Levator labii
superioris
Zygomaticus
m inor
Occipitofrontalis,
occipital belly
Orbicularis
oris
Posterior auricular
m uscle
Zygomaticus
major
Risorius
Depressor
labii inferioris
Mentalis
Depressor
anguli oris
Plat ysma
Fig. 12.2 (continued) (b) Left lateral view. (Reproduced from THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustrations by
Karl Wesker.)
d irect an d in d irect m u scu lar con n ect ion s bet w een t h e OOc
an d t h e su r rou n d in g m u scu lat u re; t h ese m ay p ar t icip ate in
t h e for m at ion of various facial expression s. A lateral m uscular
band (m alaris m uscle) can be obser ved in 54.1% of Asian s. It
origin ates from th e super cial tem poral fascia an d term in ates
in th ree di eren t region s: at th e zygom at ic arch (27.9%), at th e
ch eek region (18%), an d at th e angle of th e m outh (8.2%). It plays
a role in facial an im at ion an d dim p le form at ion . Medial m u scu
lar ban ds of th e orbit al port ion of OOc are fou n d in 65.6% of
Asian s. Th is m u scu lar ban d h elp s to p reven t fu r t h er d roop ing
of t h e OOc. On t h e ot h er h an d, t h ere are m any m u scu lar con
n ect ion s bet w een t h e OOc an d ZMi in 88.5% of t h e cases; t h is
p ar t icu lar an atom ical feat u re m ay p lay a sp eci c role in facial
exp ression .
Th e CSM origin ates from th e periosteum on th e fron t al bon e
an d m erges in to th e fron t al belly of th e occip itofron t alis m u scle
(Fb). Th e CSM con sist s of dist in ct t w o bellies: t ran sverse an d
oblique. Th e origin of th e t ran sverse belly of th e CSM is m ore
su perior an d lateral th an th e origin of th e obliqu e belly, an d
m ost are at t ach ed in to th e Fb an d th e su perolateral orbit al part
of th e OOc. Th e t ran sverse belly is located m ore deeply an d is
m ore h or izon t al t h an t h e obliqu e belly. Th e t ran sverse belly
is m ore or less t riangu lar in sh ap e w ith it s in ferom edial p art as
th e apex. Th e oblique belly is classi ed in to t w o di eren t t ypes:
n arrow ver t ical or broad t riangu lar t ypes.1 Th e CSM w ith th e
OFM cau se w rin kling of th e skin at th e glabella (Fig. 12.5).
Th e depressor su percilii (DS) is a fan or t riangular sh aped
m u scle th at origin ates from th e fron t al p rocess of th e m axilla
113
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 12.3 Frontalis. The frontal belly of the
occipitofrontalis muscle is the anterior portion
of this muscle, and it arises from the galea
aponeurotica and is inserted into the frontal
skin above the eyebrow.
an d th e n asal p or t ion of th e fron tal bon e 1 cm above th e m edial
palpebral ligam en t . At th e glabella, DS m ixes w ith bers of th e
CS is in term ingled w ith th e m ed ial bers of th e OOc. Som e
m u scu lar bers of th e DS origin ate from th e lacrim al sac, an d it
plays a role in m ovem en t of th e eyebrow.
External Nose Region
Fig. 12.4 Orbicularis oculi muscle (left side of the face). The orbicularis
oculi muscle is located around the orbit and into the eyelids, anterior
temporal region, infraorbital cheek and superciliary region.
114
Th e n ose is a dyn am ic st ruct ure; n asal m usculat ure m oves th e
n asal cart ilages an d p lays an im port an t role in n asal physiology.
Th e t ran sverse part of th e n asalis, origin at ing from th e m axilla,
is th in , at , an d h as a t riangular sh ape. It is located deep in th e
alar p ar t an d ascen d s to th e dorsu m of th e n ose. Th e t ran sverse
par t of th e n asalis, w h ich is C sh aped, su rroun ds th e p osterior
n asal ap er t u re an d ascen ds an teriorly tow ard th e dorsu m of th e
n ose (Fig. 12.6). Th is t ran sverse par t lies bet w een th e lateral
n asal car t ilage an d th e greater alar cart ilage an d receives som e
m u scle bers from t h e su p er cial layer of levator labii su p eri
oris alaquae n asi m uscle (LLSAN).
Th e procerus m uscle origin ates from th e fascia covering th e
d orsu m of t h e n ose an d in ser t s su p er iorly in to t h e skin of t h e
glabella. Th e con t ract ion of p rocer u s m akes t h e t ran sverse
w rin kles on th e radix of th e n ose.
Th e alar p ar t of n asalis or igin ates w it h t h e t ran sverse p ar t
of th e n asalis from th e m axilla an d in sert s in to th e alar facial
crease an d th e adjacen t deep su rface of th e extern al skin of th e
alar lobu le.
12 Mim etic Muscles
Fig. 12.5 Corrugator supercilii muscle. The
corrugator supercilli m uscle originates from
the periosteum on the frontal bone and
merges into the frontal belly of the occipito
frontalis muscle.
Th e dilator n aris vest ibularis m uscle is located bet w een th e
extern al an d vest ibu lar skin of th e alar lobu le.2 It s m u scle bers
radiate along the dom e shaped nasal vestibule. The dilator naris
an terior m u scle origin ates from th e fron tal surfaces of th e lat
eral h alf of th e lateral cru s an d th e accessor y alar car t ilage adja
cen t to th e lateral cru s.
Th e depressor sept i m u scle is located in the deep aspect of
t h e lip , con t in u es to t h e m a xillar y in cisive fossa, an d in ser t s
to th e m obile por t ion of th e n asal sept u m . It part icipates in en
larging th e n aris by pu lling dow n th e t ip of th e n ose.
su perioris m u scle (LLS), resp ect ively. Th e m edial slip is in serted
in to th e alar cart ilage, an d th e lateral slip con t in u es to th e lat
eral p ar t of th e u pp er lip , th en to th e LLS an d th e orbicu laris oris
(OOr). Th e super cial layer of LLSAN descen ds on th e LLS, an d
th e deep layer is located deep to th e LLS. Th e deep layer of
Anterior Cheek Region
(Upper Lip Elevators)
Th e appearan ce of th e lip fram ew ork is determ in ed by th e ac
t ivit y of various facial m u scles, such as th e levator labii superi
oris (LLS), th e LLSAN, an d th e ZMi/ZMj (Fig. 12.7). Am ong th ese,
th e LLS, th e LLSAN, an d th e ZMi determ in e th e am oun t of lip
elevat ion th at occurs during sm iling or sadness.
Th e LLS origin ates from th e orbit al rim of th e m axilla an d
zygom at ic bon e above th e in fraorbit al foram en an d in sert s in to
th e upper lip area. Th e LLS is rect angular in 83% an d t rapezoid
in 7%.3 It s m edial bers are at t ach ed to th e deep surface of th e
alar facial crease bet w een th e lateral slip of LLSAN an d ZMi an d
are m ain ly in term ingled w ith th e alar part of th e n asalis. Som e
of th e deeper m uscle bers of th e LLS exten d to th e vest ibu lar
skin of th e n asal lobu le.
Th e LLSAN origin ates from th e fron t al process of th e m axilla
an d in ser t s in to th e u p per lip an d th e ala of th e n ose. Th e LLSAN
is divided in to m edial an d lateral slips an d th en is divided in to
t w o layers, w h ich are sup er cial an d deep to th e levator labii
Fig. 12.6 Nasalis (right side of the face).
115
Anatom y for Plastic Surgery of the Face, Head, and Neck
Perioral Region
Fig. 12.7 Upper lip elevators (left side). The levator labii superioris
(LLS), the levator labii superioris alaeque nasi (LLSAN), and the
zygomaticus minor (ZMi) have a role in lip elevation that occurs during
smiling or sadness.
LLSAN origin ates from th e su per cial layer of LLSAN an d th e
fron t al p rocess of th e m axilla. It in sert s bet w een th e levator an
gu li oris an d th e OOr m u scles. Th e t ran sverse p ar t of th e n asalis
or igin ates from t h e m a xilla an d ascen d s p assing p oster ior to
t h e super cial layer of LLSAN (65%), or it origin ates as t w o m us
cle bellies from th e m axilla an d th e u pper h alf of th e alar facial
crease (35%).4
Th e ZMi origin ates from th e zygom at ic bon e beh in d th e zy
gom aticom axillar y suture an d in serts into the skin and th e upper
lip. It is separated superiorly by a n arrow t riangle shaped space
from th e LLS, an d it blen ds w ith th e m u scle in feriorly. Besides
th e bony origin of th e ZMi, th e lateral belly of th e orbital par t of
th e OOc blen ds w ith th e ZMi in 88.5% of cases. In addit ion , ZMi
at t ach es in to bot h t h e u p p er lip an d t h e ala of t h e n ose in 28%
of cases.
Th e LLSAN an d ZMi cover t h e in ser t ion of t h e LLS p ar t ially
or en t irely, an d th ese th ree m uscles converge on th e area lateral
to th e ala of th e n ose. Th e levator m uscles of th e upper lip pass
th rough th e OOr an d par t icipate in th e form at ion of th e n aso
labial fold.
116
In th e p erioral region , th e m u scles for facial exp ression are ar
ranged in fou r layers based on th eir origin s (Fig. 12.8). Th e in dividu al m u scles are arranged in th e su per cial ( rst , secon d, an d
th ird) layer an d th e deepest (fou rth ) layer, an d it h as been doc
um en ted th at th e ZMj is located in th e su per cial layer. Th e
d eep est , fou r t h layer is com p osed of t h e levator an gu li or is,
m en talis, an d bu ccin ator m u scles.
As a con st rictor of th e m outh , th e OOr en circles th e m outh
an d is located w ith in th e u p p er an d low er lip s. Most m u scle b
ers origin ate from th e oth er facial m u scles converging to th e
m ou th . A p ar t of in t rin sic m u scle bers arise from th e labial al
veolar bon e covering th e u pp er an d low er in cisors. Th is m u scle
acts in closing th e m ou th an d p rot ru sion of th e lip s in th e m an
n er of a sp h in cter. Th e OOr divides in to fou r qu adran t s, w h ich
fu r t h er d ivid e in to a p ars p er ip h eralis an d a p ars m argin alis.
Pars p er ip h eralis is a lateral stem at t ach ed to t h e labial sid e.
Most origin ate from t h e m od iolu s it self, bu t som e con t in u e
from th e oth er m odiolar m u scles. Pars m argin alis is n arrow an d
is con n ected to th e red lip m argin . It is involved w ith sp eech
an d p rod u ct ion of m u sical ton es. Its m edial bers in terface
w ith th e con t ralateral pars m argin alis an d at t ach es to th e der
m is of th e lip .
Th e levator anguli oris m u scle (LAO) origin ates from th e ca
n in e fossa below t h e in fraorbit al foram en an d in ser t s in to t h e
m odiolu s. Th is m u scle in term ingles w ith th e OOr, ZMj, an d DAO
an d in ser t s to t h e m od iolu s, t h ereby raisin g t h e cor n er of t h e
m ou th . In fraorbit al vessels an d a n er vou s plexu s lie bet w een
th e LAO an d LLS.
The depressor anguli oris m uscle (DAO) is a triangular m uscle
on the m ost super cial layer of the perioral m uscles origin at ing
from th e extern al obliqu e lin e of th e m an dible. Its con t in u at ion
form s an obliqu e lin e below an d lateral to th e depressor labii
in ferioris m u scle, an d it converges in to a n arrow fascicu lus th at
blen ds at th e m odiolus w ith th e OOr an d risorius m uscles.
Som e of it s bers con t in u e below th e m en t al t u bercle an d cross
th e m idlin e. Con sequen tly, it in terlaces w ith it s con t ralateral
m ate creat ing th e t ran sversu s m en t i m u scle. Th e m edial border
of th e DAO overlaps w ith DLI an d it s lateral border is adjacen t to
th e risoriu s, ZMj, an d plat ysm a m uscles.
Th e depressor labii in ferioris (DLI) origin ates from th e low er
par t of th e oblique lin e of th e m an dible bet w een th e sym p hysis
m en t i an d th e m en t al foram en an d in ser ts in to th e low er lip
w ith th e paired m uscle from th e opposite site an d w ith OOr. DLI
passes upw ards an d m edially in to th e skin an d m u cosa of th e
low er lip.
Th e ZMj origin ates from th e facial surface of th e zygom at ic
bon e. Th is m u scle descen ds in ferom ediall, blen ds w ith th e OOr,
an d term in ates at th e m odiolu s. Th e in sert ion p at tern s of th e
zygom at icu s m ajor are variable, an d th e existen ce of dist in ct
m u scle bers of th e ZMj p assing deep to th e LAO is n ot alw ays
obser ved. A bi d ZMj, on e t ype of ZMj, separates in to t w o por
t ion s, an d t h e LAO p asses bet w een t h e t w o h ead s. Th e ZMa
in ser t s arou n d t h e m od iolar region , an d t h e m u scle bers are
in terlaced w ith th e buccin ator, LAO, an d OOr. Even th ough all
th ese m uscles converge an d are in terdigit ated in th e m odiolar
12 Mim etic Muscles
Fig. 12.8 Perioral region.
region , kn ow ledge of th e relat ion sh ip bet w een th e deep m u scle
band of th e ZMj an d th e buccin ator is crucial in th e un derstan d
ing of facial an im at ion . In ever y case, th e m ain in ser t ion of th e
d eep m u scle ban d of t h e ZMj is at t h e an ter ior m argin of t h e
buccin ator an d it s fascia. Th is an atom ical relat ion sh ip provides
th e syn ch ron ous pulling of th e an terior region of th e buccin ator
w ith th e correspon ding bu ccal m u cosa out w ard an d upw ard to
create a sm ile. Th e out w ard m ovem en t of th e an terior m argin
of th e bu ccin ator an d th e con t ract ion of th e lip elevators n at u
rally com p ress th e ch eek fat m ass above th e n asolabial fold, an d
th is ch eek m ass becom es quite prom in en t . Th ese m uscle ac
t ion s also w iden th e n asal w idth because of th e expan sion of
the m idface contour, follow ed by the m uscle pulling upward and
laterally.
Th e risorius is a th in an d slen der m u scle an d is usually lo
cated 20 to 50 m m lateral to th e ch eilion an d 0 to 15 m m below
th e in terch eilion h orizon t al lin e. Most risorius m uscle bers
origin ate from th e SMAS an d som e bers from th e parot id fas
cia or m asseteric fascia. In som e cases, th is m uscle receives th e
u pper m u scle bers of p lat ysm a. It term in ates in th e m odiolu s
region an d act s by p ulling th e corn er of th e m outh w h en sm il
ing. Risorius can be categorized in to th ree com m on t ypes: zygo
m at icu s risoriu s, p lat ysm a risoriu s, an d t riangu laris risoriu s.5 It
also in ser ts in to th e m odiolu s in th ree d ist in ct layers in relat ion
to th e DAO: su per cial, u sh , an d deep (Fig. 12.9).
Th e bu ccin ator origin ates from th ree region s: pter ygom an
dibular raphe, m axillary, and m andibular alveolar processes. It is
located bet w een th e m a xilla an d th e m an d ible. Th e bu ccin ator
is rect angu lar an d h as fou r ban ds: (1) a ban d origin at ing from
th e m axilla, (2) a ban d from th e an terior m argin of th e pter ygo
m an dibu lar rap h e, (3) a ban d exten ding from th e m an dible, an d
(4) an addit ion al in ferior ban d also exten ding from th e m an di
ble. Th e bu ccin ator is rein forced by t h e in cisivu s labii in fer io
r is (ILI).6 A few bers sp r in g from a n e ten d in ou s ban d t h at
bridges bet w een th e m axilla an d th e pter ygoid h am ulus (Fig.
12.10).
Chin Region and Superf cial
Neck
Th e m en talis m uscle (MT) is th e on ly elevator of th e low er lip
an d th e ch in , an d it p rovides th e m ajor vert ical su pp ort for th e
low er lip . Th e absen ce of t h is m u scu lar fu n ct ion w ou ld resu lt
in th e low er cen t ral in cisors being visible at rest . Resect ion of
th e MT m ay cause th e pat ien t to drool an d m ay a ect den t u re
st abilit y. MT is con e sh ap ed ; th e ap ex of th is m u scle origin ates
from the incisive fossa of the m andible. Th e m edial bers of both
Fig. 12.9 Risorius (left side).
117
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 12.10 Buccinator.
MTs descen d an terom edially an d cross over togeth er, form ing a
dom e sh aped ch in prom in en ce. Th e lateral bers of th e MT de
scen d m ostly in ferom edially. Th e u pp er bers are sh ort an d
h orizon t al, w h ereas th e low er bers are long an d descen d in fer
om edially or ver t ically.7 MT con t ract ion cau ses th e skin over
th e m en t um to w rin kle. Th e upper bers of th e MT in term ingle
w ith th e in ferior m argin of th e OOr. In addit ion , th e origin at ing
m u scle bers of th e ILI in term ingle w ith th e u pp er lateral MT
(Fig. 12.11).
Th e plat ysm a at t ach es to th e low er border of th e m an dible
an d con sist s of t w o t yp es of bers. A at ten ed bu n d le p asses
su p erom ed ially to t h e lateral bord er of t h e DAO, an d oth ers
con t in u e deep in to DAO an d reapp ear at it s m edial border. Lack
of decu ssat ion creates a cer vical defect , resu lt ing in a redu ct ion
in elast icit y of th e cer vical skin an d plat ysm a w ith ageing,
w h ich gives rise to th e so called t u rkey gobbler n eck. Plat ysm al
bers d o n ot m erely d ecu ssate an d in terlace from each sid e,
bu t som et im es on e side of th e m u scle overlap s an d covers t h e
ot h er side.8
Modiolus
Th e m odiolus is a brom uscular st ruct u re th at decussates be
t w een th e OOr m uscle an d th e labial ret ractors, en ding at th e
lateral border of th e ch eilion (Fig. 12.12).9 It exten ds 20 m m
above an d below a h orizon tal lin e th rough th e bu ccal angle. It is
st rongly associated w ith facial exp ression , beau t y, aging, an d
form at ion of th e n asolabial fold. Th e m odiolu s is a d en se, com
pact , an d m obile m uscu lar m ass located at th e lateral border of
th e corn er of th e m ou th an d is form ed by a convergen ce of m u s
cle bers from th e zygom at icus m ajor, levator labii superioris,
depressor labii in ferioris, DAO, risorius, OOr, bu ccin ators, an d
LAO m u scles. Th e form at ion of su btle an d det ailed facial ex
Fig. 12.11 Mentalis muscle.
118
12 Mim etic Muscles
Fig. 12.12 Modiolus (left side). The modiolus
is a bromuscular structure that decussates
bet ween the orbicularis oris m uscle and the
labial retractors ending at the lateral border of
the cheilion.
pression s of th e in ferior face, such as th ose re ect ing determ i
n at ion , sat isfact ion , sm iling, purp oseful act ion , an d sadn ess, are
possible by con t ract ing th ese m uscles, w h ich term in ate at th e
m od iolu s. A ten din ou s t issu e n odu le in th e m odiolu s is fou n d in
about 20% of cases. The facial arter y passes approxim ately 1 m m
lateral to th e lateral border of th e m odiolus.
References
1. Yang HM, Kim HJ. An atom ical st udy of th e corrugator supercilii
m uscle and it s clin ical im plicat ion w ith bot ulin um toxin A injec
t ion . Surg Radiol An at 2013;35(9):817–821 Pu bMed
2. Hu r MS, Hu KS, Youn KH, Song WC, Abe S, Kim HJ. New an atom ical
pro le of th e n asal m u scu lat u re: d ilator n aris vest ibu laris, dilator
n aris anterior, an d alar par t of th e n asalis. Clin An at 2011;24(2):
162–167 PubMed
3. Hur MS, You n KH, Hu KS, et al. New an atom ic con siderat ion s on
th e levator labii su p erioris related w ith th e n asal ala. J Cran iofac
Surg 2010;21(1):258–260 PubMed
4. Hur MS, Hu KS, Park JT, You n KH, Kim HJ. New an atom ical in sigh t
of th e levator labii superioris alaeque n asi an d th e t ran sverse par t
of th e nasalis. Su rg Radiol An at 2010;32(8):753–756 Pu bMed
5. Kim HS, Pae C, Bae KS, et al. An an atom ical st u dy of th e risoriu s in
Asian s an d it s insert ion at th e m odiolus. Surg Radiol Anat 2015;
37:147–151 PubMed
6. Hur MS, Hu KS, Kw ak HH, Lee KS, Kim HJ. In ferior bun dle (fou rth
ban d) of th e buccin ator an d th e in cisivus labii in ferioris m uscle. J
Cran iofac Surg 2011;22(1):289–292 Pu bMed
7. Hur MS, Kim HJ, Ch oi BY, Hu KS, Kim HJ, Lee KS. Morph ology of th e
m en talis m uscle an d it s relat ion sh ip w ith th e orbicularis oris an d
in cisivus labii in ferioris m uscles. J Cran iofac Su rg 2013;24(2):
602–604 Pu bMed
8. Kim HJ, Hu KS, Kang MK, Hw ang K, Ch ung IH. Decu ssat ion p at tern s
of th e plat ysm a in Korean s. Br J Plast Surg 2001;54(5):400–402
Pu bMed
9. Yu SK, Lee MH, Kim HS, Park JT, Kim HJ, Kim HJ. Histom orphologic
ap p roach for th e m odiolu s w ith referen ce to recon st r u ct ive an d
aesthetic surger y. J Craniofac Surg 2013;24(4):1414–1417 PubMed
119
13
Orbital Anatomy
Sw apna Vem uri and Jerem iah P. Tao
Clinical Anatomy
Th e orbit is con ical an d h as a volu m e of abou t 30 cm 3 . Th e
an ter ior orbit al r im h as h or izon t al an d ver t ical d iam eters of
4.0 cm an d 3.5 cm , respect ively; h ow ever, th e orbit al dim ension
w iden s posteriorly, w ith a m axim um diam eter 1 cm posterior
to th e rim . Th e distan ce from th e an terior orbit al rim to th e
ap ex is app roxim ately 4.5 to 5 cm along th e m edial orbit al w all,
w h ereas th e distan ce from th e lateral orbit al rim to th e superior
orbit al ssu re is abou t 4 cm .1,2
Th e m edial orbital w alls are parallel to each oth er an d ap proxim ately 2.5 cm apar t . Th e lateral w all form s a 45-degree
angle w ith the ipsilateral m edial w all. The t w o lateral walls form
a 90-degree angle (Fig. 13.1).
Orbital Floor
Orbital Bones
Th e orbit al oor, separated from th e lateral w all by th e in ferior
orbit al ssu re, con sist s of th e zygom at ic, m axillar y, an d palat in e bon es. Th e oor form s th e roof of th e m a xillar y sin us. Th e
infraorbital groove or canal, through w hich the infraorbital nerve
(CN V2 bran ch ) an d ar ter y t ravel, divides th e oor. Th e in fraorbit al n er ve an d ar ter y th en exit th rough the in fraorbit al foram en , w h ich is ap p roxim ately 1 cm in ferior to th e orbit al rim on
th e an terior m axillar y bon e face (Fig. 13.2c).
Orbital Rim
Medial Orbital Wall
Th e orbital rim is com posed of th e fron tal, zygom at ic, an d m a xillar y bon es th at adjoin at su t u re lin es (fron tozygom at ic, zygom at icom axillar y, an d fron tom a xillar y, respect ively). Th e lateral
an d su perior rim s are th e st rongest . Th e orbit al rim creates th e
an terior lacrim al crest an d th en sp irals p osteriorly to en d at th e
posterior lacrim al crest . Th e lacrim al sac fossa is fou n d bet w een
th e t w o crest s (Fig. 13.2a).
Th e m edial orbit al w all con sist s of th e m axillar y, lacrim al, eth m oid, an d sp h en oid bon es. Th e an terior an d posterior eth m oidal foram in a, w ith eth m oidal vessels passing th rough , are foun d
on th e m edial w all along th e fron toeth m oidal sut ure. Along th e
m edial w all, th e d ist an ce bet w een th e an terior lacrim al crest ,
an terior eth m oidal foram en , p osterior eth m oidal foram en , an d
orbit al ap ex is ap p roxim ately 24 m m , 12 m m , 6 m m , resp ect ively (Fig. 13.2d).
Orbital Walls
Seven orbit al bon es com p ose t h e fou r w alls of t h e orbit (Fig.
13.2a).
Orbital Roof
Th e orbit al roof, w h ich is th e oor of th e an terior cran ial fossa,
con sist s of th e fron t al an d lesser w ing of sph en oid bon es. Th e
su p raorbit al n otch or foram en , th rough w h ich th e su praorbit al
n er ve (CN V1 ) an d vessels t ravel, divides th e m edial on e-th ird
an d lateral t w o-th irds of th e su perior orbit al rim . Th e lacrim al
glan d is fou n d laterally in th e lacrim al glan d fossa.
Lateral Orbital Wall
Th e lateral orbit al w all, separated from th e roof by th e superior
orbit al ssu re, con sist s of t h e zygom at ic an d greater w ing of
t h e sph en oid bon es (Fig. 13.2b). Th e zygom at icofacial an d zygom at icotem p oral can als t ran sm it vessels an d zygom at ic n er ve
bran ch es. Occasion ally, a m en ingo-orbit al foram en is iden t i ed
120
lateral to th e su perior orbit al ssu re an d t ran sm it s a bran ch of
th e m iddle m en ingeal arter y.3,4 W h it n all’s t u bercle is a p rot u beran ce on t h e in n er asp ect of t h e lateral orbit al r im ap proxim ately 4 m m posterior to th e rim an d 10 m m in ferior to th e
fron tozygom at ic su t u re. Th e lateral can th al ten don , lateral h orn
of the levator aponeurosis, Lockwood’s ligam ent, and ch eck ligam en t of th e lateral rect u s m u scle at t ach to th e t u bercle.
Additional Fissures, Canals, and
Foramina and Contents
Th e superior orbit al ssure (SOF) is located bet w een th e greater
an d lesser w ings of sp h en oid. Th e an n u lu s of Zin n , a ten din ou s
ring at th e orbit al apex form ed by th e ext raocu lar rect u s m u scles, divides th e SOF. Th e an n ulus also en circles th e opt ic foram en , w h ich is m edial to th e SOF. Above th e an n u lu s, th e lacrim al
an d fron tal n er ves (CN V1 bran ch es), t roch lear n er ve (CN IV),
an d su p erior oph th alm ic vein p ass th rough th e SOF. Th e su p erior an d in ferior bran ch es of th e ocu lom otor n er ve (CN III), ab ducens ner ve (CN VI), and nasociliary nerve (CN V1 ) pass through
th e an n ulu s. Th e in ferior oph th alm ic vein m ay pass below th e
an n u lu s (Fig. 13.3).
Th e opt ic foram en is located m edial to th e SOF in th e lesser
w ing of t h e sp h en oid an d sep arated by a bony opt ic st r u t . It
exten ds posteriorly as th e opt ic can al th at h as an ap p roxim ate
diam eter of 6 m m an d a length of 10 m m . Th e opt ic n er ve an d
oph th alm ic arter y pass th rough th e opt ic can al.
Th e in ferior orbital ssu re (IOF) is located in ferior to th e SOF
bet w een the greater w ing of sph en oid (lateral orbit al w all) an d
Fig. 13.1 Orbital dim ensions and volumes.
Supraorbital foraman
Sphenoid bone, lesser wing
Optic canal
Anterior and posterior ethmoidal foramina
Frontal bone
Frontoethmoidal suture
Lacrimal gland fossa
Frontozygomatic suture
Frontomaxillary suture
Ethmoid bone
Superior orbital ssure
Lacrim al sac fossa
Lacrimal bone
Anterior lacrimal crest (maxillary bone)
Nasal bone
Sphenoid bone, greater wing
Zygomaticofacial foramen
Posterior lacrimal crest (lacrimal bone)
Zygomatic bone
Maxillary bone
Inferior orbital ssure
Zygom aticom axillary suture
Infraorbital groove
Infraorbital foramen
a
Frontal sinus
Frontal bone
Zygom atic bone
Zygomatico-orbital
foramen
Maxillary
Sphenoid bone,
lesser wing
Superior orbital ssure
Sphenoid bone,
greater wing
bone
Inferior orbital ssure
Maxillary sinus
Palatine bone,
pyram idal process
b
Fig. 13.2 (a) Orbital bones, sutures, foramina, and
ssures. Anterior view. The orbital rim is composed
of the frontal, zygomatic, and maxillary bones that
adjoin at suture lines (frontozygomatic, zygomaticomaxillary, and frontomaxillary, respectively).
(b) Lateral wall, right orbit. The lateral orbital wall,
separated from the roof by the superior orbital ssure,
consists of the zygomatic and greater wing of
sphenoid bones. (continued on page 122 )
121
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 13.2 (continued ) (c) Orbital oor, right
orbit. The orbital oor, separated from the
lateral wall by the inferior orbital ssure, consists of the zygomatic, maxillary, and palatine
bones. (d) Medial wall, right orbit. The medial
orbital wall consists of the maxillary, lacrimal,
ethm oid, and sphenoid bones. (Modi ed from
THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thiem e 2010, Illustrations by Karl
Wesker.)
c
Posterior ethm oidal foram en
Frontoethm oidal suture
Anterior ethm oidal foram en
Frontal sinus
Ethm oid bone
Optic canal
(Sphenoid bone, lesser wing)
Sphenoid bone, lesser wing
Superior orbital fissure
Palatine bone
Inferior orbital
fissure
Frontal bone
6mm
12m m
24m m
Nasal bone
Lacrim al sac fossa
Lacrim al bone
Anterior lacrim al crest
Posterior lacrim al crest
Maxillary bone
Infraorbital foram en
Maxillary sinus
d
Pterygopalatine fossa
palat in e an d m axillar y bon es (orbit al oor). Th e in fra orbital
an d zygom at ic n er ves (CN V2 ), in fraorbital arter y, in ferior oph th alm ic vein , an d pter ygopalat in e ganglion auton om ic bran ch es
pass th rough th e IOF.
Periorbita and Fascial Tissues
Periosteu m covers th e orbit al bon es an d is kn ow n as p eriorbit a
along th e orbital w alls (Fig. 13.4). It is loosely adh eren t over th e
w alls but tigh tly adh eren t at sut u re lin es, th e orbital rim w h ere
it form s the arcus m argin alis, foram ina, and ssures. The orbital
sept u m origin ates from th e arcus m argin alis. At th e optic can al,
periorbita is cont in uous w ith th e dural sheath of th e opt ic ner ve.
Orbit al fascia is com plexly organ ized.5 Ten on’s capsule, a brous m em bran e, exten ds from th e posterior globe an d fuses
w ith conjun ct iva an teriorly at th e lim bus. Fibrous septa exten d
from Tenon’s to divide lobules of orbital fat. Extraocular m uscles
122
pass th rough Ten on’s fascia to in sert on to th e globe. Muscu lar
fascial sh eath s are fou n d su rrou n ding each ext raocu lar m u scle
w ith project ion s to th e orbit al w alls, kn ow n as ch eck ligam en t s.
Th e fascial sh eath in th e an terior orbit is also foun d in bet w een
each m u scle to create th e in term u scu lar sept u m .
Surgical Annotation
Orbital Surgical Spaces and
Approaches
Th e organ izat ion of orbital fascia an d st ruct ures com par t m en t alizes th e orbit . From deep to super cial, th e surgical spaces of
th e orbit in clude th e follow ing: in t racon al, sub -Ten on’s, ext raocu lar m uscles, ext racon al, subperiosteal, an d ext raorbit al (Fig.
13.5). Th e appropriate orbit al surgical approach is determ in ed
13 Orbit al Anatom y
Superior orbital
fissure
Levator palpebrae
superioris
Frontal n.
Superior
rectus
Superior
oblique
Lacrimal n.
Optic n. (CN II, in optic canal)
Superior
ophthalm ic v.
Com m on
tendinous ring
Trochlear n. (CN IV)
Oculomotor n. (CN III),
superior branch
Ophthalm ic a.
Superior
orbital fissure
Nasociliary n.
Lateral rectus
Medial
rectus
Inferior orbital
fissure
Oculomotor n. (CN III),
inferior branch
Abducent n.
(CN VI)
Inferior
ophthalm ic v.
Inferior
rectus
Fig. 13.3 Structures of the orbital apex including muscle origin, annulus of Zinn, ssures, and contents. Right orbit, anterior view, with most of the
orbital contents removed. (Reproduced from THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustration by Karl Wesker.)
Episcleral
space
Orbital roof
Eye brow
Tenon‘s capsule
Periorbita
Levator
palpebrae superioris
Arcus
m arginalis
Orbital fat
Superior rectus
Eyeball
Optic n.
with dural sheath
Upper and lower
eyelids
Inferior rectus
Orbital septum
Inferior oblique
Orbital fat
Arcus marginalis
Infraorbital n.
Sclera
Orbital floor
Fig. 13.4 Sagit tal view of right orbit demonstrating periorbita, fascia,
and relationship of extraorbital and intraorbital structures. Periorbita
covers the orbital bones. It is loosely adherent over the walls but tightly
Maxillary sinus
adherent at suture lines. (Modi ed from THIEME Atlas of Anatomy,
Head and Neuroanatomy. © Thieme 2010, Illustration by Karl Wesker.)
123
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 13.5 Axial and coronal views of right orbit demonstrating surgical spaces. From deep to super cial, the surgical spaces of the orbit include the
following: intraconal, sub-Tenon’s, extraocular m uscles, extraconal, subperiosteal, and extraorbital.
by th e locat ion of path ology w ith regards to su rgical space,
depth in orbit relat ive to th e globe equ ator, an d locat ion relat ive
to opt ic n er ve.
•
Anatomical Considerations during
Orbital Surgery
•
Orbital Wall Surgery
Du e to th e t igh t sp ace an d n u m erou s vit al st ru ct u res in th is region , orbital su rger y p oses sign i can t risks. A th orough u n derst an ding of orbit al an atom y is essen t ial for safe su rger y.
•
Orbital Floor
Th e m ost com m on ly fract ured orbital w all is th e oor. Th e in ferom edial w all (m edial to th e in fraorbit al can al) is p ar t icu larly
su scept ible. Du ring orbit al oor su rger y (i.e., fract u re rep air or
bon e decom pression ), th e safest dissect ion plan e is subperiosteal. The authors prefer a tranconjunctival approach com bined
w ith lateral canthotom y and inferior cantholysis, how ever, t ran scu tan eous approach es are altern at ive opt ion s. Th e follow ing
are im p or t an t con siderat ion s, on ce in th e orbit:
•
•
124
Anterom edially, th e inferior oblique m uscle originates on the
m axillar y bon e ju st beh in d th e in ferior orbital rim an d lateral to t h e lacr im al sac fossa. Dissect ion n ear t h e an tero m ed ial oor can resu lt in it s u n in ten t ion al disru pt ion along
w ith dam age to th e lacrim al sac.
Th e in fraorbit al n er ve t ravels in th e in fraorbital groove along
th e cen t ral oor an d sh ould be visualized an d preser ved.
Dam age to th e n er ve resu lt s in both er som e in fraorbital hypoesth esia. Elevat ion of periosteum over th e can al m ay in -
duce sm all to m edium size ar terial bleeding. Elect rocauter y
to th ese vessels sh ould be perform ed caut iously an d w ith a
m in im al en ergy tech n iqu e.
Lateral to th e in fraorbital groove, along th e p osterior oor,
th e con ten t s of th e in fraorbital ssure can be foun d en tering
th e ssu re an d sh ould n ot be con fused w ith en t rapped orbit al soft t issues.
Th e postero-m edial oor has a relatively steep supero-m edial
in clin e. Th is can result in di cu lt y visualizing th e posterom edial ledge of a oor fract u re from th e h ead -of-bed su rgeon perspect ive. En tering th e m axillar y sin u s an d follow ing
it s roof an teriorly m ay aid in th e iden t i cat ion of th e posterior ledge.
Th e p osterior w all of th e m axillar y sin u s is an excellen t
lan dm ark for th e orbit apex. In t raorbital dissect ion posterior
to th is depth is risky an d is usually n ot n ecessar y.
Medial Orbital Wall
Th e follow ing are im port an t con siderat ion s for orbit m edial
w all su rger y (fract u re rep air or decom pression ):
•
•
Th e m edial can th al ten don in sert s on to th e an terior an d
posterior lacrim al crest w ith th e lacrim al sac located in th e
lacrim al sac fossa. Th e cu tan eous approach to th e m edial
orbit o ers a pan oram ic view of th e m edial orbit , h ow ever
m edial can th al ten don disin ser t ion is n ecessar y an d a can th opexy sut ure is placed to forest all telecan th u s.6,7
Th e t ran scaru n cu lar app roach avoid s a cu t an eou s in cision
w ith preser vat ion of th e m edial can th al ten don w h ile o ering good access to th e m edial w all.8 Th e leading periosteal
edge for su bperiosteal d issect ion m u st begin at th e p osterior
lacrim al crest w ith care n ot to violate th e lacrim al sac. Hern iat ion of su rrou n ding orbital fat an d a t igh ter su rgical space
13 Orbit al Anatom y
•
•
•
•
are disadvan t ages of th is ap proach com pared to th e t ran scu tan eous approach .
Periosteal elevat ion sh ou ld begin on th e th icker fron tal bon e
m a xillar y p rocess. A su bp eriosteal p lan e is m ore di cu lt to
ach ieve on th e th in eth m oid bon e th at fract u res easily w ith
m an ip u lat ion .
Th e an terior an d posterior eth m oidal foram in a m ark th e
level of th e fovea eth m oidalis, th e roof of th e eth m oid sin us.
Th is is th e superior exten t of m edial orbit al decom pression
as th ere is risk of disru pt ing th e cribriform p late an d en tering th e an terior cran ial fossa w ith a resu lt an t cerebrospin al
u id (CSF) leak or in t racran ial h em orrh age.
Th e an terior an d posterior eth m oidal ar teries p ose a risk of
orbit al h em orrh age if lacerated.
Dissect ion greater th an a 4 cm depth from th e orbit al rim
along th e m ed ial w all risks dam age to th e opt ic n er ve.
Lateral Orbital Wall
The anterior lateral orbital w all is strong; however, the posterior
border of the deep lateral orbital wall is thin.2,9 W hen perform ing
lateral w all su rger y (i.e., zygom at icom axillar y com p lex fract u re
rep air or decom p ression ) th e follow ing sh ou ld be con sidered:
•
Th e distan ce along th e lateral w all from th e orbit al rim to
th e SOF is about 4 cm .
•
•
•
Du ring d eep lateral w all decom pression , th e d ip loic t rigon e
of th e greater w ing of sph en oid (foun d lateral to th e SOF),
lacrim al sac fossa, an d body of th e zygom a m ay be scu lpted
to allow for globe retropulsion.10 Because th ese areas of bone
can var y in th ickn ess, com puted tom ography h elps determ in e th e volu m e w h en plan n ing for su rger y. Th ese areas lie
adjacen t to in t racran ial cavit ies, w h ich m ay resu lt in a CSF
leak during decom pression. Care m ust be taken to avoid dural
p en et rat ion .
Th e m en ingo-orbit al foram en w ith a bran ch of th e m iddle
m en ingeal arter y m ay be en cou n tered lateral to SOF du ring
deep lateral w all dissect ion . Th is is an addit ion al poten t ial
in t racran ial exten sion th at m ust be avoided.
Zygom aticom alar com plex (ZMC), or tripod, fract ures con sist
of fractures at the frontozygom atic, zygom aticom axillar y, an d
zygom at icosph en oid sut ures an d th e zygom at ic arch . Often
in a ZMC fract ure, th e zygom at ic bon e telescopes aroun d th e
fron t al bon e at t h e su t u re in ad d it ion to a m ed ial rot at ion
of th e fract ured zygom at ic bon e segm en t . Adequate realign m en t d u r in g fract u re rep air requ ires torqu ein g t h e fragm en ted segm en t an d relievin g t h e telescop in g to restore
m ore n or m al orbit al an atom y. Realign m en t of t h e zygom at icosph en oid sut u re is essen t ial. Th e in t raorbit al view of th e
lateral w all o ers th e best van tage poin t to en sure proper
ZMC fract ure reduct ion .
References
1. Lem ke BN, Lucarelli MJ. Anatom y of ocular adn exa and orbit . In :
Sm ith BC, editor. Oph th alm ic Plast ic an d Recon st ru ct ive Surger y.
2n d ed. St . Lou is, MO: CV Mosby; 1997:3–78
2. W h it n all SE. Th e An atom y of th e Hum an Orbit an d Accessor y Organ s of Vision . New York: Oxford Un iversit y Press; 1932:1–252
3. Mysorekar VR, Nan dedkar AN. Th e groove in th e lateral w all of th e
hu m an orbit . J An at 1987;151:255–257 PubMed
4. Kw iatkow ski J, Wysocki J, Nitek S. Th e m orph ology and m orph om et r y of th e so-called “m en ingo-orbit al foram en ” in h u m an s. Folia
Mor ph ol (Warsz) 2003;62(4):323–325 PubMed
5. Koorn n eef L. Det ails of th e orbit al con n ect ive t issue system in th e
adu lt . In: Koorn neef L, ed. Spat ial Aspect s of Orbit al MusculoFibrous Tissue in Man: A new anatom ical and histological approach.
Am sterdam : Sw et s an d Zeitlinger; 1977
6. Nun er y W R, Tao JP, Joh l S. Nylon foil “w raparoun d” repair of com bin ed orbit al oor an d m edial w all fract u res. Oph th al Plast Recon st r Surg 2008;24(4):271–275 Pu bMed
7. Tim on ey PJ, Sokol JA, Hau ck MJ, Lee HB, Nun er y W R. Tran scut an eous m edial can th al ten don incision to th e m edial orbit . Oph th al
Plast Recon st r Surg 2012;28(2):140–144 Pu bMed
8. Sh orr N, Baylis HI, Goldberg RA, Perr y JD. Tran scaru n cular ap proach to th e m edial orbit an d orbit al apex. Oph th alm ology 2000;
107(8):1459–1463 Pu bMed
9. Kakizaki H, Nakan o T, Asam oto K, Iw aki M. Posterior border of th e
deep lateral orbit al w all—appearan ce, w idth , an d dist an ce from
th e orbit al rim . Op h th al Plast Recon st r Su rg 2008;24(4):262–265
PubMed
10. Goldberg RA, Kim AJ, Kerivan KM. Th e lacrim al keyh ole, orbit al
door jam b, an d basin of th e in ferior orbit al ssu re. Th ree areas of
deep bon e in th e lateral orbit . Arch Op h th alm ol 1998;116(12):1618–
1624 Pu bMed
125
14
Orbital Soft Tissues
Sw apna Vem uri and Jerem iah P. Tao
Extraocular Muscles and
Innervation
Th e six ext raocular m uscles (m edial, lateral, superior an d in ferior rect i, an d su p erior an d in ferior obliqu e m u scles) m ove th e
globe. With th e except ion of th e in ferior obliqu e m u scle, w h ich
origin ates on th e an terom edial orbit al oor, all th e ext raocular
m u scles origin ate at th e orbit al apex (Fig. 14.1a). Th e rect us
m u scles origin ate at th e brou s an n u lu s of Zin n . Th ese m u scles
course an teriorly, pen et rate Ten on’s capsule, an d in ser t on to th e
an terior asp ect of th e globe, form ing th e sp iral of Tillau x (Fig.
14.1b). Th e rect us m uscles form th e m uscle con e an d delin eate
th e in t racon al an d ext racon al spaces.
Th e levator palpebrae superioris m uscle origin ates on th e
lesser w ing of sp h en oid superior to th e an n u lus. Th e sup erior
oblique m uscle also origin ates on th e lesser w ing of sph en oid
m edial to the levator m uscle origin , continues anteriorly through
th e t roch lea, th en courses posterolaterally u n der th e superior
rect u s m u scle to in sert on to th e globe. Th e in ferior oblique origin ates on th e m axillar y bon e lateral to th e lacrim al sac fossa,
con t in ues posterolaterally un der th e in ferior rect us, an d in ser t s
on to th e globe posterior to th e m acula.
Th e ext raocular m uscles are in n er vated by cran ial n er ves
(CN) III (oculom otor), IV (t roch lear), an d VI (abducen s). CN III
divides in to superior an d in ferior bran ch es in th e cavern ous
sin u s before en tering th e orbit . Th e su p erior bran ch in n er vates
th e levator an d superior rect us m uscles. Th e in ferior bran ch in n er vates th e m edial rect u s, in ferior rect u s, an d in ferior obliqu e
m u scles. CN IV in n er vates th e su p erior obliqu e m u scle. CN VI
in n er vates th e lateral rect us m uscle. Cran ial n er ves III an d VI
enter th e orbit through the superior orbital ssure, travel through
th e in t racon al space, an d in n er vate th e rect us m uscles at th e
posterior on e-th ird an d an terior t w o-th irds jun ct ion . Th e blood
su p p ly for th e rect u s m u scles arises from m u scu lar an terior ciliar y ar ter y bran ch es of th e oph th alm ic arter y, lacrim al arter y,
an d in fraorbital arter y. Th e in ferior division of CN III to th e in ferior obliqu e t ravels lateral to th e in ferior rect u s to in n er vate th e
m uscle on the posterior surface. A parasym pathetic branch to the
ciliar y ganglion t ravels w ith th is in ferior oblique m uscle bran ch .
CN IV t ravels ext racon ally to in n er vate the sup erior oblique on
th e superior surface at th e posterior th ird of th e m uscle.
Optic Nerve
Th e opt ic n er ve (CN II) can be divided in to in t raocular, in t raorbit al, in t racan alicular, an d in t racran ial segm en t s m easuring
ap p roxim ately 1 m m , 25 to 30 m m , 10 m m , an d 10 m m long,
respect ively. Th e in t raorbit al opt ic n er ve exit s th e posterior as-
126
pect of the globe an d in creases in diam eter as it exten ds p osteriorly th rough th e orbit . Its in t raorbit al length is greater th an
the distance from the posterior globe to the optic canal (18 m m ),
allow in g for eye m ovem en t an d a safet y m argin in t h e even t
of p roptosis. Th e opt ic n er ve, w it h a 4-m m d iam eter an d su rroun ded by th e m en inges (pia, arach n oid, an d dura m ater), th en
en ters th e opt ic foram en , w h ich is 6.5 m m in d iam eter. Du ra
fu ses w ith th e an n u lu s of Zin n an d th e opt ic can al p eriosteu m ,
resu lt ing in im m obilizat ion of th e opt ic n er ve. Th e opt ic n er ve
cou rses t h rough t h e opt ic can al, w h ich is abou t 10 m m lon g,
an d con t in u es in t racran ially u n t il it reach es t h e opt ic ch iasm .
Su rgical m an agem en t of in t racon al p ath ology requ ires a keen
un derst an ding of th e opt ic n er ve course.
Orbital Nerves
In ad dit ion to th e cran ial n er ves p reviou sly d escribed, sen sor y,
m otor, an d au ton om ic n er ves su pp ly th e orbit .
Sensory Innervation
Th e oph th alm ic (V1 ) an d m a xillar y (V2 ) division s of th e t rigem in al n er ve (CN V) provide sen sor y inn er vat ion to th e orbit al an d
periorbit al region s (Fig. 14.2).
Ophthalmic Nerve
Th e op h t h alm ic n er ve (CN V1 ) d ivid es in to t h e fron t al an d lacr im al n er ves, w h ich en ter th e orbit above th e an n u lu s of Zin n ,
an d th e n asociliar y n er ve, w h ich en ters th rough th e an n u lu s.
Th e fron t al n er ve d ivid es fu r th er; t h e su p rat roch lear n er ve in n er vates t h e m ed ial u p p er lid , glabellar region , an d m ed ial
conju n ct iva, an d t h e su p raorbit al n er ve in n er vates t h e m ed ial
foreh ead . Th e lacr im al n er ve in n er vates t h e lateral u p p er lid ,
lacrim al glan d, an d lateral conjun ct iva. Th e n asociliar y n er ve
crosses th e opt ic n er ve su periorly from lateral to m edial an d
cou rses bet w een th e superior oblique an d m edial rect us m uscles before furth er dividing. An terior an d posterior eth m oidal
n er ves in n er vate th e m idd le an d in ferior t u rbin ates, n asal sep t um , lateral n asal w all, an d t ip of th e n ose (term in al in frat roch lear n er ve). Ciliar y n er ves provide sen sor y in n er vat ion to th e
ciliar y body, iris, an d corn ea along w ith sym path et ic in n er vat ion to th e dilator pupillae m uscle.
Ciliary Ganglion
Th e ciliar y ganglion , w h ich is located lateral to th e opt ic n er ve
and m edial to the lateral rect us m uscle, is about 1.5 cm posterior
14 Orbit al Soft Tissues
Inferior
oblique
Tendon of
superior
oblique
Trochlea
Superior
rectus
Fig. 14.1 Extraocular muscles, right eye. (a) Superior view.
(b) Anterior view. Muscle insertions onto the anterior aspect
of the globe beginning with the medial rectus and ending
with the superior rectus create the spiral of Tillaux. The distance bet ween the m uscle insertion and limbus are indicated.
(Modi ed from THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustrations by Karl Wesker.)
Superior
oblique
Inferior
rectus
Medial
rectus
Lateral
rectus
Com m on
tendinous ring
Optic nerve
Levator
palpebrae
superioris
a
Superior
oblique
Superior
rectus
Trochlea
7.7m m
Spiral of
Tillaux
5.5
mm
6.9
mm
Lateral
rectus
6.5m m
Inferior
rectus
Inferior
oblique
Medial
rectus
b
to th e globe. Sen sor y (V1 ) an d sym path et ic bers pass th rough
w ith out syn apsing, w h ereas parasym path et ic bers syn apse in
th e ganglion . Th e ganglion can be en coun tered during lateral
orbit al in t racon al surger y.
Maxillary Nerve
Th e m axillar y n er ve (CN V2 ) divides in to th e in fraorbital, zygom atic, nasal branches, palatine, superior alveolar, and pharyngeal
n erves. After leaving th e trigem inal ganglion, the m axillary ner ve
en ters t h e foram en rot u n d u m in to t h e pter ygop alat in e fossa.
Th e n er ve en ters th e in ferior orbit al ssure to con t in ue th rough
t h e in fraorbit al groove an d can al to exit an teriorly th rough th e
in fraorbital foram en as th e in fraorbit al n er ve. Th e in fraorbit al
n er ve d ivid es in to th e in ferior p alpebral bran ch , n asal bran ch ,
an d su perior labial bran ch to su p ply th e in ferior eyelid, lateral
n ose, an d u p per lip , resp ect ively. Th e zygom at ic n er ve d ivid es
in th e in ferior orbital ssu re in to th e zygom at icofacial an d zygom at icotem p oral n er ves to exit th rough th e respect ive foram in a an d in n er vate th e ch eek an d lateral foreh ead, respect ively.
Th e in fraorbit al, zygom at icofacial, an d zygom at icotem poral
m ay be en cou n tered du ring su rger y of th e m idface. Care sh ou ld
be taken to preser ve th ese sen sor y n er ves; h ow ever, com prom ise to th e zygom at icofacial an d zygom at icotem p oral n er ves
m ay be less con sequ en t ial th an in fraorbit al n er ve dam age th at
m ay resu lt in sym ptom at ic hyp oesth esia.
Motor Innervation
Motor in n er vat ion to th e facial m u scles is su p p lied by th e facial
n er ve (CN VII), w h ich is described in fu rth er d etail along w ith
facial an atom y in oth er ch apters. In th e p eriorbit al region , th e
127
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 14.2 Trigem inal nerve (CN V) cutaneous distribution. The ophthalmic (V1) and maxillary (V2)
divisions of the trigeminal nerve (CN V) provide
cutaneous innervation to the orbital and periorbital
regions.
facial n er ve lies in a deep plan e as it em erges from th e p arot id
glan d (Fig. 14.3). Th e tem poral bran ch courses superiorly an d
crosses over th e zygom at ic arch about m idw ay bet w een th e lateral can t h u s an d t ragu s. Dissect ion in t h e su bp er iosteal p lan e
is safe in th is region . Su p erior to th e arch , th e facial n er ve lies
ben eath th e super cial tem poralis fascia, w h ich is an exten sion
of th e super cial m u sculoapon eurot ic system (SMAS). To avoid
dam aging th e facial n er ve in th is region , dissect ion sh ould be
perform ed deep to SMAS, just anterior to th e deep tem poralis
fascia. In addit ion , a bran ch can be fou n d along a lin e from ap proxim ately 1 cm in ferior to th e t ragus to 1.5 cm superior to th e
lateral brow. In ferior to th e arch , dissect ion super cial to SMAS
an d th e p arot id glan d avoids th e facial n er ve.
Autonomic Innervation
Th e sym path et ic n er ves from th e su perior cer vical ganglion
en ter th e carot id can al as a p lexu s arou n d th e in tern al carot id
ar ter y (ICA). Sym p ath et ics to th e lacrim al glan d leave th e ICA to
exit th e pet rou s bon e an d even t u ally p arallel th e parasym p ath et ic bers to th e lacrim al glan d. Th e bers to th e dilator pu pillae m u scle leave th e ICA in th e cavern ous sin us an d t ravel
w ith CN VI an d t h en t h e n asociliar y bran ch of V1 before leavin g
t h e caver n ou s sin u s. Th ese bers p ass t h rough th e ciliar y gan glion w ith ou t syn apsing, t ravel w ith th e long ciliar y n er ves, an d
resu lt in pu p il dilat ion . Th e bers to Mü ller m u scle t ravel along
oph th alm ic ar ter y bran ch es to st im ulate upper lid elevat ion .
128
Sym path et ic in n er vat ion result s in low er lid ret ract ion via th e
in ferior tarsal m uscle an d cau ses h idrosis.
Parasym p ath et ic bers from th e Edinger-West ph al n u cleu s
t ravel w ith th e in ferior division of th e ocu lom otor n er ve, syn apse in th e ciliar y ganglion , an d con t in u e w ith th e bran ch to th e
in ferior obliqu e m uscle. Th ey en ter th e globe as posterior ciliar y
n er ves an d cau se accom m odat ion th rough ciliar y m u scle con t ract ion an d pupil con st rict ion th rough th e pupillar y sph in cter
m u scle. Parasym path et ic bers from th e pter ygopalat in e gan glion t ravel th rough th e in ferior orbit al ssu re th en w ith th e
lacrim al n er ve to in n er vate th e lacrim al glan d.
Orbital Vessels
The periorbital and facial region receives blood supply from both
th e ICA an d extern al carot id ar teries, result ing in rich an astom oses an d vascu lar su p ply (Fig. 14.4). In th e cavern ous sin us,
th e ICA gives o th e oph th alm ic ar ter y, w h ich th en t ravels in ferior to th e opt ic n er ve th rough th e opt ic can al. Th e p ial bran ch
of t h e op h t h alm ic ar ter y su p p lies t h e in t racan alicu lar opt ic
n er ve. Th e cen t ral ret in al ar ter y bran ch es o abou t 10 m m p osterior to th e globe. Addit ion al bran ch es in clude th e lacrim al,
su p raorbit al, eth m oidal, an d ext raocu lar m u scle bran ch es; long
posterior ciliar y ar teries; an d term in al bran ch es (suprat roch lear, m edial palpebral, an d dorsal n asal). Th e extern al carot id
arter y bran ch es in clu de th e m a xillar y an d facial arter y. Th e an -
14 Orbit al Soft Tissues
Fig. 14.3 Facial nerve (CN VII) distribution. Left
lateral view of the face. Motor innervation to the
facial muscles is supplied by the facial nerve (CN
VII). In the periorbital region, the facial nerve lies
in a deep plane as it emerges from the parotid
gland.
gu lar arter y, a bran ch of th e facial arter y, cou rses abou t 5 m m
an terior to th e m edial can th al ten don (MCT) in sert ion an d m ay
be en coun tered along w ith th e angular vein during dissect ion in
th is area. Th e superior oph th alm ic vein provides orbit al ven ous
drain age. It courses from superom edially to laterally in th e orbit
as it en ters th e cavern ou s sin u s.
Orbital Lymphatics
Lym ph at ics w ere previously th ough t to be absen t in th e orbit;
h ow ever, recen t st u dies ch allenge th is n ot ion .1,2
Orbital Fat
Orb it al fat su r rou n d s t h e glob e an d orb it al st r u ct u res. An t e r iorly, ext racon al orb it al fat is fou n d in t h e p ost se p t al p lan e
in t h e u p p e r an d low e r lid s. Th e su p e r ior orb it al fat is d ivid e d by t h e t roch lea in to t h e m e d ial an d ce n t ral fat p ad s
(Fig. 1 4 .5 ).
The inferior orbital fat is divided into the m edial, central, and
lateral fat pads (Fig. 14.5). Th e in ferior oblique m uscle courses
bet w een th e m edial an d cen t ral fat pads. Th e lateral an d cen t ral
fat pads are sep arated by th e fascial arcu ate expan sion of th e
in ferior obliqu e m u scle.
Surgical Annotation: Precautions
during Orbital Fat Pad
Manipulation
Du ring u p p er or low er lid blep h arop last y, debu lking of th e fat
p ads can result in in sidious bleeding in to th e fat an d su bsequen tly ret robulbar. If h em ost asis is n ot en sured before w oun d
closure, an orbit al com par t m en t syn drom e m ay result in vision
com prom ise. Aggressive orbital fat pad rem oval in th e u pper
an d low er lids w as on ce th ough t to im p rove cosm et ic ou tcom es.
Con ser vat ive excision an d fat preser vat ion , especially laterally,
m ay be associated w ith im p roved aesth et ic resu lts an d avoid
h ollow ing.
Upper Eyelid
Th e orbit al lobe of th e lacrim al glan d is fou n d in th e post septal,
or preapon eu rot ic, plan e lateral to th e orbit al fat pads, an d m ay
be easily con fu sed for orbit al fat; th erefore, careful dissect ion is
required if th e cen t ral fat pad is debulked during an u p per lid
bleph aroplast y. Th e lacrim al glan d appears m ore pin k an d lobu lated an d is m ore rm com pared w ith th e orbit al fat .
Low er Eyelid
Th e in ferior obliqu e m u scle is en cou n tered bet w een t h e cen t ral an d m ed ial fat p ad s of t h e low er eyelid . Du r ing low er lid
129
Anatom y for Plastic Surgery of the Face, Head, and Neck
Orbital
septum
Supraorbital artery
and nerve
Dorsal nasal
artery and vein
Depressor
supercilii
Procerus
Orbicularis oculi,
pretarsal
Orbicularis oculi,
Orbicularis oculi,
preseptal
orbital
Lateral canthal
tendon
Levator labii superioris
(cut)
Infraorbital nerve Facial artery
and vein
and artery
Lacrimal sac
Angular artery Medial canthal
and vein
tendon
Levator labii superioris
alaque nasi
Fig. 14.4 Periorbital neurovascular structures. Right orbit: Orbicularis
oculi muscle removed. The periorbital and facial region receives blood
supply from both the internal and external carotid arteries resulting in
rich anastomoses and vascular supply. (Modi ed from THIEME Atlas of
Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustration by Karl
Wesker.)
blep h aroplast y an d fat redist ribut ion , th e fat pads m u st be gen tly sep arated from t h eir con n ect ive t issu e at t ach m en t s to t h e
in ferior oblique before translocation . A restrictive strabism us
m ay oth er w ise resu lt . Som e su rgical tech n iqu es involve direct
visu alizat ion of th e in ferior obliqu e m u scle an d release from
su rrou n ding soft t issu es.3
Th e lacrim al glan d h as been foun d to receive both sym path et ic an d parasym path et ic in n er vat ion , an d in ner vat ion from
CN V an d VII. Th e lacr im al n er ve of CN V1 car r ies sen sor y in form at ion from th e glan d an d u pp er lid.
Lacrimal System
Lacrimal Gland
Th e lacrim al glan d an d accessor y glan ds of Wolfring an d Kraus
produce th e aqueous layer of th e tear lm . Th e lacrim al gland is
t h ough t to p rodu ce ch ie y re ex tears an d to con t r ibu te to
basal tear secret ion p rovid ed by t h e glan d s of Wolfr in g an d
Krau s located in th e su perior or in ferior tarsal border an d forn ix, resp ect ively. Th e lacrim al glan d is located in th e lacrim al
glan d fossa in t h e lateral asp ect of t h e fron t al bon e. It con sist s
of an orbit al lobe, w h ich is visible during an upper eyelid dissect ion , an d a p alp ebral lobe, w h ich can be visu alized in th e
su p erolateral forn ix by m an u ally elevat ing th e eyelid. Th e lateral h orn of th e levator apon eu rosis sep arates th e t w o lobes,
w ith secretor y duct u les con n ect ing th em . To avoid dam age to
th ese duct ules, an in cision al lacrim al glan d biopsy sh ould be
perform ed on th e orbit al lobe.
130
Nasalis
Nasolacrimal System and Lacrimal
Pump
Th e eyelids h elp pum p tears produced by th e lacrim al apparat us across th e ocular su rface to drain m edially th rough th e
upper an d low er lid 0.3 m m diam eter pu n cta. Th e pu n cta are
posit ion ed opposed to th e globe. With pun ct ual eversion , tears
are u n able to drain ap prop riately, resu lt ing in ep ip h ora. Lateralizat ion of th e pun ct a suggest s m edial can th al ten don laxit y or
disrupt ion .
After en tering th e pun ct a, tears t ravel 2 m m vert ically to th e
am p u lla of th e can alicu li, th en 8 m m h orizon tally th rough th e
can alicu li. In m ore th an 90 percen t of in dividuals, th e superior
an d in ferior can alicu li m erge in to a com m on can alicu lu s before
drain ing in to th e n asolacrim al sac.4,5
Th e lacrim al sac m easures abou t 12 m m ver t ically, exten ding about 3 to 5 m m su perior to th e MCT. It is located in th e
lacrim al sac fossa, w h ich is created by th e m axillar y bon e an teriorly an d lacrim al bon e posteriorly.
Th e lacrim al sac th en open s in to a n asolacrim al duct , w h ich
courses posteriorly, laterally, an d in feriorly for 18 m m in an os-
14 Orbit al Soft Tissues
Fig. 14.5 Orbital fat pad distribution in relation to surrounding
structures, right orbit. Orbital fat surrounds the globe and orbital
structures. Anteriorly, extraconal orbital fat is found in the postseptal
seou s n asolacrim al can al. Th e du ct op en s ben eath th e in ferior
t u rbin ate in to t h e in fer ior m eat u s. Th e d u ct op en ing is abou t
25 m m posterior to th e an terior n aris (Fig. 14.6).
Variou s valves h ave also been described in th e n asolacrim al
system . Th e valve of Rosen m ü ller at th e open ing of th e com m on
can aliculus to th e lacrim al sac preven ts re u x of tears. Th e
valve of Krau se is fou n d bet w een th e sac an d d u ct . Th e valve of
Hasn er is located at th e d u ct op en ing in to th e in ferior m eat u s
(Fig. 14.6).
Lid p osit ion an d ton e are im port an t to allow for adequate
lacrim al p um p fu n ct ion . In addit ion , th e organ izat ion of th e
st ru ct u res arou n d th e n asolacrim al system con t ribu tes to ap propriate tear drain age.
The pretarsal orbicularis m uscle surrounds the canaliculi. Periorbit al fascia an d th e th ick an terior an d th in posterior lim bs of
the MCT encircle the lacrim al sac. The anterior lim b inserts onto
the anterior lacrim al crest and the posterior lim b inserts onto the
posterior lacrim al crest (Fig. 14.4). Th e deep pret arsal orbicularis m u scle, also called th e Horn er m u scle, cou rses posterior to
th e lacrim al sac an d posterior lim b of th e MCT to in sert on to th e
posterior lacrim al crest .
Du ring a t ran scaru n cu lar ap p roach to th e m edial orbit , blu n t
d issect ion alon g Hor n er’s m u scle allow s id en t i cat ion of t h e
posterior lacrim al crest. A periosteal incision and elevation gives
access to th e su bperiosteal p lan e along th e m edial orbit .
plane in the upper and lower lids. The superior orbital fat is divided by
the trochlea into the medial and central fat pads. The inferior orbital fat
is divided into the medial, central, and lateral fat pads.
Surgical Annotation: Anatomical
Considerations during
Nasolacrimal Surgery
Nasolacrimal Intubation
Du ring can alicu lar in t u bat ion , gen tle in t rod u ct ion of a sten t
after the previously described an atom y prevents creation of false
p assagew ays. W h en ret rieving a can alicular in t ubat ion sten t
th rough th e n ose, a ret rieving in st rum en t in t rodu ced parallel to
th e oor of th e n asal cavit y, along th e lateral n asal w all, an d in
a p osterolateral d irect ion h elp s locate th e sten t . Occasion ally,
th e in ferior t urbin ate m ay n eed to be fract ured if it is too close
to th e lateral n asal w all.
Dacryocystorhinostomy
A dacr yocystorh in ostom y (DCR), w h et h er extern al or en doscop ic, involves st u lizat ion of t h e lacr im al sac in to t h e n asal
cavit y for m an agem en t of n asolacr im al d u ct obst r u ct ion . Th e
lacr im al sac is located in a fossa bet w een t h e an ter ior lacr im al
crest of t h e m a xillar y bon e an d t h e p oster ior lacr im al crest
of t h e lacr im al bon e. For an exter n al DCR, after m aking a
t ran scu t an eou s in cision along t h e m ed ial can t h u s, d issect ion
131
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 14.6 Lacrim al system, right orbit.
Orbital septum and levator muscle
aponeurosis divided. Inset: Details of
naso lacrimal system structures.
con t in u es dow n to p er iosteu m . Th e an terior lacrim al crest is
exp osed , th e sac is elevated ou t of th e fossa, an d th e p osterior
lacrim al crest is visu alized . Alt h ough th e an terior lim b of th e
MCT m ay be in ten t ion ally d isin ser ted , too p osterior of a d issect ion m ay resu lt in disin ser t ion of t h e poster ior lim b of t h e MCT
at t h e p osterior lacrim al crest an d loss of lid ap p osit ion to t h e
globe.
An osteotom y is created an terior to th e m iddle m eat us to
en ter th e n asal cavit y. In m any in dividu als, eth m oidal air cells
are presen t m edial to th e lacrim al sac fossa or at least exten d
anterior to th e posterior lacrim al crest.6,7 The ethm oidal air cells
m ay h ave to be rem oved for th e n ew osteotom y to com m u n i-
132
cate w ith th e n asal cavit y an d n ot w ith th e eth m oid sin us. A
larger osteotom y an d th e absen ce of obst ruct ion of th e com m on
in ter n al ost iu m m ay in crease t h e ch an ce of a su ccessfu l DCR.8
A dist an ce of at least 5 m m h as been suggested bet w een th e
com m on in tern al ost iu m an d osteotom y m argin .9
If a p at ien t h as p ersisten t ep ip h ora d esp ite a p aten t DCR,
lacrim al su m p syn d rom e sh ou ld be con sid ered .10 In ad equ ate
drain age of tears th at accu m ulate in an in t act in ferior lacrim al
sac w ith p ossible bon e rem ain ing m edially m ay resu lt in th is
f n ding. Th is can be avoid ed by en su ring th at th e osteotom y an d
lacrim al sac m arsu pializat ion exten d in ferior to the p roxim al
n asolacrim al du ct .
14 Orbit al Soft Tissues
References
1. Sh er m an DD, Gon n ering RS, Wallow IHL, et al. Id en t i cat ion of
orbit al lym p h at ics: en zym e h istoch em ical ligh t m icroscop ic an d
elect ron m icroscop ic st u d ies. Op h th al Plast Recon st r Su rg 1993;
9(3):153–169 PubMed
2. Gausas RE, Gon n ering RS, Lem ke BN, Dor t zbach RK, Sh erm an DD.
Iden t i cat ion of h um an orbit al lym ph at ics. Op h th al Plast Recon st r
Surg 1999;15(4):252–259 Pu bMed
3. Massr y G. “Th e inverse sh oe sh in e sign ” in t ran sconjun ct ival low er
blep h aroplast y w ith fat rep osit ion ing. Oph th al Plast Recon st r Su rg
2012;28(3):234–235 PubMed
4. Jon es LT. An an atom ical approach to problem s of the eyelids an d
lacrim al app arat u s. Arch Oph th alm ol 1961;66:111–124 Pu bMed
5. Lem ke BN. Lacrim al anatom y. Adv Oph th alm ic Plast Reconst r Surg
1984;3:11–23
6. W h it nall SE. Th e relat ion s of th e lacrim al sac fossa to th e eth m oidal cells. Oph th alm ic Res 1911;30:321–325
7. Blaylock W K, Moore CA, Lin berg JV. An terior eth m oid an atom y facilitates dacr yocystorh in ostom y. Arch Oph th alm ol 1990;108(12):
1774–1777 PubMed
8. Lin berg JV, An derson RL, Bu m sted RM, Barreras R. St udy of in t ran asal ost ium extern al dacr yocystorhin ostom y. Arch Oph th alm ol
1982;100(11):1758–1762 Pu bMed
9. Jon es LT. Th e cure of epiph ora du e to can alicu lar disorders, t rau m a
an d su rgical failures on th e lacrim al passages. Tran s Am Acad Oph th alm ol Otolar yngol 1962;66:506–524 PubMed
10. Jordan DR, McDon ald H. Failed dacr yocystorh in ostom y: th e sum p
syn drom e. Oph thalm ic Surg 1993;24(10):692–693 Pu bMed
133
15
Eyelid Anatomy
Catherine Y. Liu, Sw apna Vem uri, and Jerem iah P. Tao
Surface Anatomy
Th e eyelids provide globe protect ion , con t ribute to tear produ ct ion , an d dist ribute tears. Th e adjacen t foreh ead an d m idface
in u en ce correct eyelid p osit ion ing. Un derstan ding th ese relat ion sh ips is essen t ial in eyelid surger y.
Th e upper an d low er eyelids, along w ith th e upper an d low er
pu n cta, oppose th e globe. Th e u pper lid n at urally rest s 1 to 2
m m below th e su perior lim bu s an d p eaks 1 m m m ed ial to th e
cen ter of th e pupil. Th e low er lid rest s at th e in ferior lim bus an d
peaks 1 m m lateral to th e cen ter of th e pu pil. Horizon t al an d
vert ical in terp alp ebral ssu res are abou t 30 m m an d 10 m m ,
respectively. The lateral canthal angle is about 2 m m higher than
th e m edial can th al angle. Th e m edial can th al angle is sligh tly
rounded com pared w ith the sharply peaked lateral canthal angle
(Fig. 15.1).
Th e eyebrow s set above th e superior orbit al rim but sligh tly
low er at th e rim in m ales. Th e brow u sually peaks at th e lateral
lim bus. Th e foreh ead exten ds from th e h airlin e to th e glabella
and superior orbital rim . The m idface exten ds from the low er lids
tapering m edially to th e n asolabial folds to en com pass a t rian gu lar area. Facial m im et ic m u scles, th ose con t ribu t ing to facial
exp ression , in u en ce brow posit ion , an d also cau se skin fu rrow s, including in the forehead, periorbital region, and m idface.
Eyelid Anatomy
Upper Eyelid Layers
Th e layers of t h e u p p er eyelid var y d ep en d in g on t h e locat ion
in th e eyelid (Fig. 15.2a). An terior to th e t arsu s, th e st ruct ures
from an terior to p oster ior in clu d e skin , orbicu lar is ocu li m u scle, tarsus, an d conjun ct iva. A few m illim eters above th e t arsus,
st ru ct u res in clu de skin , orbicu laris, orbit al sept u m , orbit al fat ,
levator p alp ebrae su p er ior is m u scle, Mü ller m u scle, an d con ju n ct iva. Th e orbit al sept u m fu ses w it h t h e levator m u scle
abou t 2 to 5 m m su p er ior to t h e t arsu s in n on -Asian s an d an terior to t arsus in Asian s. Orbital fat descen ds in feriorly to ll
th e space bet w een th e sept um an d levator, w h ich resu lt s in a
fu ller lid ap pearan ce.
134
Skin
Th e eyelid skin is th e th in n est in th e body. Th e lid also lacks
su bcu t an eou s t issu e so th e skin at tach es d irectly to th e u n derlying orbicularis m u scle. In th e u pper lid, th e levator m uscle
sen d s fascial at t ach m en t s to th e overlying orbicu laris an d skin
to create an upper lid crease. Th e crease is about 10 m m or 8 to
9 m m above th e lid m argin in fem ales an d m ales, respect ively.
In Asian s, it m ay be closer to th e lid m argin or absen t . Th e u p per
lid skin is con t in uous w ith th at of th e th icker skin of th e brow.
Th e superior sulcus is located below th e brow an d ten ds to h ollow w ith age.
Protractors
Orbicu laris ocu li m u scle con t ract ion resu lt s in eyelid closu re. It s
bers are con cen t ric arou n d th e eyelids. It is divided in to th e
pret arsal, presept al, an d orbit al region s (Fig. 15.3). Th e pret arsal an d preseptal orbicu laris are involved in involu n t ar y blin k,
w h ereas th e orbit al port ion is involved in volun t ar y lid closure.
Th e orbicularis oculi con t ribu tes to th e lacrim al pum p.
Th e pret arsal orbicularis oculi divides in to a super cial an d
deep head at the m edial canthus. The super cial head fuses w ith
the m edial canthal tendon (Fig. 15.4). The deep head, also know n
as Horn er’s m u scle, in sert s on to th e posterior lacrim al crest .
Con t ract ion pulls th e lid m edially an d posteriorly again st th e
globe. Laterally, th e bers from th e u pp er an d low er lid s fu se
in to a com m on ten don an d in sert on to W h it n all’s t ubercle.
Th e presept al orbicularis also divides in to a super cial an d
deep h ead th at in sert on to th e m edial can th u s. Th e super cial
Lateral canthus
Superior
orbital rim
Eyebrow
Upper
eyelid
1-2 m m
10 m m
Medial
canthus
Low er Eyelid Layers
Vertical palpebral
fissure
Th e layers of th e low er lid are sim ilar those of th e upper except
t h at t h e lid ret ractors con sist of t h e cap su lop alp ebral fascia,
an alogou s to th e levator m u scle, an d th e in ferior t arsal m u scle,
an alogou s to Mü ller m u scle (Fig. 15.2a).
Fig. 15.1 Surface anatomy of periorbital region. Right eye, anterior
view. (Modi ed from THIEME Atlas of Anatomy, Head and Neuro
anatomy. © Thieme 2010, Illustrations by Karl Wesker.)
30 m m
Horizontal palpebral fissure
Lower
eyelid
15 Eyelid Anatom y
Retroorbicularis oculi fat
Orbital fat
Orbital roof
Eyebrow
Arcus
m arginalis
Periorbita
Levator palpebrae
superioris
Orbital
septum
Superior rectus m uscle
Superior
conjuctival form ix
Orbicularis
oculi, orbital part
Müller’s m uscle
Skin
Superior tarsus with
m eilbom ian glands
Lens
Upper
eyelid
Cornea
Inferior tarsus
Glands of
Zeis and Moll
Suborbicularis
oculi fat
Orbital
septum
Sclera
Lower
eyelid
Arcus
m arginalis
Lower lid retractors
Orbicularis oculi,
pretarsal & preseptal
Infraorbital nerve
Orbital fat
a
Superior
fornix
Ocular
conjunctiva
Palpebral
conjunctiva
Forniceal
conjunctiva
Inferior
fornix
b
Fig. 15.2 Structure of eyelids and conjunctiva. (a) Sagit tal view of eyelids and
surrounding structures. (b) Anatomy of conjunctiva. (Modi ed from THIEME Atlas of
Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustrations by Karl Wesker.)
135
Anatom y for Plastic Surgery of the Face, Head, and Neck
Galea
aponeurotica
(epicranial
aponeurosis)
Occipitofrontalls,
frontal belly
Corrugator
supercilli
Procerus
Orbicularis oculi,
orbital
Levator labil
superioris
alaeque nasi
Orbicularis oculi,
preseptal
Orbicularis oculi,
pretarsal
Levator labii superioris
alaque nasi (cut)
Nasalis
Levator labii superioris
(cut)
Levator labil
superioris
Zygom aticus m inor (cut)
Zygom aticus
m inor
Zygom aticus m ajor (cut)
Levator anguli oris
Levator anguli oris
Fig. 15.3 Periorbital facial mimetic muscles. Orbicularis oculi muscle
contraction results in eyelid closure. Its bers are concentric around the
eyelids. It is divided into the pretarsal, preseptal, and orbital regions.
The pretarsal and preseptal orbicularis are involved in involuntary blink;
the orbital portion is involved in voluntary lid closure. (Modi ed from
THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010,
Illustrations by Karl Wesker.)
h ead in sert s on to th e m edial can th al ten don an d th e deep h ead
inserts onto the lacrim al sac fascia. Laterally, the upper and low er
bers join to form th e lateral p alpebral rap h e an d con n ect to th e
u n derling lateral can th al ten don .
Th e orbit al orbicularis arises from th e m edial orbital rim ,
broadens out w ard in concentric bands superiorly and inferiorly,
an d join s at th e lateral orbit al rim to form a con t in u ou s ellip se.
It exten ds beyon d th e orbit al rim .
m m p osterior to th e an terior rim ) an d sligh tly above th e m edial
can th al angle. Usually th e sut ure is secured to periosteu m , but
a drill h ole m ay be h elp fu l if th e periosteal t issu e is in ad equ ate
(i.e., scar). In p at ien ts w ith a p rom in en t globe, th e lid sh ou ld be
rean ch ored sligh tly m ore an teriorly on th e in n er aspect of th e
rim in order to avoid slip ping of th e low er lid u n der th e globe.
Medial can th al ten don rean ch oring or t igh ten ing of th e an terior lim b is to th e an terior lacrim al crest . Tigh ten ing of th e
posterior lim b presen t s a greater ch allenge given th e lacrim al
sac obscu res access to th e p osterior lacrim al crest .
Lateral and Medial Canthal
Tendons
Th e m edial can th al ten don (MCT) split s in to an terior an d posterior lim bs, w h ich at tach to th e correspon ding lacrim al crest en circling th e lacrim al sac (Fig. 15.4).Th e an terior lim b of th e MCT
gives th e lid structural support w hereas the posterior lim b keeps
th e eyelid apposed to th e globe. Th e lateral can th al ten don is
form ed by su p erior an d in ferior lim b th at fu ses to form a com m on ten d on in ser t ing on to W h it n all’s t u bercle.
Surgical Annotation. Lateral and Medial
Canthal Reanchoring
In lateral can th al an ch oring (can th op last y or can th op exy), th e
lid is su t u red to in n er aspect of th e lateral orbital rim (abou t 10
136
Orbital Septum
Th e orbital sept um is a con n ect ive t issue st ruct ure th at form s
from th e p eriosteu m of th e orbit al rim at th e arcu s m argin alis
(Fig. 15.2a). It divides th e lid in to an terior (skin an d orbicularis)
an d p osterior (tarsu s, conju n ct iva, an d lid ret ractors) lam ella.
Orbital Fat Pads
Orbit al fat , also kn ow n as p reap on eu rot ic fat , is san dw ich ed
bet w een t h e sept u m an d t h e lid ret ractors. As d iscu ssed in
Ch apter 14, th ere is a m edial an d cen t ral fat pad in th e u pp er lid
an d a m edial, cen t ral, an d lateral fat p ad in th e low er lid . Th ese
fat p ads can at rop hy w ith age, creat ing a h ollow ed su p erior or
137
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Anatom y for Plastic Surgery of the Face, Head, and Neck
in ferior su lcu s or a bu lge beh in d a w eaken ed sept u m , causing
orbit al fat prolapse an d bu lging.
Retractors
Levator Palpebrae Superioris Muscle
Du r in g a t ran sconju n ct ival su rgical ap p roach , conju n ct iva
an d low er lid ret ractors are in cised an d reapp roxim ated often
w ith ou t com prom ising lid st abilit y. With low er lid dissect ion ,
th e low er lid ret ractors course posteriorly in to th e orbit , w h ich
h elp s to d ist ingu ish th em from th e orbit al sept u m th at arises
from th e arcu s m argin alis along th e in ferior orbit al rim .
Th e levator palpebrae m uscle arises from th e lesser w ing of th e
sph enoid bon e above th e superior rectus at tachm ent. It projects
an teriorly tow ard th e globe (Fig. 15.2a, Fig. 15.4). W h it n all’s
ligam ent is a band of brous tissue derived from the m uscle itself
that at taches m edially to the trochlea and laterally to the capsule
of the lacrim al gland and lateral orbital w all (Fig. 15.4). Near
W hitnall’s ligam ent, the levator m uscle changes course from an terior-posterior to superior-in ferior an d also t ran sit ion s to an
ap on eu rosis. Th e ap on eu rosis sen ds fascial slip s p osteriorly to
at t ach to th e an terior surface of t arsus an d an teriorly to th e orbicu laris m uscle an d skin to form th e lid crease. Th e lateral an d
m ed ial levator h orn s an ch or to p eriosteu m . Th e lateral h orn d ivides th e lacrim al glan d orbit al an d palp ebral lobes as described
in Chapter14. The levator m uscle contributes about 10 to 12 m m
of u pper lid elevat ion . It is in n er vated by cran ial n er ve (CN) III.
Tarsus and Conjunctiva
Müller’s Muscle
Eyelid Margin
Mü ller’s m u scle is fou n d posterior to th e levator m u scle (Fig.
15.2a). It is a sm ooth m uscle th at is in n er vated by sym path et ic
n er ves. It con t ribu tes abou t 2 m m of lid elevat ion . It arises from
beh in d th e levator close to th e jun ct ion w h ere th e m uscle bers
t ran sit ion to an apon eu rosis. It in ser ts on to th e superior border
of th e t arsu s. Mü ller’s m uscle m ay ser ve as a coupling m ech an ism for t ran sm it t ing levator apon eu rosis forces to th e t arsu s.
Surgical Annotation
External Levator Advancement Ptosis
Surgery
With ap on eu rot ic u p p er lid ptosis, th e levator apon eu rosis m ay
elongate or disin sert , resu lt ing in ptosis associated w ith a h igh
lid crease. Du ring extern al apon eu rot ic ptosis repair, th e levator
m u scle is rean ch ored to t h e t arsu s. Th e orbit al sept u m sh ou ld
be carefu lly d issected free from t h e levator. Su t u r ing t h e sep t u m m ay tet h er t h e eyelid , im p air eyelid excu rsion , an d cau se
lagop h th alm os.
Th e t arsus is a den se, con n ect ive t issu e plate th at gives st ru ct ural support to th e eyelid (Fig. 15.2a, Fig. 15.4). It is about
1 m m th ick, an d its ver t ical h eigh t m easures abou t 8 to 10 m m
in th e upper lid an d 4 m m in th e low er lid bu t t apers m edially
an d laterally. Th e tarsu s con t ain s m eibom ian glan ds, w h ich secrete th e sebaceous layer of th e tear lm . Th ere are about 25
glan d s in th e u p p er lid an d 20 glan ds in th e low er lid. Th e lateral
an d m ed ial can t h al ten d on s an ch or t arsu s to p er iosteu m . Palp ebral conju n ct iva lin es t h e p oster ior su r face of t arsu s an d
con t in u es su p er iorly or in feriorly to t h e for n ix t h en re ect s on
t h e globe as bulbar conju n ct iva (Fig. 15.2b). Th e conju n ct iva
con t ain s goblet cells, w h ich provide th e m ucus layer of th e tear
lm .
Th e eyelid m argin is a con uence of several eyelid st ruct u res
(Fig. 15.5). St ar t ing posteriorly an d in con tact w ith th e globe is
th e m ucosal surface of th e conjun ct iva, creat ing th e m ucocut an eou s ju n ct ion . Con t in u ing an teriorly, th e m eibom ian glan d
open ings of t arsu s are visible. Th e m uscle of Riolan , represen ting th e pret arsal orbicularis m uscle, m akes up th e gray lin e. Fin ally, th e skin is th e m ost an terior st ru ct u re w ith h air follicles
em an at ing. Abou t 100 eyelash es are fou n d in th e u p p er lid an d
abou t 50 in th e low er lid organ ized in to t w o or th ree irregu lar
row s. Glan ds of Zeis are oil glan ds associated w ith h air follicles.
Glan ds of Moll are eccrin e, or sw eat , glan ds th at are located at
th e eyelid m argin .
Th e gray lin e is an im por t an t lan dm ark du ring surgical realign m en t of th e lid m argin such as du ring a m argin al lacerat ion
repair or w edge lesion excision repair. With out precise align -
Capsulopalpebral Fascia and Inferior
Tarsal Muscle
Th e low er lid ret ractors con t ract to depress th e lid in dow n gaze
an d also h elp to m ain t ain t arsal p osit ion . Th e capsu lop alp ebral
fascia arises from th e in ferior rect u s m u scle sh eath , split s to en w rap th e in ferior oblique m u scle, an d fuses to form th e Lockw ood’s su spen sor y ligam en t (Fig. 15.2a). It con t in ues superiorly
to fuse w ith th e orbital sept um an d in sert on th e in ferior t arsal
border. Th e in ferior t arsal m u scle is poorly developed but lies
along th e p osterior su rface of th e cap su lopalp ebral fascia (Fig.
15.2a, Fig. 15.4).
138
Fig. 15.5 Lower eyelid margin anatomy.
15 Eyelid Anatom y
m en t , a n otch or step -o can resu lt , resu lt ing in ocu lar su rface
exp osu re, poor cosm esis, or both .
Forehead, Temporal, and
Midface Anatomy
Th e facial plan es guide surgical dissect ion . Th ey var y sligh tly
based on th e facial region but th ey in clude th e follow ing: skin ,
su bcu t an eou s t issu e, su p er cial m u scu loap on eu rot ic system
(SMAS) an d facial m im et ic m u scles, loose areolar t issu e, an d
deep facial fascia.
Forehead
The forehead represents the upper third of the face. The layers of
the forehead include skin, subcutaneous tissue, frontalis m uscle
(en com passed in th e galea apon eurot ica an d con t in uous w ith
SMAS), loose areolar t issu e, periosteu m , an d fron tal bon e (Fig.
15.6). Sen sor y bran ch es from CN V1 an d vessels can be foun d
coursing on th e an terior su rface of the fron t alis m uscle.
Temporal Forehead
Th e tem poral region con sist s of skin , su bcut an eous t issue, super cial tem poralis or tem poroparietal fascia (con t in uous w ith
SMAS), loose areolar t issu e, deep tem p oral fascia su rrou n ding
th e su per cial tem poral fat pad, an d tem poralis m uscle (Fig.
15.6). Th e super cial tem poral ar ter y, w h ich is obtain ed during
a tem poral arter y biopsy, is found in loose areolar tissue bet w een
th e super cial an d deep tem poralis fasciae; h ow ever, care m ust
be t aken to avoid dam aging th e facial n er ve th at courses in th e
su p er cial tem p oral fascia.
th e orbicu laris oculi m uscle an d periosteum (Fig. 15.2a).Th e
SMAS su rrou n ds th e facial m im et ic m u scles. Ligam en tou s att ach m en t s bet w een SMAS an d skin derm is as w ell as SMAS an d
th e un derlying bon e con t ribute to facial expression an d su ppor t
respect ively. Th e orbitom alar ligam en t at t ach es th e orbicularis
oculi m uscle th at is en com passed in th e SMAS to th e in ferior
orbital rim .1 Th e zygom at ic ligam en t exten ds from th e p eriosteum of th e zygom a an d zygom at ic arch an d th rough th e m alar
fat p at to th e m alar skin .
Surgical Annotation
Low er Lid Malposition
In addit ion to dow nw ard vectors of th e low er lid, m idfacial ptosis an d descen t can also greatly in u en ce low er lid p osit ion ing.1
W h en perform ing surger y of th e low er lid or m idface, m in im al
(if any) skin , m u scle, or soft t issu e sh ou ld be excised in t h e
zon e exten ding from th e low er lid m argin to th e m outh . Th e
low er lid is suscept ible to any in ferior vectors su ch as an terior
lam ellar sh or ten ing (e.g., cicat rix), ligam en tou s at ten u at ion , or
soft t issu e d ebu lking. In addit ion to direct ing w ou n d closu re
an d ten sion h orizon t ally or at least obliqu ely, t issu e recru itm en t an d resu sp en sion in th e su perolateral asp ect of th e low er
lid and lateral canthus increase the likelihood of surgical success
an d longevit y.
Eyebrow
Th e skin of th e brow is th icker th an th at of th e eyelid an d th in n er th an th at of th e foreh ead. Elevators an d depressors in u en ce brow p osit ion , w h ich in t u rn in u en ces u p per lid posit ion .
Fron t alis m uscle con t ract ion elevates th e upper lid about 2 m m .
Th e orbicularis, corrugator, an d procerus m uscles depress th e
brow (Fig. 15.3).
Th e fron t alis m u scle in terdigitates w ith th e orbicularis oculi
m u scle above th e su p erior orbital rim . Posterior to th e m u scle is
th e brow fat pad, also kn ow n as th e ret ro-orbicularis oculi fat
pad (ROOF). It is separated from th e orbit al fat pads by th e orbital sept um (Fig. 15.2a). With aging, th e brow pad can con t rib u te to su b -brow fu lln ess an d su bsequ en t u pp er lid droop an d
fu lln ess. ROOF is con t in u ou s w ith th e su borbicu laris ocu li fat
(SOOF) of th e low er lid.
Midface
The planes of the m idface are especially im portant to understand
for e ect ive t reat m en t of low er lid ret ract ion or m idfacial rejuvenation . Sub-orbicularis oculi fat (SOOF) is positioned bet ween
Fig. 15.6 Layers of forehead and temporal forehead regions. The
temporal region consist s of skin, subcutaneous tissue, super cial
temporalis or temporoparietal fascia (continuous with the super cial
musculoaponeurotic system [SMAS]), loose areolar tissue, and deep
temporal fascia surrounding the super cial temporal fat pad and
temporalis muscle.
139
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 15.7 Aging changes of the face. Nasojugal
groove (tear trough), palpebromalar groove,
and malar mound identi ed on an aging face.
Addressing the Nasojugal Groove,
Palpebromalar Groove, and Malar
Region
With age, th e m idfacial soft t issu es descen d, ligam en t s at ten u ate, an d orbit al fat h ern iates. Weaken ing of the orbit al sept u m
an d elon gat ion of t h e orbitom alar ligam en t resu lt s in an ter ior
p rot r u sion of orbit al fat w it h accen t u at ion of t h e n asojugal
groove, or tear t rough , an d p alp ebrom alar groove (Fig. 15.7).2
E ect ive su rgical m an agem en t of t h e tear-t rough d efor m it y
an d palp ebrom alar grooves requ ires release of th e orbitom alar
ligam en t at th e arcu s m argin alis along w ith orbit al fat p ad redist ribut ion an d orbicu laris m uscle t igh ten ing.3
In th e m alar region , SOOF descen ds w ith age. Zygom at ic ligam ent suspension and SMAS and SOOF dissection, m obilization,
an d elevat ion eith er su bp eriosteally or prep eriosteally im p rove
m idface d escen t .4,5 At ten t ion to th ese com p on en t s addresses
th e double convexit y th at occurs w ith aging. Th e ch ief st ruct ure
th at m ust be preser ved w ith th ese dissect ion s is th e in fraorbit al
n er ve th at exit s th e an terior m axilla app roxim ately 1 cm below
th e rim , cen t rally. Laterally, th e zygom at icofacial an d zygom at icotem poral n er ves m ay be en cou n tered. Inju r y to th ese sm aller
sen sor y n er ves m ay be less con sequ en t ial th an th e large in fraorbit al n er ve.
Nerves, Vessels, and
Lymphatics
Nerves
In addit ion to th e in n er vat ion p reviou sly described, th e op h th alm ic (CN V1 ) an d m axillar y (CN V2 ) division s of th e t rigem i-
140
n al n er ve carr y sen sor y bers from th e periorbital region . Facial
m im et ic m u scles receive m otor in n er vat ion from bran ch es of
th e facial n er ve (CN VII). Fur th er det ails of in n er vat ion to periorbit al st ruct u res are discu ssed in Ch apter 13.
Vessels
Th e in tern al an d extern al carot id ar teries su pp ly t h e periorbit al region , resu lt ing in rich an astom oses. Th ese an astom oses
form t w o ar terial arcad es of th e u p p er lid : t h e m argin al an d
p erip h eral arcad es. Th e m argin al arcad e is located abou t 2 m m
aw ay from th e lid m argin an terior to t arsu s. Th e p er iph eral
arcade is located bet w een t h e Mü ller’s an d levator m u scles.
Du ring extern al ptosis rep air, th e p erip h eral arcad e can be visu alized as tor t u ou s vessels on th e an ter ior su rface of Mü ller’s
m u scle an d h elp s d ist in gu ish t h e m u scle from levator. Bot h
arcad es m ay sign i can t ly bleed d u r in g lid su rger y. Th e in fer ior m argin al arcad e lies at t h e in fer ior t arsal bord er of t h e
low er lid.
Ven ou s d rain age of p ret arsal t issu es is in to t h e an gu lar an d
su p er cial tem p oral vein s. Post -t arsal t issu e d rain s in to t h e
d eep er vein s of t h e orbit , in clu d in g t h e orbit al vein s, pter ygoid
p lexu s, an d d eep bran ch es of t h e an ter ior facial vein . Ch apter
13 fu r t h er descr ibes t h e vascu lar su p p ly of t h e p er iorbit al
region .
Lymphatics
Th e m edial an d cen t ral low er lids h ave been suggested to drain
in to th e subm an dibular lym ph n od es, th e upper lid, m edial can th us, an d lateral low er lid in to th e preauricular lym ph n odes 6 ;
h ow ever, recen t st u dies sh ow th at su bst an t ial variabilit y exist s.
Recent evidence suggests that the preauricular lym ph node basin
m ay be resp on sible for m ost eyelid lym p h at ic drain age.7,8
15 Eyelid Anatom y
References
1. Lu carelli MJ, Kh w arg SI, Lem ke BN, Kozel JS, Dort zbach RK. The
an atom y of m idfacial ptosis. Op h th al Plast Recon st r Su rg 2000;
16(1):7–22 Pu bMed
2. Kikkaw a DO, Lem ke BN, Dort zbach RK. Relat ion s of th e su per cial
m u scu loap on eu rot ic system to t h e orbit an d ch aracterizat ion of
t h e orbitom alar ligam en t . Op h t h al Plast Recon st r Su rg 1996;
12(2):77–88 PubMed
3. Korn BS, Kikkaw a DO, Coh en SR. Tran scu t an eou s low er eyelid
blep h aroplast y w ith orbitom alar su sp en sion : ret rospect ive review
of 212 con secut ive cases. Plast Recon st r Surg 2010;125(1):315–
323 Pu bMed
4. Hoen ig JA, Sh orr N, Sh or r J. Th e su borbicu laris ocu li fat in aest h et ic an d recon st r u ct ive su rger y. In t Op h t h alm ol Clin 1997;
37(3):179–191 PubMed
5. Aiach e AE, Ram irez OH. Th e su borbicu lar is ocu li fat p ad s: an an atom ic an d clin ical st udy. Plast Recon st r Surg 1995;95(1):37–42
PubMed
6. Cook BE Jr, Lucarelli MJ, Lem ke BN, et al. Eyelid lym ph at ics II: a
search for drain age pat tern s in th e m on key an d correlat ion s w ith
h um an lym ph at ics. Ophth al Plast Recon st r Su rg 2002;18(2):99–
106 Pu bMed
7. Nijhaw an N, Marriot t C, Har vey JT. Lym ph at ic drain age pat terns of
th e hu m an eyelid: assessed by lym ph oscin t igraphy. Oph th al Plast
Recon st r Surg 2010;26(4):281–285 Pu bMed
8. Ech egoyen JC, Hirabayash i KE, Lin KY, Tao JP. Im aging of eyelid lym phatic drainage. Saudi J Ophthalm ol 2012;26(4):441–443 PubMed
141
16
Nasal Cavity and Paranasal Sinuses
Joe Iw anaga, Tsuyoshi Saga, and Koichi W atanabe
Introduction
Floor of the Nasal Cavity
Th e n asal cavit y is located in th e cen t ral region of th e face an d
is divided by th e n asal sept um in to a pair of cavit ies. Th ese t w o
cavit ies con st it ute th e upperm ost port ion of th e respirator y
t ract an d con t in ue an teriorly to th e outer environ m en t via th e
n ares an d p osteriorly to th e n asoph ar yn x via th e ch oan ae. Th e
n asal cavit y is divided in to t w o region s: th e n asal vest ibu le an d
th e n asal cavit y. Th e n asal vest ibule is th e in it ial par t of th e
n asal cavit y as en tered th rough th e n ares; it is lin ed by ep ith eliu m an d con t ain s h air (vibrissae) an d sebaceou s glan ds. Th e
n asal cavit y is th e large sp ace follow ing th e n asal vest ibu le an d
is lin ed by m u cosa. It is divided in to four m eat uses (th e superior, m idd le, in ferior, an d com m on m eat u s) by th ree n asal con ch ae th at arise m edially from th e lateral n asal w all an d cur ve
in feriorly. Each m eat us w ith th e except ion of th e com m on m eat u s is located in ferior to th e con ch ae. Th e superior m eat us is
in ferior to th e su perior con ch a, th e m iddle m eat us is in ferior to
th e m iddle con ch a, an d th e in ferior m eat us is in ferior to th e in ferior con ch a. Th e com m on m eat u s is th e m edial port ion of th e
n asal cavit y; it is located on both sides of th e n asal sept u m an d
exten ds ver t ically. Th e n asal cavit y is also divided in to t w o region s according to fu n ct ion : th e olfactor y region an d th e respirator y region . Th e olfactor y region is located in th e upper part
of th e n asal cavit y an d is lin ed by olfactor y epith eliu m , w h ich
con t ain s olfactor y receptors. Th e residual part of th e n asal cavit y h as a respirator y fun ct ion .1–3
Th e oor of th e n asal cavit y m ain ly con sist s of th e superior surface of th e m axilla an d palat in e bon e, w h ich togeth er con st it u te
t h e h ard p alate (Fig. 16.2). Th e m a xilla occu p ies t h e an ter ior
t w o - th irds of th e oor, an d th e p alat in e bon e occu p ies th e p oster ior on e-t h ird . Th e in cisive can al is located in t h e an ter ior
p ar t of t h e oor, im m ed iately lateral to t h e n asal sept u m . Th e
n asop alat in e n er ve an d ter m in al en d of t h e greater p alat in e
ar ter y p ass th rough th e in cisive can al.1–3
Roof of the Nasal Cavity
Th e roof of th e n asal cavit y com prises th e n asal bon e, fron t al
bon e, eth m oid bon e, an d sph en oid bon e (Fig. 16.1). In th e coron al sect ion , it is t r ian gu lar; t h e roof is ext rem ely n ar row , an d
t h e oor is w id e. In a sagit t al sect ion , it s h eigh t is greatest in
t h e cen t ral region, w hich contains the cribriform plate of the
ethm oid bon e; th e roof th en decreases in h eigh t as it progresses
in th e an terior an d posterior direct ion s. Th e roof is adjacen t to
th ree paran asal sin uses: th e fron tal sin us, sph en oid sin u s, an d
eth m oid sin u s.1–3
142
Medial Wall (Nasal Septum)
Th e nasal sept u m form s th e m edial w all of th e n asal cavit y an d
divides th e en t ire n asal cavit y in to t w o (Fig. 16.3). Histologically, th e n asal sept um is m ade up of a cart ilagin ous par t an d a
bony part . Th e sept al n asal car t ilage form s th e car t ilagin ou s
par t an d occupies th e an terior par t of th e n asal sept u m . Th e
posterior part is th e bony par t an d is m ade up prim arily of th e
vom er in th e in ferior p osterior region an d th e p erp en d icu lar
plate of th e eth m oid bon e in superior region . Th e m ost an teroin ferior par t of th e n asal sept um , w h ich is p osit ion ed m ore an teroin ferior to th e edge of th e n asal sept al car t ilage, is called th e
colum ella. The n asal sept um often curves an d shifts to either th e
righ t or left an d som et im es obst ru ct s th e com m on n asal m eat us on on e side. Th e reported frequency of n on t raum at ic sept al
deviat ion is 20% to 58%.4–6 Guyu ron et al7 classi ed septon asal
deviat ion in to six t ypes: sept al t ilt , C-sh aped deform it y (eith er
an terop osterior or cep h alocau dal), S-sh aped deform it y (eith er
an terop osterior or cep h alocau dal), an d localized deform it y. Th e
m ost com m on t yp e of deviat ion is th e sept al t ilt t yp e, in w h ich
th e sept u m h as n o cur ve but is t ilted tow ard on e side in th e
coron al sect ion . Th is t ype is obser ved in approxim ately 40% of
pat ien ts w ith septon asal deviat ion . Th e secon d m ost com m on
t ype is th e C-sh aped an teroposterior deviat ion , w h ich occu rs in
ap p roxim ately 32%of pat ien t s. In th is t yp e, th e sept u m exh ibit s
a C-sh ap ed cu r ve in th e coron al sect ion . Th e C-sh ap ed ceph alocaudal deviat ion , in w h ich th e sept um form s a C sh ape in th e
coron al sect ion , is obser ved in approxim ately 4% of pat ien ts.
16 Nasal Cavit y and Paranasal Sinuses
Anterior
cranial fossa
Cribriform
plate
Superior
m eatus
Crista galli
Frontal bone
Sphenoid bone,
lesser wing
Middle cranial fossa
Frontal sinus
Nasal bone
Hypophyseal fossa
Lacrimal bone
Sphenoid sinus
Frontal process
of maxilla
Superior concha,
ethmoid bone
Body of
sphenoid bone
Anterior nasal
aperture
Pterygoid process,
m edial plate
Choana
Middle
m eatus
Pterygoid process,
lateral plate
Inferior
concha
Palatine process
of m axilla
Palatine bone,
horizontal plate
Inferior
m eatus
Middle concha
(ethm oid bone)
Fig. 16.1 Sagit tal section of the nasal cavit y (right side). (From THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thiem e 2010, Illustration by
Karl Wesker.)
An terop osterior an d cep h alocau dal S-sh aped deviat ion s are ob ser ved in 9% an d 1% of p at ien t s, resp ect ively. Fin ally, localized
deform it ies are obser ved in abou t 14%of pat ien t s w ith septon asal deviat ion .7
An im p or t an t region of th e n asal sept u m is Kiesselbach’s or
Lit tle’s area, located in th e an terior part of th e n asal sept u m .
Five ar ter ies su p p lyin g t h e n asal sept u m an astom ose at t h is
p oin t to create an ar ter ial p lexu s (Fig. 16.4). Th is area is frequ en tly involved in ch ron ic epist axis, especially in ch ildren .
Lateral Wall of the Nasal
Cavity
Th e lateral w all of th e n asal cavit y is ch aracterized by th ree con ch ae th at are long in th e an teroposterior direct ion an d prot rude
m edially tow ard th e n asal cavit y; th eir free edge rolls in feriorly
(Fig. 16.4). Th ese con ch ae are term ed th e superior n asal con ch a, m iddle n asal con ch a, an d in ferior n asal con ch a, an d th e
m eat u ses below th ese con ch ae are called th e su p erior n asal m eat us, m iddle nasal m eatus, and inferior nasal m eatus, respectively. At th e posterior en d of th ese con ch ae, th e th ree m eat u ses
con ate an d m eet at th e n asoph ar yn x; th is poin t is term ed th e
n asoph ar yngeal m eat u s. An at roph ic su p rem e n asal con ch a is
som et im es fou n d above th e su p erior con ch a.8 Th e p osterosu p erior p ar t of th e n asal cavit y, w h ich form s th e space bet w een th e
n asal roof an d su perior con ch a, is th e sp h en oeth m oidal recess.
Som e im p ort an t st ru ct u res are located arou n d th e m iddle
m eat u s. Th e eth m oid bu lla, w h ich con t ain s th e eth m oid bu lla
cells of th e eth m oid sinu s, projects from th e m edial w all of th e
orbit . Par t of th e eth m oid bulla is exposed on th e superior part
of th e lateral w all of th e m iddle n asal m eat u s. Th e un cin ate process is th e th in , bony project ion located above th e at t ach m en t
of th e in ferior n asal con ch a. The deep groove bet w een th e eth m oid bu lla an d u n cin ate p rocess is called th e sem ilu n ar h iat u s.
143
Anatom y for Plastic Surgery of the Face, Head, and Neck
Anterior
nasal spine
Incisive
canal
Maxillary
sinus
Nasal crest
Palatine process
of maxilla
Palatine bone,
perpendicular
plate
Transverse
palatine suture
Greater
palatine canal
Palatine bone,
pyramidal process
Pterygoid process,
m edial plate
Pterygoid process,
lateral plate
Posterior
nasal spine
a
Incisive
canal
Palatine process
of maxilla
Transverse
palatine suture
Median
palatine suture
Greater
palatine foram en
Lesser
palatine foram en
Inferior
orbital fissure
Pterygoid process,
medial plate
Pyram idal process
Pterygoid
fossa
Choana
Posterior
nasal spine
b
Pterygoid process,
lateral plate
Foram en for
pterygoid plexus
Fig. 16.2 Floor of the nasal cavit y. The oor of the nasal cavit y com prises mainly the superior surface of the maxilla and palatine bone. In
the anterior part of the oor, the incisive canal is observed immediately
144
Vom er
Foram en
ovale
lateral to the nasal septum. (a) Superior view. (b) Inferior view. (From
THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010,
Illustrations by Karl Wesker.)
16 Nasal Cavit y and Paranasal Sinuses
Fig. 16.3 Nasal septum. Parasagit tal section viewed from the left side.
Histologically, the nasal septum comprises t wo parts: the cartilaginous
part and the bony part. The septal nasal cartilage forms the cartilaginous part and occupies the anterior part of the nasal septum. The
posterior part is the bony part and mainly comprises the vomer in the
inferior posterior part and the perpendicular plate of the ethmoid
bone in the superior part. (From THIEME Atlas of Anatomy, Head and
Neuroanatomy. © Thieme 2010, Illustration by Karl Wesker.)
Sphenoid
sinus
Agger Nasi
Superior
nasal concha
Sphenoethm oid
recess
Middle
nasal concha
Superior
m eatus
Middle
m eatus
Pharyngeal
tonsil
Inferior
nasal concha
Salpingopharyngeal
fold
Lim en nasi
Nasal
vestibule
Inferior
m eatus
Antrum of the m iddle m eatus
Fig. 16.4 Right lateral wall of the nasal cavit y. (Modi ed from THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme, 2010, Illustration by
Karl Wesker.)
145
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 16.5 Left inferior nasal meatus (cadaver
dissection). Anterior part of the inferior nasal
concha was cut. Slitlike opening of the nasolacrim al duct is observed just beneath the
at tachm ent of the inferior nasal concha.
146
Th e sem ilun ar h iat us is divided in to t w o part s in it s an terior
region by th e p roject ion of th e eth m oid bulla: th e superior an d
in ferior sem ilu n ar h iat u s. Th ese st ru ct u res are involved in con n ect in g t h e p aran asal sin u ses. Th e et h m oid al in fu n d ibu lu m is
t h e fu n n el-sh ap ed sp ace in sid e t h e m ed ial w all of t h e n asal
cavit y. It is su r rou n ded by t h e u n cin ate p rocess m ed ially an d
eth m oid bu lla laterally an d con t in u es to th e sem ilu n ar h iat u s
posteriorly. Th e bony bulge an terior to th e an terior en d of th e
m idd le n asal con ch a is called th e agger n asi. Th e ou t w ard bu lge
im m ediately an terior to th e m iddle m eat us is called th e an t rum
of th e m iddle m eat us.1–3
The opening of the nasolacrim al duct is located in the anterosu perior p ar t of th e in ferior m eat u s, ju st below th e at t ach m en t
of th e in ferior con ch a (Fig. 16.5). Th e open ings of each paran asal sin u s an d th e n asolacrim al du ct are described in th e sect ion
t h at d iscu sses t h e p aran asal sin u ses, n asolacr im al d u ct s, an d
th eir open ings in to the n asal cavit y.
Fig. 16.6 Arterial blood supply of the nasal cavit y. (a) Arterial blood
supply of the nasal septum. Kiesselbach’s area is located in the anterior
part of the nasal septum . Five arteries supplying the nasal septum
anastomose in this region and form the arterial plexus. (b) Arterial
blood supply of the lateral nasal wall.
Blood Supply of the Nasal Cavity
Th e n asal cavit y, in cluding both th e m edial an d lateral w alls, is
su p plied by ve arteries: th e an terior eth m oidal ar ter y, p osterior eth m oidal arter y, sp h en op alat in e ar ter y, greater p alat in e
arter y, an d su p erior labial arter y (Fig. 16.6).2
Both th e an terior eth m oidal arter y an d p osterior eth m oidal
ar ter y are bran ch es of t h e op h t h alm ic ar ter y. Th ey bran ch
w ith in t h e orbit al cavit y, en ter t h e n asal cavit y t h rough t h e
eth m oidal bon e, an d m ain ly su pp ly th e u p p er region of th e cavit y. A bran ch of th e an terior eth m oidal ar ter y run s an teriorly,
16 Nasal Cavit y and Paranasal Sinuses
pierces th e n asal bon e, an d dist ributes its blood supply to th e
n asal epith elium . Th e m ain arter y sup plying th e n asal cavit y is
th e sph en opalat in e arter y. Th is arter y arises from th e m axillar y
arter y in th e pter ygopalat in e fossa an d en ters th e n asal cavit y
through the sphenopalatine foram en, w hich is located on the lateral w all p osterior to th e su p erior n asal m eat u s. After en tering
th e n asal cavit y, th e arter y gives o various bran ch es. Th e t w o
m ain bran ch es cou rse to th e posterior part of th e n asal sept u m
an d p osterior p ar t of th e lateral n asal w all. Th e greater p alat in e
arter y, w h ich is th e term in al bran ch of th e descen ding p alat in e
arter y, en ters th e n asal cavit y th rough th e in cisive can al an d
dist ributes it s blood supply to th e low er part of th e n asal cavit y.
Th e su perior labial ar ter y, w h ich is a bran ch of th e facial arter y,
also en ters th e n asal cavit y th rough th e soft t issu e in th e u pp er
lip an d dist ribu tes it s blood sup ply to th e an terior an d low er
part s of th e n asal cavit y. Th ese arteries an astom ose w ith on e
an oth er on both th e lateral n asal w all an d th e n asal sept u m . Th e
Frontal
sinus
region in w h ich t h ese ve ar ter ies m eet an d an astom ose at t h e
an ter ior p ar t of t h e n asal sept u m is called Kiesselbach ’s area
(Fig. 16.6b).1–3,9
Sensory Innervation of the
Nasal Cavity
Th e sen sor y in n er vat ion of th e n asal cavit y is separated in to
t w o areas by th e lin e con n ect ing th e an terior n asal sp in e an d
th e sph en oeth m oidal recess (Fig. 16.7). Th e upper area of th e
n asal cavit y con tain s th e an terior eth m oidal n er ve, w h ich is a
bran ch of th e oph th alm ic n er ve ( rst division of th e t rigem in al
n er ve). Th is n er ve, accom pan ied by th e an terior eth m oidal arter y, en ters t h e n asal cavit y t h rough t h e et h m oid bon e an d
Cribriform plate
of ethm oid bone
Olfactory
bulb
Anterior ethm oidal nerve
(ophthalm ic division)
Sphenoid
sinus
Maxillary division
Olfactory fibers
Medial nasal
branches
Ophthalm ic division
Perpendicular
plate of
ethm oid bone
Trigem inal
ganglion
Mandibular division
Cartilaginous
nasal septum
Pterygopalatine ganglion in
pterygopalatine fossa
Medial superior
posterior nasal branches
(m axillary division)
Vom er
Maxilla
a
Anterior
ethm oidal nerve
Cribriform
plate
Middle
nasal concha
Nasopalatine
nerve
Zygom atic
process
Sphenopalatine
foram en
Sphenoid
sinus
Lateral
superior
posterior
nasal branches
External
nasal
branch
Pterygopalatine
ganglion
Inferior
posterior
nasal branches
Lesser
palatine nerves
Lateral nasal
branches
b
Internal nasal
branches
Inferior
nasal concha
Greater
palatine nerve
Fig. 16.7 Sensory innervation of the nasal cavit y (a) Sensory
innervation of the nasal septum. (b) Sensory innervation
of the lateral nasal wall. (Modi ed from THIEME Atlas of
Anatomy, Head and Neuroanatomy. © Thieme 2010,
Illustrations by Karl Wesker.)
147
Anatom y for Plastic Surgery of the Face, Head, and Neck
cou rses t h rough t h e an ter ior an d su p er ior p ar t s of t h e n asal
cavit y. Th e low er area of t h e n asal cavit y is in n er vated by a
bran ch d er ived from t h e m a xillar y n er ve (secon d d ivision of
t h e t rigem in al n er ve). Th e n asopalat in e n er ve an d m edial superior p osterior bran ch of th e greater p alat in e n er ve in n er vate th e
n asal sept u m in th is region of th e n asal cavit y. Th e m edial su perior p osterior bran ch in n er vates th e u p p er h alf of th is area, an d
th e n asopalat in e ner ve in n er vates th e low er h alf. Th e lateral
su p erior p osterior n asal bran ch an d in ferior p osterior n asal
bran ch of th e greater palat in e n er ve in n er vate th e lateral n asal
w all in th is region of th e n asal cavit y.
Paranasal Sinuses,
Nasolacrimal Ducts, and
their Opening to the Nasal
Cavity
Frontal Sinus
Th e fron t al sin u s is u su ally d ivided in to t w o p ar t s arou n d t h e
m id lin e (Table 16.1, Fig. 16.8). It is som et im es m ad e u p of
m u lt ip le air cells. Th e bilateral fron t al sin u ses exten d in to th e
fron t al bon e an d are located p osterior to th e su p raciliar y arch es
of th e fron tal bon e. Th e sin uses are adjacen t to th e cran ial cavit y, orbital cavit y, eth m oidal cells, an d n asal cavit y. Th e sin u ses
som et im es exten d qu ite w idely, sp read ing p osteriorly an d covering th e en t ire orbit al roof. Cases of aplasia h ave also been described . In on e rep or t , th e sin u s w as 24.3 m m (range, 5.0–66.0
m m ) in h eigh t , 29.0 m m (range, 17.0–49.0 m m ) w id e from th e
m idlin e cou rsing in th e lateral direct ion , an d 20.5 m m (range,
10.0–46.5 m m ) long in th e an teroposterior direct ion .3 Th e sin u s
con t in ues dow nw ard an d passes th rough th e eth m oid bon e on
th e w ay to th eir open ing of th e n asal cavit y. Th e par t of th e
fron t al sin u s con t ain ed w ith in th e eth m oid bon e is called th e
fron t al recess, w h ich ser ves as a drain age path w ay of th e fron t al
Table 16.1 Paranasal sinuses, nasolacrimal ducts, and their
opening to the nasal cavity
Paranasal sinus
Opening
Frontal sinus
Sem ilunar hiatus (m iddle m eatus),
or ethm oidal infundibulum
(m iddle m eatus)
Anterior ethmoid sinus
Ethm oidal infundibulum (m iddle
m eatus), lateral recess (m iddle
m eatus)
Posterior ethm oid sinus
Sphenoethm oidal recess
Sphenoid sinus
Sphenoethm oidal recess
Maxillary sinus
Ethm oidal infundibulum (m iddle
m eatus), accessory openings
(m iddle m eatus)
Nasolacrim al duct
Anterior edge of the at tachm ent of
the niferior nasal concha (inferior
m eatus)
sin u s. Th e sin u ses u su ally op en in to th e sem ilu n ar h iat u s or th e
eth m oidal in fu n dibu lu m . Th e drain age p at tern depen ds on th e
locat ion at w h ich th e un cin ate process at tach es an teriorly. If th e
un cin ate process in ser t s in to th e lam in a orbit alis (lam in a p apyracea), th e eth m oidal in fu n dibu lu m en ds blin dly at th e su perior
posit ion an d th e fron tal recess open s to th e m iddle m eat us or
su p rabu llar recess. If th e u n cin ate p rocess in ser t s at th e sku ll
base or m id d le n asal m eat u s, t h e fron t al recess op en s to t h e
m iddle m eat u s via th e eth m oidal in fu n d ibu lu m . Th is blin d en d
is called a term in al cell.
Surgical Annotation (Frontal Sinus
Cranialization for Frontal Fractures and
Anterior Skull Base Reconstruction)
Fron t al sin u s cran ializat ion is required to t reat severe fron tal
fract u res th at h ave sp read to th e posterior table of th e fron t al
sin u s w it h cerebrosp in al u id leakage, as w ell as to p er for m
Fig. 16.8 Frontal sinus (cadaver dissection).
Calvaria vault and brain were removed.
148
16 Nasal Cavit y and Paranasal Sinuses
p oral pericran ial ap or a fron t al p ericran ial ap is usu ally
selected. On com p let ion of th e fron tal cran iotom y, th e p osterior
t able of th e fron tal sin us an d m ucosa on th e sin us are com p letely rem oved . Th e soft t issue ap is t ran splan ted to th e an terior sku ll base, ju st above th e p oin t at w h ich th e fron tal sin u s
m eet s th e fron ton asal du ct , to discon n ect th e cran ial cavit y an d
n asal cavit y.
Fron t al sin us cran ializat ion is n ot n eeded to t reat fract ures
localized on ly in th e an terior t able of th e fron tal bon e. In stead,
reposit ion ing an d xat ion of th e fract ure is e ect ive. Placem en t
of a drain age t ube in th e fron ton asal duct h elps to preven t disch arge from pooling in th e fron tal sin us.10,11
Ethmoid Sinus and Sinus around
the Frontal Recess
Fig. 16.9 Operative ndings of frontal sinus cranialization. Case of a
comminuted fracture of the frontal bone. The posterior wall of the
frontal sinus and mucosa were removed, and the anterior skull base
was reconstructed using a frontal musculoperiosteal ap. In this
illustration, the frontal musculoperiosteal ap had just been created.
an terior sku ll-base t u m or resect ion involving com m u n icat ion
bet w een th e cran ial cavit y an d n asal cavit y (Fig. 16.9). Fron t alsin u s cran ializat ion allow s th e fron t al sin u s to becom e p ar t of
th e cran ial cavit y by rem oving th e posterior table of th e fron t al
sin u s. A bicoron al skin in cision is u su ally ch osen for th e fron t al
bon e approach . A ap for th e an terior sku ll base is th en prepared during dissect ion of th e cran ial soft t issue. Eith er a tem -
Th e eth m oid sin us is located in th e eth m oidal labyrin th an d
com prises m any sm all air cells (Fig. 16.10). The sin us is adjacen t to th e m edial w all of th e orbit , n ear th e orbit al plate of th e
eth m oidal labyrin th laterally an d exten ding to th e n asal cavit y
n ear th e m edial w all of th e eth m oidal labyrin th m edially (Table
16.2). Th e eth m oid sin us usually con t ain s ve bony sept a called
basal lam ellae, w h ich separate th e sin us in th e an teroposterior
direct ion . Th ese lam ellae are n um bered from an terior to posterior. Th e rst lam ella is th e sept u m th at con t in u es to th e u n cin ate process. Th e secon d lam ella arises from th e p osterior w all
of th e eth m oidal bulla. Th e th ird lam ella is th e th ickest of all ve
basal lam ellae an d is un iform in sh ape. It arises from th e m iddle
n asal con ch a. Th e fou r th lam ella con t in u es to th e su p erior n asal
con ch a. Fin ally, th e fth lam ella is th e sept u m support ing th e
su perior n asal con ch a. Th e sp h en oeth m oidal recess is located
p osterior to th e fth basal lam ella (basal lam ella of th e su perior
con ch a).12 Th e eth m oid sin u s is gen erally divided by th e th ird
basal lam ella (basal lam ella of th e m iddle t u rbin ate) in to t w o
p art s: th e an terior eth m oid sin u s an d posterior eth m oid sin us.
Fig. 16.10 Horizontal section of the right ethm oid sinus.
149
Anatom y for Plastic Surgery of the Face, Head, and Neck
Table 16.2 Lamellae of the ethmoid sinus
Basal lamellae
Related structure
The rst lam ella
Uncinate process
The second lam ella
Posterior wall of the ethm oidal
bulla
The third lam ella (basal
lam ella of the middle
turbinate)
Middle nasal concha
The fourth lam ella
Superior nasal concha
The fth lamella
Superior nasal concha
Th e posterior eth m oid sin us is th e air cell th at drain s to th e
sph en oeth m oidal recess. Th e posterior sin u s som et im es develops w ith in th e sph en oid sin u s, an d th e opt ic n er ve an d in tern al
carot id ar ter y m ay th us be exposed w ith in th e air cells. Th ese
cells con st it u te th e sph en oeth m oidal sin u s an d are som et im es
term ed On odi cells.8 In th e an terior eth m oidal sin us, th e cells
bet w een the secon d an d th ird basal lam ella con st it ute w h at is
som et im es called th e m iddle eth m oid sin u s; h ow ever, th is term
h as n ot been u sed recen tly.9
Th e eth m oidal bulla cells, w h ich form th e an terior eth m oid
sin u s, are located relat ively p osterior to an d w ith in th e space
bet w een th e m iddle n asal con ch a an d un cin ate process (i.e., th e
m iddle eth m oid sin u s). Th e eth m oidal bu lla cells u su ally op en
to t h e lateral recess, w h ich is t h e sp ace located p oster ior to
t h e eth m oidal bulla cells. These st ruct ures som et im es form th e
sin us called the lateral recess. The drainage pathw ay of the frontal sin u s passes bet w een th e rst an d secon d basal lam ella an d
open s to th e m iddle n asal m eat u s th rough th e eth m oidal in fun dibulum . The sh ape of th is duct is n ot a sim ple t ube con n ect ing
th e fron tal sin us an d eth m oidal in fun dibu lum but is in stead an
Supratrochlear
artery
irregu larly sh aped cell. Th us, th e term frontonasal duct is used
less frequen tly today.9 Th e air cells located in th e su p erior an terior p ar t of th e an terior eth m oidal sin u s an d su rrou n ding th e
drain age path w ay of the fron t al sin us (fron t al recess) are called
t h e fron t al recess cells. Th e air cells located arou n d t h e et h m oidal in fu n d ibu lu m an d t h at op en to it are called t h e in fu n dibular cells.
An terior to the eth m oidal sin us, som e air cells originate from
th e fron t al process of th e m axilla. Th e agger n asi cells, fron tal
eth m oidal cells, an d fron t al bu lla cells are in clu ded in th is categor y. A single agger n asi cell is u su ally located beh in d th e agger
n asi, w h ich is th e bu lge an terior to th e m iddle n asal con ch a. By
com puted tom ography, th is air cell is detected in m ore th an 90%
of cases as th e m ost super cial cell in th e coron al sect ion .13,14 It
is an im port an t lan dm ark in th e approach to th e fron t al recess
during endoscopic surgery. The air cells facing the lacrim al bone
(in ferior to th e agger n asi cells) are term ed th e lacrim al cells.
Surgical Annotation
Causes of Bleeding During Ethmoid Sinus
Surgery
W h en perform ing t reat m en t s involving th e m edial orbit al w all,
such as fracture repair (m edial orbital w all fract ures, etc.), tum or
resect ion , or et h m oidal sin u s su rger y, u n exp ected m assive
bleeding som et im es occurs (Fig. 16.11). Th is bleeding is usu ally
caused by dam age to th e an terior eth m oidal arter y or posterior
et h m oidal ar ter y. Th ese ar ter ies are bran ch es of t h e op h t h alm ic arter y, w h ich en ters th e orbit al cavit y along w ith th e opt ic
n er ve th rough th e opt ic can al. Th e arter y an d n er ve th en pen et rate th e m edial orbit al w all th rough th e an terior an d posterior
eth m oidal foram en s, resp ect ively, w h ich are located on th e su -
Supraorbital artery
Lacrimal artery
Medial palpebral
artery
Anterior
ethmoidal artery
Posterior
ethm oidal artery
Ophthalmic artery
Short posterior
ciliary arteries
Long posterior
ciliary arteries
Central
retinal artery
Anastom otic
branch
Internal
carotid artery
Middle
m eningeal artery
150
Fig. 16.11 Anterior and posterior
ethmoidal arteries. (From THIEME
Atlas of Anatomy, Head and
Neuroanatomy. © Thieme 2010,
Illustration by Karl Wesker).
16 Nasal Cavit y and Paranasal Sinuses
Fig. 16.12 Sagit tal section of the right
sphenoid sinus. The black string indicates the
opening of the sphenoid sinus.
perior part of th e m edial orbit al w all. Th e an terior eth m oidal
artery supplies the anterior and m iddle ethm oidal air cells and
the frontal sinus. After entering the cranium , this artery branches
in to th e m en ingeal bran ch an d n ally en ters th e n asal cavit y
th rough th e eth m oidal foram en to supply th e n asal cavit y. Th e
term in al bran ch of th is ar ter y em erges from th e dorsum of th e
n ose bet w een th e n asal bon e an d th e lateral car t ilage. Th e posterior ethm oidal arter y supplies th e posterior eth m oidal air cell
after leaving th e orbit th rough th e p osterior eth m oidal can al
an d th en bran ch es in to th e m en ingeal bran ch after en tering th e
cran ium ; it n ally en ters an d supplies th e n asal cavit y.15
Sphenoid Sinus
The sphenoid sinus is located posterior to the ethm oidal air cells
an d is p osit ion ed w ith in th e body of th e sp h en oid, form ing th e
posterior roof of th e n asal cavit y (Fig. 16.12). It con t ain s a bony
sept u m t h at d ivid es t h e bilateral sin u ses. In m ost cases, t h e
bony sept um deviates from th e m idlin e. Th e sin us open s to th e
sph en oeth m oidal recess (th e sp ace su perior an d p osterior to
th e su perior n asal con ch a) th rough th e ost ium open ing on th e
an terior w all of th e sph en oid sin u s. It lies adjacen t to im p or t an t
st ru ct u res in th e cran ial cavit y, in clu ding th e opt ic n er ve, opt ic
ch asm , pit uit ar y glan d, in tern al carot id arter y, an d cavern ou s
sin u s.3,16
Maxillary Sinus
Th e m axillar y sin uses are located w ith in th e m axilla an d h ave
the largest capacit y of all the paranasal sinuses (Fig. 16.13). They
m ain ly op en to t h e m id d le n asal m eat u s at t h e et h m oidal in fu n dibu lu m . Th is op en ing is called th e n at u ral ost iu m . Th e
m a xillar y sin u ses h ave on e or m ore accessor y open ings at th eir
fontanelle in th e m iddle nasal m eatus. The shape of these sin uses
Fig. 16.13 Maxillary sinus (left maxillary sinus, inferior view). The white
string indicates the natural ostium of the left maxillary sinus (posterolateral view, after removal of the oor of the maxilla and nasal oor).
151
Anatom y for Plastic Surgery of the Face, Head, and Neck
is pyram id al, t h eir base is t h e lateral w all of t h e n asal cavit y,
an d t h eir ap ex exten d s to t h e zygom at ic p rocess. Th eir roof
form s th e orbit al oor an d exten ds m edially to th e in ferior orbital can al.1,2 Th e m axillar y sin uses m ay h ave sept a th at divide
th e sin uses into in tercom m un icat ing spaces. Th e size of th ese
sin u ses varies from 9.5 to 20.0 m l; th e average is abou t 15.0 m l.3
Som e im port an t st ru ct u res are located in th e m axillar y sin u ses.
Th e n asolacr im al d u ct is located in t h e an ter ior p ar t of t h e
m edial w all of th is sin u s. Th e in fraorbit al n er ve, a bran ch of th e
m axillar y n er ve, p asses th rough a bony w all (th e in fraorbit al
can al) in th e roof of th e m a xillar y sin us to the m axillar y skin.
Th e m axillar y n er ve gives o th ree bran ch es: th e posterior superior; m iddle superior; an d an terior superior alveolar n er ves,
w h ich in n er vate th e m a xillar y teeth . Th e posterior su perior alveolar n er ve arises ju st before th e m axillar y n er ve th at en ters
th e in fraorbit al can al, th e m iddle su perior alveolar n er ve from
th e posterior par t of th e in fraorbit al can al, an d th e an terior superior alveolar n er ve from just before th e n er ve com ing out
from th e can al. Th ese alveolar n er ves ru n in th e bony w all of th e
m axillar y sin u s; in fratem p oral su rface (p osterior su perior), lateral (m iddle su perior), an d an terior su rface (an terior su p erior),
respect ively; com m un icate w ith each oth er; an d in n er vate th e
teeth . In th e posterior region , th e m axilla is con t iguou s w ith th e
lateral pter ygoid p late an d form s th e pter ygom axillar y ssu re.
Th e pter ygopalat in e fossa is located in side th e ssure an d gives
Infraorbital
artery
o th e term in al bran ch es of th e m axillar y n er ve an d m axillar y
artery. Th e descending palatine artery an d greater palatine ner ve,
w h ich course to th e palate, pass th rough th e greater palat in e
can al in th e in ferior par t of th e fossa.1 Th is n eu rovascu lar com plex is ext rem ely im por tan t in Le For t I osteotom y.
Surgical Annotation (Le Fort I
Osteotomy and Maxillary Fracture)
Th e opport u n it y to t reat th e in ferior m eat us su rgically (e.g., by
LeFort I osteotom y or m axillar y sin u s drain age for m axillar y
fract u res) som et im es arises in th e eld of p last ic su rger y. In
su ch cases, th e su rgeon m u st p ay at ten t ion to t w o im p or tan t
st ru ct u res in th e in ferior n asal m eat u s. On e is th e op en ing of
th e n asolacrim al duct , w h ich is located at th e an terior en d of
th e in ferior n asal m eat us just below th e in ferior n asal con ch a,
an d th e oth er is th e descen ding palat in e ar ter y, w h ich is located
w ithin the greater palatine canal, inferior to the m axillary sinus.
Obstruction of the nasolacrim al duct m ay rarely occur after m axillar y surger y, usu ally becau se of secon dar y in am m at ion or
som et im es direct inju r y of th e valve of Hasn er.17,18 To open th e
m a xillar y sin u s, d rain age to t h e in fer ior m eat u s also sh ou ld
m ake en ough rear w ard to t h e valve of Hasn er. Th e d escen d in g
p alat in e ar ter y (Fig. 16.14) p oses a p oten t ial r isk of m assive
Greater wing of
sphenoid bone
Pterygopalatine
fossa
Inferior orbital
fissure
Sphenopalatine
artery
Deep temporal
arteries
Posterior superior
alveolar artery
Pterygoid branches
Maxillary artery
Descending
palatine artery
Artery of
pterygoid canal
Pterygomaxillary
fissure
Zygomatic
process (divided)
Maxillary tuberosit y
Masseteric artery
Buccal artery
Pterygoid process,
lateral plate
Greater
palatine artery
Lesser
palatine artery
Fig. 16.14 Descending palatine artery. Left lateral view. The descending palatine artery arises from the m axillary artery in the pterygopalatine fossa and descends in the greater palatine canal. The descending
palatine artery becomes the greater palatine artery after emerging
152
from the greater palatine foramen at the palate. (From THIEME Atlas of
Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustration by Karl
Wesker.)
16 Nasal Cavit y and Paranasal Sinuses
Fig. 16.15 Variation of the opening of the
nasolacrimal duct. Orange arrowhead indicates
the opening of the nasolacrimal duct. Various
t ypes of openings are observed. From left upper
to right lower: ssure t ype (Rt), pseudo-obstruction t ype (Rt.), wide-open t ype (Lt.), small open
t ype (Rt.), and pinhole t ype (Lt.).
bleeding during Le Fort I osteotom y. To avoid dam age to th e descen ding p alat in e arter y, osteotom y p erform ed u sing a ch isel or
bon e saw sh ould be stopped before reach ing th e ar ter y, an d
blu n t dow n fract ure to th e residual posterior par t of th e m axilla
sh ou ld be p erform ed . Li et al19 repor ted th at th e average dist an ce from th e piriform rim to th e descen ding arter y w as 35.4
m m (range, 31.0–42.0 m m ). Th ey fou n d th at th e greater palat in e foram en w as located bet w een the secon d an d th ird m olars
an d th at th e average distan ce bet w een th e pter ygom axillar y
ssu re an d greater palat in e foram en w as 6.6 m m (range. 2.0–
10.0 m m ).19
n ost ril, an d 14.10 ± 3.76 m m ver t ically from th e n asal oor. Th e
sh ap e of th e valve reportedly ranges from a rou n d to slit sh ape,
an d th e frequ en cy of th e sh ap e varies am ong report s. Sch aeffer 21 reported th at an oval sh ape w as m ost frequen t am ong European s. In con t rast , Orh an et al22 reported a h igh frequen cy of
th e vert ical su lcus t ype. In ou r st udy, th e ssure t ype w as ob ser ved m ost frequ en tly (Table 16.3).20
Table 16.3 Variations of the opening of the nasolacrimal duct
Opening of the nasolacrimal duct
Opening of Nasolacrimal Duct
(Valve of Hasner)
Th e n asolacrim al du ct open s obliquely on th e lateral n asal w all
of th e in ferior n asal m eat us, aroun d th e an terior edge of th e
at t ach m en t of th e in ferior n asal con ch a (Fig. 16.15). In our cadaver dissect ion st udy,20 th e open ing of th e n asolacrim al du ct
w as located 36.60 ± 3.92 m m from th e an terior edge of th e n ost ril, 19.20 ± 3.21 m m h orizon t ally from th e an terior edge of th e
Frequency (%)
Wide opening t ype
17
Sm all opening t ype
15
Pinhole t ype
14
Fissure t ype
32
Pseudo-obstruction t ype
22
Obstruction t ype
0
Source: Tanaka K. An anatomical study of the inferior nasal meatus region
of the human nasolacrim al duct. Kurume Igakkai Zasshi 2008;71:38–52.
153
Anatom y for Plastic Surgery of the Face, Head, and Neck
References
1. Clem en te CD, ed . Gray’s An atom y. Ph ilad elp h ia: Lea & Febiger;
1985
2. Moore KL, Dalley AF, Agu r AMR. Clin ically Orien ted An atom y. Ph ilad elp h ia: Lipp in cot t William s & Wilkin s; 2013
3. Lang J. Clin ical An atom y of th e Nose, Nasal Cavit y an d Paran asal
Sin u ses. New York: Th iem e; 1989
4. Blaugrun d SM. Nasal obst ru ct ion : The n asal sept u m an d con ch a
bullosa. Otolar yngol Clin North Am 1989;22(2):291–306 Pu bMed
5. Ear w aker J. An atom ic varian t s in sinon asal CT. Radiograph ics
1993;13(2):381–415 Pu bMed
6. Pérez-Piñ as I, Sabaté J, Carm on a A, Cat alin a-Herrera CJ, Jim én ezCastellan os J. An atom ical variat ion s in th e h u m an p aran asal sin u s
region st udied by CT. J Anat 2000;197(Pt 2):221–227 PubMed
7. Guyuron B, Uzzo CD, Scull H. A pract ical classi cat ion of septon asal deviat ion an d an e ect ive guide to sept al surger y. Plast Reconst r Su rg 1999;104(7):2202–2209, discu ssion 2210–2212 PubMed
8. Jan faza P, Nad ol JB, Galla RJ, Fabian RL, Mon tgom er y W W, eds.
Su rgical An atom y of th e Head and Neck. Cam bridge, MA: Har vard
Un iversit y Press; 2011
9. St am m berger HR, Ken n edy DW; An atom ic Term in ology Group.
Paran asal sin u ses:an atom ic term in ology an d n om en clat u re. An n
Otol Rh in ol Lar yngol Su pp l 1995;167:7–16 PubMed
10. Ruggiero FP, Zen d er CA. Fron t al sin u s cran ializat ion . Op er Tech
Otolar yngol—Head Neck Su rg 2010;21(2):143–146
11. St rong EB, Pah lavan N, Saito D. Fron t al sin us fract ures: a 28-year
ret rospect ive review. Otolar yngol Head Neck Surg 2006;135(5):
774–779 PubMed
12. Kim SS, Lee JG, Kim KS, Kim HU, Ch ung IH, Yoon JH. Com puted tom ograph ic an d an atom ical an alysis of th e basal lam ellas in th e
eth m oid sin us. Lar yngoscope 2001;111(3):424–429 Pu bMed
154
13. Worm ald PJ. Surger y of th e fron t al recess an d fron t al sin us. Rh in ology 2005;43(2):82–85 Pu bMed
14. Worm ald PJ. Th ree-dim en sional building block approach to un derst an ding th e an atom y of th e fron t al recess an d fron t al sin us. Oper
Tech Otolar yngol—Head Neck Surg 2006;17(1):2–5
15. Erdogm us S, Govsa F. Th e an atom ic lan dm arks of eth m oidal ar teries for th e surgical app roach es. J Cran iofac Surg 2006;17(2):280–
285 PubMed
16. Kim HU, Kim SS, Kang SS, Ch ung IH, Lee JG, Yoon JH. Su rgical an atom y of th e n at u ral ost ium of th e sph en oid sin us. Lar yngoscope
2001;111(9):1599–1602 Pu bMed
17. Osgu t h orp e JD, Calcaterra TC. Nasolacrim al obst r u ct ion after
m a xillar y sin us an d rh in oplast ic su rger y. Arch Otolar yngol 1979;
105(5):264–266 PubMed
18. Serdah l CL, Berris CE, Ch ole RA. Nasolacrim al duct obst ruct ion
after en doscopic sin us surger y. Arch Oph th alm ol 1990;108(3):391–
392 Pu bMed
19. Li KK, Meara JG, Alexan der A Jr. Locat ion of th e descen ding palat in e
ar ter y in relat ion to th e Le For t I osteotom y. J Oral Maxillofac Surg
1996;54(7):822–827 Pu bMed
20. Tan aka K. An an atom ical st udy of th e in ferior n asal m eat us region
of th e h um an nasolacrim al duct . Kurum e Igakkai Zassh i 2008;71:
38–52(in Japan ese)
21. Sch ae er JP. Types of ost ia n asolacrim alis in m an an d th eir gen et ic
sign i can ce. Am J An at 1912;13:183–192
22. Orh an M, Ikiz ZAA, Saylam CY. An atom ical feat ures of the open ing
of th e nasolacrim al du ct an d th e lacrim al fold (Hasn er’s valve) for
in t ran asal surger y: a cadaveric st udy. Clin An at 2009;22(8):925–
931 Pu bMed
17
External Nose
Hideaki Rik im aru
Introduction
Th e n ose is located in th e cen ter of th e face an d is on e of th e
m ost im p ressive feat u res to oth er people. Th e sh ap e is a th reedim en sion ally com plex an d di ers bet w een in dividual, sex, an d
race. Th is com plex st ruct ure is form ed by skin , soft t issue, bon e,
cart ilage, an d m u cosa, w h ich di er in com posit ion depen ding
on th e region of th e n ose. Th e vascular su pply an d in n er vat ion
of th e n ose are also in t ricate. Several vessels an d n er ves are dist ribu ted w it h in t h e relat ively sm all sp ace of t h e n ose. Th u s, it
is essen t ial to h ave a good u n d erst an d ing of th e an atom y of th e
n ose for any su rgical procedu re.
External Anatomy of the
Nose
In th e lateral view of th e skeleton , th e u p perm ost p ar t of th e
n asal bon e con n ect s to th e fron t al bon e by th e n asofron t al su t ure. Th e m idlin e poin t on th e sut ure is de n ed as th e nasion.
The depressed area below the nasion is the nasal root, w here the
m ost dep ressed p ar t is u su ally located sligh tly su p erior to th e
m edial can th al ten don of th e eyelid. On th e skin , th e m ost depressed poin t is usually m ore cran ial to th e poin t directly over
th e bony n asal root because th e su bcut an eous fat an d th e m im et ic m u scles are th ick in th is area. Head ing dow nw ard along
th e n asal ridge, th e long st raigh t par t prot ruding an teriorly is
th e n asal dorsum . Th e n asal dorsum is n arrow est at th e in tercan th al lin e, w h ich is th e lin e con n ect ing th e bilateral m edial
can t h al ten d on s t h at becom es w id er as you m ove d ow n t h e
n ose. Th e ju n ct ion al p oin t bet w een t h e u p p er lateral car t ilage
an d low er lateral car t ilage is t h e su p rat ip breakp oin t , w h ich is
t h e in fer ior bord er of t h e n asal d orsu m . Below t h e su p rat ip
break poin t , th e h igh est part of th e n ose is th e n asal t ip, an d th e
h igh est poin t is th e pron asale. Th e in ferior border of th e n asal
t ip is th e colu m ellar breakpoin t , w h ich is th e poin t correspon d ing to th e angle bet w een th e m edial cru s an d m iddle crus of th e
lower lateral cartilage. The area superior to the tip de ning point
in th e n asal t ip is th e su prat ip lobule an d in ferior to th e poin t is
th e in frat ip lobule. Th e colum ella is th e in ferior m argin of th e
n asal sept u m , en ding in th e subn asale (Fig. 17.1).
In t h e in fer ior view , t h e sh ap e of t h e n ost r il an d t h e len gt h
of th e colum ella a ect th e gen eral sh ape of th e low er n ose. In
gen eral, th e length bet w een th e bilateral alar creases an d th e
length from th e subn asale to th e p ron asale are equal. Fu r th erm ore, th e rat io bet w een th e length of th e h eigh t of th e n ost ril
an d th e length of th e in frat ip lobu le is 2:1 1 ; h ow ever, th e sh ape
an d prop or t ion of th is area var y by race (Fig. 17.2).2,3
Skin
Th e ch aracterist ics of th e n asal skin are dist in ctly di eren t bet w een its upper and low er parts. The upper part of the skin ten ds
to be th in an d m obile. Som e w rin kles can be obser ved during
ch anges in facial expression . Conversely, th e skin in th e low er
p art of th e n ose is th icker an d ten ds to x to u n derlying st ruct ures. As a result , w rin kles are n ot obser ved during ch anges in
facial exp ression in th is area. Th e skin also p lays a role in form ing th e th ree-dim en sion ally com plicated n asal st ruct u re w ith
th e un derlying cart ilage. Th e low er part of th e skin usually h as
m any exocr in e glan d s, n am ely, sebaceou s an d sw eat glan d s.
Regarding th e th ickn ess of th e n asal skin , Lesserd an d Dan iel
reported th at it is t h ickest at t h e n asofron t al groove at ap proxim ately 1.25 m m an d th in n est at th e rh in ion at approxim ately
0.6 m m .1,4 Th is m ean s th at th e skin is th e th in n est in th e m iddle
area of th e n ose (arou n d th e rh in ion ), an d becom es th icker
above an d below th is poin t . Th e th ickn ess of th e skin ch anges by
region w ith th e skin in th e colum ella an d along th e alar m argin
u sually being th in n er.1 At th e n ost ril apex, th ere is a soft t rian gle w h ere th e n ost ril lin ing skin an d lobu le skin tou ch w ith ou t
any su bcu t an eou s st ru ct u re (Fig. 17.2).
Subcutaneous Layer
Lesserd an d Dan iel also rep or ted th at fou r layers are obser ved in
th e soft t issue st ruct ures un der th e skin : th e super cial fat t y
p an n iculus; th e brom u scu lar layer; th e deep fat t y layer; an d
th e periosteum (or perich on drium ) (Fig. 17.3). Th e super cial
fat t y pan n icu lu s is th e layer con sist ing of su bderm al adipose
t issue an d in terlacing vert ical brous septa. Th is layer presen t s
th rough out th e n ose but is con cen t rated in th e glabellar an d su pratip regions. The brom uscular layer consists of nasal m uscles
155
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 17.2 The inferior view of the external nose. C, Columella; IL,
infratip lobule; PN, pronasale; SN, subnasale; ST, soft triangle.
Blood Supply of the Nose
Fig. 17.1 The lateral view of the external nose. CB, Columella breakpoint; IL, infratip lobule; N, nasion; PN, pronasale; SB, supratip
breakpoint; SL, supratip lobule; SN, subnasale.
and brous layers covering the m uscles from super cial and deep
asp ect s. Th is layer is de n ed as th e n asal su p er cial m u scu loap on eu rot ic system (SMAS) an d is con t in u ou s w ith th e facial
SMAS. Th e deep fat t y layer con sist s of th e loose areolar fat
w ith out brou s sept a, w h ich gives m obilit y to n asal skin .5
Muscle Layer of the Nose
Th e m usculat ure of th e n ose is categorized fun ct ion ally in to
fou r grou p s: th e elevators; dep ressors; com p ressors; an d dilators (Table 17.1).1,4,6 Th e elevators in clu d e th e p roceru s, levator
labii su perioris alaeque n asi, an d an om alu s n asi m uscles. Th ese
m u scles h ave a role in lift in g an d sh or ten in g t h e n ose, an d also
in op en in g t h e n asal valve. Th e d ep ressors in clu d e t h e alar
p ar t of t h e n asalis m u scle an d d ep ressor sept i m u scle. Th ese
m u scles length en th e n ose an d d ilate th e n ost ril. Th e com p ressor in clu des th e t ran sverse p ar t of th e n asalis m u scle. Th is m u scle also w orks to length en th e n ose an d n arrow th e n ost ril. Th e
dilators con sist of the dilator n aris an terior an d posterior m uscles an d w ork to dilate th e n ost ril. Th e zygom at ic bran ch of th e
facial n er ve in n er vates each of th ese m u scles.
156
Fou r arteries origin at ing eith er from th e in tern al carot id or
from th e extern al carot id ar teries are th e m ain su p ply for th e
extern al n ose (Table 17.2). Th e ar teries origin at ing from th e in tern al carot id arter y are th e dorsal n asal an d an terior eth m oidal
arteries, both of w h ich are bran ch es of th e op h th alm ic arter y.
Tw o arteries, th e angular ar ter y an d superior labial arter y, origin ate from th e facial arter y, on e of th e m ain bran ch es of th e extern al carot id ar ter y.
Th e dorsal n asal ar ter y em erges from th e orbit al cavit y to
th e subcut an eou s layer above th e m edial can th al ten don , w h ich
ru n s obliqu ely in ferom edially an d dist ribu tes in th e u p p er d orsal p ar t of th e n ose. Th e an terior eth m oidal arter y, w h ich is also
a bran ch of th e op h th alm ic arter y, em erges from th e base bet w een th e n asal bon e an d th e lateral n asal car t ilage an d run s
dow nw ard to th e n asal t ip. Th e angular arter y, w h ich is a con t in uat ion of th e facial arter y, h as a n um ber of bran ch es, such as
th e lateral n asal bran ch to th e low er lateral n ose. Th e superior
labial arter y prim arily sup plies th e n ost ril sill an d colum ella.
Th e ven ou s drain age of th e n ose is carried out by vein s w ith
th e sam e n am e as th e arteries th ey t ravel w ith . Th ese n ally
drain in to th e facial vein or th e cavern ous sin us via th e oph th alm ic vein .
Th e arterial an d ven ous n et w orks dist ribute in or above th e
m im et ic m u scle layer ( brom u scu lar layer; n asal SMAS layer).
Th en , th e desirable layer of dissect ion of th e n ose is u n der th e
brom u scu lar layer to p reser ve th e blood circu lat ion of th e
n asal skin , preven t bleeding, an d to redu ce edem a after su rger y.
Especially, open rh in oplast y requires ext rem ely accurate t reatm en t abou t dissect ion of th e layers.
17 External Nose
b
Fig 17.3 Soft tissue layers of the external nose. (a) The external nose
is dissected under the subcutaneous layer. The brom uscular layer is
exposed. LLSAN, Levator labii superioris alaeque nasi, Na, Nasalis;
P, Procerus. (b) The bromuscular layer and periosteum are dissected
and turned over to the lateral sides. Bony and cartilaginous structures
are exposed. FP, Frontal process of the maxilla; LLC, lower lateral
cartilage; NB, nasal bone; ULC, upper lateral cartilage.
a
Table 17.1 Muscles of the nose
Group
Action
Muscles
Elevators
Lifting and shortening the nose
Procerus
Levator labii superioris alaeque nasi
Anom alous nasi
Depressors
Lengthening the nose and dilating the nostril
Alar part of the nasalis
Depressor septi
Compressors
Narrowing the nostril
Transverse part of the nasalis
Dilators
Dilating the nostril
Dilator naris anterior and posterior
Table 17.2 Blood supply of the nose
Artery
Origin
Distribution
Dorsal nasal artery
Ophthalm ic artery
Upper dorsal part
Anterior ethm oidal artery
Ophthalm ic artery
Nasal tip
Branches of the angular artery
Facial artery
Lower lateral nose
Superior labial artery
Facial artery
Nostril and colum ella
157
Anatom y for Plastic Surgery of the Face, Head, and Neck
Table 17.3 Sensory innervation of the nose
Nerve
Origin
Distribution
Supratrochlear nerve
Ophthalm ic nerve
Upper part of the nose
Infratrochlear nerve
Ophthalm ic nerve
Upper part of the nose
Anterior ethmoidal nerve
Ophthalm ic nerve
Distal dorsum and nasal tip
Infraorbital nerve
Maxillary nerve
Distal nose (ala, colum ella, etc.)
Sensory Innervation of the
Nose
Fou r n er ves, th e su prat roch lear, th e in frat roch lear, th e an terior
eth m oidal, an d th e in fraorbit al n er ves provide sen sor y in n er vat ion to th e extern al n ose (Table 17.3). Th e suprat roch lear an d
in frat roch lear n er ves or igin ate from t h e op h t h alm ic d ivision
of t h e t r igem in al n er ve, em ergin g from t h e m ed ial orbit al r im
an d t raveling to th e su bcu t an eou s layer to be dist ribu ted to th e
u p per par t of th e n ose. Th e an terior eth m oidal n er ve em erges
from bet w een t h e n asal bon e an d lateral n asal car t ilage, an d
is d ist r ibu ted to th e dist al dorsu m an d th e n asal t ip . Inju r y of
th e an terior eth m oidal n er ve causes sen sor y dist urban ce to th e
n asal t ip . Th e in fraorbit al n er ve is a bran ch of th e m axillar y division of th e t rigem in al n er ve th at ru n s in ferom edially to th e
ala after em erging from th e in fraorbit al foram en , an d d ist rib u tes in th e distal n ose, in cluding th e ala an d colum ella.
Bony and Cartilaginous
Structures of the Nose
The bony and cartilaginous fram e of the nose can be divided into
three parts according to structure (Fig. 17.4). Pairs of nasal bones
form th e u p per p ar t an d fron t al p rocesses of th e m axilla, th e
m idd le p ar t is m ade of p airs of u p per lateral cart ilages, an d th e
low er par t con sist s of low er lateral cart ilages.
In th e u p per part , th e p aired n asal bon es an d fron tal p rocesses of th e m axilla form th e pyram idal vault in h orizon t al sec-
tion. The paired nasal bones are rectangular shaped bone and
fu se in th e m idlin e. In th e lateral view, th e n asal bon e ch anges
th e angle of th e ridgelin e at approxim ately th e upper on e-th ird
poin t , de n ed as th e n asofron tal groove. Th e n asal bon e is also
fu sed w ith th e fron tal bon e su periorly by th e fron ton asal su t u re
an d w ith th e fron tal process of th e m axilla by th e n asom axillar y sut ure. Th e in ferior border join s to th e upper lateral car t ilage. At th e in tern al surface, th e n asal bon e con n ects w ith th e
st r u ct u res for m in g t h e n asal sept u m , su ch as t h e n asal sp in e
of th e fron tal bon e, th e perpen dicular plate of th e eth m oid, an d
th e cart ilage of th e n asal sept um . Th e n asal bon e is gen erally
th icker an d n arrow er in th e superior region an d th in n er an d
w id er in fer iorly. Th e bon e var ies in for m an d size in di eren t
in d ivid u als. How ever, Lessard an d Dan iel rep or ted t h at t h e
average length from th e n asofron tal sut ure lin e to th e in ferior
border is 25.1 m m .4 Th e fron tal process of th e m axilla is th e
upw ard project ion of th e m a xilla an d fu ses w ith th e fron t al
bon e superiorly, w ith th e n asal bon e m edially, an d th e lacrim al
bon e laterally. Th e levator labii superioris alaeque n asi and orbicularis oculi m uscles at t ach to th e process. Th e m edial can th al ten don at tach es to th e fron t al process at th e n arrow est part
of th e n ose. Th e lin e con n ect ing th e bilateral m edial can th al
ten d on a is t h e in tercan t h u s lin e. Taking t h e in ter can t h u s lin e
as a referen ce, th e n asofron tal su t u re is ~10.7 m m above, th e
n asofron t al groove is ~5.8 m m above, an d th e in ferior bord er of
th e n asal bon e is ~14.4 m m below th e lin e.4
In th e m iddle part of th e n ose, th e u p p er lateral car t ilage
m akes u p th e h ard st ru ct u re. At th e t ran sit ion zon e bet w een
th e n asal bon e an d upper lateral cart ilage, n asal bon e overlaps
th e cart ilage (th e n asal bon e lies on th e upper lateral cart ilage),
an d th ey con n ect to each oth er by den se con n ect ive t issu e. Th e
overlap ping area is called th e keyston e area, w h ich form s a cresMajor alar
cartilage,
lateral crus
Glabella
Major alar
cartilage,
m edial crus
Nasal bone
Frontal process
of maxilla
Naris
Lateral
nasal
cartilage
Nasal ala
Major alar
cartilage
a
Septal
cartilage
Anterior
nasal spine
Minor alar
cartilages
Fig. 17.4 Bony and cartilaginous structures of the external nose. (a) Left lateral view. (b) Inferior view. (Modi ed from THIEME Atlas of Anatomy,
Head and Neuroanatomy. © Thieme 2010, Illustrations by Karl Wesker.)
158
b
17 External Nose
Fig. 17.5 The upper lateral cartilage. Bilateral
upper lateral cartilages and cartilaginous
regions of the nasal septum integrate as a
uni ed structure, but a linear gap appears
bet ween the upper lateral cartilage and the
septal cartilage, which is less than t wo-thirds of
the area. LLC, Lower lateral cartilage; NB, Nasal
bone; SC, Septal cartilage; ULC, Upper lateral
cartilage.
cent shape in a con cave upw ard direction, w idest in the m idlin e,
decreasing in w idth laterally.7 In th e upper region of th e upper
lateral car t ilage, in clu d in g an overlap p in g area, t h e bilateral
u p p er lateral cart ilages an d th e cart ilagin ou s part of th e n asal
sept u m in tegrate as a u n i ed st ru ct u re, bu t a lin ear gap ap p ears
bet w een th e u pper lateral car tilage an d th e septal car t ilage th at
con st it utes less th an t w o-th irds of th e area (Fig. 17.5). Som e
p eople con sider th e u pp er lateral cart ilages to be w inglike exten sion s of th e septal cart ilage.8–10 At th e low est p art , th e u p p er
lateral car t ilage con n ect s w ith th e lateral cru s of th e low er lateral cart ilage, w h ich is referred to as th e scroll.9 In m ost cases,
th ese t w o car t ilages overlap in various sh apes, and th is con n ect ion bears a m ajor t ip -suppor t ing m ech an ism .11
In th e low er part , a p air of low er lateral car t ilages, th e alar
cart ilages, are th e support ing st ruct ures an d a ect greatly th e
sh ap e of th e low er n asal st ru ct u re (Fig. 17.6). Th e low er lateral
cart ilage can be divided in to th ree crura—th e m edial, m iddle,
an d lateral cru ra—all th ree of w h ich in t im ately correlate to th e
ou ter sh ap e of t h e n ose.12,13 Th e m ed ial cr u s con sist s of t h e
colum ella an d is divided in to t w o segm en ts; th e foot plate an d
colum ella segm en t s. Th e cart ilage is cur ved convex tow ard th e
m edial side as a w h ole, ju st like a sect ion of cu t cylin der, an d it
cur ves laterally in th e fron t al view an d posteriorly in th e lateral
view bet w een th e t w o segm en t s. Th e foot plate segm en t form s
the bulge in the base of the colum ella, and the colum ella segm ent
form s th e colu m ella. Th e bilateral cart ilages in th e colu m ella
segm en t are open in th e fron t al view. In ap prop riate dissect ion
of th e colum ella du ring open rh in oplast y can cause un expected
bi dit y. At th e upper border of th e colum ella segm en t , th e colu m ella segm en t t ran sits to th e m iddle crus, a region kn ow n as
th e colum ella–lobular jun ct ion . In th is region , th e cart ilage is
cur ved posteriorly to som e degree in th e lateral view, w h ich is
referred to as rot at ion angle.1,12 Th e m iddle cru s is th e part correspon ding to th e sh ape of th e surroun ding t ip area, in clu ding
th e n asal t ip an d soft t riangle. Th e m iddle crus is also divided
in to t w o segm en t s: th e lobular an d dom al segm en t s. Th e lobu lar segm en t is relat ively st raight , but bilateral car t ilages adjoin
th e posterior an d an terior par ts. Th e dom al segm en t is th e region w h ere th e car t ilage cu r ves drast ically in th e in ferolateral
direct ion on th e fron t al view and posteriorly on th e lateral view.
Fig. 17.6 The left alar cartilage (lower lateral cartilage). AC, accessory cartilage; Co, columella segment; Do, domal segment in the middle crura;
F, footplate segment; LC, lateral crura; Lo, lobular segment in the middle crura; MiC, middle crura; MeC, medial crura.
159
Anatom y for Plastic Surgery of the Face, Head, and Neck
Th e ben t par t form s th e h igh can opy of th e n ares. Dan iel (1992)
described th e length of th e lobu lar segm en t as correlat ing sign i can tly w ith t ip sh ap e, an d th e dom al segm en t corresp on ds
to th e sh ape of th e soft t riangle of th e lobu le. Lateral to th e
dom al segm ent is the dom al junction, w here the transition from
th e m iddle crus to th e lateral cru s is foun d. Th e region is located
at t h e bord er bet w een t h e t ip an d ala, w it h t h e t ip d e n in g
p oin t s fallin g on t h e d om al ju n ct ion lin e.12 Th e lateral cr u s is
located in t h e alar an d is t h e largest p ar t of t h e low er lateral
car t ilage. Th is region a ect s th e sh ape, size, an d posit ion of th e
ala. Th e lateral cru s con n ects to th e pyriform is th rough som e
accessor y car t ilages located lateral to th e cru s.12 Th e low er lateral cart ilage, accessor y cart ilage, an d th e ligam en t s su p port ing
th ese cart ilages form a ring surroun ding th e n ostril an d h ave an
im port an t role in th e sh ape of th e n ost ril.14,15
Tip Support Mechanism
Th e n asal t ip lies on t h e bilateral low er lateral car t ilages an d
is th u s su p ported by th e soft elast ic pillars. Regarding th e su p p or t ing system of th e n asal t ip , An derson advocated th e t ripod
con cept .16 Th is system p ost u lates th e t ip su pp ort ing st ru ct u re
as a t rigon al pyram id w ith bilateral low er lateral cart ilages an d
t h eir con n ect ion to t h e su r rou n d ing t issu es. On e p illar of t h e
t r igon al pyram id is alm ost p er p en d icu lar an d con sist s of t h e
com bin at ion of th e bilateral m edial cru s of th e low er lateral cart ilages. The oth er t w o pillars are sloped an d m ain ly con sist of
the lateral crus of the low er lateral cartilage. There are also som e
oth er st ru ct u res con t ribu t ing to th e su pp ort of th e n asal t ip , in cluding the ligam en t con n ect ing th e bilateral m iddle cru a, th e
ligam en t con n ect ing th e bilateral m edial crua, th e con n ect ion
bet w een th e lateral cr u s an d cau dal en d of t h e u p p er lateral
car t ilage, kn ow n as th e scroll area, th e m em bran ou s sept u m ,
th e length of th e m edial crus, th e fat pad ben eath th e colum ella,
an d th e lateral cru s it self.
Conversely, Jan eke an d Wrigh t an d oth ers h ave repor ted four
kin ds of tip -su ppor t ing st ruct ures, th e jun ct ion bet w een th e
low er and upper lateral cartilages, the lateral sesam oid cartilage
com plex (con n ect ion bet w een low er lateral cart ilage an d th e
pyriform is), th e jun ct ion bet w een th e m edial crus an d caudal
sept u m (con n ect ion bet w een th e cau dal sept u m an d th e bilateral m edial crus), and the interdom al sling (conn ection bet w een
th e bilateral m iddle crus).17–20 Th e balan ce of th ese th ree p illars
greatly a ect s th e sh ap e of th e base of th e n ose.
References
1. On eal RM, Beil RJ Jr, Sch lesinger J. Surgical anatom y of th e n ose.
Clin Plast Surg 1996;23(2):195–222 PubMed
2. Farkas LG, Kolar JC, Mu n ro IR. Geograp hy of th e n ose: a m orph om et ric st udy. Aesth et ic Plast Surg 1986;10(4):191–223 Pu bMed
3. Leong SC, Eccles R. A system at ic review of th e n asal in dex an d th e
sign i cance of th e sh ape and size of th e n ose in rh in ology. Clin
Otolar yngol 2009;34(3):191–198 PubMed
4. Lessard ML, Dan iel RK. Surgical an atom y of septorh in oplast y. Arch
Otolar yngol 1985;111(1):25–29 Pu bMed
5. Letourn eau A, Dan iel RK. Th e su per cial m u scu loapon eu rot ic system of th e n ose. Plast Recon st r Surg 1988;82(1):48–57 PubMed
6. Griesm an BL. Mu scles an d car t ilages of the n ose from the st an dp oin t of a t yp ical rh in op last y. Arch Otolar yn gol Head Neck Su rg
1944;39(4):334–341
7. Nat vig P, Seth er LA, Gingrass RP, Gardn er W D. An atom ical det ails
of th e osseous-car t ilagin ous fram ew ork of th e nose. Plast Recon st r
Su rg 1971;48(6):528–532 Pu bMed
8. Basm ajian JV, Gran t JCB. Gran t’s Meth od of An atom y: By Region s,
Descriptive and Deductive. Baltim ore, MD: William & Wilkins, 1972
9. McKin ney P, Joh n son P, Walloch J. An atom y of th e n asal h u m p .
Plast Reconst r Surg 1986;77(3):404–405 PubMed
10. An d erson KJ, Hen n eberg M, Norris RM. An atom y of th e n asal prole. J An at 2008;213(2):210–216 PubMed
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11. Lam SM, William s EF III. An atom ic con siderat ion s in aesth et ic rh in oplast y. Facial Plast Su rg 2002;18(4):209–214 Pu bMed
12. Dan iel RK. Th e n asal t ip : an atom y an d aesth et ics. Plast Recon st r
Surg 1992;89(2):216–224 Pu bMed
13. Sh een JH, Sh een AP. Aest h et ic Rh in op last y. 2n d ed . St . Lou is:
Mosby; 1987
14. Farkas LG, Deut sch CK, Hreczko TA. Asym m et ries in n ost rils an d
th e surroun ding t issues of th e soft n ose—a m orph om et ric st udy.
An n Plast Surg 1984;12(1):10–15 Pu bMed
15. Steven s MR, Em am HA. Ap plied su rgical an atom y of th e n ose. Oral
Maxillofac Su rg Clin Nor th Am 2012;24(1):25–38 Pu bMed
16. An d erson JR. A reason ed ap p roach to n asal base su rger y. Arch
Otolar yngol 1984;110(6):349–358 Pu bMed
17. Bern stein L. Applied an atom y in correct ive rhin oplast y. Arch Otolar yngol 1974;99(1):67–70 Pu bMed
18. Jan eke JB, Wrigh t W K. St u dies on th e su p p or t of th e n asal t ip. Arch
Otolar yngol 1971;93(5):458–464 Pu bMed
19. Han SK, Lee DG, Kim JB, Kim W K. An an atom ic st u dy of n asal t ip
supporting structures. Ann Plast Surg 2004;52(2):134–139 PubMed
20. Roh rich RJ, Hoxw or th RE, Th orn ton JF, Pessa JE. Th e pyriform ligam en t . Plast Reconst r Su rg 2008;121(1):277–281 Pu bMed
18
Auricle and External Acoustic Meatus
Noritaka Kom une, Junichi Fukushim a, and Albert L. Rhoton, Jr.
Introduction
Th e extern al ear is form ed by th e auricle, extern al acoust ic m eat u s, an d t ym p an ic m em bran e. Th e auricle is a con cave st ruct ure th at directs soun d w aves in to th e extern al acoust ic m eat us.
It is also cosm et ically im p or tan t an d its an atom ical st ru ct u res
are ext rem ely com plicated an d delicate.
Th e extern al ear is a focus of otologic an d plast ic surger y, but
it is also im port an t in n eurologic an d lateral skull-base su rger y.
Su rger y resu lt ing in cosm et ic an d fu n ct ion al sat isfact ion relies
n ot on ly on th e su rgeon’s skill an d u se of advan ced tech n ologies
but also on th eir com plete un derst an ding of th e area’s m icrosu rgical an atom y, w h ich m akes su rger y gen tler an d safer.
Th is ch apter exam in es t h e m icrosu rgical an atom y of t h e
au ricle an d extern al acou st ic m eat u s in cadaveric dissect ion s
an d organ izes th e resu lts in th e follow ing sect ion s: (1) bon e
st ru ct u re, (2) au ricle, (3) cart ilagin ou s skeleton of th e au ricle,
(4) external acoustic m eatus, (5) m uscles, (6) neural inner vation,
(7) vascular supply, an d (8) fascial st ruct ure. Fin ally, th ere is a
sh ort descript ion of clin ical con siderat ion s.
Bone Structure
The tem poral bone consists of ve com ponents: squam ous, t ym pan ic, pet rous, m astoid, an d st yloid part s (Fig. 18.1a). Th e bony
can al of th e extern al acoust ic m eat us is com posed of th ree par ts
of the tem poral bon e: squam ous, t ym panic, an d m astoid. Th e an terior and inferior bony w alls are form ed by the t ym panic part.
Th e superior an d posterior bony w alls are form ed by th e squam ou s an d m astoid p art s, an d th e squ am om astoid su t u re can be
iden t i ed (Fig. 18.1b). Th e t ym pan ic part produces th ree sutures: t ym panosquam ous, t ym panom astoid, and petrot ym panic.
Th e t ym pan osquam ous sut ure, bet w een th e squam ous an d
t ym pan ic par ts, is con t in u ous m edially w ith th e p et rot ym p an ic
an d petrosquam ous ssures (Fig. 18.1b). Additionally, t w o spines
are iden t i ed in th e bony p ort ion of th e m eat u s: en dom eat al
an d su pram eatal sp in es. Th e su p ram eatal sp in e (Hen le’s sp in e)
is sit u ated at th e u pper an d posterior p art of the ori ce of th e
extern al acou st ic m eat u s. Th e en dom eatal sp in e is form ed by a
project ion of th e t ym pan osquam ous sut ure in to th e can al.
Th e p oster ior root of t h e zygom at ic arch of t h e squ am ou s
p ar t for m s t h e roof of t h e exter n al acou st ic m eat u s. At t h e an terior edge of th is roof, th e postglen oid process is posit ion ed
bet w een th e m an dibular fossa an d an terior w all of th e extern al
acou st ic m eat u s. Th e t ym pan osqu am ou s su t u re ru n s bet w een
th e postglen oid process an d th e t ym pan ic par t of th e tem poral
bon e.
Th e edge of th e t ym pan ic m em bran e is th icken ed to form a
brocar t ilagin ou s ring (t ym p an ic an n u lu s) at tach ed to th e t ym -
p an ic sulcus, an in com p lete ring of th e t ym pan ic bon e th at is
in terrupted by th e n otch of Rivin us. Above th e su perior en d of
th e t ym pan ic sulcus, th e t ym pan ic an n ulus becom es a brous
ban d . Th e t ym p an ic m em bran e w it h in t h e n otch of Rivin u s,
above t h e an ter ior an d p oster ior m alleolar fold s exten d in g
to th e lateral process of th e m alleus, is called th e pars accida.
Th is part is closely related to th e an terior an d posterior can al for
th e ch orda t ym pan i an d th e pet rot ym pan ic sut ure.
Auricle
Th e au r icle is t h e lateral-m ost p ar t of t h e exter n al ear an d is
com p osed m ain ly of car t ilage an d skin . It is d ivid ed in to t w o
su rfaces: lateral an d m edial.
Th e lateral surface is covered by a th in layer of skin , w h ich is
form ed m ain ly by th e p erich on driu m an d an ext rem ely n e
su bcu t an eou s layer. On th is su rface, th e m argin al edge is form ed
m ain ly by th e h elix, w h ich is a sm ooth an d rou n d arch . Th e
h elix st art s at th e cru s of th e h elix, p asses an terosu periorly,
t urn s posteriorly an d th en in feriorly, an d n ally en ds at th e h elical t ail, w h ich is cont in u ou s w ith th e lobule. Th e scaph oid
fossa is located ju st an terior to th e h elix along m ost of its length
(Fig. 18.2a,b).
Next to th e en t ran ce of th e extern al acou st ic m eat u s, a w ellde n ed h ollow, th e con ch a, leads in to th e m eat us. Th is h ollow
h as t w o part s: th e cym ba an d th e cavu m con ch ae, sep arated by
th e crus of th e h elix. The an t ih elix, w h ich h as a Y sh ape, passes
u pw ard an terior to th e posterior rim of th e h elix an d divides
into superior and inferior crura, separated by the triangular fossa.
Th e root of th e in ferior cru s of th e an t ih elix form s th e sh arp rim
of t h e con ch a an d sep arates it from t h e t r iangu lar fossa. Th e
su p erior cru s of th e an t ih elix form s th e an terior border of th e
scap h oid fossa. Th e t ail of th e an t ih elix join s th e an t it ragu s. Th e
in ferior crus, t ragus, an d an t it ragu s overh ang th e con ch a, m aking it look sm aller. Th e w ell-de n ed n otch bet w een th e t ragus
an d an t it ragu s is called th e in tert ragic n otch .
Th e skin of th e m edial surface is th icker th an th at of th e lateral su rface. On th e m ed ial su rface, th e p rom in en ces an d su lci
follow an obviou sly inverse p at tern to th at on th e lateral su rface
(Fig. 18.2c). From th e m edial view, th e con ch a an d fossa on th e
lateral surface are seen as em in en ces, an d th e crura are seen as
grooves. Em in en ces in clu de th e scaph oid , t riangu lar, an d con ch al em in en ces. Th e an t ih elix on th e lateral surface form s a dep ression on th e m edial surface called th e an t ih elical fossa.
Th e m ost in ferior part of th e auricle is th e lobule. Th e lobule
is soft , form ed m ain ly by fat t y t issue bet w een t w o cu t an eou s
layers. Th e m ain d e n in g feat u re of t h is area is t h e lack of cart ilage, w h ich m akes th e recon st ru ct ion of th e lobule di cu lt
because of postoperat ive ret ract ion .
161
Anatom y for Plastic Surgery of the Face, Head, and Neck
a
Fig. 18.1 Osseous anatomy and relationships of the external acoustic
canal. (a) Lateral view. (b) Oblique view from anterior, laterally and
inferiorly. Aud., Auditory; Ext., external; Glen., glenoid; Mast., mastoid;
Petro., petrous; Petrosquam., petrosquamous; Petrot ymp., petrot ym -
Cartilage
Th e en t ire auricle except th e lobule h as elast ic cart ilage as it s
fram ew ork (Fig. 18.3). Th is car t ilage allow s th e auricle to be
at ten ed, ben t , an d fold ed . Rep air of cart ilage defect s an d recon st ru ct ion of th e auricle rem ain ch allenging because th e cart ilage is a u nique t issue w ith out its ow n vascularizat ion . A th in ,
adh eren t layer of p erich on driu m covers th e au ricu lar car t ilage
an d can be separated from it; h ow ever, th is perich on driu m is
m ore adh eren t in som e lesion s to th e fossae.
Th e car t ilage is st rikingly sim ilar to th e su rface of th e auricle. Convexit ies on th e lateral su rface of th e auricle in clude th e
h elix, an t ih elix, su perior an d in ferior cru ra of th e an t ih elix, cru s
of h elix, t ragus, an d an t it ragus. Con cavit ies in clude th e t riangu lar fossa, cym bal an d cavu m con ch ae, an d scaph oid fossa. Th e
depression s an d elevat ion s on th e lateral surface are align ed
w ith th e elevat ion s an d depression s on th e m edial surface.
From th e surface of th e auricle, som e cart ilagin ous st ruct ures th at are n ot seen are th e in cisura term in alis, pon t iculu s,
an t it ragoh elicin a ssu re, cau da of th e h elix, cart ilage of th e extern al acoust ic m eat us, an d spin e of th e h elix. Th e in cisura term in alis separates th e t ragal lam in a, w h ich is th e ver t ical cu r ved
p late of th e t ragu s, an d th e cart ilage of th e extern al acoust ic
m eat u s from th e m ain au ricu lar cart ilage. Th e low er p ar t of th e
h elix con t in u es dow nw ard as a p rocess called th e cau da of th e
h elix. Th e cau da of t h e h elix is sep arated from t h e an t it ragu s
by a deep ssu re, th e an t it ragoh elicin e ssure. Th e spin e of th e
h elix is th e an terior ext rem it y of th e cru s of th e h elix. Th e p on t icu lus is th e ver t ical ridge crossing th e em in en ce of th e con ch a
on th e m edial surface. A deep groove can be iden t i ed on th e
m ed ial su r face bet w een t h e em in en ces of t h e t r ian gu lar fossa
an d con ch a. Th is d eep groove is called t h e t ran sverse su lcu s
of th e an t ih elix an d correspon ds to th e an t ih elix an d it s in ferior
crus on th e lateral surface.
Th e car t ilage of th e extern al acoust ic m eat us form s a sem ican al th at exten ds m edially from th e lateral lam in a of th e t ragu s. Th is cart ilagin ou s sem ican al is u su ally in terru pted by t w o
162
b
panic; Proc., process; Sphenosquam., sphenosquam ous; Squam.,
squamous; Squamomast., squamomastoid; Tymp., t ympanic; Tym panomast., t ympanomastoid; Tympanosquam., t ympanosquamous.
vertical ssures in th e anterior portion of th e cartilage (San torin i
ssures). These ssures can allow infections and m alignant t u m ors to exten d bet w een th e extern al acoust ic m eat u s an d parot id
glan d.
Th e cart ilage of th e auricle is at t ach ed to th e au ditor y process, w h ich is th e lateral edge of th e t ym pan ic par t of th e tem poral bon e an d h as an ext rem ely rough surface (Fig. 18.1b), an d
xed to th e sku ll by th ree ligam en t s: an terior, su perior an d p osterior. Th e an terior ligam en t at t ach es th e h elix an d t ragus to th e
zygom at ic process. Th e su perior ligam en t at tach es th e spin e of
th e h elix to th e superior m argin of th e bony extern al auditor y
can al. Fur th erm ore, th e posterior ligam en t is located bet w een
th e m edial surface of th e con ch a an d th e m astoid process.
External Acoustic Meatus
Th e extern al acoust ic m eat us exten ds from th e bot tom of th e
con ch a to th e t ym pan ic m em bran e, form ing an S sh ape th at is
divided in to cart ilagin ous an d bony port ion s (Fig. 18.4). First , it
exten ds m ed ially an d sligh tly an teriorly an d su p eriorly, th en it
t urn s m edially an d sligh tly posteriorly (car t ilagin ou s par t), an d
n ally p asses m ed ially, an teriorly an d sligh tly in feriorly (bony
par t). Pu lling the auricle posteriorly an d su periorly m akes th e
can al st raigh t an d provides bet ter visualizat ion of th e t ym pan ic
m em bran e.
Th e extern al can al h as t w o n arrow por t ion s. On e is close to
th e in n er en d of th e car t ilagin ou s por t ion (cart ilage-bony jun ct ion ), an d th e oth er is th e isth m us in th e osseous port ion . Th e
isth m u s is th e n arrow est poin t along th e can al an d is located
n ot at th e car t ilage-bony ju n ct ion bu t in th e bony p ort ion .
Th e car t ilagin ou s p or t ion is con t in u ou s w it h t h e car t ilage
of th e au ricle an d at t ach es to th e auditor y process, w h ere th e
cart ilage is at t ach ed m edially to th e bony par t w ith den se con n ect ive t issu e (Fig. 18.1b). Th e posterior an d superior par t of
th e cart ilagin ous par t act ually lacks cart ilage but is lled w ith
brou s t issu e.
18 Auricle and External Acoustic Meatus
a
c
b
Fig. 18.2 Anatomy of the auricle. (a) Lateral view;
(b) anterior view; (c) posterior view. Ac., Acoustic;
Emin., eminence; Ext., external; Inf., inferior; Meat.,
meatus; Sup., superior; Triang., triangular.
163
Anatom y for Plastic Surgery of the Face, Head, and Neck
a
b
Fig.18.3 Anatomy of the cartilage. (a) Lateral view; (b) medial view;
(c) anterior view. In (b), yellow dashed line represents the place
where the parietotemporal fascia at taches. Auric., Auricular; Emin.,
em inence; Fiss., ssure; Inf., inferior; Sup., superior; Triang.,
triangular; Tuberc., tubercle.
c
Th e bony por t ion is n arrow er th an th e cart ilagin ous por t ion .
Th e con ically sh aped t ym pan ic m em bran e is located at th e m edial en d of th e m eat us an d is t itled an teroin feriorly. Th e angle
bet w een th e t ym pan ic m em bran e an d th e an teroin ferior bony
w all (an ter ior t ym p an om eat al an gle) is acu te an d often ob st ructed by th e bony em in en ce of th e an terior w all.
Th e t ym pan ic m em bran e is com posed of th ree layers. Th e
lateral epith elial layer is con t in uou s w ith th e skin of th e extern al acou st ic m eat u s. Th e m id dle brou s layer is called th e lam in a p rop ria, w h ich is n ot iden t i ed in th e pars accida. Th e
m edial m u cosal layer is con t in u ou s w ith th e m u cosa of th e
m iddle ear cavit y.
164
Th e skin covering th e m eat us is visibly th in , th ough sligh tly
thicker on the cartilaginous portion than the bony portion, and it
ad h eres closely to th e car t ilagin ou s an d osseou s p ort ion s of th e
m eat u s. Th e skin of th e bony p ort ion h as n o h air or glan ds. In
th e cart ilagin ous par t , th e subcut an eous t issue h as h air follicles
and cerum in ous and sebaceous glands, w h ich secrete the yellow ish brow n earw ax.1,2 In the auricle, the sebaceous glands are predom inant in the concha and triangular fossa; cerum inous glands
are located aroun d the ori ce of the external acoustic m eatus.3,4
In t h ree region s, t h e skin is m ore r m ly ad h eren t to t h e
bony can al: (1) supra m eat al spin e (Hen le’s spin e), (2) t ym pan om astoid su t u re, an d (3) en d om eat al sp in e an d t ym p an o-
18 Auricle and External Acoustic Meatus
a
b
Fig. 18.4 Anatomy of the external acoustic meatus. (a) Lateral view;
(b) anterior view; (c) inferior view. Ac., Acoustic; Auric., auricular;
Fiss., ssure; Inf., inferior; Sup., superior; Triang., triangular; Tuberc.,
tubercle.
c
squ am ou s su t u re. Th ese su t u res an d sp in es m ake elevat in g a
t ym pan om eat al ap from th e bony can al di cult .
Muscle and Facial Nerve
Th e m uscles an d ligam en t s th at at tach to th e auricle are divided
in to t w o t yp es: ext rin sic an d in t rin sic (Fig. 18.5). Th e ext rin sic
m u scles in clu d e th e p osterior, su perior, an d an terior au ricu lar
m u scles. Th ese m u scles are sm all bu t h old t h e au r icle r m ly
in place. Th e in t rin sic m u scles in clu de th e h elicis m ajor, h elicis
m in or, t ragicu s, an t it ragicu s, t ran sverse au ricu lar, obliqu e auricular, pyram idal auricular, an d incisurae helicis m uscles (Table
18.1). Th ese in t rin sic m u scles con t ribute to creat ing th e com p lex folded con gurat ion of th e cart ilage. In h um an s, th e au ricu lar m u scles are con sidered vest igial rem n an ts an d th us u seless
st ru ct u res.
Th eoret ically, th e superior, posterior, an d an terior au ricular
m u scles fu n ct ion to p u ll t h e au r icle, u pw ard , backw ard , an d
for w ard, resp ect ively; h ow ever, th ese m u scles are gen erally too
w eak to do so. In ou r dissect ion , w e did n ot iden t ify th e h elicis
m ajor, in cisu rae h elicis, an d pyram idal au ricu lar m u scles.
Th e superior auricu lar m uscle arises from th e galeal apon eurosis, w h ich is con t in uou s w ith th e tem poropariet al fascia, an d
in sert s in to th e area aroun d th e spin e of th e h elix. Th e p osterior
au ricu lar m u scle u su ally h as t w o or th ree fascicles an d is su p p or ted by th e posterior au ricular ligam en t . Th ese m uscles an d
165
a
b
Fig. 18.5 (a) Muscular structures of the auricle. (b, c) Intrinsic
muscles on the lateral and medial surfaces, respectively. The orange
line in (b) shows the intrinsic muscles that are not identi ed in our
dissection. Ant., Anterior; Auric., auricular; Lig., ligament; M., muscle;
Occip., occipital; Post., posterior; Sternocleidomast., sternocleidomastoid; Sup., superior; Temporopar., temporoparietal; Transv.,
transverse.
c
Table 18.1 Origin and insertion of the auricular muscles
Muscles
Origin
Insertion
Helicis m ajor
Helix
Spine of helix
Helicis m inor
Spine of helix
Crus of helix
Tragicus
Tragus
Tragus
Antitragicus
Antitragus
Antitragus
Pyram idal
Tragus
Spine of helix
Transverse auricular
Em inence of concha
Em inence of scaphoid fossa
Oblique auricular
Em inence of triangular Fossa
Em inence of concha
Incisurae helicis
Tragus
Antitragohelicine ssure
Lateral surface
Medial surface
166
18 Auricle and External Acoustic Meatus
ligam en t ar ise from t h e m astoid p er iosteu m an d are at t ach ed
to th e em in en ce of th e cym bal con ch a an d th e pon t iculu s. Th e
p oster ior au r icu lar ligam en t su p p or t s t h is m u scle an d r u n s
p arallel to it . Th e an terior au ricu lar m u scle at tach es to th e zygom at ic arch an d tem poroparietal fascia at th e an terior en d,
an d th e spin e of th e h elix at th e p osterior en d . Th is m u scle is
su p p or ted by th e an terior au ricu lar ligam en t , w h ich teth ers th e
t ragus an d th e spin e of th e h elix to th e zygom at ic arch an d tem poroparietal fascia. In addit ion to th ese th ree ext rin sic m uscles,
the tem poroparietal m uscles and part of the occipital m uscle are
also at tach ed to th e m edial su rface of th e au ricle by a brou s
ligam en t , w h ich is par t of th e tem poropariet al fascia.
Innervation
Bot h cran ial an d cer vical n er ves are involved in t h e sen sor y
in n er vat ion of t h e au r icle (Fig. 18.6). Fou r cran ial n er ves con t ribu te to t h e in n er vat ion of t h is region : t r igem in al, facial,
glossoph ar yngeal, an d vagu s n er ves. Tw o bran ch es of th e cer vical plexus are involved: th e lesser occipit al an d great auricular
n er ves.
Th e auriculotem poral n er ve is a bran ch of th e m an dibular
n er ve, w h ich is th e th ird division of th e t rigem in al n er ve.5 It
arises as t w o roots from the posterior division of the m an dibular
n er ve an d en circles th e m iddle m en ingeal ar ter y before form ing a single t ru n k. It ru n s bet w een th e n eck of th e m an dible an d
th e sph en om an dibular ligam en t an d en ters th e ret rom an dibular region of th e parot id glan d posterior to th e tem porom an dibu lar join t an d m an dibu lar n eck. It gives o p arot id bran ch es an d
t u rn s superiorly to give o an terior bran ch es to th e au ricle,
w h ich in n er vate th e an terosu perior part s of th e lateral surface.
It t h en crosses over t h e root of t h e zygom at ic p rocess of t h e
tem p oral bon e, p arallel to t h e su p er cial tem p oral ar ter y. It
p en et rates th e su per cial m uscular apon eu rot ic system (SMAS)
an d passes u pw ard su p er cial to th e tem porop arietal fascia.
Th e bers of th e su perior root of th is n er ve pass th rough the
ot ic ganglion w ith out syn apsing an d supply cutan eous sen sat ion to th e an terior region of th e auricle, extern al acoust ic m eat u s, out side of th e t ym pan ic m em bran e an d skin in th e tem poral
region . Th e bran ch in n er vat ing th e an terior part of th e external
acou st ic m eat u s an d ou t side of th e t ym p an ic m em bran e p asses
in to th e pet rot ym pan ic ssure in th e glen oid fossa. Th e glossoph ar yngeal n er ve gives o th e p arasym p ath et ic bers th at
form th e t ym pan ic n er ve. Th is n er ve en ters th e t ym pan ic cavit y
an d form s th e t ym p an ic p lexu s w ith th e in tern al carot id n er ve,
w h ich is com posed of sym path et ic bers, on th e prom on tor y in
th e m iddle ear cavit y. Th is plexus gives o th e lesser pet rosal
n er ve, w h ich syn apses in th e ot ic ganglion , an d its p ostganglion ic bers form th e in ferior root of th e auriculotem poral n er ve,
w h ich provides sym path et ic in n er vat ion to th e scalp, an d parasym p ath et ic in n er vat ion to th e p arot id glan d.
Fou r cer vical bran ch es, th e t ran sverse cer vical, greater, and
lesser occipital and supraclavicular nerves exit the posterior edge
of th e stern ocleidom astoid m uscle at th e n er ve poin t . Th ese
n er ves arise from th e cer vical n er ve p lexu s form ed by th e ven t ral ram u s of th e C2 an d C3. Th e lesser occipit al n er ve penet rates th e post auricular fascia, w h ere th e fasciae of th e occipital
an d stern ocleid om astoid m u scles at tach t igh tly to th e su p erior
n u ch al lin e, divid e in to th e au ricu lar an d th e occip it al bran ch es,
an d com m u n icate w ith th e greater occip ital, p ostau ricu lar, an d
great au ricu lar n er ves.
Th e great au r icu lar n er ve ascen d s from t h e n er ve p oin t an d
p lays a m ajor role in t h e sen sor y in n er vat ion of t h e au r icle.
Th is n er ve d ivid es in to t h ree t yp es of bran ch es. Th e m ost an ter ior bran ch es in n er vate th e preauricular area. Bran ch es of th e
secon d t yp e pass th rough th e lobu le an d in n er vate th e in ferior
an d p osterosu p erior p ar t s of th e lateral su rface of th e au ricle.
Th e th ird t ype of bran ch es passes un der or beh in d th e lobule
an d su p plies th e m edial su rface of th e au ricle an d th e skin over
th e m astoid t ip.
Th e vagu s n er ve, w h en it exit s th e in t rajugular part of th e
jugu lar foram en , gives o th e auricu lar bran ch , also called Arn old’s n er ve. A bran ch of th e glossop h ar yngeal n er ve th en join s
Arn old’s n er ve, w h ich passes along th e an terolateral edge of th e
jugu lar fossa an d en ters th e m astoid can aliculu s. It t ravels in th e
tem poral bon e an d crosses th e facial n er ve, giving o a t iny
bran ch to th e facial n er ve, w h ich divides in to t w o bran ch es. On e
join s th e posterior auricu lar n er ve, an d th e oth er passes th rough
th e t ym pan om astoid ssure, located bet w een th e m astoid process an d th e t ym pan ic part of th e tem poral bon e, to in n er vate
t h e p osterior w all of t h e exter n al acou st ic m eat u s an d skin
arou n d th e m eat al en t ran ce.
Th e p osterior au r icu lar an d fron t al bran ch es of t h e facial
n er ve in n er vate th e au ricu lar m u scles. Th e p osterior au ricu lar
n er ve arises ju st after th e facial n er ve exits th e st ylom astoid
foram en . Th is n er ve p asses backw ard an d u pw ard alon g t h e
an terior su rface of th e m astoid p rocess. Th e au ricu lar bran ch of
th e vagus an d th e great au ricular an d lesser occipit al n er ves
give o bran ch es th at join th e p osterior au ricu lar n er ve. Th is
n er ve gives o th e t w o m ain bran ch es th at in n er vate th e occip it al an d auricular region s an d th e occipital, posterior au ricular,
an d in t r in sic m u scles on t h e m ed ial su r face of t h e au r icle. In
ou r dissect ion , th e occipital bran ch passed m edial to th e poster ior au r icu lar m u scles an d gave o t iny bran ch es to t h e occip it al region an d p osterior au ricu lar m u scle. Th e bran ch es to th e
occipit al region course bet w een th e fascicles of th e posterior
au ricu lar m u scle p assing along th e su p erior n u ch al lin e. Th e
fron tal an d p osterior au ricu lar bran ch es in n er vate th e an terior
au ricu lar an d posterior au ricu lar m u scles, resp ect ively.
Vascular Supply
Th e arterial supply of th is area is derived from bran ch es of th e
extern al carot id arter y (Fig. 18.7). Th e ven ous drain age follow s
the arteries. The external jugular vein, m axillary vein, and pter ygoid ven ou s p lexu s are resp on sible for ven ou s drain age. Th e
extern al carot id ar ter y gives o occip it al an d posterior au ricular bran ch es an d n ally divides in th e parot id glan d in to t w o
term in al bran ches: m axillar y an d super cial tem poral. Th ese
fou r ar teries p lay an im port an t role in th e vascu larizat ion of th e
extern al ear.
Th e th ree m ain arteries supplying th e auricle are th e posterior au ricu lar, su p er cial tem poral, an d occipit al ar teries. Th ese
vessels form a com p lex n et w ork bet w een th e skin an d perich on drium of th e auricle. Th e posterior auricu lar arter y passes
arou n d th e m astoid p rocess, gives o th e m astoid bran ch to th e
167
Anatom y for Plastic Surgery of the Face, Head, and Neck
b
a
Fig. 18.6 Innervation of the auricle. (a) Posterolateral view. The green
dashed area is enlarged in (c). (b) Anterolateral view. (c) Course of the
postauricular nerve. The yellow arrow in (a) shows the anastom osis of
the lesser and greater occipital nerves. The red, blue, and black fabric
enhances the course of the great auricular, facial, and lesser occipital
nerves, respectively. Auric., Auricular; Auriculotemp., auriculotem poral; Front., frontal; Gr., great; Less., lesser; M., muscle; N., nerve;
Occip., occipital; Post., posterior; Sup., superior; Tr., trunk; Zygo.,
zygomatic; Zygomaticofac., zygomaticofacial.
c
skin on th e m astoid process, an d passes su p eriorly to su pp ly th e
m ed ial su rface of th e au ricle th rough th ree m ain bran ch es: su perior, m iddle, an d in ferior.
Th ese bran ch es perforate th e car t ilage to an astom ose w ith
th e ar terial n et w ork on th e lateral surface. Th e su per cial tem p oral ar ter y gives o t h e an ter ior au r icu lar bran ch es, w h ich
in clu d e su p er ior, m id d le, an d in fer ior au r icu lar ar ter ies t h at
su p p ly t h e lateral su r face of t h e au ricle from t h e h elix to t h e
lobu le. Th ere are also p erforat ing bran ch es th at pen et rate th e
car t ilage from th e region s of th e an t it ragus, cym bal con ch ae,
an d t riangu lar fossa to su p ply th e m ed ial su rface of th e au ricle.
168
Th e superior auricular arter y’s t ypical course con n ect s th e su perior tem poral arter y an d th e p osterior auricular arterial n etw ork. Th e au ricu lar bran ch of th e occip ital arter y su pp lies th e
m edial su rface of th e au ricle, esp ecially arou n d th e em in en ce of
th e con ch a.
Th e extern al acoust ic m eat us is supplied m ain ly by th ree arteries: posterior auricular, super cial tem poral, an d m axillar y.
Th e auricu lar bran ch es of th e super cial tem poral ar ter y supply
th e an terior region an d th e roof of th e extern al acoust ic m eat us.
Th e auricular bran ch es of th e posterior auricular arter y pen et rate th e cart ilage of th e auricle an d supply th e posterior por-
18 Auricle and External Acoustic Meatus
a
b
Fig. 18.7 Vascular supply of the auricle. (a) Medial surface of the
auricle. (b) Lateral surface of the auricle. A., Artery; Ant., anterior;
Auric., auricular; Auriculotemp., auriculotemp; Br., branch; Comm .,
communicating; Inf., inferior; M., muscle; Mid., middle; N., nerve; Orb.,
orbital; Post., posterior; Sup., superior; Temp., temporal; Transv.,
transverse; V., vein.
t ion of th e can al. Th e deep auricular bran ch arises from th e rst
port ion of th e m axillar y arter y an d ascen ds in th e parot id glan d
beh in d th e tem porom an dibular join t to pierce th e cart ilagin ous
or bony port ion of th e extern al acoust ic m eat us to supply th e
an terior w all of th e m eat u s an d th e ou ter su rface of th e t ym pan ic m em bran e.
Aydin et al6 dem on st rated th e lym p h at ic drain age p at tern of
th e auricle. Th e lym ph at ic drain age pat tern closely follow s th e
vascu lar su pp ly. Th eir st u dy w ith lym ph oscin t igrap h ies sh ow ed
that the injection sites of the technetium -99–labeled nanocolloid
w ith in th e territor y of th e super cial tem poral arter y drain ed
along th e super cial tem poral vein to the parotid sentinel lym ph
n odes. Th e sites w ith in th e territor y of th e posterior au ricu lar
arter y drain ed along th e p osterior au ricu lar vein to th e ext rap arotid sentin el lym ph nodes. This drainage pat tern h as a parallel
relationship w ith em bryonic developm ent. The anterior three
h illocks d erived from th e m an dibu lar arch correspon d p redom in an tly to th e territories of th e sup er cial tem p oral ar ter y. On
th e other h an d, th e posterior th ree h illocks derived from th e
hyoid arch correspon d to th e territories of th e posterior auricular ar ter y.
Fascial Layers
Th e skin of th e lateral surface of th e auricle is t igh tly adh eren t
to th e perich on drium covering th e cart ilage fram ew ork w ith out
th e in terposit ion of fat t y t issue (Fig. 18.8). Vessels an d n er ves
p ass w ith in an ext rem ely th in layer bet w een th e skin an d perich on drium . Th e skin covering th e an terior surface of th e lam in a
of th e t ragus an d th e area bet w een th e an t it ragus an d h elical
t ail located above th e lobule is th icker th an th at covering th e
oth er area of th e lateral su rface an d slides over th e cart ilage.
In con t rast , th e skin of th e m edial su rface is loosely adh eren t
to th e car t ilage w ith in terposit ion of adipose t issue, w h ich is
com p osed of t w o layers: su p er cial an d d eep . Th e su p er cial
layer is r m w it h large fat cells. Th e d eep layer overlyin g t h e
169
Anatom y for Plastic Surgery of the Face, Head, and Neck
a
170
b
Fig. 18.8 Fascial layers of the auricle. (a) Anterior view. (b) Posterior
view. Blue fabric shows the periosteum of the glenoid fossa covering
the auricular disc of the temporomandibular joint. Aud., auditory;
Auric., auricular; Ext., external; Lat., lateral; M., muscle; Post., posterior;
Pteryg., pterygoid; Temp., temporal; Temporopar., temporoparietal;
TMJ, temporom andibular joint.
perich on drium is th in an d loose. Th e n er ves, vessels, an d lym phatics pass through this adipose tissue, m ainly bet w een its t w o
layers. Th e su bcutan eous vascular n et w ork also passes m ore
super cially. The skin exten ds over th e h elical rim w ith th e t ransit ion of its st ru ct u re from on e t yp e to th e oth er.
Gen erally, th e soft t issu e of th e face is divided in to ve basic
layers: (1) skin , (2) su bcut an eou s, (3) m uscu loapon eurot ic layers, (4) areolar t issu e, an d (5) deep fascia/p eriosteu m .7,8 In th e
p ar ietotem p oral region , t h e tem p oral m u scle layer is located
bet w een t h e fou r t h an d ft h layers. Davidge et al9 review ed
p reviou s st u d ies on th e layers of th e tem p orop ariet al area an d
proposed, based on th e term in ologica an atom ica,10 th at th e layers of fascia in th e tem poropariet al region are (1) skin an d su b cu tan eous t issue, (2) tem poropariet al fascia, (3) loose areolar
t issue plan e, (4) super cial lea et of tem poral fascia, (5) tem po ral fat pad of tem poral fascia, (6) deep lea et of tem poral fascia,
(7) fat pad deep to tem poral m u scle, (8) tem poral m uscle, an d
(9) pericran ium . Th ese layers are closed related to th e fasciae of
th e auricle. Our dissect ion sh ow ed th e relat ion sh ip bet w een th e
au ricu lar an d cran ial fascial layers is sh ow n .
Th e tem poroparietal fasciae in clude th e superior auricular
an d parietotem p oral m u scles an d are con t in u ou s w ith th e fron t al m u scle an ter iorly, occip it al m u scle p oster iorly, an d galea
ap on eu rot ica su periorly. Th is layer at t ach es arou n d th e au ricle
along th e tran sverse sulcus and ponticulus. Furtherm ore, it fuses
w ith the super cial layer of the adipose layer of the auricle. Thus,
th e auriculoceph alic sulcus correspon ds to th e junct ion of th e
tem poropariet al fascia on th e cran ial surface an d the super cial
adipose layer of th e au ricle. Th e tem p orop ariet al fascia is t igh tly
ad h eren t to t h e su r face of t h e m astoid p rocess an d is con t in u ou s w it h t h e st ron g, h eavyt h ick brou s fasciae, called t h e su p er cial m astoid fascia.11 Dat t a an d Carlu cci 1 1 exam in ed t h e
facial layers arou n d th e m astoid p rocess. In th is region , th e tem poropariet al fascia get s th icker an d m ore brous an d is bet ter
vascu lar ized . Th e areolar layer in t h e p ar ietotem p oral region
is con t in u ou s w ith th e deep m astoid fascia. In ou r dissect ion ,
th ese fasciae at t ach ed t igh tly to th e superior n uch al lin e an d
posterolateral surface of th e m astoid p rocess.
The super cial fascia of the tem poral m uscle (super cial tem poral fascia) is on e of th e t w o fascia layers covering th e tem p oral m u scle an d is t igh tly at t ach ed to th e an terior bord er of th e
zygom at ic arch an d an terior ligam en t of th e au ricle, w h ich att ach es to t h e p oster ior root of t h e zygom at ic p rocess. Loose
areolar t issu e is located bet w een t h e su p er cial tem p oral an d
tem poropariet al fasciae. On th e posterolateral surface of th e
m astoid p rocess, th ese layers are fu sed w ith th ick brou s t issu e.
Th is areolar layer covers t h e p er ich on d r iu m of t h e car t ilage
of the auricle on th e m edial surface of th e auricle. Th e an terior
au ricu lar m u scle is in a di eren t layer from th e tem p orop ariet al
fascia an d w as related to th e looser areolar layer on th e cran ial
sid e in ou r dissect ion .
Tw o adipose layers are presen t on th e m edial surface of th e
au ricle bet w een th e an terior su rface of th e lam in a of th e t ragu s
and the anterior surface of th e helix. The outer adipose layer and
parietotem p oral fascia are fused togeth er an d at tach ed to th e
zygom atic process. The anterior auricular ligam ent, w hich arises
from th e sp in e of th e h elix, is also at t ach ed to th e zygom at ic
process.
In th e area bet w een th e car t ilage of th e t ragu s an d th e p oster ior bord er of t h e p lat ysm a, w h ich is in clu d ed in t h e SMAS,
is a d i u se area of t h e ligam en tou s at t ach m en t , d escr ibed as
t h e p lat ysm a au r icu lar fascia.1 2 In t h is area, t h e layers from
su bcu tan eou s to deep cer vical are at tach ed as a ret ain ing ligam en t an d are d i cu lt to sep arate in to layers. Th is ligam en tou s
18 Auricle and External Acoustic Meatus
region is n am ed by a variet y of auth ors, in cluding Furn as, St u zin
et al, an d Loré, as t h e p lat ysm a au r icu lar ligam en t , p arot id cu t an eou s ligam en t , an d t ym p an op arot id fascia (Loré’s fascia),
respect ively.7,12,13
Th e deep cer vical fascia is at t ach ed from th e superior n uch al
lin e of th e occip it al bon e to th e m astoid p rocess of th e tem poral
bone, an d exten ds to th e in ferior border of th e body of th e m an d ible. Th is fascia en closes th e stern ocleidom astoid m uscle an d
binds it s an terior edge to th e m an dible. It also en closes th e parot id glan d u n d er th e p arot id om asseteric fascia, an d togeth er
th ey exten d superiorly an d posteriorly to at t ach to th e zygom atic arch , au ricle, an d m astoid p rocess. A th ick brou s ban d is
located in ferior to th e au ricle, w h ere it rm ly teth ers th e parot id gran d to th e au ricle an d th e stern ocleidom astoid . Th is brous layer exten ds upw ard an d m edial to th e parot id glan d to
th e st yloid process form ing th e st ylom an dibular ligam en t .
Clinical Considerations
Recon st ru ct ion of deform it ies of th e auricle is on e of th e m ain
con cer n s of p last ic an d otologic su rgeon s. Defor m it ies of t h e
au r icle are classi ed in to t w o grou p s: con gen it al an d acqu ired .
Previous st udies presen ted a classi cat ion of congen it al an om alies of t h e au r icle: an ot ia, m icrot ia, p rom in en t ear, an d so
for th .14–16 Th ese classi cat ion s ut ilized em br yologic, an atom ical, fun ct ion al, an d clin ical elem en t s to iden t ify th e an om alies
of t h e ear. Ap p rop r iate su rgical p lan n ing for recon st r u ct ion
d ep en ds on th e classi cat ion of th e abn orm alit y. Acqu ired deform it ies of th e au ricle are also di cu lt to recon st ru ct . Becau se
of it s locat ion , th e auricle is vuln erable to deform it ies caused by
extern al t rau m a. Fu r th erm ore, deform it ies can also be cau sed
by surger y for m align an cies of th e lateral skull base. Defect s or
dam ages a ect ing th e cart ilage are m ore di cult to recon st ruct
th an skin -on ly defect s. Th e postauricular ap, u sed to repair defect s of th e au ricle, is con st ru cted of skin from th e p osterior ear,
w h ich h as an abu ndan t vascular su pply, an d it s locat ion en sures
th at th e postoperat ive scar is h idden beh in d th e au ricle. Th is
ap in th e post au ricu lar region from th e m edial su rface of th e
au ricle to th e su per cial m astoid su rface h as been u sed in a variet y of applicat ion s in cosm et ic an d otologic su rger y.
Th e posterior auricular arter y h as been reported to be a
don or arter y for th e m iddle cerebral ar ter y bypass, alth ough it
is usually too sm all for th is u se.17,18 Preoperat ive angiography
m ay reveal th at th e p osterior au ricu lar ar ter y is large en ough to
u se for bypass.
Th e an atom y of th e extern al ear is com plex. It is im port an t
to un derst an d th e m icrosurgical an atom y of th e extern al ear to
obt ain sat isfactor y cosm et ic an d fun ct ion al surgical resu lt s. Th e
extern al ear is im port an t in cosm et ic, gen eral, an d otologic su rger y, as w ell as n eu rologic an d lateral sku ll-base su rger y.
References
1. Perr y ET, Sh elley W B. Th e h istology of th e hu m an ear can al w ith
special referen ce to the cerum in ou s glan d. J Invest Derm atol 1955;
25(6):439–451 PubMed
2. Sh elley W B, Perr y ET. Th e physiology of th e apocrin e (cerum in ous)
glan d of th e h um an ear can al. J Invest Derm atol 1956;26(1):13–22
PubMed
3. Morris H, McMu rrich JP. Morris’s Hu m an An atom y: A Com p lete
System at ic Treat ise by English an d Am erican Au th ors. 4th ed. Ph iladelph ia: P. Blakiston’s Son & Co.; 1907
4. Sh i m an MA. Advanced Cosm et ic Otoplast y Art , Science, an d New
Clin ical Tech n iques. Berlin , New York: Springer; 2013
5. Joo W, Yosh ioka F, Fun aki T, Mizokam i K, Rh oton AL Jr. Microsu rgical an atom y of th e t rigem inal n er ve. Clin An at 2014;27(1):61–88
PubMed
6. Aydin MA, Oku dan B, Aydin ZD, Ozbek FM, Nasir S. Lym p h oscin t igrap h ic d rain age pat tern s of th e au ricle in h ealthy su bject s. Head
Neck 2005;27(10):893–900 Pu bMed
7. St uzin JM, Baker TJ, Gord on HL. Th e relat ion sh ip of the super cial
an d deep facial fascias: relevan ce to rhyt id ectom y an d aging. Plast
Recon st r Su rg 1992;89(3):441–451 PubMed
8. Men delson BC. Advances in th e un derst an ding of th e surgical an atom y of th e face. In : Eisen m an n -Klein M, Neu h an n -Loren z C, eds.
In n ovat ion s in Plast ic an d Aesth et ic Surger y. New York: Springer
Verlag; 2007:141–145
9. Davidge KM, van Fu r th W R, Agu r A, Cu sim an o M. Nam ing th e soft
t issue layers of th e tem poropariet al region : un ifying an atom ic term in ology across su rgical d iscip lin es. Neu rosu rger y 2010; 67(3,
Su ppl Operat ive):120–130 PubMed
10. Federat ive Com m it tee on An atom ical Term in ology, In tern at ion al
Federat ion of Associat ion s of An atom ist s. Term in ologia An atom ica
In tern at ion al Anatom ical Term in ology. 2n d ed. St ut tgart: Th iem e;
2011
11. Dat t a G, Carlucci S. Recon st r uct ion of th e ret roauricular fold by
‘n onp edicled’ su per cial m astoid fascia: det ails of an atom y an d
surgical tech n ique. J Plast Recon st r Aesth et Su rg 2008;61(Su p p l 1):
S92–S97 PubMed
12. Furn as DW. Th e ret ain ing ligam en t s of th e ch eek. Plast Recon st r
Surg 1989;83(1):11–16 PubMed
13. Loré JM, Wabn it z R. An Atlas of Head an d Neck Su rger y. Vol 2. 3rd
ed. Ph iladelph ia: Saun ders; 1988
14. Tan zer RC. Th e const ricted (cup and lop) ear. Plast Reconst r Su rg
1975;55(4):406–415 PubMed
15. Rogers BO. Microt ic, lop , cu p an d p rot r u d ing ears: fou r d irect ly
in h erit able deform it ies? Plast Recon st r Surg 1968;41(3):208–231
Pu bMed
16. Meln ick M, Myrian th opoulos NC, Pau l NW. Extern al ear m alform at ions: epidem iology, gen et ics, an d n at ural h istor y. Birth Defect s
Orig Ar t ic Ser 1979;15(9):i–ix, 1–140 PubMed
17. Horiu ch i T, Ku san o Y, Asan u m a M, Hongo K. Poster ior au r icu lar
ar ter y-m iddle cerebral ar ter y bypass for addit ional surger y of
m oyam oya disease. Act a Neuroch ir (Wien ) 2012;154(3):455–456
Pu bMed
18. Tokugaw a J, Nakao Y, Kudo K, et al. Posterior auricular ar ter ym iddle cerebral ar ter y byp ass: a rare su p er cial tem p oral ar ter y
varian t w ith w ell-develop ed posterior au ricu lar ar ter y: case repor t . Neurol Med Ch ir (Tokyo) 2013;(Oct):21 PubMed
171
19
Mandible and Masticatory Muscles
Kyung-Seok Hu and Yang Hun Mu
Introduction
Th e m an dible p rovid es su p p or t for t h e teet h an d at t ach m en t
of th e m axillofacial m uscles an d w ith th e tem poral bon e, form s
th e tem porom an dibular join t (TMJ). Tributaries of th e in ferior
alveolar n eu rovascu lar bu n dle, p assing th rough th e m an dibu lar
can als, are dist ributed to th e skin of th e ch in an d m an dibular
teeth . An im pingem en t of th e m an dibular can al can resu lt in
sen sor y disorders of th e m an dibu lar teeth an d skin of th e ch in .
Th e m ast icator y m uscles con sist of th e m asseter, tem poralis,
an d m ed ial an d lateral pter ygoid s, an d th ese are in n er vated by
th e m an dibular n er ve. Th e m ast icator y m u scles an d th eir associated n eurovascular an d fascial system s are im port an t in various surgical approach es.
Mandible
Th e m an dible is th e on ly bon e of th e low er jaw. It con sists of an
arch -sh ap ed body an d t w o qu adrilateral ram i (Fig. 19.1). Th e
m an dible p rovides su p port for th e m an dibu lar teeth ; p rovides
for at t ach m en t of m u scles, in clu ding facial, m ast icator y, an d in frahyoid m u scles; an d is th e low er com p on en t for th e TMJ. Th e
bon e also provides passage for th e in ferior alveolar n er ve an d
vessels su p p lying th e m an dibu lar teeth an d low er face.
Body
Th e body of th e m an dible is U-sh aped an d convex an teriorly. It
h as extern al an d in tern al su rfaces an d an alveolar part (tooth bearing por t ion ). Th e in ferior border of th e body con t in ues w ith
th e ram u s, an d togeth er th ey form th e m an dibular base.
External Surface of the Body of the
Mandible
Du r in g d evelop m en t , h alf-sid es of t h e m an d ible are fu sed by
a m an dibu lar sym p hysis in th e m idlin e (Fig. 19.2). A vague m edian ridge at th e upper external surface in an adult m an dible
can in dicate th e fused site. Th e ridge bifurcates at th e low er extern al surface, an d th e m en t al prot uberan ce lies bet w een th em
an d is t riangu lar-sh aped. Tw o m en tal t u bercles an d th e sm all
cen t ral depression bet w een th em lie on th e base of th e m en t al
prot uberan ce.
Th e m en tal prot u beran ce an d t ubercles con st it ute th e ch in
(i.e., th e m en t u m ). Th e m en t al foram en is u su ally located below
th e in ter val bet w een th e prem olar teeth or secon d prem olar,
ap p roxim ately on th e m id poin t bet w een u pp er an d low er bor-
172
der of th e m an dible. Th e m en tal n eurovascular bu n dle em erges
from th e m en tal foram en after p assing th rough a can al in sid e
t h e m an d ible (m an d ibu lar can al). Th e bu n d le em erges backw ard , an d t h u s t h e p oster ior r im of t h e foram en is sm oot h ,
w h ereas the an terior rim is m ore dist in ct . Th e exact posit ion of
th e m en tal foram en an d th e cou rse of th e n eurovascular bun dle
w ith in it are im port an t du ring den tal im plan t procedures.
The external oblique line is faint and ascends posteriorly from
th e m en t al t ubercle to th e an terior border of th e ram us of th e
m an dible. Th e lin e is dist in ct farth er backw ard an d con t in u ou s
w ith th e sh arp an terior border of th e ram us.
Surgical Annotation. Harvesting Bone from
the Chin
Alveolar bon e resor pt ion resu lt ing from toot h loss red u ces
su p p ort ing bon e for th e den t al im p lan t p lacem en t . To en h an ce
vert ical bon e d im en sion s, th e m an dibu lar sym p hysis area is
recom m en ded as th e don or site for th e au togen ous bon e graft .
An osteotom y sh ould be m ade aw ay from th e apex of th e root of
th e in cisors. It is suggested th at th e surgical site of th e osteotom y be located 5 m m from th e den tal root s.1
Add it ion ally, en croach m en t of th e m en t al foram en by th e
osteotom y resu lt s in in sen sit ivit y on t h e ch in . Accord ing to
d en t it ion , th e m en tal foram en lies below th e p rem olar area, especially in th e in ter val bet w een th ese teeth . Su per cially, th e
m en tal foram en lies abou t 2 cm below th e corn er of th e m ou th
an d sligh t ly lateral to it . Th e d ist an ce bet w een t h e bilateral
m en t al n er ves is abou t 45 m m .2 Regarding t h e an ter ior loop
(m an d ibu lar can al an ter ior to m en t al foram en (Fig. 19.3), t h e
safe area m igh t be n ar row er t h an t h e in ter val bet w een t h e
m en tal foram in a.
Th e cor t ical p late on t h e ch in is t h ick fu r t h er d ow nw ard .
An atom ical research in Asian s h as dem on st rated th at th e m axim um volum e of graft block can be h ar vested from th e rect an gu lar site from th e m an dibu lar sym p hysis w ith a h eigh t of 1 to
1.5 cm an d a w idth of 4.0 cm cen tered at th e m idlin e.1
Internal Surface of the Body of the
Mandible
An oblique m ylohyoid lin e exten ds from th e area below th e
m an dibu lar th ird m olar as far for w ard as th e m idlin e an d gives
at tach m en t to th e m ylohyoid (Fig. 19.4). Th e con cave area
below th e lin e is a subm an dibu lar fossa providing space for th e
su bm an dibu lar glan d. Th e lin e is fain t fu r th er for w ard an d en d s
by w iden ing in to a con cave sublingual fossa for th e sublingu al
glan d . Th e m ylohyoid groove from th e ram u s lies below th e
m ylohyoid lin e at th e posterior en d of th e m ylohyoid lin e. Th e
digast ric fossa lies n ear th e m idlin e on each side on th e in tern al
19 Mandible and Masticatory Muscles
su rface of th e m an dible an d gives at tach m en t to th e an terior
belly of digast ric.
Men t al sp in es lie n ear th e in tern al asp ect of th e m an dibu lar
sym p hysis on both sides. Alth ough it som et im es m erges in to a
single t u bercle or is absen t , th e sp in e u su ally divides in to t w o
p art s: an u pp er part for at tach m en t to gen ioglossu s an d a low er
p art for at t ach m en t to gen iohyoid.
Alveolar Part
Fig. 19.1 Body and ramus of mandible.
Th e upper border bet w een th e in tern al an d extern al surfaces of
the m andible form s the alveolar part, giving support for the m andibular teeth. It contains the alveoli (alveolar sockets) for seven to
eigh t m an dibu lar teeth on on e side. Th e alveolar part con sist s of
th e bu ccal an d lingual plates, w h ich are located on th e extern al
Fig. 19.2 External surface of mandible.
(From THIEME Atlas of Anatomy, Head and
Neuroanatomy. © Thieme 2010, Illustration
by Karl Wesker.)
Fig. 19.3 Anterior loop of the mandibular canal. The yellow portion of
thick canal represents the mandibular canal, and the red represents
the anterior loop of the mandibular canal proceeding toward the
mental foram en. The blue portion presents the incisive canal. The
yellow small lines in the anterior region indicate the incisive nerves
innervating the incisive teeth.
Fig. 19.4 Internal surface of mandible.
173
Anatom y for Plastic Surgery of the Face, Head, and Neck
and internal aspects of th e bone, and in terden tal and interradicu lar sept a, w h ich sep arate each tooth an d root , respect ively.
Ramus
Th e ram us of th e m an dible is a broad square-sh aped par t exten ding backw ard an d upw ard from beh in d th e body (Fig. 19.5).
It con sist s of lateral an d m edial su rfaces, fou r borders (su p erior,
in fer ior, an ter ior, an d p osterior), con dylar, an d coron oid p ro cesses. Th e ram us provides entrance and passage for the in ferior
alveolar bu n d le (m an dibu lar foram en an d can al), at t ach m en t
for m ast icator y m u scles, an d th e con dylar p rocess for art icu lat ion at th e TMJ.
Surfaces and Borders
Th e lateral su r face is sm oot h except w h ere t h e m asseter at tach es to its low er part . Th e m edial surface of th e ram us is m ore
com plicated. Th e m an dibular foram en , th e open ing of th e m an dibular can al, is located at th e poin t just above a cen ter of th e
ram u s. Th e an terior port ion of th e foram en is p art ially covered
by a sh arp t riangular spin e, th e lingula. Th e t ip of th e n eedle
sh ou ld be placed at th e vicin it y of th e lingu la du ring an in ferior
alveolar n er ve block (Fig. 19.6). Th e ligula lies about 1 cm above
th e occlusal plan e.
Th e m ylohyoid groove exten ds for w ard an d dow nw ard from
th e low erm ost part of th e m an dibular foram en . Th e an terior
en d of th e groove lies below th e m ylohyoid lin e. Ner ve an d vessels p roceed on t h e groove an d d ist r ibu te to t h e m ylohyoid ,
w h ich is t h e m ain m u scle for m ing t h e oor of t h e m ou t h . Th e
m ed ial pter ygoid m u scle at t ach es to a rough su rface beh in d an d
below th e m ylohyoid groove.
Mandibular
notch
Coronoid
process
Th e extern al oblique ridge con t in ues along th e an terior border of the ram us on its lateral surface. From the tip of the anterior
bord er (coron oid p rocess), a r idge d escen d s on t h e m ed ial sid e
of t h e p rocess to t h e area p oster ior to t h e t h ird m olar region .
Th is r idge, t h e tem p oral crest , con st it u tes a sm all t r iangu lar
d ep ression (ret rom olar fossa) w ith th e extern al obliqu e lin e.
Th e join ing of th e m an dibu lar base an d th e posterior border
of th e ram us form s th e angle of m an dible. A por t ion of th e m an dibular base an terior to th e angle is sligh tly cur ved superiorly
an d is called th e prem asseteric n otch . Th e facial ar ter y p asses
ben eath th e prem asseteric n otch ; th us, th e pu lsat ion of th e arter y can be palpated h ere.
Th e superior border bears a sh arp, t riangular coron oid process an d a roun d an d claviform con dylar process. Th e m an dibular n otch is an in cisure w ith a sh arp sup erior edge bet w een t w o
dist in ct processes. Ner ve an d vessels to th e m asseter on th e lateral su rface of th e ram u s pass th ough th e m an dibu lar n otch .
Surgical Annotation: Identifying the
Mandibular Foramen
With a th u m b on th e an terior border of th e ram u s t s on th e
con cave lin e of th e border, th e lin e th rough th e dist al en d of th e
th um bn ail an d th e in terproxim al poin t of th e t w o prem olars on
th e opposite side passes th rough th e vicin it y of th e m an dibular
foram en . Th is lin e is u su ally u sed for an in ferior alveolar n er ve
block.
Coronoid Process
The coronoid process is thin, triangular shaped, and protects up w ard. Its an terior border is a continuum of the extern al oblique
ridge, an d th e m an dibu lar n otch lim it s its posterior bord er. Th e
Head of
mandible
Pterygoid
fovea
Condylar process
Mandibular
foram en
Ramus
of mandible
Alveolar
part
Mental
tubercle
Angle
Mental
foram en
174
Oblique
line
Fig. 19.5 Internal surface of ramus of
mandible. (From THIEME Atlas of Anatomy,
Head and Neuroanatomy. © Thieme 2010,
Illustration by Karl Wesker.)
19 Mandible and Masticatory Muscles
Fig. 19.6 Passage of needle to mandibular foramen for inferior
mandibular block.
tem poralis is at t ach ed to th e an terior, posterior, an d m edial
borders of th e coron oid process.
Condylar Process
The condylar process consists of the articular head and the neck.
Th e ar t icular h ead part icipates in art iculat ion w ith th e m an dibu lar fossa of th e tem poral bon e. Th e pter ygoid fovea is a sm all
fossa on th e an terior surface of th e n eck an d gives at t ach m en t
to th e u p p er h ead of th e lateral pter ygoid. Sin ce th e h ead of th e
con dylar process is larger th an it s n eck an d th e con dylar process
act s as an axis of jaw join t , th e con dylar p rocess is frequ en tly
fract u red w ith t rau m a.
Mandibular Canal
Th e m an d ibu lar can al is t h e bony can al exten d ing from t h e
m an d ibu lar foram en to t h e m en t al foram en . Th e can al r u n s
dow nw ard an d for w ard w ith in th e ram us th en run s h orizon tally w ith in th e body un der th e tooth -bearing port ion . Th e
can al is closer to th e extern al surface (labial cort ical plate) farther forward. In the anterior end of the canal, it extends anterior
to th e m en t al foram en an d cu r ves back to th e foram en , form ing
th e an terior loop.
Th e inferior alveolar n er ve an d vessels en ter th e m an dibular
can al th rough th e m an dibular foram en . Th e t run k of th e in ferior alveolar n er ve divides in to m en t al an d in cisive n er ves. Th e
form er exits through th e m ental foram en and innervates the skin
of th e ch in . Th e lat ter passes m edially w ith in th e m an dible an d
in n er vates th e in cisors. Th e bony passage of th e in cisive n er ve is
called th e in cisive can al.
Th e n eu rovascu lar bu n d le from t h e in fer ior alveolar n er ve
an d vessels to t h e teet h is w it h in n u m erou s t iny can alicu li bet w een t h e can al an d t h e alveolar p ar t . Rad iograp h ically, t h e
m an dibu lar can al’s u p per border is less dist in ct com pared w ith
it s low er border.
Fig. 19.7 Arrangement of inferior alveolar neurovascular bundle.
Yellow represents the inferior alveolar nerve, mental nerve, and incisive
nerve. Red and blue represent the inferior alveolar artery and vein,
respectively.
Damage to the Mandibular Canal
Th e in ferior alveolar n er ve in n er vates all m an dibu lar teeth , an d
t h e m en t al n er ve su p p lies sen sat ion of t h e skin an d m u cosa
of th e ch in . In t ru sion of an in st rum en t or den t al im plan t can
result in a sen sor y disorder of th e teeth dist al to th e inju r y site.1
Th erefore, an injur y of th e in ferior alveolar n er ve w ith in th e
m an d ibu lar can al cau ses part ial or com plete n u m bn ess of th e
ch in area.
Addit ion ally, th e m en t al n er ve is a bran ch from th e in ferior
alveolar n er ve, an d it s sen sor y com p on en t is conveyed th rough
th e buccal port ion of th e in ferior alveolar n er ve. Th e foram en is
located below th e p rem olars in about h alf th e cases.2 Th e posit ion of th e m en t al foram en varies am ong races an d individuals.
Th erefore, it s posit ion on radiography sh ould be perform ed before su rgical in ter ven t ion on th e p rem olar area.
The inferior alveolar nerve lies below the inferior alveolar vessels, an d the artery is located lingual to the vein in m ost cases
(Fig. 19.7).1 Th erefore, t ran sien t n u m bn ess can resu lt in d irectly
from th e com p ression of, for exam p le, a h em atom a.
Som e surgeon s t r y to overcom e lim it at ion of a xt u re p lacem en t becau se of th e m an dibu lar can al by altering angu lat ion or
p osit ion of th e xt u re; h ow ever, som e di cult sit u at ion s (m ore
th an 10%) occur in w h ich th e m an dibular can al follow s m idw ay
or a lingu al on e-th ird passage w ith in th e m an dible.1 Th e bu ccolingual posit ion sh ou ld be evalu ated radiograph ically before
in ter ven t ion .
Masticatory Muscles
Th e m ain m ast icator y m uscles con sist of th e m asseter, tem poralis, an d m ed ial an d lateral pter ygoids. Th e m asseter lies on th e
extern al su rface of th e ram u s of th e m an dible an d th e tem poralis is located in th e tem poral fossa. Th e t w o pter ygoid m u scles
an d th e ten don of tem p oralis are located in th e in fratem p oral
fossa (Fig. 19.8a– c).
Th e four m uscles are derived from th e rst ph ar yngeal arch
an d are in n er vated by th e m an dibu lar division of th e t rigem in al
175
Anatom y for Plastic Surgery of the Face, Head, and Neck
n er ve. Th e m axillar y arter y from th e extern al carot id arter y
an d su p p lem en t ar y bran ch es from th e facial or su p er cial tem poral ar teries supply blood to th e m ast icator y m uscles. Th e
m ast icator y m u scles p rod u ce m ovem en t s of th e m an d ible at
the TMJ; elevate the m andible (m asseter, tem poralis, m edial pterygoid); pu ll dow n (lateral pter ygoid), prot ru de (lateral pter ygoid)
an d ret ract it (tem p oralis). Th ey also act togeth er to p rovide
com p licated sid e-to-sid e m ovem en t s. Fu n ct ion ally, t h e in frahyoid m uscles, in cluding th e digast ric, st ylohyoid, gen iohyoid,
an d m yohyoid m u scles, p ar t icip ate in accessor y m ast icat ion
fu n ct ion s su ch as op en in g t h e m an d ible. Th e fou r m ast icator y
m u scles in n er vated by t h e m an d ibu lar n er ve are com m on ly
regarded as p rin cip al m overs of th e jaw.
Masseter
Th e m asseter h as been com m on ly described as a m u scle arising
from th e m axillar y p rocess of th e zygom at ic bon e an d th e zygo-
Zygomatic
arch
m at ic arch an d in sert ing in to th e angle an d th e low er p ar t of th e
lateral su rface of th e ram u s of th e m an dible. Th e m ain act ion of
th e m asseter is to occlude th e teeth by elevat ing th e m an dible.
Act u ally, t h e m asseter con sist s of t h ree layers; su p er cial,
m iddle, an d deep layers. Alth ough th e bers of th e th ree layers
m ostly pass dow nw ard an d backw ard, det ailed direct ion s of th e
m u scle bers are sligh tly di eren t according to th e layer. Th e
su p er cial layer arises from th e m axillar y p rocess of th e zygom at ic bon e an d th e an terior t w o-th ird s of th e zygom at ic arch
an d in sert s in to th e angle an d it s n eigh boring p or t ion of th e
extern al su rface of th e ram u s. Th e origin of th e m idd le layer lies
posterior to th e su per cial layer. Th e m iddle layer arises from
th e m edial aspect of th e an terior t w o-th irds of th e zygom at ic
arch an d th e low er bord er of th e p osterior on e-th ird of th e arch
an d in ser t s in to th e cen t ral part of th e ram u s. Th e direct ion of
th e super cial layer is an terior to th e m iddle on e, an d th us th e
su p er cial layer p ar t icip ates m ore in p rot ract ion of th e m an dible. Th e deep layer arises from th e deep surface of th e zygom at ic arch an d in ser ts in to th e u pp er p ar t of th e ram u s an d th e
Frontal bone
Parietal bone
Masseter,
deep part
Tem poralis
External
acoustic m eatus
Mastoid process
Joint capsule
St yloid process
a
Masseter,
superficial part
Lateral ligam ent
Fig. 19.8 Four masticatory muscles; masseter, temporalis, medial, and lateral pterygoids. (a) Masseter with temporalis muscle.
176
19 Mandible and Masticatory Muscles
Zygomatic
arch
Tem poralis
Joint capsule
Lateral ligament
Lateral
pterygoid
b
Coronoid
process
Masseter
Tem poralis
Lateral
pterygoid,
superior part
Lateral
pterygoid
Articular
disc
Lateral
pterygoid,
inferior part
Medial
pterygoid
Masseter
Medial
pterygoid
Lateral plate,
pterygoid process
c
d
Fig. 19.8 (continued ) (b)Temporalis muscle (masseter and zygomatic
arch are removed). (c) Lateral pterygoid muscle (coronoid process of
mandible is removed). (d) Medial pterygoid m uscle (lateral pterygoid
muscle is removed). (From THIEME Atlas of Anatomy, Head and
Neuroanatomy. © Thieme 2010, Illustrations by Karl Wesker.)
177
Anatom y for Plastic Surgery of the Face, Head, and Neck
coron oid process. Som e par t s of th e m iddle an d deep layers are
involved in ret ract ion of th e m an dible. Th e tem p oralis an d buccin ator m uscles lie deep to th e m asseter. Most of th e buccal
bran ch es, som e zygom at ic bran ch es of th e facial n er ve, an d facial vein cross over the m asseter. Th e parot id glan d overlaps th e
posterior par t of m asseter.
Vascular Supply of the Masseter
Th e m a xillar y arter y gives rise to th e m asseteric ar ter y, w h ich
su p p lies th e m asseter. Th e m ain t ru n k of th e m axillar y arter y
proceeds an teriorly an d m edial to th e m an dibular con dyle
w ith in th e in fratem poral fossa. It gives o th e m asseteric arter y
n ear t h e lateral pter ygoid an d t h e ar ter y leaves t h e in fratem p oral fossa w ith th e m asseteric n er ve th rough th e m an dibu lar
n otch . Several bran ch es from th e facial ar ter y an d th e t ran sverse tem p oral arter y are located on th e extern al su rface of th e
m asseter; th ey su pp ly blood to th e an terior an d su perior part s
of th e m asseter, respect ively. Th e facial ar ter y gives o th e prem asseteric arter y passing u pw ard along th e an terior border of
th e m asseter. Th e t ran sverse facial arter y arises from th e supercial tem poral ar ter y an d also su p plies th e m asseter. It u su ally
t ravels an teriorly bet w een th e parot id duct an d th e zygom at ic
arch .
Various Masseteric Branches
Kn ow ledge of th e ar terial dist ribu t ion to m asseter is cru cial in
preven t ing vascular com plicat ion s during various surgical procedures, such as m asseter ap form at ion , redu ct ion of th e m an dibular angle, parot idectom y, an d ram u s osteotom y. Alth ough
th e m assteric arter y from th e m axillar y arter y is delin eated
prim arily as a m ain vessel dist ribut ing m asseter, th e m u scle can
be supplied by several oth er arterial bran ch es from th e extern al
carot id arter y (Fig. 19.9).3 (1) Th e t ran sverse facial ar ter y from
the super cial tem poral artery gives o m asseteric branches that
cross t ran sversely over th e m uscle. It s in t ram uscular bran ch es
to th e m asseter are dist ributed to a broad posterior area of th e
m u scle. (2) Th e extern al carot id arter y an d su p er cial tem poral
arter y give rise to direct m asseteric bran ch es to th e angu lar an d
art icu lar p ort ion s of th e m asseter. Th e facial ar ter y d irectly
gives o th e m asseteric bran ch as it em erges on th e extern al
su rface of th e m an dible after t u rn ing u pw ard. It is dist ribu ted to
th e an terior low er port ion of th e m u scle. Th e facial arter y gives
o th e prem asseteric arter y run n ing along th e an terior border
of m asseter, an d it also gives rise to a sm all m asseteric bran ch
su p p lyin g blood to t h e an ter ior m id p or t ion of t h e m u scle.
(3) Th e deep tem poral arter y, an oth er t ribut ar y of th e m axillar y arter y, also supplies a branch to th e m asseter an d sp eci cally to its an terior upper por t ion .
Innervation of the Masseter
Th e m asseteric n er ve of th e m an dibular n er ve in n er vates th e
m asseter. Th e m asseteric n er ve passes th ough th e m an dibu lar
n otch an d is accom p an ied by th e m asseteric arter y. Th e p roxim al p art of th e m asseteric n er ve is located bet w een th e m an dibular n otch an d th e at t ach m en t of th e m asseter (subm asseteric
t issue space). Abscess resu lt ing from in fect ion of th e m an dibu lar t h ird m olar toot h h as been kn ow n to invad e t h e su bm asseter ic t issu e sp ace an d ir r it ate t h e m asseter ic n er ve w it h
resu lt an t m u scle sp asm an d t r ism u s (p at h ologic lim it at ion of
jaw open ing).
Intramuscular Innervation to Masseter
Th e m asseter ic n er ve r u n s d ow nw ard an d for w ard bet w een
t h e m iddle an d deep layers of m asseter an d is divided in to four
t w ig groups: anterosuperior, anteroinferior, posterosuperior, and
posteroin ferior groups (Fig. 19.10).4
Th e su per cial, m iddle, an d deep layers of th e m asseter are
m ost ly in n er vated by t h e an teroin fer ior, p osterosu p er ior, an d
p osteroin ferior grou p s, resp ect ively. Th e an teroin fer ior grou p
provides perforat ing bran ch es to th e sup er cial layers, an d its
term in at ion lies m ostly on th e in ferior m idport ion of th e m asseter. Th e in ferior m idp or t ion m igh t be an e cien t site for botulin inject ion .
Temporalis
Fig. 19.9 Arteries to the masseter muscle. DTA, deep temporal artery;
ECA, external carotid artery; FA, facial artery; MA, maxillary artery; PA,
premasseteric artery; STA, superf cial temporal artery; TFA, transverse
facial artery. Masseteric branches from ECA(MbECA), STA(MbSTA),
TFA(MbTFA), DTA(MbDTA), MA(MbMA), PA (MbPA), and FA (MbFA).
178
Th e tem poralis is a fan -sh aped m ast icator y m uscle th at arises
from th e tem p oral fossa an d th e in n er su rface of th e tem p oral
fascia. Th e m u scle’s ten don converges an d p asses to th e in fratem poral fossa bet w een th e zygom at ic arch an d th e lateral side
of th e skull. Th e ten don of tem poralis at t ach es to th e m edial
su r face, ap ex, an d ap ical bord er of t h e coron oid p rocess. Tem p oralis elevates an d it s p oster ior bers ret ract t h e m an d ible.
Direct ion s of th e m u scle bers of tem p oralis var y according to
their location. The m uscle bers of tem poralis are arranged m ore
h or izon t ally p oster iorly. Th e an ter ior p ar t s of tem p oralis are
ar ranged m ore ver t ically. Som e bers of it s an terior p ar ts arise
from t h e in n er su r face of t h e zygom at ic bon e. Th ese bers
st ron gly elevate t h e m an d ible by p u llin g t h e coron oid p rocess
19 Mandible and Masticatory Muscles
Fig. 19.10 Four groups of masseteric nerves.
a
u pw ard. Th e posterior m ore h orizon t al p art s of tem poralis also
part icipate in closing th e m outh by rot at ing th e m an dible tow ard th e m axilla on th e axis of th e jaw join t .
Signi cant struct ures, including the super cial tem poral vessels, th e au ricu lotem p oral n er ve, an d tem p oral bran ch es of th e
facial n er ve, lie on th e tem p oralis an d th e tem poral fascia.
Vascular Supply
Artery
Th e m axillar y ar ter y gives rise to th e an terior an d posterior
deep tem poral arteries on th e lateral pter ygoid. Th e deep tem poral ar teries ascen d on th e lateral pter ygoid an d in fratem poral
crest of th e sph en oid bon e an d th en en ter tem poralis w ith th e
deep tem poral bran ch es of th e m an dibu lar n er ve. Th e supercial tem p oral ar ter y gives rise to th e m iddle tem p oral ar ter y
just above th e zygom at ic arch an d en ters th e tem poralis after
piercing th e tem poral fascia. Th e an terior deep tem poral arter y
supplies blood to th e an terior portion of tem poralis and the poster ior d eep tem p oral ar ter y su p p lies t h e p oster ior p ar t s. Th e
m id d le tem p oral ar ter y is d ist r ibu ted to t h e m id p or t ion of t h e
tem poralis. Th e fron tal bran ch of th e super cial tem poral arter y ascen ds on tem poralis u pw ard an d for w ard.
b
tem poropariet al fascia an d tem poral fascia, a surgical approach
can be safely perform ed deep to th e tem poralis.
Th e ar ter y divides in to several fron tal bran ch es as it passes
over th e tem p oralis. Usu ally, on e or t w o w ill reach th e border
bet w een t h e tem p oralis an d fron t alis (t h e fron t al belly of occip itotem poralis) abou t 2 cm (approxim ately th e w idth of th e
th u m b) above th e eyebrow. Th e pulsat ion of th e fron tal bran ch
can easily be detected by palpat ion at it s bran ch ing poin t from
th e super cial tem poral ar ter y an d as it en ters fron t alis. Th erefore, t h e su rgeon can p red ict it s cou rse by p alp at ion of t h e
bran ch ing p oin t s becau se t h e fron t al bran ch rarely bifu rcates
except bet w een m u scles.
Veins
Th e vein s of th e tem poral, fron t al, an d pariet al areas converge
as th e sen t in el vein . Th e m edial tem p oral vein an d it s con t in u um (i.e., th e sup erior tem p oral vein ) drain to th e ret rom an dibu lar vein , th e an terior an d p osterior bran ch es of w h ich drain to
Superf cial Temporal Artery Over the
Anterior Temporalis
Th e an terior port ion of tem poralis lies over th e tem ple n ear th e
pterion . Various surgical in ter ven t ion s n ear th is area in clude
face lift p rocedu res, th e inject ion of ller m aterial, th e inject ion
of bot ulin toxin for aesth et ic purposes, an d th e inject ion of an esth et ics for th e t reat m en t of h eadach es. Th erefore, kn ow ledge
of th e super cial tem poral ar ter y an d its topography is im portan t to th e clin ician .
Th e su per cial tem poral ar ter y bran ch es from th e extern al
carot id ar ter y in th e preauricular area at a dist an ce of 2 to 5 cm
from t h e Fran kfu r t lin e (lin e t h rough t h e low er m ost p oin t of
t h e orbit to th e upperm ost par t of th e port ion ), an d it passes
for w ard an d upw ard over th e tem p oralis (Fig. 19.11). Because
the frontal branch lies w ithin the tem poral fascia or bet w een the
Fig. 19.11 Superf cial temporal artery (STA) passing over temporalis.
179
Anatom y for Plastic Surgery of the Face, Head, and Neck
th e extern al an d in tern al jugular vein s, respect ively. Th e blood
ow in th e sen t in el vein can act u ally ow tow ard both th e in fraorbital sp ace an d th e th oracic area via th e valveless ven ou s
vessels of th e h ead an d n eck.
Th e m edial zygom at icotem poral vein h as been obser ved in
th e vicin it y of th e tem poral bran ch of th e facial n er ve du ring
en d oscop ic p rocedu res aim ed at lift ing th e u p p er face. Th e sen tinel vein is easily identi ed on direct or endoscopic view during
facelift p roced u res an d is read ily d etected in recu m ben t p at ien t s or in con scious pat ien t s using a Valsalva m an euver.
Th e sen t in el vein pierces th e parietotem poral fascia, w h ich
is p art of th e su per cial m uscu loap on eurot ic system (SMAS) in
abou t 17% of cases.
Innervation
Th e deep tem poral n er ve bran ch es from th e m an dibular n er ve
an d in n er vates th e tem p oralis. Th e deep tem poral n er ve con sist s of t w o or t h ree bran ch es. Th e bran ch es of t h e d eep tem p oral n er ve p ass bet w een th e in fratem poral crest an d u pp er
b ord e r of t h e late ral pt e r ygoid . Th ey e n t e r te m p oralis w it h
the deep tem poral arteries. Som etim es the anterior branch of the
d eep tem p oral n er ve bran ch es from t h e bu ccal n er ve an d t h e
posterior bran ch bran ch es from th e m asseteric n er ve.
Fasciae of the Temporal Region
Th e au r icu lotem p oral n er ve, tem p oral bran ch es of t h e facial
n er ve, an d su per cial tem p oral vessels are involved in variou s
su rgical in ter ven t ion s of th e tem p oralis or tem poral region , regardless of th eir dist ribu t ion to th e tem poralis. Th e an atom y of
th e fasciae of tem poralis is th erefore im por tan t in th e preser vat ion of th ese n eurovascu lar st ruct ures. Th e tem poral fascia is a
den se apon eurot ic layer covering th e tem poralis an d providing
at t ach m en t for th e su rface for th e m uscle. Its up perm ost port ion m erges w ith th e periosteum at th e superior tem poral lin e.
Th e tem poral fascia divides in to super cial an d deep sublayers,
w h ich at t ach to th e m edial an d lateral m argin s of th e zygom at ic
arch , resp ect ively. Th e adip ose t issu e (su per cial tem p oral fat
pad) lies bet w een th em , an d th ey su rroun d bran ch es of th e super cial tem poral arter y and zygom aticotem poral nerve. Hence,
placem en t of an in st rum en t deep to th e tem poral fascia can
provide a safe surgical approach for m an ipulat ing zygom at ic
arch fract u res (Gillies app roach ).5
Th e tem p orop ar iet al fascia lies su p er cial to t h e tem p oral
fascia. It is on th e sam e plan e as th e su per cial m u scu loapon eurot ic system (SMAS) blen ding w ith th e galea apon eurot ica. Th e
sp ace bet w een t h e tem p orop ariet al fascia an d t h e tem p oral
fascia en closes th e loose con n ect ive t issu e w ith adip ose t issu e
(tem p orop ar iet al fad p ad), con t in u ing w it h a su bgaleal loose
connective tissue plane of the scalp. The auriculotem poral ner ve,
facial n er ve bran ch es, an d su p er cial tem p oral vessels are located w it h in or sligh t ly deep to t h e tem p orop ar iet al fascia.
Su rgeon s can u se t h is fascia as a lan d m ark to avoid facial n er ve
dam age. Clin ically, th e tem poropariet al fascia is called th e super cial tem poral fascia, an d th e tem poral fascia is called th e
deep tem poral fascia.
180
Medial Pterygoid
Th e m edial pter ygoid is a square-sh aped m ast icator y m u scle
th at con sist s of t w o h eads th at arise super cial an d deep to th e
low er h ead of th e lateral pter ygoid. Th e deep h ead of th e m ed ial
pter ygoid arises from th e m edial surface of th e lateral pter ygoid
p late of t h e sp h en oid bon e. Th e su p er cial h ead ar ises from
t h e m axillar y t uberosit y an d pyram idal process of th e palat in e
bon e. Tw o h eads descen d backw ard an d at t ach to th e m edial
su r face of t h e ram u s an d t h e an gle of t h e m an d ible. Th e p osteroin fer ior d irect ion of t h e m ed ial pter ygoid an d it s act ion
of elevat ing t h e m an d ible are sim ilar to t h ose of t h e m asseter.
W h en t w o pter ygoid m uscles of on e side act togeth er, th ey rot ate th e m an dible for w ard an d m edially to th e opposite side.
Th e lateral pter ygoid, th e sph en om an dibular ligam en t , m axillar y ar ter y, t h e in fer ior alveolar ar ter y an d vessels, an d t h e
lingu al n er ve are located bet w een th e lateral side of th e m edial
pter ygoid an d th e m edial surface of th e ram us of th e m an dible.
In sert ion of th e m edial pter ygoid reach es u pw ard to th e m an dibular foram en an d for w ard to th e m ylohyoid lin e.
Vascular Supply and Innervation
Th e m axillar y arter y provides several pter ygoid bran ch es su p plying blood to th e m ed ial an d lateral pter ygoid m u scles. Th e
buccal ar ter y from th e m axillar y arter y also gives o bran ch es
to t h e m edial pter ygoid . A p ar t of t h e facial ar ter y p roceed s
m edial to th e ram u s of th e m an dible bet w een th e su bm an d ibu lar glan d an d th e m edial pter ygoid along th e in ferior border of
th e m an dible. Som e bran ch es are derived from th e facial arter y
h ere an d are d ist ribu ted to th e m ed ial pter ygoid at it s in sert ion
n ear th e angle of th e m an dible. Th e m an dibu lar n er ve gives rise
to th e n er ve to th e m edial pter ygoid.
Medial Pterygoid and Mandibular Angle
Reduction
Both th e m edial pter ygoid an d m asseter lie dow nw ard an d
backw ard 70 degrees from th e m an dibular base, an d th ey in ser t
on to th e m edial an d lateral surfaces of th e angle of th e m an dible, respect ively. Th eir in ser t ion s are located n ear th e gon ion
(t h e m ost p osteroin fer ior p oin t of t h e angle of t h e m an d ible)
by a dist an ce of 2 cm .6 Th erefore, th e m edial pter ygoid is an
im p or tan t lan dm ark for m an dibular angle reduct ion . Injur y to
t h e ar ter ies ap p roach ing t h e angle is a com p licat ion d u r ing
m an d ibu lar angle redu ct ion . Accord ing to m ost an atom y textbooks, th e m ain bran ch supplying th e m edial pter ygoid derives
from th e m a xillar y ar ter y after passing over th e con dylar pro cess of th e m an dible; h ow ever, th e facial ar ter y provides oth er
bran ch es to th e angular por t ion of th e m edial pter ygoid.7 Th e
arter y gives o th e ascen ding palat in e arter y m edial to th e
angle of th e m an dible. It also gives o m u scu lar bran ch es before
em erging on th e su p er cial asp ect of th e m an dible. Th ere are
also sm all m u scu lar bran ch es ar isin g d irect ly from t h e facial
ar ter y an d t raveling to th e angu lar p ort ion of th e m ed ial pter ygoid (Fig. 19.12). Th erefore, surgeon s approach ing th e angle of
19 Mandible and Masticatory Muscles
ar ter y. Th e sp h en om an dibu lar ligam en t , th e m iddle m en ingeal
ar ter y, an d th e m an dibu lar n er ve t ru n k are deep to th e m u scle.
Function of Lateral Pterygoid:
Side -to -Side Movement
Th e m ain jaw depressor is n ot th e lateral pter ygoid; rath er, it is
th e in frahyoid m uscles (e.g., digast ric an d gen iohyoid).5 Prot rusion of th e m an dible by th e lateral pter ygoid is lim ited to an
assisting m ovem ent for jaw opening and alone is n ot signi can t.
Th e m ost im port an t fun ct ion provided by th e lateral pter ygoid
is lateral excursion , side-to-side m ovem en t of th e m an dible.
Th e ipsilateral m edial an d lateral pter ygoids pull th e m an dible
m edially. Th e sligh t bu t st rong m edial m ovem en t of th e jaw is
crucial in food grinding. Spasm of the lateral pterygoid can occur
in cases of TMJ dysfun ct ion ; in such cases, ten derness m ight be
palpated posterior to the m axillar y tuberosit y.
Fig. 19.12 Arteries to medial pterygoid muscle. APA, ascending
palatine artery; ECA, external carotid artery; FA, facial artery; MA,
maxillary artery.
th e m an dible sh ould be aw are n ot on ly of th e m ain t run k of th e
facial ar ter y bu t also of th e m u scu lar bran ch es to th e m asseter
an d m edial pter ygoid m u scles.
Lateral Pterygoid
Th e lateral pter ygoid is a h orizon tally arranged m uscle w ith in
th e in fratem poral fossa m uscle an d com prises upper an d low er
heads. The upper head arises from the infratem poral surface and
crest of th e greater w ing of th e sph en oid bon e, an d th e low er
h ead ar ises from t h e lateral su r face of t h e lateral pter ygoid
plate. Th e t w o h eads of th e lateral pter ygoid ru n backw ard, an d
th eir m uscle bers converge to be in serted in to th e pter ygoid
fovea, a depression on th e an terior side of th e n eck of th e m an dible. Ch aracterist ically, som e m uscle bers of th e upper h ead
at t ach to th e capsule of th e TMJ an d th e an terior border of th e
art icu lar disc. Becau se th e TMJ is located lateral to th e lateral
pter ygoid plate, th e bellies of th e t w o h eads proceed out w ard,
an d th e m u scu lar bers of th e u p p er h ead at t ach to th e m edial
border of th e disc. Th e lateral pter ygoid pulls th e n eck of th e
m an dible for w ards an d th e con dyle of th e m an dible m oves n ot
on ly for w ard, but it also dow nw ard along th e an terior slope of
th e m an dibular fossa.
Th e ram i of th e m an dible, th e m asseter, th e super cial h ead
of th e m edial pter ygoid, an d th e ten don of tem poralis are super cial to th e m edial pter ygoid an d to m ost of th e m axillar y
Vascular Supply and Innervation
Th e m a xillar y ar ter y crosses th e lateral pter ygoid an terosuperiorly. Th e lateral pter ygoid is a lan dm ark for dem arcat ion of th e
m axillar y ar ter y. Th e p roxim al p or t ion of th e m axillar y ar ter y
beh in d th e m uscle is th e m an dibular par t , th e m idport ion on
th e m u scle is th e pter ygoid part , an d th e distal port ion in fron t
of th e m u scle is th e pter ygopalat in e par t . Th e m an dibular par t
of th e ar ter y gives o th e pter ygoid arteries dist ributed to th e
lateral pter ygoid as th e arter y crosses it . Th e ascen ding palat in e
ar ter y bran ch es from th e facial ar ter y an d also su p p lies th e lateral pter ygoid . Th e m an dibu lar n er ve gives rise to th e n er ve to
th e lateral pter ygoid.
Spatial Relations of Lateral Pterygoid to
Mandibular Nerves
Many bran ch es from th e m an d ibu lar n er ve h ave a sp at ial relat ion sh ip w ith th e lateral pter ygoid.5 Th e deep tem poral n er ves
an d m asseteric n er ve ru n along th e in fratem poral crest an d th e
u pper border of th e upper h ead of th e lateral pter ygoid. Th e
bu ccal n er ve p asses bet w een t h e u p p er an d low er h ead s of
t h e m uscle. Th e lingual n er ve an d inferior alveolar n er ve pass
below th e low er h ead. Th e n er ve to the lateral pter ygoid arises
directly from th e m an dibular n er ve or from th e buccal n er ve
passing bet w een th e t w o h eads of the m uscle. Th e n er ve, after
arising directly from th e m an dibu lar n er ve, en ters th e deep
part of th e lateral pter ygoid an d in ner vates th e m edial par t of
th e low er h ead. Th e n er ve bran ch es from th e buccal n er ve are
dist ributed to th e upper h ead an d lateral par t of th e low er h ead.
Th e buccal n er ve, after passing th rough th e lateral pter ygoid,
term inates as a cut an eous n er ve supplying th e ch eek.
181
Anatom y for Plastic Surgery of the Face, Head, and Neck
References
1. Hu KS, Yun HS, Hur MS, Kw on HJ, Abe S, Kim HJ. Bran ch ing pattern s an d in t raosseou s course of th e m en t al n er ve. J Oral Maxillofac Su rg 2007;65(11):2288–2294 Pu bMed
2. Song WC, Kim SH, Paik DJ, et al. Locat ion of th e in fraorbit al an d
m en tal foram en w ith referen ce to th e soft-t issue lan dm arks. Plast
Recon st r Su rg 2007;120(5):1343–1347 PubMed
3. Kw ak HH, Hu KS, Hu r MS, et al. Clin ical im p licat ion s of t h e top ograp hy of t h e ar ter ies su p p lyin g t h e m ed ial pter ygoid m u scle.
J Cran iofac Surg 2008;19(3):795–799 Pu bMed
4. Kim DH, Hong HS, Won SY, et al. In t ram uscular n er ve dist ribut ion
of th e m asseter m uscle as a basis for bot u lin um toxin inject ion .
J Cran iofac Su rg 2010;21(2):588–591 Pu bMed
182
5. St andring S. Gray’s An atom y : Th e An atom ical Basis of Clin ical
Practice. 40th ed. Edinburgh: Ch urch ill Livingstone; 2008:530–539
6. Yang SJ, Hu KS, Kang MK, Youn KH, Kim HJ. Topography an d m orph ology of th e m edial pter ygoid m uscle for th e surgical approach
of t h e m an d ibu lar ram u s. Korean J Phy An t h rop ol. 2007;20(3):
157–167
7. Won SY, Ch oi DY, Kw ak HH, Kim ST, Kim HJ, Hu KS. Top ograp hy
of th e arteries supplying th e m asseter m uscle: Using dissect ion
an d Sih ler’s m eth od. Clin An at 2012;25(3):308–313 Pu bMed
20
Oral Cavity and Pharynx
Joe Iw anaga, Shinya Mik ushi, and Haruka Tohara
Introduction
Th e oral cavit y is th e en t ran ce of th e upper digest ive t ract , con t in u ing in to th e oroph ar yn x; it is divided in to t w o region s (Fig.
20.1). Th e rst region is th e oral vest ibule, located extern al to
th e den tal arch . Th e secon d region is th e oral cavit y proper, located in tern al to th e den t al arch . Th e com pon en t s of th e oral
cavit y in clu de th e upper an d low er lip m ucosa, teeth an d gin giva, alveolar m u cosa, bu ccal m u cosa, tongu e, h ard an d soft palate, oor of th e m outh , an d uvula. Th e palate is th e roof of th e
m ou th an d sep arates th e oral an d n asal cavit ies. Th e ph ar yn x is
located at th e p osterior aspect of th e oroph ar yngeal isth m u s.
Tw o im port an t fun ct ion s involving th e oral cavit y an d ph ar yn x
are m astication and swallow ing. Multiple m uscles w ork together
to send a bolus of food to th e esophagus. Oth er m ajor funct ion s
are occlu sion an d aesth et ics. Th e oral cavit y an d ph ar yn x con tain an abun dan t supply of blood vessels an d n er ves in a con st ricted sp ace, p roviding a p art icu lar ch allenge for clin ician s
u n dert aking su rgical p rocedu res. In th is ch apter, w e explain th e
det ails of th e clin ical an atom y of oral cavit y an d ph ar ynx to prom ote bet ter u n derst an ding for clin ical pract ice.
Oral Vestibule
Th e oral vest ibule is th e region surroun ded by th e lip (buccal)
m u cosa, m u cobu ccal fold, alveolar m u cosa, gingiva, an d u p per
an d low er den t al arch es. It s sh ap e in th e axial p lan e is th at of a
h orsesh oe, an d it is separated from th e oral cavit y p roper w h en
Nasal
septum
Hard
palate
Oral cavit y
proper
th e upper an d low er teeth are in occlusion . Mucosal folds th at
ru n from th e cen t ral in cisor region of th e alveolar m u cosa to th e
lip m ucosa are th e fren ulum of th e u pper an d low er lips (Fig.
20.2). Mucosal folds th at run from th e m olar region of th e alveolar m ucosa to th e buccal m ucosa are called buccal fren ula. Th e
p arot id d u ct r u n s from t h e p arot id glan d , p asses in fron t of
t h e m asseter m uscle, en ters in to th e bu ccal fat pad, an d th en
reach es th e parot id papilla located in th e buccal m ucosa (Fig.
20.3). A sm all t riangle (th e ret rom olar t riangle) lies just beh in d
th e m ost dist al m olar an d a sm all ridge in th e ret rom olar region
(th e ret rom olar pad) (Fig. 20.4). Th e lingual n er ve bran ch es o
th e m an dibular n er ve an d occasion ally crosses over th e ret rom olar t riangle.1 Th e extern al obliqu e ridge, w h ich begin s lateral
to th e ret rom olar pad, con t in ues on to th e an terior border of th e
ram u s. W h en t h e m an d ible op en s an d closes, or w h en t h e lip s
su ck, t h e bon e m ovem en t an d m u scle con t ract ion ch an ge t h e
for m of t h e oral vest ibu le. Th e low er p ar t of t h e oral vest ibu le
in p art icu lar is a ected by th e su p erior ph ar yngeal con st rictor
m u scle, m asseter m u scle, bu ccin ator m u scle, orbicu laris oris
m u scle, m en talis m u scle, an d coron oid p rocess; th e u pp er p art
is a ected by the orbicularis oris m uscle, buccinator m uscle, m edial pter ygoid m uscle, levator anguli oris m uscle, n asal m uscle,
depressor sept i m uscle, an d in frazygom at ic crest . If the superior
labial fren ulum is located in a h igh posit ion on th e gingiva, th e
righ t an d left m axillar y in cisor teeth m ay exh ibit a m edian diastem a, an d fren oplast y is often required.
Th e orbicu laris oris m uscle an d bu ccin ator m uscle are presen t ben eath th e m u cou s m em bran es of th e labial an d bu ccal
m u cosae. In th e m an dible, th ere are t w o m en t al foram in a, ju st
in ferior to th e apex of th e secon d prem olars, th rough w h ich th e
Torus
tubarius
Soft
palate
Superior
labial
vestibule
Uvula
Upper lip
Lower lip
Tongue
Hyoid bone
Mandible
Mylohyoid
Epiglot tis
Geniohyoid
Fig. 20.1 Midsagit tal plane of the oral cavit y
and pharynx. (From THIEME Atlas of Anatomy,
Head and Neuroanatomy. © Thieme 2010,
Illustration by Karl Wesker.)
183
Anatom y for Plastic Surgery of the Face, Head, and Neck
Frenulum of
upper lip
Oral
vestibule
Palatoglossal
arch
Palatopharyngeal arch
Faucial
isthm us
ju st below t h e alveolar m u cosa; n er ves exit in g t h e foram in a
are th en easily com p ressed by den t u res. Recen t developm en t s
in im aging h ave revealed th at accessor y m en t al foram in a exist
arou n d th e m en t al foram en in ap p roxim ately 10% of cases 3,4
(Fig. 20.5) an d t h at t h e accessor y m en t al n er ve bran ch es o
from th ese accessor y foram in a.
Hard
palate
Soft
palate
Uvula
Palatine
tonsil
Oral cavity
proper
Dorsum
of tongue
Oral
vestibule
Frenulum of
lower lip
Fig. 20.2 Frenulum of the upper and lower lips. (From THIEME Head
and Neck Anatomy for Dental Medicine. © Thieme 2010, Illustration by
Karl Wesker.)
m en t al n er ves, ar teries, an d vein s em erge. Th e vert ical d ist an ce
from th e m argin of th e m an dible to th e m en t al foram en is reported to be approxim ately 12 m m .2 Surgical procedures in th e
prem olar region sh ould be un der taken carefu lly. W h en teeth
are lost , th e alveolar bon e p roper resorbs an d th e th ickn ess of
the m andible decreases, so the m ental foram ina som etim es open
Teeth and Periodontal
Tissues
Th e teeth con sist of a crow n , th e su rface of w h ich is covered by
en am el, a h ard t ran slu cen t t issu e, an d th e root , w h ich is covered by cem en t u m . With in th e crow n an d root is a layer of den t in surroun ding a cen t ral pu lp cavit y. Th e apical foram en is a
h ole at th e t ip of th e root , th rough w h ich th e den t al pu lp, blood
vessels, an d lym p h vessels en ter an d exit th e den t al p u lp ch am ber. Th e root is surroun ded by th e periodon t al ligam en t (Fig.
20.6). En am el is th e hardest t issue in th e h um an body; at th e
sam e t im e, it is a fragile an d breakable t issu e. Th e en am el is
ap p roxim ately 96% in organ ic m at ter called hyd roxyap at ite; it
reach es a m a xim u m t h ickn ess of 2.5 m m over t h e cu sp s an d
is qu ite th in at th e cer vical m argin s. After crow n form at ion is
com plete, n o addit ion al en am el form s, but th e en am el of young
people is easily dem in eralized an d rem in eralized. Den t in is a
yellow ish t issu e com posed of hydroxyap at ite (70%), collagen
(20%), an d w ater (10%). Den t in is m ore exible th an en am el, so
it act s as a bu er to preven t th e en am el from fract uring. Addit ion ally, if in am m at ion occu rs in th e den t al pulp as a result of
den t al caries or t raum at ic injur y after th e st ar t of occlusal fun ct ion , secondar y den t in w ill form in side th e dent in . Th e cem en t um covers th e surface of the den t in of the root an d is covered
by th e periodon t al ligam en t , w h ich con sist s of brou s conn ect ive t issue th at is 0.15 to 0.38 m m th ick. Sh arpey’s bers, w h ich
Fig. 20.3 The left parotid papilla (the ori ce
of the parotid duct) is indicated by the black
arrow. HP, Hard palate; LP, lower lip.
184
20 Oral Cavit y and Pharynx
Fig. 20.4 The left retromolar region. Yellow region, retromolar pad;
dot ted line, internal oblique ridge; solid line, external oblique ridge.
BM, Buccal mucosa; RP, retrom olar pad; T, tongue.
em erge from the cem entum , penetrate th e periodon tal ligam ent
an d en ter th e alveolar bon e. Th e m ain roles of th e p eriodon t al
ligam en t are to su ppor t th e teeth , con t rol sen sit ivit y, an d provide a blood su p p ly. Th e act ivit y of th e p eriodon tal ligam en t
an d th e n u m ber of bers it con tain s d ecrease w ith age. Den t al
pulp is a soft t issue th at in cludes blood vessels, n er ve bers,
lym ph vessels, and connective tissue. It is divided into t w o parts,
th e coron al pulp an d the radicular pulp, w h ich com m u n icate at
th e cer vical region . Th e radicular pulp of an terior teeth is sin -
gle; bu t for posterior teeth , th ere are m u lt ip le areas of radicu lar
p ulp . Both coron al pulp an d radicular pu lp becom e th in n er as
den t in deposit ion con t in u es w ith aging. Th e apical foram en becom es n arrow er because of deposit ion of cem en t um .
Th e n um ber of h um an adult perm an en t teeth is 32, an d
th ese are each su rroun ded by alveolar bon e. Alveolar bon e is
divided in to t w o part s: alveolar bon e proper, w h ich is adjacen t
to t h e cem en t u m , an d su p p or t ing bon e. Th e alveolar bon e
proper resorbs along w ith the loss of teeth. There are eight kin ds
of perm an en t teeth : cen t ral in cisor, lateral in cisor, can in e, rst
p rem olar, secon d p rem olar, rst m olar, secon d m olar, an d th ird
m olar (w isdom teeth ) from th e m idlin e to p osterolateral. Th e
m esial an d dist al tooth su rfaces are th ose closest to an d farth est
from th e m id lin e, respect ively. Th e term labial is u sed for in cisors an d can in e teeth , an d buccal is used for prem olar an d m olar
teeth . Palatal den otes th e in side surface of m axillar y teeth , an d
lingual den otes th e in side surface of m an dibular teeth (Fig.
20.7). Th ese design at ion s are used to describe th e precise locat ion of sm all cariou s lesion s. Th e decidu ous teeth tot al 20, an d
t h ey are called d ecid u ou s cen t ral in cisor, d ecid u ou s lateral in cisor, deciduous can in e, rst decidu ous m olar, an d secon d deciduou s m olar from m edian to posterolateral. Deciduous teeth
begin to erupt 6 to 8 m on th s after birth . Th e decidu ous cen t ral
in cisor erupt s rst , an d th e deciduou s den t it ion n ish es eru pting at approxim ately 2 years of age. Th en deciduou s teeth begin
to be replaced by perm an en t teeth at age 6 to 7 years. Th e perm an en t d en t it ion is com p lete by th e age of 13, except for th e
th ird m olar, for w h ich th e age of erupt ion di ers bet w een in dividuals. The upper teeth are inn ervated by th ree superior n erves
arising from th e m axillar y n er ve: th e posterior su p erior alveolar n er ve, th e m iddle su perior alveolar n er ve, an d th e an terior
Fig. 20.5 Lateral view of the left mandible.
AMF, Accessory mental foramen; MF, mental
foramen.
185
Anatom y for Plastic Surgery of the Face, Head, and Neck
b
a
Fig. 20.6 (a) Longitudinal section of the incisor tooth and periodontal tissues. (Modi ed from THIEME Atlas of Anatomy, Head and Neck Anatomy
for Dental Medicine. © Thieme 2010, Illustration by Karl Wesker.) (b) Magni ed view of the rectangular zone in (a) showing the periodontal tissues
of the neck region.
Labial
Mesial
Distal
Buccal
Lingual
Palatal
Buccal
Distal
Mesial
Labial
Fig. 20.7 Designation of surfaces of the teeth. (a) Inferior view of the maxillary teeth. (b) Superior view of the mandibular teeth. (Modi ed from
THIEME Head and Neck Anatomy for Dental Medicine. © Thieme 2010, Illustrations by Karl Wesker.)
186
20 Oral Cavit y and Pharynx
Table 20.1 Innervation of the oral mucosa
Labial or buccal
m ucosa
Upper jaw
Dominant nerve
Low er jaw part
Dominant nerve
Anterior part
Infraorbital nerve, anterior superior
alveolar branch
Anterior
Mental nerve
Middle part
Buccal nerve
Middle
Buccal nerve
Posterior part
Labial or buccal
gingiva
Palatal or lingual
m ucosa, gingiva
Posterior
Anterior part
Infraorbital nerve, anterior superior
alveolar branch
Anterior
Mental nerve
Middle part
Infraorbital nerve, middle superior
alveolar branch
Middle
Buccal nerve
posterior part
Infraorbital nerve, posterior superior
alveolar branch
Posterior
Anterior part
Nasopalatine nerve
Anterior part
Middle part
greater palatine nerve (hard palate)
Middle part
Posterior part
su p erior alveolar n er ve. Th e low er teeth are in n er vated by th e
in ferior alveolar n er ve arising from th e m an dibular n er ve. Both
th e upper an d low er teeth are supplied by bran ch es of th e m axillar y ar ter y. Th e u pper teeth are su pplied by th e an terior, m id dle, an d posterior superior alveolar arteries, an d th e low er teeth
are su p p lied by t h e in fer ior alveolar ar ter y. Th e vein s accom p anyin g t h e m a xillar y ar ter y d rain t h e u p p er an d low er jaw
in to th e pter ygoid ven ous plexu s an d collect th e m axillar y vein ,
deep facial vein , an d buccal vein an d th en drain in to th e ret rom an dibu lar vein an d facial vein .
Gingiva/Alveolar Mucosa
Th e im m obile an d kerat in ized m u cosa th at surroun ds th e alveolar bon e an d coh eres to th e periosteum is called gingiva (Table
20.1). Th e m obile m ucosa bet w een th e gingiva an d th e gingivobuccal fold is kn ow n as th e alveolar m ucosa an d is n ot n orm ally
kerat in ized. Th e gingiva is fu rth er su bd ivided in to free gingiva
an d at t ach ed gingiva by th e free gingival groove (Fig. 20.6). In n er vat ion of th e low er gingiva an d alveolar m ucosa com es from
th e lingu al, buccal, an d m en tal n er ves; in n er vat ion of th e upper
gingiva an d alveolar m u cosa com es from th e n asopalat in e,
greater palat in e, an d bu ccal n er ves (Fig. 20.8a,b).
Palate
Th e h ard palate form s th e roof of th e oral cavit y an d is lined by
bon e (Fig. 20.8b, Table 20.1). Th e posterior soft part of th e palate lacks bon e, is called th e soft palate, an d con sist s of st riated
m u scles. Th e border bet w een th e h ard an d soft palates is easy
to visu alize by h aving th e p at ien t say “Ah ”; th en on ly th e soft
palate vibrates. Th e posterior en d of th e soft palate is th e palat in e velum , in th e m iddle of w h ich th e uvula h angs. Th e bony
palate is form ed by th e m axillar y bon e in it s an terior t w o-th irds
an d by th e palat in e bon e in its p osterior on e-th ird. On th e su r-
Inferior alveolar nerve
Posterior part
face of th e palat in e m u cosa are in cisive p ap illa, t ran sverse palat in e folds, palat in e raph e, and palat in e foveolae. Th e m ucosa of
the hard palate is com posed of the epithelium , proper lam ina and
subm ucosal tissue. The epith elium is keratin ized, and th e proper
lam in a is th ick an d lled w ith con n ect ive t issu e in th e an terior
p ar t of th e h ard palate. Th e subm u cosal t issue of th e in cisive
p apilla an d th e t ran sverse p alat in e folds are lled w ith fat t issu e, bu t th e p alat in e raph e lacks su bm u cosal t issu e. If th e p alat in e toru s exist s, th e palat in e m ucosa is so th in th at it is easily
injured an d m ay form ulcers cau sed by physical an d ch em ical
dam age. Palat in e glan ds are presen t at th e posterior surface of
th e soft palate. Many t aste buds are also located in th e soft palate. Th e in cisive fossa is just u n der th e in cisive papilla an d ascen ds to th e in cisive can al. Th e n asopalat in e ar ter y, vein , an d
n er ve ru n th rough th e in cisive can al; so care n eed s to be taken
w h en in cising over th e in cisive papilla. Th e greater palat in e foram en is located 15 m m lateral to th e p alat in e rap h e, bet w een
th e secon d an d th ird m olar. Th e greater palat in e arter y an d
n er ve ru n to th e an terior p ar t of th e h ard palate from th e greater
p alat in e foram en , so it is risky to in cise th e palate t ran sversely.
Many clin ician s h ave rep or ted cases in w h ich repair of an oroan t ral st u la w as u n der taken u sing th e p alat in e m u cosa for th e
axial pat tern ap an d using the greater palatine artery as a feeding vessel.5 Th e m uscles th at form th e soft palate are described
in th e sect ion on sw allow ing.
Tongue
Th e tongue is a m u scular organ , arising from th e oral oor an d
sp reading in to th e oral cavit y p roper (Fig. 20.9). Th e in t rin sic
m u scles ch an ge t h e sh ap e of t h e ton gu e, an d t h e ext r in sic
m u scles m ove th e tongu e an d in tersect an d p lay im p or t an t
roles in m ast icat ion , sw allow ing, an d speech . In addit ion , on e of
th e m ost im port an t fun ct ion s of th e tongue is as a t aste recep tor. Th ree cran ial n er ves convey th e t aste bers: CN VII (facial
n er ve, ch orda t ym p an i bran ch ), CN IX (glossop h ar yngeal n er ve),
187
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 20.8 Sensory innervation of the upper and lower gingiva,
tongue, and palatal mucosa.
a
Mental nerve
Infraorbital nerve,
superior labial branches
Buccal nerve
Nasopalaline
nerve
Median palatine
suture
Posterior septal
branches
Incisive
foram en
Buccal nerve
Infraorbital nerve,
anterior superior alveolar branches,
m iddle superior alveolar branch
Lingual nerve
Greater palatine
nerve
Infraorbital nerve, posterior
superior alveolar branches
Lesser palatine
nerve
Greater palatine
artery
Vom er
Greater palatine
foram en
Pterygoid ham ulus
Lesser palatine
foramen
Lesser palatine
arteries
Medial plates Pterygoid
Lateral plates process
Hypoglossal nerve
Palatopharyngeal
arch
Epiglot tis
Vagus nerve
b
Lingual
tonsil
Taste
Somatic sensation
Foram en
cecum
Vagus
nerve
(CN X)
Palatine
tonsil
Palatoglossal
arch
Sulcus
term inalis
Posterior
(pharyngeal)
part
Dorsum
Anterior
(oral) part
a
Glossopharyngeal
nerve (CN IX)
Glossopharyngeal
nerve (CN IX)
Facial nerve
(CN VII via
chorda tympani)
Median
furrow
Vagus
nerve
(CN X)
Lingual nerve
(m andibular
nerve, CN V3 )
Apex
Fig. 20.9 (a) Surface anatomy of the lingual mucosa. (b) Soma tosensory innervation (left side) and taste innervation (right side) of the tongue.
(Modi ed from THIEME Head and Neck Anatomy for Dental Medicine. © Thieme 2010, Illustrations by Karl Wesker.)
188
b
20 Oral Cavit y and Pharynx
an d CN X (vagu s n er ve). Th u s, a dist u rban ce in t aste sen sat ion
involving th e an terior t w o-th ird s of th e tongue in dicates th e
presence of a facial nerve (chorda t ym pani) lesion, w hereas a disturbance of som atic sensation indicates a lingual ner ve lesion.
On th e dorsal m u cosa of th e tongu e are fou r kin d s of p apillae: liform papillae, fu ngiform papillae, foliate p ap illae, an d
circum vallate papillae (Fig. 20.10). Filiform papillae are th e
sm allest an d are dist ribu ted over th e w h ole an terior t w o-th irds
of th e tongue; th ey are th e on ly papillae th at h ave n o t aste buds.
Th ey are kerat in ized an d w h ite. Fungiform papillae exist predom in an tly at th e lingual apex an d som et im es h ave t aste buds.
Th ey are n ot kerat in ized, so th ey t ake on th e red color of th e
capillar y vessels. Foliate papillae are th e four to seven folds located on th e posterolateral region of th e tongue. In adult s, th e
taste buds in th e foliate papillae degen erate. Serous glan ds lie
u n der th e foliate p ap illae for th e p urpose of clean ing th e taste
buds. Approxim ately 10 circum vallate papillae are posit ion ed in
fron t of th e term in al su lcu s an d form a V-sh ap ed lin e. Th ey are
Filiform
papilla
th e largest tongue papillae (3 m m in diam eter) an d are surroun ded by a deep groove in w h ich th ere are taste bud s in th e
epithelium . In adults, approxim ately t w o-thirds of the taste buds
are on th e tongu e. Th e soft palate also h as m any taste bu ds. In n er vat ion of th e an terior t w o-th ird s of th e tongu e com es from
th e ch orda t ym pan i, an d th e posterior th ird is in n er vated by th e
glossop h ar yngeal an d vagu s n er ves. Th erefore, it is kn ow n th at
if th ese n er ves are inju red by surgical procedures, ch em oth erapy, or radioth erapy, dysgeu sia m ay occu r. It is di cu lt to exam in e th e root of th e tongu e w h en th e m ou th is open . In cases
of an kyloglossia, in w h ich th e lingual fren ulum is too rigid to
allow m ovem en t of th e tongu e an d sp eech is h am p ered, lingu al
fren op last y m igh t be n ecessar y. Th e d eep lin gu al ar ter y an d
vein an d th e lingu al n er ve are sit u ated on th e in ferior su rface of
th e tongue, so sen sor y paralysis an d bleeding m ay occur if th ey
are inju red. In p ar t icu lar, care sh ou ld be t aken n ot to inju re th e
deep lingu al vein because of its posit ion directly u n der th e m u cosa (Fig. 20.11). If th e tongue is exten ded, th e border bet w een
Circum
(vallate) papilla
Fungiform
papilla
Lingual
m ucosa
Lingual aponeurosis
Lingual muscles
Keratinized squamous
epithelium on
tips of papillae
a
Papilla
Sulcus
Tip of papilla
(partially covered
by keratinized
epithelium)
Wall of papilla
Taste buds
Excretory
duct of a
serous gland
Serous
glands
(von Ebner
glands)
b
Connective
tissue core
c
d
Foliate
papillae
Taste buds
Excretory
duct of gland
e
Serous
gland
Fig. 20.10 Papillae of the tongue. (a) Sectional block diagram of the
lingual papillae. (b) Circumvallate papillae. (c) Fungiform papillae. (d) Filiform papillae. (e) Foliate papillae. (From THIEME Head and Neck Anatomy
for Dental Medicine. © Thieme 2010, Illustrations by Karl Wesker.)
189
Anatom y for Plastic Surgery of the Face, Head, and Neck
Deep lingual
artery
Lingual nerve
Styloid
process
Glossopharyngeal
nerve
Submandibular
ganglion
Dorsal lingual artery
Hypoglossal nerve
Hyoglossus
Mandible
Lingual artery
and vein
Deep lingual vein
C1 bers to thyrohyoid
Submental artery
and vein (from
facial artery and vein)
a
Sublingual
artery
Hyoid bone
Sublingual
vein
Thyrohyoid membrane
Apex of tongue
Anterior
lingual glands
Frenulum
Sublingual
fold
Sublingual
papilla
b
190
Deep lingual
artery and vein
Lingual nerve
Submandibular
duct
Fig. 20.11 Nerves and vessels of the tongue.
(a) Left lateral view. (b) View of the inferior
surface of the tongue. (From THIEME Head
and Neck Anatomy for Dental Medicine.
© Thieme 2010, Illustrations by Karl Wesker.)
20 Oral Cavit y and Pharynx
th e in ferior surface of th e tongu e an d th e oral oor is h ard to
see. It is w ell kn ow n th at th ere are com m u n icat ing bran ch es
bet w een th e lingual an d hypoglossal n er ves in th e body an d
ap ex of tongu e; h ow ever, th eir physiologic fu n ct ion is n ot fu lly
u n derstood .6
Buccal Fat Pad
Th e bu ccal fat pad (an atom ically, th e corpus adiposum bu ccae)
is th e fat located deep in th e ch eek region (Fig. 20.12). Th is fat is
also called Bich at’s fat p ad an d is n am ed after th e Fren ch an atom ist w h o rst recogn ized th e n at u re of th is t issu e. Th e bu ccal
fat p ad is located bet w een t h e m u scles of m ast icat ion in w h at
is called th e m ast icator y sp ace an d h as a role in facilit at ing th e
sm ooth gliding of th e m ast icator y m u scles. It also form s th e
sh ap e of th e bu lge of th e ch eek.
According to St u zin et al, th e bu ccal fat p ad con sists of a
m ain body an d th ree exten sion s: bu ccal, pter ygoid, an d tem p oral.7 Th e m ain body is th e par t above th e parot id duct an d is
located su p er cial to t h e bu ccin ator an d an ter ior to t h e an ter ior edge of th e m asseter. It also exten ds m edially to th e p osterior p ar t of th e m axilla. At th e su perior an d m ed ial sect ion , it
tou ch es th e m axillar y arter y an d th e m axillar y n er ve (a bran ch
of the t rigem in al n er ve). Th e buccal exten sion is th e super cial
segm en t located along th e an terior edge of th e m asseter an d
ben eath th e parot id duct . Th e buccal bran ch es of th e facial
n er ve ru n over th is exten sion . At th e an terior border, th e facial
ar ter y an d vein ru n obliqu ely. Th e pter ygoid exten sion is in th e
area bet w een th e ram u s of m an dible an d th e pter ygoid m u scles. Th e tem poral exten sion passes ben eath th e an terior par t of
Fig. 20.12 Buccal fat pad. The buccal fat pad
consists of a main body and three extensions:
buccal, pterygoid, and temporal. The main
body is the part above the parotid duct and
is located super cial to the buccinator and
anterior to the anterior edge of the masseter.
The buccal extension is the super cial segment
located along the anterior edge of the masseter
and beneath the parotid duct. The pterygoid
extension is in the area bet ween the ramus
of mandible and the pterygoid muscles. The
temporal extension passes beneath the
anterior part of the zygomatic arch and lies
bet ween the temporalis muscle and the deep
temporal fascia.
191
Anatom y for Plastic Surgery of the Face, Head, and Neck
th e zygom at ic arch an d lies bet w een th e tem poralis m uscle an d
th e deep tem poral fascia.
Th e buccal fat pad is used in free graft s an d pedicle aps for
variou s t issu e defect s, m ost com m on ly for th e rep air of oroan t ral st ulae an d also for th e t reat m en t of oth er oral cavit y t issue
d efect s, ran gin g from t h e an gle of m ou t h to t h e ret rom olar
t rigon e an d palate.8
tine velum w ith a m edian process know n as the uvula. Tw o folds
ru n laterally dow nw ard from th e palat in e velu m . Th e an terior
fold is th e palatoglossal arch , an d th e p osterior fold is th e p alatoph ar yngeal arch . Th e palat in e ton sils are sit uated bet w een
th ese t w o folds on both sides.
Pharynx
Floor of Mouth and
Sublingual Space
Th e oor of th e m outh is th e region surroun ded by th e low er
alveolu s an d th e tongu e. Th e su bm u cosal t issu e of th e oor of
th e m outh is com posed of sparse con n ect ive t issu e an d is h igh ly
m obile. Th e oor of th e m ou th is divided in to t w o part s by th e
lingu al fren u lu m . Th e su bm an dibular duct (W h ar ton’s duct)
open s at th e sublingual carun cle after join ing th e greater sub lingu al du ct , an d m any lesser sublingual du ct s op en at th e su b lin gu al fold p oster ior to t h e su blin gu al car u n cle. Ben eat h t h e
oor of th e m ou th is a su blingu al sp ace located su p erior to th e
m ylohyoid m u scle an d on th e lateral side of th e gen ioglossus
an d gen iohyoid m u scle. Th e con ten t s of th is space are th e su b lingu al glan d; th e su bm an dibular du ct; th e greater an d lesser
su blingu al du ct s; th e lingu al n er ve, arter y, an d vein ; an d th e
hypoglossal n er ve. Th is space is th erefore quite im port an t in
clin ical sit uat ion s. Th e subm an dibular du ct arises from th e sub m an dibu lar glan d, w h ich is located p osterior to th e en d of th e
m ylohyoid m u scle an d run s to th e su blingu al carun cle. On th e
proxim al part of the subm andibular duct, the lingual nerve t raverses in ferior to th e su bm an dibu lar du ct an d is th en dist ribu ted
to th e tongue. Th e reported in ciden ce of sublingual glan d prot r u sion t h rough d efect s in t h e m ylohyoid m u scle is ap p roxim ately 25 to 40%.9 Care sh ou ld be t aken arou n d t h is area, as
t h e su bm en t al arter y (a bran ch of th e facial ar ter y) an d th e sub lingual artery (a branch of the lingual arter y) travel into the dorsal sid e of th e m idlin e of th e m an dible at th e lingu al foram en .
Th ere are m any variat ion s of an astom oses of th e subm en t al an d
su blingu al arteries.10
Oropharyngeal Isthmus
Th e oroph ar yngeal isth m us form s th e border of th e oral cavit y
an d th e p h ar yn x an d is th e posterior en d of th e oral vest ibu le
(Fig. 20.2). Th e posterior en d of th e soft palate form s th e pala-
192
Th e p h ar yn x is t h e d igest ive t u be located bet w een oral cavit y
an d t h e esop h agu s, p oster ior to t h e oral an d n asal cavit y. Th e
p h ar yn geal cavit y is t h e in tersect ion of t h e d igest ive t ract
an d t h e resp irator y system . Th e p h ar yn x is com p osed of t h e
ep i(n aso)ph ar yn x, oroph ar yn x, an d hypoph ar yn x. Th e ep ip h aryn x is p osit ion ed dorsal to th e p osterior n asal ap ert u res at th e
back en d of th e n ose; th e ph ar yngeal open ing of th e auditor y
t ube, w h ich is con n ected w ith th e t ym pan um open s in th e lat eral w all; an d t h e p h ar yn geal ton sil is located in t h e p oster ior
w all. Wald eyer’s rin g is com p osed of t h e p alat in e ton sil, t h e
lin gu al ton sil, an d th e p h ar yngeal ton sil, an d it com p rises im m u n ocom peten t lym p h at ic t issu e. Th is is th e rst biophylaxis
again st foreign invasion . Th e oroph ar yn x is located posterior to
th e oral cavit y, an d th e hypoph ar yn x com m u n icates w ith th e
lar yngeal cavit y th rough th e lar yngeal aper t ure.
Sw allow ing
Th e act of eat ing an d sw allow ing, w h ich is required for th e in t ake of food, can be easily explain ed by dividing it in to ve
st ages: th e aw aren ess p h ase (p relim in ar y p h ase), th e prep arator y ph ase (ch ew ing ph ase), th e oral cavit y ph ase, th e ph ar yn geal p h ase, an d th e esoph ageal p h ase. In th e aw aren ess ph ase,
th e body becom es aw are of food an d creates a n at ural eat ing
pace. During th e prep arator y phase, food p laced in th e m ou th is
ch ew ed an d m ixed to create a food bolus in a con dit ion th at can
be sw allow ed. During th e oral cavit y ph ase, th e bolus th us created is t ran sferred from th e m ou th to th e th roat , after w h ich it
m oves from th e th roat to th e esop h agu s du ring th e ph ar yngeal
ph ase. During th e esoph ageal ph ase, it is t ran sferred from th e
esop h agu s to th e stom ach in a p rocess of con t in u al m ovem en t
(Fig. 20.13).11 Repor ts n ote cases in w h ich food is t ran sferred
in to th e orophar yn x du ring ch ew ing, before th e sw allow ing reex begin s,12–15 an d in w h ich repeated sw allow ing resu lt s in a
pat tern in w h ich th e lar yn x is elevated.16,17 During sw allow ing,
m any m u scle grou p s, in clu ding th e m im et ic m u scles su rrou n ding th e oral cavit y, m ast icator y m uscles, tongue m u scles, p alate
20 Oral Cavit y and Pharynx
Fig. 20.13 Schematic diagram of swallowing.
(a) Retention of the food bolus in the oral
cavit y. (b) Immediately before the beginning
of the swallowing re ex. (c) Food bolus moves
to the oropharynx. (d) Food bolus m oves from
the lower pharynx to the esophageal entrance.
(e) Food bolus passes through the esophageal
entrance. (f) Food bolus moves from the
esophagus to the stomach.
a
d
b
c
e
m uscles, upper an d lower hyoid m uscles, th e ph aryngeal m uscle,
an d laryngeal m uscle, all w ork togeth er, w ith these m uscles cont rolled by th e t rigem in al n er ve, facial n er ves, glossoph ar yngeal/
vagu s n er ve, hyp oglossal n er ve, an d cer vical n er ves, w h ich receive in st ruct ion s from th e m ast icat ion an d sw allow ing cen ter.
In th is sect ion , w e presen t an exp lan at ion of sw allow ing m ovem en t from th e p rep arator y p h ase onw ard, based m ain ly on th e
m u scles related to sw allow ing.
Mechanism of Sw allow ing and the
Involved Muscles
Preparatory Phase (Chew ing and Food
Bolus Formation)
Th e food t aken in to th e oral cavit y is form ed in to a food bolu s
by th e tongue if it does n ot require ch ew ing (Fig. 20.13a, Fig.
20.14e).11 Food th at requires ch ew ing is broken dow n by th e
act ion n ot on ly of th e tongu e bu t also of th e jaw an d ch eeks, an d
th en it is m ixed w ith saliva. W h en ch ew ing begin s, th e food is
f
sw iftly posit ion ed on th e m olars an d ch ew ed by th e su bsequ en t
raising action of the jaw w hile being held in place by the expression m uscles, m im etic m uscles such as the cheek and tongue
m u scles (Fig. 20.14b– e, Fig. 20.15). Th e low er jaw closes w h en
th e m asseter m uscle, tem poralis m uscles, an d m edial pter ygoid
m u scles on both sides con t ract; m oves for w ard w h en th e an terior lateral pter ygoid m u scle con t ract s; an d rot ates w h en th e
lateral pter ygoid m uscle on on e side con t racts (Fig. 20.14b, Fig.
20.16). It open s as a result of th e m ovem en t of th e lateral pter ygoid m u scle an d su p rahyoid m u scle. Th e tongu e con tain s in t rin sic an d ext rin sic m u scles (Fig. 20.14e ), w ith m ovem en t of
th e in t rin sic m uscles causing it to con t ract or becom e long an d
th in or w ide an d at . Of th e ext rin sic m uscles, th e gen ioglossus
m u scle p rot r u d es t h e ton gu e; t h e st yloglossu s m u scle raises
t h e posterior aspect of th e tongue, along w ith th e palatoglossal
m u scle. Th e gen ioglossu s m u scle an d t h e st yloglossu s m u scle
m ove toget h er to ret ract t h e ton gu e. Th e hyoglossu s m u scle
w orks to m ove t h e sid es of t h e ton gu e d ow nw ard ; t h e ton gu e
is low ered by t h e gen ioglossu s m u scle an d hyoglossu s m u scle.
W h en a food bolu s is for m ed w it h in t h e oral cavit y, a dep ression is created in th e cen ter of th e tongu e, w h ich “h old s” th e
food bolu s, requ iring th e soft p alate an d th e tongu e to be close
193
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i
g
.
2
0
.
1
4
O
r
o
p
h
a
r
y
n
g
e
a
l
m
u
s
c
l
e
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a
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n
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r
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.
Anatom y for Plastic Surgery of the Face, Head, and Neck
194
20 Oral Cavit y and Pharynx
form at ion of Passavan t’s ridge, resu lt ing in th e u p p er p h ar yn x
being rm ly closed (Fig. 20.14d, Fig. 20.17).
Th e food th en begin s to be passed in to th e ph ar yn x, an d th e
sw allow ing re ex begin s, at w h ich p oin t th e hyoid bon e begin s
to be elevated (Fig. 20.18). Th e hyoid bon e m oves sligh tly backw ard at rst , after w h ich it begin s to m ove u pw ard, an d th en
n ally st rongly for w ard an d dow nw ard . Th e rear w ard m ovem en t of th e hyoid bon e at th e st ar t is fu rth erm ore believed to
be caused by con t ract ion of th e st ylohyoid m uscle an d th e posterior belly of th e digast ric m uscle (Fig. 20.14c, Fig. 20.18).
Fig. 20.15 Schematic diagram of the movement of the cheeks,
tongue, and lower jaw during chewing.
to on e an oth er. To facilit ate th is act ion , th e tongu e t akes on th e
for m at ion of a sp oon an d is elevated at t h e back by t h e st yloglossu s m u scle; t h e soft p alate is d raw n tow ard t h e tongu e
by th e palatoglossal an d palatoph ar yngeal m uscles (Fig. 20.14d,
Fig. 20.17).18
End of the Oral Cavity Phase and
Beginning of the Pharyngeal Phase
Th e food bolus in th e oral cavit y is t ran sferred to th e ph ar yn x;
im m ediately before th e ph ar yngeal p h ase begin s, th e in t rin sic
an d ext r in sic ton gu e m u scles cau se t h e ton gu e to ad h ere to
t h e palate, gripping th e food bolus so that it is m oved tow ards
t h e p h ar yn x (Fig. 20.13b). From t h e st ar t of t h e t ran sfer (oral
cavit y p h ase), t h e act ion becom es re exive, an d volu n t ar y
con t rol becom es im p ossible. W h en t h e t ran sfer is n ally im p lem en ted, th e low er jaw an d th e lip s are u su ally closed. At th e
sam e t im e, to p reven t th e food bolu s from p assing in to th e n asoph ar yn x, th e soft palate is elevated by th e ten sor an d levator
m u scles of th e p alat in e velu m (Fig. 20.14b,d, Fig. 20.17); furth erm ore, con t ract ion of th e ph ar yngeal con t ractor causes th e
Pharyngeal Phase (Food Bolus Moves to
the Oropharynx)
With th e soft palate st ill elevated, th e food bolu s is p u sh ed ou t
from th e base of th e tongu e to th e orop h ar yn x (Fig. 20.13c, Fig.
20.14b,c), at w h ich poin t th e upper ph ar yngeal an d oroph ar yn geal contractors begin to contract (Fig. 20.14d), causing the hyoid
bon e an d lar yn x to m ove tow ard th eir h igh est posit ion (Fig.
20.14d, Fig. 20.18). On ce th e hyoid bon e is elevated, th e m ylohyoid m uscle and the anterior belly of the digastric m uscle m ove
th e hyoid bon e upw ard w h ile th e gen iohyoid m uscle m oves th e
hyoid bon e for w ard s (Fig. 20.14b,f). It is believed t h at t h ese
act ion s togeth er cau se elevat ion of th e hyoid bon e (Fig. 20.14f).
Next , th e thyrohyoid m u scle con t racts to elevate th e lar yn x. At
th e sam e t im e as th e elevat ion of th e lar yn x, th e ph ar yngeal
con st rictor m uscles im plem en t perist alt ic con st rict ion from th e
u pper to th e low er ph ar yn x to t ran sfer th e food from th e ph arynx in to th e esoph agus. Con traction in the orophar yn x is caused
n ot on ly by th e ph ar yngeal con st rictor act ion bu t also by th e
base of th e tongue, w h ich form s th e ph ar yngeal an terior w all,
m oving tow ard th e rear (Fig. 20.14e).
Furth erm ore, during th e sw allow ing react ion , th e glot t is is
closed by th e act ion of th e lar yngeal in t rin sic m uscles, in h ibiting th e air w ay (Fig. 20.14d, Fig. 20.19). Th e lar yngeal m uscles
an d lateral thyroar yten oid m u scles both act to addu ct th e vocal
cords; h ow ever, th e thyroar yten oid m uscle sh or ten s th e vocal
cord s by con t ract ing inw ard , an d t h e lateral t hyroar yten oid
Fig. 20.16 Movements of the mandible by at tached muscles.
195
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 20.17 Schematic diagram of velopharyngeal muscles action during speech. 1, Tensor veli palatini; 2, levator veli palatini; 3, palatoglossus;
4, palatpharyngeus; 5, superior constrictor.
m u scle len gt h en s t h e vocal cord s by con t ract in g ou t w ard . Because th e in terar yten oid m uscles also adduct th e vocal cords,
th e posterior cricoar yten oid m uscle is th e on ly m uscle that ab ducts the vocal cords. In addition, the cricothyroid m uscle causes
th e thyroid cart ilage an d cricoid car t ilage to approach on e an oth er, st retch ing th e vocal cords an d raising th e p itch of th e
voice (Fig. 20.14d).
Pharyngeal Phase (Food Bolus Moves
from the Low er Pharynx to the
Esophageal Entrance)
Th e act ion of th e suprahyoid an d in frahyoid m uscles results in
th e hyoid bon e being m oved as far upw ard an d for w ard as pos-
196
sible, bringing th e hyoid bon e close to th e lar yn x (Fig. 20.20).
Ph ar yngeal con t ract ion reach es th e orop h ar yn x, an d th e act ion
of th e palatoph ar yngeal an d palatoglossal m uscles low ers th e
soft p alate (Fig. 20.13d, Fig. 20.14d,f, Fig. 20.18). Th e glot t is rem ain s closed, and con traction of the aryepiglot tic m uscle results
in t h e ep iglot t is an d ar yten oid car t ilage bein g brough t close
togeth er, n arrow ing th e en t ran ce to th e lar yn x (Fig. 20.14d).
Th e furth er rear w ard m ovem en t of th e base of th e tongue an d
th e dow nw ard pressure from above on th e food th at h as been
sw allow ed resu lt in th e ep iglot t is collap sing inw ard, closing th e
lar yn x an d preven t ing foreign bodies from en tering th e air w ay
du ring sw allow ing an d tem porarily stopping breath ing (sw allow in g ap n ea). W it h t h e lar yn x closed , t h e food bolu s p asses
t h rough t h e low er p h ar yn x on t h e sid e of t h e lar yn x. Th e base
of t h e low er p h ar yn x feat u res d ep ression s to t h e left an d r igh t
20 Oral Cavit y and Pharynx
Fig. 20.19 Schematic diagram of laryngeal m uscle actions. (a) Cricoid
cartilage. (b) Thyroid cartilage. (c) Vocal cord membranous part.
(d) Arytenoid cartilage. (e) Thyroarytenoid muscle. (f) Lateral
cricoarytenoid muscle. (g ) Interarytenoid muscles. (h) Posterior
cricoarytenoid muscle.
Fig. 20.18 Elevation pat terns of the hyoid bone during swallowing
1. Moving backward; 2. moving forward; 3. to a lowered resting
position.
kn ow n as t h e p ir ifor m recesses, w h ich are in t h e for m of an
inver ted con e. Th eir bases are closed by th e con t ract ion of th e
cricoph ar yngeus m u scle, th e sph in cter m u scle th at form s th e
en t ran ce to th e esop h agu s. Th e cricop h ar yngeu s m u scle is p ar t
of th e low er ph ar yngeal con st rictor m uscles; w h en th e cricoph ar yngeu s m uscle relaxes an d th e lar yn x is elevated (m oved
for w ard), th e esoph ageal en t ran ce is op en ed, allow ing th e food
bolus to pass th rough (Fig. 20.14d). On ce th e food bolus passes
th rough th e esoph ageal en t ran ce, it is com pressed by th e lar yn x
an d th e cer vical ver tebrae an d passes, separately, to th e left an d
righ t p iriform recesses, avoiding th e cen ter.
End of the Pharyngeal Phase to the
Esophageal Phase
W h en th e food bolu s is t ran sferred to th e esoph agus, th e soft
palate, tongue, hyoid bon e, an d lar yn x ret urn to th eir origin al
posit ion s (Fig. 20.13f). Th e glot t is is open ed w ide an d th e
cricoph ar yngeus m uscle con st ricts, closing th e en t ran ce to th e
esop h agu s. Th e food bolu s th at h as en tered th e esop h agu s is
carried to th e stom ach by perist alsis, at a t ran sfer speed of ap proxim ately 40 cm per secon d in th e upper esoph agus an d 4 cm
per secon d in th e low er part , passing th rough th e esoph agu s in
arou n d 10 secon ds. In a h ealthy esoph agu s, p eristalsis occu rs
after sw allow ing via a rst con t ract ion , occu rring at th e sam e
t im e th at th e food bolus en ters th e upper esoph agus, an d a second con t ract ion th at occurs in respon se to th e st im u lat ion of
th e esoph agus being w iden ed by th e food bolus.
Occlusion
Con cepts about occlusion bet w een th e upper an d low er teeth
h ave ch anged over t im e; h ow ever, th e th eor y relat ing to occlu sion in th e t reat m en t of facial fract u res is sim ple an d u n ch anging. In th is subch apter, w e describe occlu sion in relat ion to jaw
fract u re t reat m en t . Du ring su rger y after facial t rau m a, th e aim
is to set th e occlusion in th e in tercu sp al posit ion w ith th e teeth
in m a xim u m in tercu sp at ion an d t h en t igh ten t h e bon es w it h
screw s. For sim p le fract u res, it is easy to n d t h e in tercu sp al
p osit ion ; h ow ever, in cases of com p licated an d m u lt ip le fract u res, it is d i cu lt for t h e su rgeon to d eter m in e t h e cor rect
occlu sal posit ion . On e m eth od for determ in ing th e in tercuspal
p osit ion is to look for occlusal facet s in th e upper an d low er
teeth . According to Schyler, th ese facet s are presen t on th e occlusal surfaces of th e teeth as a result of fun ct ion al or som et im es secon dar y m ovem en t of t h e m an dible. Th is is regard ed
as a n at u ral an d in evit able p rocess of occlu sal equ ilibrat ion .
Th e facets also guide th e m an dible du ring th e occlusal ph ase of
m ast icat ion .19
197
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 20.20 Schematic diagram of the action
of the muscles during swallowing and
opening of the mouth.
Aesthetic Region
W h en con sidering th e m axillofacial region as an aesth et ic zon e,
w e sh ou ld th in k abou t m any factors, su ch as face, eyes, lips, gin giva, an d teeth .20 In th is sect ion , w e h ave m ade sligh t m en t ion
of th e lips, gingiva, an d teeth , w h ich are closely related to th e
oral cavit y. According to Lom bardi, th e facial m idlin e is located
at th e cen ter of the face an d perpen dicu lar to th e in terpu pillar y
lin e.21 Magn e et al described th e im p or t an ce of th e relat ion sh ip
bet w een th e edge of th e in cisor teeth an d th e low er lip lin e (Fig.
20.21). Th ey also m en t ion ed th at th e “golden propor t ion ” an d
th e “golden percen t age,” w h ich apply to th e apparen t size of th e
teeth w h en view ed directly from th e fron t (lateral in cisor in a
proport ion of 1:1.618 to th e cen t ral in cisor an d 1:0.618 to th e
can in e) are too r igid for d en t ist r y.20 In 2012, Tsu kiyam a et al
u n d er took a st u dy com p ar in g t h e m or p h ology of t h e cen t ral
in cisor, lateral in cisor, can in e, an d rst p rem olar bet w een w h ite
an d Asian pop u lat ion s. Th ey con clu d ed th at th e cen t ral in cisors
of Asian subject s w ere n arrow er an d m ore slen der th an th ose of
w h ite subject s (Fig. 20.22).22 Th is st u dy con rm s th at th ere is
racial variat ion bet w een w h ite an d Asian p op u lat ion s in term s
of th e m orph ology of th e m axillar y cen t ral in cisor teeth an d th e
facial skeleton . W h en th in king abou t th e ideals of th e aesth et ic
region , in cluding th e oral cavit y, w e sh ou ld ackn ow ledge th e
existen ce of di eren t id eals am ong th e races.
Fig. 20.21 Relationship bet ween the edge of
the incisor teeth and the lower lip line. (Picture
provided by Dr. T. Tsukiyama with permission
from Elsevier.)
198
20 Oral Cavit y and Pharynx
Fig. 20.22 Comparison of central incisors
bet ween Asian and white subjects. The
numbers on the surface of the teeth show the
width-to-length ratio of the central incisors (%).
(Picture provided by Dr. T. Tsukiyama, with
permission from Elsevier.)
References
1. Beh n ia H, Kh eradvar A, Sh ah rokh i M. An an atom ic st u dy of t h e
lin gu al n er ve in t h e t h ird m olar region . J Oral Ma xillofac Su rg
2000;58(6):649–653 Pu bMed
2. Ud h aya K, Saralad evi KV, Sr id h ar J. Th e m or p h om et r ic an alysis of
t h e m en t al foram en in ad u lt d r y h u m an m an d ibles: a st u dy on
t h e Sou t h In dian p op u lat ion . J Clin Diagn Res 2013;7(8):1547–
1551 Pu bMed
3. Kalen der A, Orh an K, Aksoy U. Evaluat ion of th e m en t al foram en
an d accessor y m en t al foram en in Tu rkish p at ien t s u sing con ebeam com p u ted tom ograp hy im ages recon st ru cted from a volum etric ren dering program . Clin Anat 2012;25(5):584–592 PubMed
4. Naitoh M, Yosh ida K, Nakah ara K, Gotoh K, Ariji E. Dem on st rat ion
of th e accessor y m en t al foram en using rot at ion al pan oram ic radiography com pared w ith con e-beam com puted tom ography. Clin
Oral Im p lan t s Res 2011;22(12):1415–1419 Pu bMed
5. Anavi Y, Gal G, Silfen R, Cald eron S. Palat al rot at ion -advancem en t
ap for delayed rep air of oroan t ral st u la: a ret rosp ect ive evalu at ion of 63 cases. Oral Su rg Oral Med Oral Path ol Oral Radiol En dod
2003;96(5):527–534 Pu bMed
6. Fit zgerald MJT, Law ME. Th e periph eral con n exion s bet w een th e
lingual and hypoglossal nerves. J Anat 1958;92(2):178–188 PubMed
7. St uzin JM, Wagst rom L, Kaw am oto HK, Baker TJ, Wolfe SA. Th e
an atom y an d clin ical applicat ion s of th e buccal fat pad. Plast Recon st r Surg 1990;85(1):29–37 PubMed
8. Alkan A, Dolan m az D, Uzu n E, Erdem E. Th e recon st ru ct ion of oral
defect s w ith bu ccal fat p ad. Sw iss Med Wkly 2003;133(33-34):
465–470 PubMed
9. Oton ari-Yam am oto M, Nakajim a K, Tsuji Y, et al. Mylohyoid m u scle
defect s: com parison of CT n d ings an d d issected sp ecim en s. Oral
Radiol 2011;27:50–56
10. Lou kas M, Kin sella CR Jr, Kap os T, Tu bbs RS, Ram ach an dra S. An atom ical variat ion in ar terial su p ply of th e m an dible w ith special
regard to im plan t placem en t . In t J Oral Maxillofac Surg 2008;
37(4):367–371 Pu bMed
11. Don n er MW, Bosm a JF, Rober t son DL. An atom y an d p hysiology of
th e p h ar yn x. Gast roin test Radiol 1985;10(3):196–212 PubMed
12. Palm er JB, Ru din NJ, Lara G, Crom pton AW. Coordin at ion of m ast icat ion an d sw allow ing. Dysph agia 1992;7(4):187–200 PubMed
13. Palm er JB, Hiiem ae KM, Liu J. Tongue-jaw linkages in h u m an feeding: a prelim in ar y video uorograph ic st u dy. Arch Oral Biol 1997;
42(6):429–441 PubMed
14. Palm er JB. Bolus aggregat ion in th e oroph ar yn x does n ot depen d
on gravit y. Arch Phys Med Reh abil 1998;79(6):691–696 Pu bMed
15. Hiiem ae KM, Palm er JB. Food transport and bolus form ation during
com plete feeding sequ en ces on foods of di eren t in it ial con sisten cy. Dysph agia 1999;14(1):31–42 PubMed
16. Ch i-Fish m an G, Son ies BC. Motor st rategy in rap id sequ en t ial sw allow ing: n ew in sigh t s. J Speech Lang Hear Res 2000;43(6):1481–
1492 PubMed
17. Dan iels SK, Foun das AL. Sw allow ing physiology of sequen t ial st raw
drin king. Dysp h agia 2001;16(3):176–182 PubMed
18. Frit zell B. Th e veloph ar yngeal m uscles in speech . An elect rom yograph ic an d cin éradiograph ic st udy. Act a Otolar yngol 1969;250:
250, 1 Pu bMed
19. Sch uyler CH. Factors con t ribu t ing to t rau m at ic occlu sion . J Prosth et Den t 1961;11:708–715
20. Magn e P, Gallu cci GO, Belser UC. Anatom ic crow n w idth /length rat ios of u nw orn an d w orn m axillar y teeth in w h ite su bject s. J Prosth et Den t 2003;89(5):453–461 Pu bMed
21. Lom bardi RE. Th e prin cip les of visu al p ercept ion an d th eir clin ical
ap p licat ion to den t u re esth et ics. J Prosth et Den t 1973;29(4):358–
382 Pu bMed
22. Tsukiyam a T, Marcush am er E, Gri n TJ, Arguello E, Magn e P, Gallucci GO. Com parison of th e an atom ic crow n w id th /length rat ios
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J Prosth et Den t 2012;107(1):11–16 Pu bMed
199
21
Neck
Sherine S. Raveendran and Lucian Ion
Introduction
Th e n eck is a cylin drical st ruct ure th at exten ds from th e base of
the skull to the thoracic inlet (Fig. 21.1). The neck encloses m any
vit al st ru ct u res an d act s as a con du it bet w een th e cran iu m su periorly an d th e th orax an d upper lim b in feriorly. An atom ically,
th e n eck is organ ized in to th ree basic com part m en t s:
•
•
•
Posterior com partm ent: m usculoskeletal (support and m ovem en t of th e h ead an d n eck)
An terior com part m en t: visceral (glan du lar, resp irator y, an d
gast roin test in al)
Lateral com p ar t m en t: large blood vessels an d n er ves
Skeletal Support
Cervical Spine
Th e cer vical spin e con sists of seven ver tebrae w ith som e com m on ch aracterist ics an d sp eci c feat u res for C1, C2, an d C7 (Fig.
21.2). In th e cer vical region , th e bodies of th e ver tebrae are relat ively sm all, an d w ider t ran sversely th an an teroposteriorly,
th e pedicles are directed laterally an d posteriorly, an d th e lam in ae are relat ively n arrow. Th e t ransverse processes are pierced
by foram en t ran sversaria, th rough w h ich pass th e vertebral arter y from usually C1 to C6 ver tebrae (Fig. 21.3).
Th e atlas (C1) is th e u pperm ost of th e vertebrae; it ar t iculates w it h t h e base of t h e sku ll an d allow s an terop oster ior
m ovem en t . It does n ot h ave a vertebral body. Th e axis (C2) is
th e secon d vertebra an d art iculates w ith th e atlas as a pivot th at
allow s rotat ion . It h as a ch aracterist ic odon toid p rocess, rising
perpen dicu lar from th e su perior surface of th e body. A st rong
t ran sverse ligam en t com pletes th e ar t iculat ion bet w een th e
atlas an d th e od on toid process posteriorly. C7 is kn ow n as th e
vertebra p rom in en s an d h as a ch aracterist ic prom in en t sp in ou s
process th at can be palpated; it represen ts th e extern al lan d m ark for t h e low er p ar t of t h e cer vical sp in e. In som e in d ivid u als, C7 is associated w ith an abn orm al ext ra rib (cer vical rib),
w h ich can produ ce sym ptom s of com pression of blood vessels
at th e root of th e n eck or of th e brach ial plexu s. W h en sym ptom at ic, it is referred to as th oracic ou tlet syn drom e.
Surgical Annotation
In a n u m ber of gen et ic syn drom es, in clu d ing Dow n’s syn drom e,
after in fect ion s of th e sp in e an d in p at ien t s w ith a h istor y of
200
rh eum atoid ar th rit is, th e atlan toaxial join t can be un st able, an d
in hyperexten sion , it leads to com pression of th e spin e, w h ich
m ay be fatal. Pat ien t s w h o h ave a h istor y of rh eu m atoid or predisposing gen et ic syn drom es are at greater risk for a gen eral
an esth et ic as a resu lt of th e n eed to hyp erexten d th e n eck du ring in t u bat ion .
Hyoid Bone
Th e hyoid t akes suppor t on ly from th e m u scles an d ligam en t s
associated w ith m obilit y of th e gast roesop h ageal an d resp irator y visceral st ruct ures in th e n eck an d oor of m outh (Fig.
21.4). Th e bon e h as a U-sh ape con tour an d is divided in to th ree
com pon en t s: th e body, posit ion ed an terior an d h orizon t ally,
an d laterally p aired p roject ion s, th e greater an d lesser h orn s or
corn ua. Th e greater h orn s project posteriorly an d superiorly,
an d th e lesser h orn s project su periorly. Th e hyoid bon e provides at t ach m en t to m u scles th at m ove th e tongu e, depresses
th e m an dible, an d m oves th e lar yn x. Th e superior at t ach m en t s
are for th e m id dle p h ar yngeal con st rictor, hyoglossu s, m ylohyoid, gen iohyoid, st ylohyoid, an d digast ric m uscles. Th e in ferior
at tach m en t s are for th e thyrohyoid, st ylohyoid, an d om ohyoid
m u scles.
Skin, Adipose Tissue, Fascia
Skin
Th e skin on th e n eck is th in an d drapes along th e con tour of th e
deeper st ruct u res an teriorly. Th e skin on th e posterior n eck h as
th icker derm is, w ith st ronger st abilizing brous septae, an d h as
lim ited m obilit y. In th e su bm en tal and su bm an d ibular areas,
th e skin is less adh eren t . In th e post au ricular an d m astoid region s, it is closely at t ach ed to th e u n derlying t issu es.
Adipose Tissue
Th e adipose t issue in th e n eck is dist ributed in th e supraplat ysm al, in terp lat ysm al, an d su bp lat ysm al p lan es (Fig. 21.5). Th e
an atom ical st u dies reveal th at th e fat in th e su bcu t an eou s plan e
ranges from 8.4 to 15 g (Fig. 21.5a). Th e tot al am oun t of fat in
t h is region can var y in t h e p resen ce of w eigh t excess. Th e fat
in th e su bp lat ysm al p lan e averages 3.7 g (Fig. 21.5b). In clin ical
set t ings, it ap pears to be less in u en ced by w eigh t variat ion s.
Th e fat is com part m en t alized in th e subm en t al region .1–3
21 Neck
Frontal bone
Zygom atic
bone
Supraorbital m argin
Infraorbital m argin
Helix
Fig. 21.1 Surface anatomy and external
landmarks of the neck. (From THIEME
Atlas of Anatomy, General Anatomy and
Musculoskeltal System. © Thieme 2005,
Illustration by Karl Wesker.)
Philtrum
Antihelix
Com m issure of lips
Tragus
Antitragus
Mental protuberance
Mandibular angle
Subm andibular gland
Mandible,
inferior border
Thyroid cartilage
Trapezius
Omohyoid,
inferior belly
Clavicle
Clavicular Sternal
head
head
Jugular notch
Sternocleidom astoid
Transverse
foramen
Transverse
process
a
Superior
articular process
Superior
articular facet
Inferior
articular
process
Body
Sulcus for
spinal nerve
Uncinate
process
Vertebral
foramen
Posterior
tubercle
Sulcus
for spinal
nerve
Spinous
process
Inferior
articular facet
Superior
articular process
Anterior
tubercle
Body
Transverse
process
Inferior
articular facet
Spinous process
b
Spinous process
Vertebral arch
Lam ina
Superior
articular facet
Pedicle
Transverse
process with
sulcus for
spinal nerve
c
Posterior
tubercle
Transverse
foramen
Body
Anterior
tubercle
Fig. 21.2 Typical cervical vertebra (C4). (a) Left lateral view. (b) Anterior view. (c) Superior view. (From THIEME Atlas of Anatomy, General
Anatomy and Musculoskeltal System. © Thieme 2005, Illustrations by
Karl Wesker.)
201
Anatom y for Plastic Surgery of the Face, Head, and Neck
Vertebral artery
Ascending pharyngeal
artery
External carotid artery
Lingual
artery
Internal carotid artery
Infrahyoid branch
Superior
thyroid artery
Superior
laryngeal artery
Vertebral artery
Inferior thyroid artery
Ascending cervical artery
Cricothyroid branch
Com m on carotid artery
Transverse cervical artery
Glandular branches
Suprascapular artery
Thyrocervical trunk
Left subclavian artery
Fig. 21.3 Passage of the vertebral artery through the foramen transversarium of the cervical vertebra. (From THIEME Atlas of Anatomy, General
Anatomy and Musculoskeltal System. © Thieme 2005, Illustration by Karl Wesker.)
Lesser horn
Greater horn
Body
a
Lesser horn
Greater horn
Body
b
Lesser horn
Greater horn
c
202
Fig. 21.4 The hyoid bone. (a) Anterior view. (b) Posterior view. (c) Left
lateral view. (From THIEME Atlas of Anatomy, General Anatomy and
Musculoskeltal System. © Thieme 2005, Illustrations by Karl Wesker.)
21 Neck
Fig. 21.5 Adipose tissue distribution in the
super cial and deep planes of the neck (a) supercial fat and (b) deep fat.
a
b
Surgical Annotation
Cervical Fascia
Th e volum e of th e n eck is determ in ed by th e exten t of fat deposit ion , w h ich in t u rn determ in es th e girth of th e n eck. In th e
fat t y n eck, th ere is fat deposit ion in th e su p er cial an d th e
deeper layers, gen erat ing a less de n ed or even convex sh ape of
th e cer vicom en t al angle. Volum e reduct ion during n eck con tou ring can in corp orate volu m e red u ct ion in all fat com partm en t s of th e an terior n eck to redu ce girth an d to im prove
con tours. In slim n ecks, th ere is m in im al fat an d th e skin drapes
over th e p lat ysm a cau sing visible ban ds in old er su bjects.
Th e cer vical fascia is broadly divided in to super cial an d deep
layers (Fig. 21.6).
Super cial Cervical Fascia
Su p er cial cer vical fascia is t h e con t in u at ion of t h e su p er cial
m u scu loap on eu rot ic system (SMAS), also refer red to as t h e
SMAS layer. It con t ain s cu t an eou s n er ves, blood vessels, lym p h at ics, an d var iable am ou n t s of fat . Th e p lat ysm a is fou n d
203
Anatom y for Plastic Surgery of the Face, Head, and Neck
Pretracheal layer
muscular portion
Investing
layer
Fig. 21.6 Cervical fascia layers. (a) Transverse section of the neck. (b) Anterior view
with skin, super cial fascia, and plat ysma
removed. (From THIEME Atlas of Anatomy,
General Anatomy and Musculoskeltal System.
© Thieme 2005, Illustrations (a) by Markus
Voll and (b) by Karl Wesker.)
Pretracheal
visceral portion
Carotid
sheath
Prevertebral
layer
a
Mandible
Parotid gland
Investing
layer
Sternohyoid
Visceral portion,
pretracheal layer
Sternocleidomastoid
Carotid sheath
Muscular portion,
pretracheal layer
Prevertebral
layer
Trapezius
Clavicle
b
204
21 Neck
an terolaterally an d is ad h eren t to t h e skin via m u lt ip le con n ect ive t issu es ban d s. It is a p aired m u scle fou n d lateral to t h e
m id lin e.
Platysma
Th e plat ysm a m uscle is a th in , w ide super cial m uscle, origin at ing from th e su per cial fascia over th e u pper th orax (Fig.
21.7a). Th e m uscle bers fan ou t superiorly an d in ser ted in to
th e low er border of th e m an dible an d skin an d in term ingle w ith
the m uscles of facial expression on the low er face. Its innervation
is provided by th e cer vical bran ch of th e facial n er ve, an d th e
blood supply is provided by th e facial arter y, superior thyroid
ar ter y, an d bran ch es of t h e p oster ior au r icu lar an d occip it al
ar teries. It s m ain act ion in h u m an s is as an accessor y dep ressor
of th e oral com m issure. Th e plat ysm a m uscle courses over th e
con cave con tours of th e n eck an d does n ot h ave any reten t ion
ligam en ts or pulleys super cial to it . Its deep at t ach m en ts, th e
cer vical ret ain ing ligam en t s, adh eren t to th e su per cial layer of
th e deep fascia, are respon sible lim it ing th e an terior displacem en t of t h e m u scle belly d u r in g con t ract ion . Later in life, t h e
m u scle is resp on sible for t h e ap p earan ce of ver t ical dyn am ic
bands, labelled as plat ysm a ban ds.
Surgical Annotation
Th e plat ysm a is classi ed in to th ree t ypes, depen ding on th e
exten t of d ecu ssat ion 4 :
•
•
•
Typ e 1: Lim ited decu ssat ion of th e plat ysm a m u scles, exten ding 1 to 2 cm below th e m an dibular sym physis (75%)
Typ e 2: Decu ssat ion of th e plat ysm a from th e m an dibu lar
sym p hysis to th e thyroid car t ilage (15%)
Typ e 3: No decu ssat ion of th e p lat ysm a m u scles in th e m idlin e (10%)
Isolated plat ysm al ban ds associated w ith ageing can be su ccessfu lly t reated w ith n eu rotoxin s. Correct ion of exten sive laxit y
an d divaricat ion requ ires op en p roced u res w ith in ter ven t ion s
on th e plat ysm a m uscles; plicat ion , excision , an d m yotom y, an d
so for th .5–7 Th e su p eriorly an d p osteriorly based p lat ysm a m u scle m yocutan eous aps are supplied prim arily by th e subm en tal arter y and secon darily by th e superior thyroid, post auricular,
an d occip ital ar teries. Th e extern al jugu lar an d su bm en tal vein s
provide the ven ous drain age. Th e plat ysm a skin ap can be
used to recon st ru ct defect s in th e orofacial region .8,9
Deep Cervical Fascia
Th e deep fascia can be divided in to th ree layers: th e invest ing
layer of th e deep cer vical fascia, prevertebral fascia, an d pret rach eal fascia.
Investing Layer of the Deep Cervical Fascia
Th e invest ing layer com pletely en circles th e n eck an d split s to
en close th e t rap eziu s an d stern ocleidom astoid m u scles. Th e in vest ing layer of th e deep cer vical fascia is at t ach ed su p eriorly to
the external occipital protuberance and superior nuchal line and
in feriorly to th e stern um , clavicle, an d acrom ion of th e scapula.
Th e posterior at t ach m en t s are on th e spin es of th e cer vical ver-
tebrae an d ligam en t um n uch ae, an d th e an terior at tach m en t s
are on th e m an dibu lar m idlin e, body of th e hyoid, an d m an u brium stern i. Th e fascia splits to en close th e su prastern al space
an d th e at t ach m en t s of th e t rap eziu s an d stern ocleidom astoid
m u scles.
In th e m astoid region , th e invest ing layer of th e fascia is referred to as th e parot id fascia, w h ich sp lit s in to t w o layers to
en close th e p arot id glan d . Th e p arot id fascia is at t ach ed to th e
t ip of th e m astoid process, cart ilagin ous par t of th e extern al
acou st ic m eat u s, an d low er bord er of th e zygom at ic arch . Th e
deep layer exten ds along th e base of th e skull and m erges w ith
th e carot id sh eath . Th e fascia bet w een th e st yloid process an d
th e angle of th e m an dible form s th e st ylom an dibular ligam en t .
Pretracheal Fascia
Th e p ret rach eal fascia exten d s from t h e hyoid to t h e t h ora x.
Th e visceral layer envelops th e t rach ea, esoph agus, an d thyroid
glan d an d th e m u scu lar p ar t en closes th e in frathyroid m u scles.
It is at tach ed su p eriorly to th e lar yn x, an d in feriorly it exten ds along th e superior m ediast in um an d m erges w ith th e brous pericardium .
Prevertebral Fascia
Th e prevetebral fascia en closes th e cer vical spin e an d th e prevetebral an d post vertebral m uscles. It also form s th e oor of th e
p osterior t riangle of th e n eck. Th e fascia exten ds su periorly to
th e skull base in fron t of th e longus capit is an d rect us capit is
lateralis m uscles an d in feriorly in to th e th orax, w h ere it m erges
w ith th e an terior longit u din al ligam en t of th e th ird th oracic
ver tebra. Th e fascia in ser t s p oster iorly on t h e t ran sverse an d
sp in ou s p rocesses of t h e cer vical ver tebrae an d ligam en t u m
n u ch ae. In fer iorly, t h e fascia covers t h e scalen e m u scles an d
exten ds laterally as axillar y sh eath .
Carotid Sheath
Th e carot id sh eath receives con t ribut ion s from prevetebral an d
p ret rach eal fasciae. It en closes th e carot id ar ter y, vagus n er ve,
lym ph n odes, an d in tern al jugu lar vein . Th e at tach m en t s of th e
carot id sh eath are su periorly to th e skull base, an d in feriorly th e
fascia m erges w ith th e con n ect ive t issu e su rrou n ding th e aor t ic
arch .
At t achm ent s
•
•
Su p erior: Base of th e sku ll
In fer ior: Th e fascia m erges w it h t h e con n ect ive t issu e
arou n d th e arch of th e aort a
Surgical Annotation
The arrangem ents of the fascial layers of the neck determ ine the
spread of in fection in th e neck. They form im portant barriers to
in fect ion ; on ce in fect ion is est ablish ed, th e fascial layers play a
p art in direct ing it s sp read. Th e in fect ion m ay t ravel th rough
p ath s of least resistan ce from on e space to an oth er. Th e investing layer lim it s th e spread of super cial in fect ion . Deeper in fect ion s can spread to th e th ora x an d ret roph ar yngeal spaces.10,11
205
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 21.7 Neck muscles. (a) The plat ysma
muscle. (b) The super cial and middle
layers of the muscle in the neck.
Sternocleidomastoid
Depressor
anguli oris
Platysma
Trapezius
a
St ylohyoid
Digastric,
posterior belly
Digastric,
anterior belly
Thyrohyoid
Mylohyoid
Sternohyoid
Interm ediate tendon
of om ohyoid
b
206
Sternothyroid
Om ohyoid,
superior and
inferior bellies
21 Neck
Rectus capitis
anterior
Rectus
capitis lateralis
Longus capitis
Superior
oblique part
Vertical part
Longus colli
Inferior
oblique part
Middle
scalene
Anterior
scalene
Middle
scalene
Posterior
scalene
Posterior
scalene
Interscalene
triangle
Anterior
scalene
Groove for
subclavian artery
c
Second rib
Scalene
tubercle
First rib
Fig. 21.7 (continued ) (c) The deep muscle layers of the neck. (From THIEME Atlas of Anatomy, General Anatomy and Musculoskeltal System .
©Thieme 2005, Illustrations by Karl Wesker.)
Muscular Anatomy
•
Lateral Compartment
•
Sternocleidomastoid
•
Th is m uscle is an im port an t lan dm ark of th e n eck as it de n es
th e t riangles of th e n eck an d is closely related to th e deeper
n eurovascu lar st ru ct ures (Fig. 21.7b):
•
Origin : It arises from t w o h ead s, ten din ou s (stern al) h ead
from th e m an u briu m stern i an d m u scu lar (clavicu lar) h ead
from th e u p p er su rface of th e m edial th ird of th e clavicle.
In sert ion : Th e m u scle passes u pw ard an d ou t w ard an d is in serted onto th e m astoid process and th e superior nuchal line.
Blood supply: The blood supply is through the superior thyroid, occipital, posterior auricular, and suprascapular arteries.
Ner ve su pp ly: Th e sp in al accessor y n er ve is th e n er ve
su pp ly.
207
Anatom y for Plastic Surgery of the Face, Head, and Neck
•
Act ion : W h en on e m u scle con t ract s, th e h ead is t ipp ed tow ard th e sh ou lder on th e sam e side to rot ate th e face to th e
op p osite side. W h en act ing toget h er, t h e h ead is m oved
for w ard.
•
Th e m uscle is sacri ced in radical n eck dissect ion along w ith
oth er st ru ct u res of th e n eck.
•
Anterior Belly
•
Surgical Annotation
In congen ital u n ilateral hypoplasia of th e stern ocleidom astoid
m uscle, th e m uscle belly is shortened and tight, leading to a con dit ion called tor t icollis. If left un t reated, it leads to progressive
m an dibu lar an d facial asym m et r y th rough th e grow th period .
•
•
•
Anterior Compartment
Strap Muscles of the Neck
•
•
•
•
Su per cial layer: Om ohyoid, stern ohyoid
Deep layer: Stern othyroid, thyrohyoid
Ner ve su p p ly: An sa cer vicalis, thyrohyoid by th e rst cer vical n er ve
Blood su p ply: Su perior thyroid an d lingu al arteries
Th e om ohyoid h as superior an d in ferior bellies th at are join ed
by an in term ediate ten don . Th e superior belly is at t ach ed to th e
hyoid bon e, an d th e in ferior belly is at t ach ed to th e scapula. Th e
in term ediate ten d on is at t ach ed to th e clavicle an d rst rib. Th e
om ohyoid depresses th e hyoid bon e from th e elevated posit ion .
Th e stern ohyoid an d stern othyroid m uscles origin ate from th e
posterior su rface of th e m an ubrium stern i. Stern ohyoid h as addit ion al at tach m en t on th e clavicle an d is in ser ted in to th e in ferior border of th e body of th e hyoid bon e. Th e stern othyroid is
at t ach ed to th e oblique lin e of th e thyroid cart ilage. Th e thyrohyoid m uscle arises from th e oblique lin e of th e thyroid car t ilage an d is at t ach ed to th e body an d grater h orn of th e hyoid.
The strap m uscles act on the hyoid bone and larynx and assist in
sw allow ing. Th e digast ric, st ylohyoid, m ylohyoid, gen iohyoid,
hyoglossus, an d gen ioglossus are classi ed togeth er as m uscles
of th e oor of th e m outh .
Digastric Muscle
Origin : Th e digast ric fossa on th e in ferior border of th e m an dible is th e origin .
In ser t ion : Th e m u scle r u n s d ow nw ard an d backw ard an d
is con n ected to t h e p oster ior belly via t h e in ter m ed iate
ten don .
Blood su p ply: Blood su pp ly is th rough th e su bm en tal bran ch
of th e fascial ar ter y.
Ner ve su pp ly: Th e m an dibu lar division of th e t rigem in al
n er ve p rovides th e n er ve su p ply.
Act ion : Th e digast ric m u scle h elp s to raise th e hyoid bon e
an d base of th e tongu e an d assist s in depressing an d ret racting th e m an dible.
Surgical Annotation
Excision of th e an terior belly of digast ric m uscles is carried out
as p art of som e n eck dissect ion s, as w ell as du ring som e cosm et ic in ter ven t ion s on th e n eck. Th e hyp oglossal n er ve cou rses
deep to th e an terior belly of th e digast ric m u scle an d m ylohyoid
m u scles, t ran sversely over th e hyp oglossu s, an d n eeds to be
protected during surgery. Blunt dissection w ith hem ostat clam ps
can be used to elevate th e m uscle belly from th e un derlying
st ru ct u res, an d on ce th e hypoglossal n er ve h as been visu alized,
su p erior an d in ferior t ran sect ion of th e m u scle belly can be carried ou t safely.
Posterior Compartment
Posterior Neck Muscles: Trapezius
•
•
•
•
Origin : Extern al occip ital p rot u beran ce, su perior n u ch al
lin e, ligam en t um n u ch ae, an d th e spin e of th e seven th cer vical vertebra an d spin es of th e all th e th oracic vertebrae.
In sert ion : Spin e an d acrom ion of th e scapu la, lateral th ird of
th e clavicle
Ner ve su p p ly: Accessor y n er ve, cer vical p lexu s
Blood su p p ly: Su p er cial cer vical, t ran sverse cer vical
ar ter ies
Act ion : Elevates, rot ates, an d ret ract s th e scap u la w ith oth er
m u scles. W h en scap u la is xed, th e t rap eziu s m oves th e
h ead backw ard an d lateral.
Th e digast ric m uscle con sists of t w o bellies: th e an terior belly
an d th e p osterior belly. Both bellies are con n ected by an in term ed iate ten don an ch ored to th e hyoid.
•
Posterior Belly
Surgical Annotation
•
•
Th e t rapezius m yocut an eous ap is used for m ost of th e h ead
an d n eck recon st ru ct ion . It is classi ed as t yp e V in th e Math es
an d Nah ai classi cat ion an d can be u sed as p edicled-islan ded
ap, free ap , an d t u rn over ap. Th e ap is a p opu lar ch oice for
recon st r u ct ion of t h e d efect s over t h e occip it al, p arot id glan d ,
cer vical sp in e, an d an ter ior n eck. Th e su p er ior bers are d esign ed m ain ly for h ead an d n eck recon st ru ct ion , bu t th e arc of
•
•
208
Ner ve su p ply: Th e p osterior belly is su p plied by th e facial
n er ve.
Origin: The m astoid notch is posterior to the m astoid process.
Th e posterior belly of th e digast ric m u scle ru n s for w ard an d
dow nw ard an d passes th rough th e st ylohyoid m u scle.
In ser t ion : In ser t ion is to th e greater h orn of th e hyoid bon e
by a brou s loop.
Blood su pp ly: Th e blood su p p ly is th rough th e p osterior au ricu lar an d occipit al arteries.
21 Neck
rot at ion is lim ited; h ow ever, it is possible to use th e m iddle an d
in ferior bers of th e t rap eziu s for m yocut an eous aps.12,13
Paravertebral Muscles
The paravertebral m uscles are located in front of the bodies of the
cervical vertebrae, deep to the prevertebral fascia (Fig. 21.7c). Th e
m u scles are longu s colli, longu s capit is, rect u s cap it is an terior
an d lateralis, scalen e m u scles, an d th e levator scap u lae.
•
•
•
Blood su p ply: Vertebral arteries, ascen ding p h ar yngeal, an d
in ferior thyroid ar teries
Ner ve su pp ly: Cer vical sp in al n er ves
Act ion : Scalen e m u scles are exors an d rot ators of th e vertebral colum n . Th e scalen us an terior an d m edius elevate th e
rst rib an d scalen u s posterior elevates th e secon d rib.
Postvertebral Muscles
Th e p ost ver tebral m u scles lie d eep to t h e t rap eziu s, beh in d
t h e ver tebral colu m n , an d are ar ranged in t h ree layers: su p ercial layer (sp len iu s cer vicis an d cap it is m u scles); m id d le
layer (t h e erector sp in ae m u scles); an d d eep layer (t ran sversosp in alis m u scles). W h en act in g on bot h sid es of t h e sp len iu s
cap it is, t h ey cau se exten sion of t h e h ead . Th e sp len iu s cer vicis
is involved in t h e exten sion of t h e cer vical sp in e. W h en act in g
on on e sid e, t h ey cau se t ilt ing of t h e h ead w it h sligh t rot at ion
to on e sid e.
Peripheral Nerves of the
Neck
Th e ven t ral an d d orsal ram i of t h e secon d an d t h ird cer vical
n er ves in n er vate th e an terior an d posterior skin of th e n eck,
respect ively.
Cervical Plexus
Th e cer vical plexus is form ed from th e ven t ral ram i of th e rst
cer vical n er ves (C1–C4) an d also receives an astom oses from th e
accessor y n er ve, hypoglossal n er ve, an d sym p ath et ic t ru n k. It s
cut an eous bran ch es em erge from the posterior border of th e
stern ocleid om astoid app roxim ately m idpoin t along th e m u scle;
th e m otor division s rem ain posterior to th e stern ocleidom astoid . Th e cu tan eou s bran ch es of th e cer vical p lexu s in clu de th e
lesser occip it al n er ve, greater au r icu lar n er ve, an d t h e su p raclavicu lar n er ves (Fig 21.8). Th e m otor bran ch es are t h e an sa
cer vicalis an d t h e segm en t al bran ch es to t h e an ter ior an d
m id d le scalen e n er ves (Fig 21.9). Th e p h ren ic n er ve ar ises
from t h e cer vical p lexu s an d h as both th e sen sor y an d m otor
com pon en t s.
Th e dorsal ram i of th e rst , sixth , seven th , an d eigh th cer vical n er ves h ave n o cu tan eous bran ch es. Th e an sa cer vicalis is
p ar t of cer vical plexus, w h ich m ain ly in n er vates th e in frahyoid
m u scles. Th e brach ial plexu s is d erived from th e ven t ral ram i of
th e cer vical spin al n er ves an d lies deep in th e posterior t riangle
of t h e n eck. Th e cer vical sym p at h et ic t r u n k lies beh in d t h e
carot id sh eath on th e p revertebral fascia. Th e m ain cut an eou s
bran ch es of th e cer vical plexus are th e lesser occipital, th e great
au ricu lar, th e t ran sverse cer vical, an d th e su p raclavicu lar
n er ves. Th e lesser occip it al n er ve arises from th e ven t ral ram u s
of th e secon d an d th ird cer vical n er ves an d supplies th e lateral
p ar t of th e scalp. Th e greater occipit al n er ve is a bran ch of dorsal ram u s of th e secon d cer vical n er ve. Th is n er ve is fou n d in
th e suboccipital t riangle; it pierces th e t rapezius an d supplies
the posterior scalp. The transverse cervical ner ve arises from the
secon d an d th ird cer vical n er ves an d passes across th e stern ocleidom astoid m uscle to supply th e skin on th e an terior n eck.
Th e su praclavicu lar n er ve receives bers from th e th ird an d
fou rth cer vical n er ves. Th e n er ve ru n s dow nw ard tow ard th e
clavicle an d divides in to th ree bran ch es. Th ese are th e m edial,
in term ediate, an d lateral supraclavicu lar n er ves, an d th ey su p p ly th e skin over th e low er n eck an d up per th orax.
Th e great auricular n er ve arises from th e secon d an d th ird
n er ves of th e cer vical plexu s an d t ravels from a deep to su per cial plan e. The n er ve reach es th e posterior border of th e stern ocleidom astoid m uscle at th e jun ct ion of th e superior an d m iddle
th irds of th e m uscle.14
Surgical Annotation
Th e surface lan dm ark of th e great auricular n er ve is referred to
as th e n er ve p oin t , located 6.5 cm in ferior to th e extern al au ditor y m eat us. Th e n er ve takes an oblique path tow ard th e earlobe follow ing th e course of th e extern al jugular vein . Th e vein
lies about 0.5 cm m edial to th e n er ve. Because th e n er ve is covered on ly by th e SMAS su p eriorly, th is layer sh ou ld be iden t i ed
to p rotect t h e n er ve d u r in g dissect ion . Dam age to t h e n er ve
lead s to n u m bn ess of t h e low er t w o -t h ird s of t h e ear, p reau ricu lar skin , an d p ost au r icu lar skin an d m ay resu lt in n eu rom a
form at ion .
Th e ph ren ic n er ves arise from C3, C4, an d C5 an d descen d
over the anterior scalene m uscle deep to th e prevertebral fascia.
Cranial Nerves in the Neck
Th e cran ial n er ves in th e n eck are anatom ically related to th e
carot id sheath . Th e vagus n er ve run s w ith in the carot id sh eath ,
an d th e glossop h ar yngeal, accessor y, an d hyp oglossal n er ves
are closely related to th ese st ru ct u res.
Th e glossoph ar yngeal n er ve exit s th e skull th rough th e jugu lar foram en . Th e su perior an d in ferior ganglia are foun d w ith in
t h e foram en . Th e n er ve is fou n d an ter ior to t h e vagu s an d accessor y n er ves an d r u n s bet w een t h e in ter n al jugu lar vein an d
carot id arter y. It w in ds aroun d th e st yloph ar yngeu s m u scle an d
p asses bet w een th e superior an d m iddle con st rictors. Th e m ain
bran ch es in clu d e t h e t ym p an ic, lesser p et rosal, carot id , p h aryngeal, ton sillar, lingu al, an d a bran ch to th e st yloph ar yngeus
m u scle.
209
Anatom y for Plastic Surgery of the Face, Head, and Neck
Lesser
occipital n.
Great
auricular n.
Transverse
cervical n.
Supraclavicular
nn.
Fig. 21.8 Cutaneous branches of the cervical plexus. (From THIEME Atlas of Anatomy, General Anatomy and Musculoskeltal System. © Thieme
2005, Illustration by Karl Wesker.)
Th e accessor y n er ve h as cran ial an d spin al par ts. Th e cran ial
p ar t join s t h e vagu s n er ve. Th e sp in al p ar t of t h e n er ve is d er ived from t h e u p p er ve cer vical segm en t s. Th e m ain t r u n k
p asses t h rough t h e foram en m agn u m , crosses t h e in ter n al jugu lar vein , an d r u n s d ow nw ard tow ard t h e ster n ocleid om astoid
m u scle an d su pp lies th e m u scle. It th en crosses th e posterior
t riangle an d supplies th e t rapezius m uscle. Th e spin al an d cran ial p ar ts of th e accessor y n er ves u n ite in th e jugu lar foram en
an d soon sep arate as th ey em erge th rough th e cran iu m .
Th e vagus n er ve exits the jugular foram en an d is join ed by
th e cran ial par t of th e accessor y n er ve. Th e n er ve passes w ith in
th e carot id sh eath an d gives rise to th e righ t recurren t lar yngeal
Hypoglossal
nerve
C1
C2
C3
Geniohyoid
Thyrohyoid
Om ohyoid
Sternohyoid
Sternothyroid
Infrahyoid
m uscles
210
C4
Inferior root
of ansa
cervicalis
Phrenic nerve
Anterior
scalene
Middle
scalene
Fig. 21.9 The motor innervations of the neck muscles. (From
THIEME Atlas of Anatomy, General Anatomy and Musculoskeltal
System. © Thieme 2005, Illustration by Karl Wesker.)
21 Neck
n er ve in th e root of th e n eck. Th e left recu rren t lar yngeal n er ve
arises in th e th orax, an d both n er ves cou rse u pw ards bet w een
t h e t rach ea an d esop h agu s. Th e ot h er bran ch es of t h e vagu s
nerve include the m eningeal, auricular, pharyngeal, carotid body,
su p erior lar yngeal, an d cardiac n er ves.
Surgical Annotation
Th e n er ves th at are closely related to th e carot id sh eath can be
dam aged during n eck dissect ion . Th e accessor y n er ve em erges
at th e posterior border of th e stern ocleidom astoid an d t akes a
posterior an d in ferior course tow ard th e t rapezius m uscle. It
ru n s su p er cially, u n der th e cer vical fascia, an d can be easily
inju red du ring n eck dissect ion . Dissect ion in th e posterior region of th e posterior border of th e stern ocleid om astoid n eeds to
take in to accoun t th e super cial posit ion of th e n er ve. At th is
poin t , th e n er ve em erges approxim ately at th e m idpor t ion of
th e stern ocleidom astoid an d courses posteriorly. Th e accessor y
n er ve is rem oved in rad ical n eck clearan ce an d is preser ved in
m odi ed radical dissection s. Rem oval of this ner ve causes weakn ess an d ch ron ic sh oulder p ain .15,16
Facial Nerve Branches in the Neck
Th e m argin al m an d ibu lar n er ve is a bran ch of facial n er ve an d
is on e of th e m ost com m on n er ves to be dam aged du ring n eck
su rger y (Fig. 21.10). Th e n er ve follow s th e m an dibular border
an teriorly an d lies 2 cm below th e in ferior bord er before crossing th e facial arter y an d vein . It sup plies th e depressor labii in -
ferioris, dep ressor angu li oris, an d th e m en talis m u scles (Fig.
21.11).
Surgical Annotation
Th e n er ve is vuln erable du ring liposuct ion , n eck lift , n eck dissection, and m andibular im plant placem en t. Surgical techniques,
su ch as st aying deep to th e su p er cial cer vical fascia an d elevat ion of th e deep fascia w ith th e periosteu m of th e m an dible,
w ill h elp to protect th e n er ve.17
Th e cer vical bran ch of th e facial n er ve in n er vates th e plat ysm a m u scle an d en ters t h e d eep er su r face of t h e m u scle su p erolaterally. Dam age to th is n er ve is rep orted at 1.7% du ring
rhyt idectom y.18 Inju r y to th is n er ve can m im ic m argin al m an dibular n er ve dam age; h ow ever, th e pat ien t w ill st ill be able to
evert th e low er lip du e to an in t act m en talis m u scle. In th e
low er face, th e facial n er ve ru n s deep to th e plat ysm a an d SMAS
an d in n er vates th e m u scles on th eir u n d er su rfaces except for
th e buccin ator, levator anguli oris, an d m en t alis m uscles.
Surgical Annotation
Iden t i cat ion of th e facial n er ve du ring p arot idectom y can be
carried ou t in th e n eck. Dissect ion st art s w ith th e posterior border of th e plat ysm a approxim ately 5 cm below th e gon ial angle
and exten ds inferiorly and superiorly. The parotid fascia and parotid glan d are exposed, an d th e dissect ion can progress to th e
anterior border of the glan d for a retrograde identi cation of the
facial n erve branches and dissection or to th e posterior border of
the gland for identi cation of the nerve trunk w ith an antegrade
Tem poral branches
Posterior
auricular nerve
Zygomatic branches
Facial nerve
Buccal branches
Digastric branch
Cervical branch
Marginal
mandibular branch
Fig. 21.10 Branches of facial nerve. (From THIEME Atlas of Anatomy, General Anatomy and Musculoskeltal System. © Thieme 2005, Illustration by
Karl Wesker.)
211
Anatom y for Plastic Surgery of the Face, Head, and Neck
Fig. 21.11 Course of the marginal mandibular
nerve.
dissect ion . During facelift su rger y, dissect ion un der th e plat ysm a starts superiorly and progresses inferiorly along the posterior border of the m uscle. Th e m arginal m andibular branch exit s
th e parot id above th e jun ct ion bet w een th e low er border and
anterior aspect of the gland, and the cervical branch exits at the
lower border; they need to be protected. Blunt dissection w ith a
sm all cot ton ball is com m only used to provide safe dissection.
Vascular Anatomy of the
Neck
Arteries
Th e carot id ar teries are th e m ain arterial st ruct ures of th e n eck
(Fig. 21.12). The righ t com m on carot id arter y arises from th e
brach ioceph alic arter y, an d th e left arises from th e arch of th e
aort a. Th ey bifu rcate at th e level of th e u p p er border of th e thy-
212
roid cart ilage in to th e in tern al an d extern al carot id ar teries. Th e
in tern al carot id ar ter y usu ally does n ot h ave any bran ch es in
th e n eck an d passes th rough th e carot id can al to th e cran iu m .
Bran ch es of th e extern al carot id arter y are th e su perior thyroid,
ascen ding p h ar yngeal, lingu al, facial, occip it al, posterior au ricular, m axillary, and super cial tem poral arteries. The rst branch
of th e extern al carot id ar ter y is th e superior thyroid arter y. It
arises ju st below th e grater h orn of th e hyoid bon e an d ru n s
dow nw ard tow ard th e upper pole of th e thyroid glan d. Th e artery supplies the thyroid, stern ocleidom astoid m uscle, in frahyoid
m u scles, an d lar yn geal m u scu lat u re. Th e facial ar ter y ar ises
from th e extern al carot id ar ter y an d ru n s for w ard an d u pw ard
to en ter th e digast ric t riangle. It courses deep to th e digast ric
m u scle an d p osterior to th e su bm an dibu lar glan d, w h ere it
gives rise to th e bran ch es to th e glan d . Th e ar ter y exit s from th e
su p erior p ar t of th e glan d, w in ding arou n d th e in ferior bord er
of th e m an dible, an d en ters th e face along th e an terior border of
th e m asseter m uscle. In th e n eck, it gives rise to th e ascen ding
palat in e, ton sillar, an d su bm en tal arteries.
21 Neck
Fig. 21.12 The great vessels of the
neck. (From THIEME Atlas of Anatomy,
Head and Neuroanatomy. © Thieme
2010, Illustration by Karl Wesker.)
213
Anatom y for Plastic Surgery of the Face, Head, and Neck
Surgical Annotation
Carot id body t u m ors ar ise from t h e adven t it ia of t h e carot id
ar ter y bifu rcat ion m edially. Th ey often m an ifest as an asym ptom at ic lu m p in th e an terior n eck, w ith cran ial n er ve p alsies, or
w ith paroxysm al hyperten sion an d palpit at ion s. Th e carot id
ar teries are in im m in en t danger du ring n eck dissect ion , an d carot id arter y blow out can occur in pat ien t s w h o un dergo n eck
dissect ion an d radioth erapy, w h ich can be fat al.19–21
Veins
Th e m ain vein s in th e n eck are th e extern al an d in tern al jugulars (Fig. 21.13). Th e in tern al jugular vein em erges from th e
base of th e skull th rough th e jugular foram en , an d accom pan ies
th e carot id arter y w ith in th e carot id sh eath . It join s th e subclavian vein to form th e brach iocep h alic vein . Th e im p or tan t t rib u t aries in clu de th e facial, lingual, ph ar yngeal, superior, an d
in ferior thyroid vein s. Th e extern al jugu lar vein origin ates at th e
ap ex of th e p arot id glan d an d p asses along th e lateral border of
th e sternocleidom astoid m uscle, pierces the deep cer vical fascia,
an d drain s in to th e su bclavian vein . Th e t ribu taries are occipital,
p osterior extern al jugu lar, su p er cial cer vical, su p rascap u lar,
an d an ter ior jugu lar vein s. Th e an terior jugu lar vein receives
Fig. 21.13 The triangles of the neck.
214
vein s from th e su bm an dibu lar region an d th e facial an d p arot id
vein s, p asses an teriorly in th e n eck, an d drain s in to th e extern al
jugu lar or su bclavian vein s. Th e u n ion of su per cial tem poral
an d m axillar y vein s form s th e ret rom an dibu lar vein . Th e vein
en ters th e parot id glan d su p er cial to th e extern al carot id arter y, bet w een th e m an dibular ram us an d stern ocleidom astoid
m u scle. It d ivid es in to an ter ior an d p oster ior bran ch es. Th e
an terior bran ch join s th e facial vein an d becom e th e com m on
facial vein . Th e p osterior bran ch join s th e p osterior au ricu lar
vein an d becom e th e extern al jugu lar vein . Th e relat ion sh ip of
th e vein to th e facial n er ve is im port an t during parot idectom y.
In m ost sit u at ion s, th e vein lies m edial to th e u pp er an d low er
t ru n ks of th e facial n er ve.
Surgical Annotation
Th e low er plat ysm a m yotom y is som et im es carried out during
n eck lift su rger y. W h en d issect ing along th e p osterior border of
t h e m u scle, care m u st be t aken to avoid inju r y to t h e greater
au r icu lar n er ve. Th is n er ve em erges at t h e p oster ior bord er of
th e stern ocleidom astoid approxim ately 6 cm below th e m astoid
an d cou rses an terior an d su p erior. Th e extern al jugu lar vein can
be iden t i ed un der th e super cial cer vical fascia an d below th e
posterior bers of th e p lat ysm a approxim ately at th e level of
21 Neck
th e cricoid cart ilage. Dissect ion of th e posterior plat ysm a bers
w ith gentle elevation reduces the risk of injur y to the vein, w h ich
is rest rain ed by th e fascia. During radical dissect ion of th e n eck,
the internal jugular vein is rem oved along w ith other struct ures,
w hich m ay lead to facial edem a as a long-term com plication.22,23
II
Lymphatics
Th e lym p h n od es in t h e n eck are broad ly classi ed in to su p ercial an d d eep grou p s, an d t h e lym p h n od es are fou n d to be
in relat ion to t h e t r ian gles of t h e n eck. Th e su p er cial grou p
con sist s of su bm en t al, subm an dibular, an terior cer vical, an d
su p er cial cer vical lym p h n od es. Th e deep grou p con sist s of in frahyoid, prelar yngeal, p ret rach eal, ret rop h ar yngeal, an d deep
cer vical n odes.
Su per cial grou p drain in to th e d eep grou p an d deep grou p
in t urn d rain in to th e jugu lar t run k. On th e left side, th e left
jugu lar t ru n k drain s in to th e th oracic du ct . Th e th oracic du ct is
th e m ain lym ph at ic t run k in th e body, collect ing from all areas
except th e righ t side of th e h ead, n eck, th orax, an d arm . Th e
th oracic du ct en ters th e n eck th rough th e th oracic in let beh in d
the left carotid artery and left vagus nerve. It passes bet w een the
left com m on carot id ar ter y an d su bclavian ar teries an d en ters
th e left subclavian t run k. At th is poin t , th e duct receives th e left
su bclavian t ru n k. On th e righ t sid e, th e jugu lar t ru n k an d su b clavian t run k drain in to th e righ t lym ph at ic duct . Th e righ t lym ph at ic du ct passes along th e m edical border of th e scalen us
m u scle to drain in to th e su bclavian vein .
V
III
Fig. 21.14 The lymph node of the neck. (From THIEME Atlas of
Anatomy, General Anatomy and Musculoskeltal System. © Thieme
2005, Illustration by Karl Wesker.)
Lym ph n odes in th is com part m en t are located in th e t rach eoesop h ageal groove (p arat rach eal n odes), in fron t of th e t rach ea
(pret rach eal n odes), arou n d th e thyroid glan d (parathyroidal
n odes), an d on th e cricothyroid m em bran e (precricoid).
Surgical Annotation
•
•
•
•
•
VI
IV
Classi cation of the Lymph Nodes
Level 1: Su bm en tal (1a), su bm an dibu lar (1b) (Fig. 21.14)
◦ Bou n daries: Th e body of th e m an dible, st ylohyoid m u scle, an terior belly of th e digast ric m uscle
Levels 2, 3, an d 4: Th e u p p er, m iddle, an d low er jugu lar
n odes
◦ Level 2 is divided in to 2a an d 2b by th e spin al accessor y
n er ve.
◦ Level 3 n od es bou n daries: Th e hyoid bon e an d a h orizon t al plan e de n ed by th e in ferior border of th e cricoid cart ilage, stern ohyoid m uscle, an d posterior border of th e
stern ocleidom astoid m u scle.
◦ Level 4 refers to th e grou p of n odes related to th e low er
th ird of th e jugu lar vein .
Bou n daries: In ferior border of th e cricoid cart ilage, clavicle, stern ohyoid m uscle, an d posterior border of th e
stern ocleidom astoid m u scle.
Level 5 n odes are located in the posterior triangle of th e n eck.
◦ Bou n daries: Th e p osterior bord er of th e stern ocleidom astoid, an terior border of th e t rap eziu s m u scle an d
clavicle. Th is level is subdivided by a plan e de n ed by th e
in ferior border of th e cricoid cart ilage in to level 5a sup eriorly an d level 5b in feriorly.
Level 6 n odes are in th e an terior, or cen t ral, com part m en t of
th e n eck.
◦ Bou n dar ies: Carot id ar teries, hyoid bon e, su p raster n al
n otch
I
•
•
•
Met astasis: Level 1a from th e oor of th e m ou th , an terior
tongu e, an terior m an dibular alveolar ridge, an d low er lip.
Level Ib receives m et ast ases from can cers of th e oral cavit y,
an terior n asal cavit y, soft t issu e st ru ct u res of th e m idface,
an d su bm an dibu lar glan d .
Level 2 n od es m ay be involved in can cers of th e oral cavit y,
n asal cavit y, n asop h ar yn x, orop h ar yn x, hypop h ar yn x, laryn x, an d parot id glan d m ay involve th ese n odes.
Level 3 receives m etastasis from can cers th at origin ate in th e
oral cavit y, n asoph ar yn x, oroph ar yn x, hypoph ar yn x, an d
lar yn x. Th e n odes of level 4 com m on ly h arbor m et astasis
from can cer th at origin ates in th e lar yn x, hyp op h ar yn x, thyroid, an d cer vical esoph agus.
Level 5 m ay h arbor m etast asis from can cers th at arises in th e
n asoph ar yn x, orop h ar yn x, or skin of th e p osterior scalp an d
n eck. Lym p h n odes in th e cen t ral com p ar t m en t are n ot rou t in ely excised in radical n eck dissect ion ; m ost com m on ly,
th ey are rem oved during surger y for thyroid, lar yngeal, an d
hypoph ar yngeal can cers.24–27
Triangles of the Neck
Th e n eck is broadly d ivid ed in to an ter ior an d p oster ior t r ian gles (Fig. 21.15).
215
Anatom y for Plastic Surgery of the Face, Head, and Neck
Parietal
region
Submandibular
triangle
Carotid triangle
Sternocleidomastoid
Subm ental
triangle
Trapezius
a
Lateral cervical region,
occipital triangle
Occipital
region
Muscular
triangle
Om oclavicular (subclavian)
triangle
Lesser supraclavicular fossa
Posterior cervical region
Fig. 21.15 Regions of the neck (cervical regions), right lateral view. For descriptive purposes, the anterior and lateral neck are divided into t wo
triangles which share the sternocleidomastoid as a boundary. (From THIEME Atlas of Anatomy, Neck and Internal Organs. © Thieme 2010,
Illustrations by Karl Wesker.)
Anterior Triangle
Carotid Triangle
Th e an atom ical boun daries of th e t w o an terior t riangles of th e
n eck com m en ce from th e m idlin e of th e n eck, exten ding from
th e stern al n otch to th e ch in . Th ey are bordered posteriorly by
th e an terior m argin of th e stern ocleidom astoid m uscle an d superiorly by th e in ferior border of th e m an dible. Th e space can
be fur th er divided in to subm en tal, subm an dibular carot id an d
m u scu lar t riangles.
Th e carot id t riangles con tain som e of th e im por tan t st ruct ures
of th e n eck. Th ese in clude th e hypoglossal, accessor y an d vagus
n er ves, su perior lar yngeal n er ve an d bran ch es of th e facial
n er ve, sym path et ic t ru n k, carot id vessels, an d th e bran ch es of
th e jugular vein s. Th e an terior border of th e carot id t riangle is
form ed by th e om ohyoid m u scle. Posteriorly, it is lin ed by th e
stern ocleidom astoid m u scle an d su periorly by th e p osterior
belly of th e digast ric an d st ylohyoid m uscles. Th e oor is form ed
by th e m iddle an d in ferior ph ar yngeal con st rictors, hyoglossu s,
an d th e thyrohyoid m u scles.
Submental Triangle/Suprahyoid
Triangle
Th e subm en t al t riangle, also referred to as th e suprahyoid t rian gle, is bou n d an teriorly by th e an terior belly of th e digast ric
m u scle. Th e hyoid bon e form s th e in ferior bord er, an d th e m ylohyoid form s th e oor of th e t riangle. Th e m edial border exten ds
u p to th e m id lin e of th e n eck. Th e su bm en t al t riangle con t ain s
th e subm en t al lym ph n odes an d th e veins.
Submandibular Triangle/ Digastric
Triangle
Th e su bm an dibular t riangle is bordered an teroin feriorly an d
posteroin feriorly by th e an terior an d posterior belly of th e digast ric m u scle resp ect ively. Th e low er border of th e m an dible
form s th e su p erior border. Th e im port an t con ten ts in clu d e th e
su bm an d ibu lar salivar y glan d , facial ar ter y an d vein , an d t h e
m argin al m an dibu lar n er ve.
216
Muscular Triangle/ Inferior Carotid
Triangle
Th e m uscular t riangle is also referred to as th e in ferior carot id
triangle and contains the sternothyroid and sternohyoid m uscles,
oesoph agus, thyroid glan d, an d t rach ea. Th e space is bordered
posteriorly by th e an terior border of th e stern ocleid om astoid
m u scle. Th e su p erior belly of th e om ohyoid form s th e postero
su p erior border, an d th e sp ace exten ds u p to th e m idlin e of th e
n eck from th e hyoid bon e to th e stern u m .
Posterior Triangle
Th e posterior t riangle is boun ded an teriorly by th e posterior
border of th e stern ocleidom astoid m uscle. Th e posterior border
is form ed by th e anterior border of th e t rapeziu s, an d th e in fe-
b
21 Neck
rior border is form ed by th e m id dle th ird of th e clavicle. Th e
t riangle is furth er divided in to th e occipital an d subclavican t riangle by th e in ferior belly of th e om ohyoid . Th e con ten t s in clude th e spin al accessory n erve, branches of the cervical plexus,
root s an d t ru n ks of th e cer vical plexu s an d p h ren ic n er ve, subclavian an d t ran sverse cer vical ar ter y, exter n al jugu lar vein ,
in fer ior belly of t h e om ohyoid m u scle, scalen e, sp len iu s an d
levator scapu lae m u scles.
Surgical Annotation
Lym ph n ode stat us is on e of th e im por t an t progn ost ic factors
for h ead an d n eck can cers. Ap propriate m an agem en t of th e region al lym p h at ics, th erefore, p lays a cen t ral role in th e t reatm en t of th e h ead an d n eck can cer pat ien t s. Th e t riangles of th e
n eck h ave on cologic sign i can ce related to th e surgical m an agem en t of th e region al m et astasis.
Th e neck dissect ion can be broadly divided in to com preh en sive or select ive. Th e com p reh en sive n eck dissect ion is fu rth er
divided in to radical, m odi ed radical, an d exten ded radical dissect ion . Th e select ive n eck dissect ion in clu d es su praom ohyoid,
an terolateral, an terior, an d p osterior dissect ion s. Th e classi cat ion is m ain ly based on th e surgical m an agem en t of region al
lym ph n odes an d preser vat ion or rem oval of st ruct ures in relat ion to th ese n odes.28,29
Submandibular Gland
Th e subm an dibular glan d is located in th e su bm an dibular t rian gle (Fig. 21.16). Th e glan d is envelop ed by a cap su le an d h as
t w o p or t ion s. Th e su p er cial lobe is large an d is fou n d su p ercial to t h e m ylohyoid m u scle. Th e glan d p aren chym a exten d s
alon g t h e p oster ior bord er of t h e m u scle to for m t h e sm aller
d eep lobe. W h ar ton’s d u ct ar ises from t h e d eep er lobe, crosses
t h e su blingu al sp ace, an d op en s n ear t h e fren u lu m of t h e
tongu e.
Many im p or t an t st ru ct u res are closely related to th e su b m an dibu lar glan d an d h ave sign i can t clin ical relevan ce. Th e
m argin al m an dibu lar bran ch of th e facial n er ve passes along th e
an teroin ferior p art of th e glan d, crosses th e m an dible, an d su p plies th e m u scles of th e low er lip an d ch in . Th e cer vical bran ch es
of th e facial n er ve an d th e facial vein are related to th e an teroin ferior part of th e glan d. Th e facial arter y courses su perolaterally, an d th e deep lobe is closely related to th e glossoph ar yngeal,
lin gu al, an d hyp oglossal n er ves an d t h e su bm an d ibu lar gan glion . Th e d eep su r face of t h e glan d overlies t h e m ylohyoid ,
hyoglossu s, st yloglossus, st ylohyoid, an d th e posterior belly of
th e digast ric m uscle. Th e lingual n er ve lies above an d lateral to
th e du ct of th e subm an dibular glan d.
Surgical Annotation
Dissect ion of th e glan d is often p erform ed in on cologic n eck
surger y and neck lift procedures, and it is im portant to ackn ow ledge th e close relat ion sh ip of th ese st ru ct u res to th e glan d.30
Direct access to th e glan d in n eck an d on cologic procedu res is
th rough th e su bm an dibular approach , w h ereas th e aesth et ic
resect ion is carried out via su bm en tal app roach . With th e aging
process, th ere m ay be pseu doptosis rath er th an act ual descen t
of th e glan d in th e n eck. An atom ical st udies h ave revealed th at
abou t 40% of th e glan d rep resen ts th e cer vical part of th e su bm an dibu lar glan d. Par t ial resect ion of th e p rom in en t glan d du ring n eck con tou ring carries a risk of dam age to th e facial arter y,
vein , an d m argin al m an dibu lar n er ve. Dissect ing th e glan d in
the subcapsular plane m ay prevent injury to the nerve.3,30–32 Subm an d ibu lar glan d excision involves direct access, du ring w h ich
it is im por tan t to protect th e m argin al m an dibular bran ch of th e
facial n er ve. Th e skin in cision is th erefore p laced app roxim ately
4 cm below th e m an dibular border, an d th e plat ysm a m uscle
n eeds to be elevated carefu lly. In t racapsu lar dissect ion allow s
p rotect ion of th e pericap sular st ru ct ures as in reduct ion of th e
glan d . At th e u p p er segm en t of th e dissect ion , th e lingu al n er ve
sh ou ld be iden t i ed su p erior to W h ar ton’s du ct an d p rotected ,
an d th e n er ve bers passing to th e glan d are divided. In t racap su lar dissect ion p rovides protect ion to th e hypoglossal n er ve,
w h ich courses over th e hyoglossus. W h en th e su bm an dibular
glan d is redu ced du ring n eck lift su rger y, access is th rough th e
an teroin ferior segm en t of th e cap su le. To avoid dam age to su rroun ding st ru ct ures, th e dissect ion n eeds to rem ain in t ra cap su lar. Th e relat ion sh ips of th e cap su le are th e facial n er ve an d
facial artery posterior and superior, th e facial vein posterior, and
th e lingual n er ve at th e superior border of th e glan d. Th e hypoglossal n er ve lies to t h e m ed ial sid e in t h e low er t w o -t h ird s;
d ep en d in g on t h e size of t h e su bm an d ibu lar glan d , it t akes a
t ran sverse cou rse over hyoglossu s an d p asses su p er ior to t h e
m ylohyoid m uscle.33,34
Visceral Structures
Th e im p or t an t visceral st r u ct u res are t h e p h ar yn x, lar yn x,
t rach ea, an d esoph agus. Th e thyroid, parathyroid, an d thym u s
glan ds are closely related to th ese st ru ct u res. Th e cer vical esop h agu s begin s at th e low er border of th e cricoid car t ilage an d
t akes a cur ved course dow n th e n eck. Th e recurren t lar yngeal
n er ves, thyroid glan d, carot id sh eath , an d bran ch es of th e ar teries are related an terolaterally. Th e thyroid glan d con sist s of t w o
lobes, w h ich m ay be con n ected by th e isth m us.
Surgical Annotation
Trach eostom y is on e of th e m ost com m on surgical proced ures
p erform ed in in ten sive care un it s. Th e m ost com m on in dicat ion
for t rach eostom y is for prolonged air w ay access in im p aired resp irator y fun ct ion . During t rach eostom y, th e st ruct ures an terior
to th e secon d to four th rings are addressed such as th e isth m us
of th e thyroid. During prim ar y an d reoperat ion s of th e thyroid
glan ds, it is cru cial to ap p reciate th e relat ion sh ip bet w een th e
im p or tan t lan dm arks, su ch as th e recu rren t an d superior lar yn geal n er ves, brach iocep h alic arter y, an d p arathyroid glan ds.35–37
217
Anatom y for Plastic Surgery of the Face, Head, and Neck
Accessory
parotid gland
Parotid gland
Parotid duct
Buccinator
Masseter
a
Facial artery
and vein
a
Submandibular
gland
Sublingual
fold
Sternocleidomastoid
Sublingual
papilla
Oral m ucosa
Genioglossus
Sublingual
gland
Geniohyoid
Submandibular duct
Mylohyoid
Submandibular gland
Lingual artery
b
b
Hyoid bone
Hyoglossus
St ylohyoid
Fig. 21.16 Major salivary glands. (a) Lateral view and (b) superior view. Three large, paired sets of glads are distinguished: 1. Parotid glands 2. Submandibular glands 3. Sublingual glands. (From THIEME Atlas of Anatomy, Head and Neuroanatomy. © Thieme 2010, Illustrations by Karl Wesker.)
218
21 Neck
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219
Index
A
Adipose t issu e, of n eck, 200, 203f
su rgical an n ot at ion for, 203
Alveolar p ar t , of m an d ible, 173, 175f
Angu lar ar ter y, 48f
su rgical an n ot at ion for, 55
Angu lar vein , 63, 66f
An terior com p art m en t n eck m u scles
digast ric m u scle, 208
st rap m u scles, 208
An terior jugu lar vein , 69
An terior sku ll base, 13–18, 14f, 15f
m id lin e/p arasagit t al port ion s of, 14–17
n asal cavit y an d eth m oid sin uses form ed by,
13–14
ossi cat ion of, 13
paran asal sin u ses an d, 17–18
An terior t riangle, 216
An terior vertebral vein , 69
Ar terial an astom oses, 49f
Ar terial su p ply, of th e facial skin, vascu lat ure of
each region
ch eek, 43–44, 44f, 45f
foreh ead, 40, 41f
low er lip, 44–46, 45f, 46f
n ose an d u pp er lip , 42–43, 43f, 44f
u pp er eyelid, 40–42, 42f, 43f
Ar teries, of th e face an d n eck, 55f
angu lar ar ter y, 48f
su rgical an n ot at ion for, 55
deep, 48f
dorsal n asal arter y, 53f, 55f, 59f
su rgical an n ot at ion for, 61
eth m oidal ar ter y, 48f, 53f, 59
extern al carot id ar ter y, 47, 48f
bran ch es of, 50f
su rgical an n ot at ion for, 49
facial ar ter y, 48f, 53–54, 53f, 55f
in ferior labial ar ter y, 48f, 53–54, 53f, 55f
su rgical an n ot at ion for, 54
lateral n asal ar ter y, 48f, 53f, 55f
su rgical an n ot at ion for, 54
lateral p alp ebral arter y, 48f, 52f, 58–59, 59f
lingu al ar ter y, 49, 50f
su rgical an n ot at ion for, 49
m axillar y ar ter y, 48f, 56
su rgical an n ot at ion for, 56
m edial palpebral arter y, 52f, 59f
su rgical an n ot at ion for, 59
occip it al ar ter y, 49, 49f, 52f
su rgical an n ot at ion for, 51
oph t h alm ic ar ter y, 48f, 58
su rgical an n ot at ion for, 58
posterior au ricu lar ar ter y, 48f, 51–52, 52f
su rgical an n ot at ion for, 52
su bm en t al ar ter y, 53
su rgical an n ot at ion for, 53
su p er cial, 48f
su p er cial tem p oral arter y, 48f, 52f, 56–58, 60f
cou rse an d bran ch es of, 57f
su rgical an n ot at ion for, 57–58
tem poralis m u scle ap, 179–180, 180f
su p erior labial ar ter y, 53f, 55f
surgical ann ot at ion for, 54
superior t hyroid arter y, 49, 50f
origin of, 51f
surgical ann ot at ion for, 49
supraorbit al ar ter y, 48f, 60–61, 60f
surgical ann ot at ion for, 61
suprat roch lear ar ter y, 40, 42f, 48f
surgical ann ot at ion for, 60
ATN. See Au riculotem p oral n er ve
Auricle, 161. See also Extern al ear
an atom y of, 163f
deform it y recon st r u ct ion clin ical con siderat ion s for, 171
fascial layers of, 169–170, 170f
in n er vat ion for, 167–168, 168f
m uscle an d facial n er ve, 165, 166f, 166t, 167
vascular su pply for, 167–168, 169f
Auricu lotem poral n er ve (ATN)
clin ical correlat ion , 93
com p ression p oin t s and extern al lan dm arks,
91–92, 92f, 92t
origin an d course of, 91
Ch on drocran iu m , ossi cat ion of, 16
Ciliar y ganglion , 126–127
Cistern al segm en t , of facial n er ve, 72
Com puted tom ography im age (CT)
of an terior skull base, 15f
Keros classi cat ion depicted by, 16f
of m iddle skull base, 22f, 31f
of sp h en oid sin us, 23f
Con dylar process, of m an dible, 175
Conjun ct iva
eyelid an d, 135f
t arsu s an d, 138
Coron oid p rocess, of m and ible, 174–175
Corrugator supercilii (CS), 112
Corrugator supercilii m uscle (CSM), 87–88, 112,
115f
Cran ial n er ve
cavern ous sin us an d, 25f, 26f
in the n eck, 209–212
CS. See Corr ugator su percilii
CSM. See Corrugator supercilii m uscle
CT. See Com pu ted tom ography im age
B
D
Blood circulat ion m orph ology
of scalp, 34–35, 35t
of tem poral region , 36–37, 38t
Bon e har vest , from ch in , 172
Bony sept u m , 6–7, 7f
Buccal bran ch , of facial n er ve, 83, 83f, 84f
Buccal fat pad, 191–192, 191f
Buccin ator, 117, 118f
Dacr yocystorh inostom y (DCR), 131–132
Deep cer vical fascia, 205
Deep cer vical vein , 69
Deep tem poral fascia ap, 37f
surgical an n ot at ion for, 38
Digast ric m u scle
an terior belly, 208
posterior belly, 208
surgical an n ot at ion for, 208
Dorsal n asal ar ter y, 53f, 55f, 59f
surgical an n ot at ion for, 61
C
Capsu lop alpebral fascia, in ferior t arsal m uscle
an d, 138
Carot id sh eath
at t ach m en t s of, 205
surgical ann ot at ion for, 205
Carot id t riangle, 216
Car t ilage, 162, 164f
Cavern ous sin us, 24–25, 25f, 26f
Cer vical bran ch , of facial n er ve, 83f, 84, 84f
Cer vical fascia
layers of, 204f
super cial cer vical fascia, 203
carot id sh eath , 205
deep cer vical fascia, 205
p lat ysm a m u scle, 205
p ret rach eal fascia, 205
p revertebral fascia, 205
Cer vical plexus, 209
cu t an eous bran ch es of, 210f
Cer vical sp in e
surgical ann ot at ion for, 200
ver tebral ar ter y p assage th rough , 202f
ver tebra of, 201f
Ch eek
angiogram of, 44f
m ovem en t during chew ing, 195f
SMAS an d, 103, 103f
subderm al plexus of, 45f
vasculat ure of, 43–44
E
Ear. See Extern al ear
Eth m oidal ar ter y, 48f, 53f, 59
Eth m oidal foram en, 14, 16f
Eth m oidal labyrinth s, 4–5
Eth m oid bon e
cribriform plate an d, 3f, 4
in ferior view of, 4f
labyrinth s in , 4–5
perpen dicular plate an d, 4
sup erior view of, 4f
Eth m oid roof, 13
Keros classi cat ion of, 14
Eth m oid sin u ses, 149–150, 149f, 150t
an terior sku ll base form ing, 13–14
blood supply for, 150f
surgical an n ot at ion for, 150–151
Exten ded m astoidectom y, 75f
Extern al acou st ic m eat us, 162, 164–165, 165f
Extern al carot id arter y, 47, 48f
an terior bran ch es of, 50f
surgical an n ot at ion for, 49
Extern al ear
an atom y of, 162f
auricle, 161, 163f
bon e st ruct ure of, 161
car t ilage, 162, 164f
221
Index
Extern al ear (cont inued )
extern al acou st ic m eat us, 162, 164–165
m u scle an d facial n er ve an d, 165, 166f, 166t,
167
Extern al levator advan cem en t ptosis surger y, 138
Extern al m axillar y arter y. See Facial ar ter y
Extern al n ose
blood sup p ly of, 156
bony car t ilagin ous st r u ct u res of, 158–160,
158f, 159f
extern al an atom y of
blood su pp ly of, 157t
m u scle layer of, 156, 157t
skin , 155
su bcu t an eou s layer, 155–156
in ferior view of, 156f
lateral view of, 156f
m im et ic m uscle an d, 114–115
sen sor y in n er vat ion of, 158, 158t
soft t issu e layers of, 157f
t ip support m ech an ism for, 160
Extern al su rface, of m and ible, 172, 173f
Eyebrow, 139
Eyelid. See also Up p er eyelid
conju n ct iva an d, 135f
extern al levator advan cem en t ptosis su rger y
an d, 138
eyebrow an d, 139
foreh ead an atom y an d, 139, 139f
lateral and m edial canthal reanchoring and, 136
lateral an d m ed ial can th al tend on s, 136
lym p h at ics an d , 140
m argin , 138–139, 138f
m id face an atom y an d, 139
n er ves an d, 140
orbit al fat p ad s and, 136, 138
orbit al sept u m , 136
periorbit al facial m im et ic m uscles and, 136f
ret ractors for
cap su lopalpebral fascia, 138
in ferior t arsal m u scle, 138
levator palp ebrae su perioris m u scle, 138
Mü ller’s m u scle, 138
su rface an atom y of, 134f, 137f
low er eyelid layers, 134, 135f
prot ractors, 134
skin , 134
u p per eyelid layers, 134, 135f
su rgical an n ot at ion for, 136, 138
low er lid m alp osit ion , 139–140
m alar region , 140
n asojugal groove, 140
palp ebrom alar groove, 140
tem p oral foreh ead an atom y an d, 139, 139f
vessels an d, 140
F
Face. See also Ar teries, of th e face an d n eck
aging ch anges of, 140f
angiogram of, 41f
layers of, 111, 111f
m u scles of, 112f, 113f
ret ain ing ligam en t s of, 104–110
foreh ead an d tem p oral region , 106–107,
106f, 107t
m id dle an d low er facial region, 107, 108t,
109–110, 109f
periorbit al region, 107, 107t, 108f
222
vein s of
angu lar vein , 63, 66f
arteriovenogram of, 64f
com m on pat tern of, 65f
facial vein , 64–66, 66f
in ferior oph th alm ic vein , 64
m axillar y vein , 66
n asal root vein , 63, 65f
pter ygoid ven ous p lexu s, 66, 67f
ret rom an dibu lar vein , 66
su perior oph th alm ic vein , 64
su praorbit al vein , 63
su prat roch lear vein, 63
Facial ar ter y, 48f, 53–54, 53f, 55f
Facial ner ves, 104, 129f
blood supply to, 76
bran ch es of, 211f
classi cat ion of, 73t
course an d bran ch es of, 74f
injur y during facelift surger y, 79
in t raop erat ive view of, 75f
m ajor bran ch es of, 73t
m iddle ear cavit y in relat ion to, 75f
in th e n eck, 211
n u clei an d in ternal bran ches of, 74f
over view of, 80f
in parot id glan d, 81f
periph eral bran ch es of, 81f
buccal bran ch , 83, 83f, 84f
cer vical bran ch, 83f, 84, 84f
fascia plan e for, 82f
fron t al/tem poral bran ch, 79–82, 83f
m and ibular bran ch , 83–84, 83f, 84f
zygom at ic branch , 82, 83f
radiologic an atom y an d, 76–77, 77f
segm ent s of
cistern al segm ent , 72
gen icu late ganglion segm en t , 73
in t racran ial por t ion , 72
in t ratem poral por t ion , 73
labyrin th in e segm ent , 73
m astoid segm en t , 76, 76f
m eat al segm en t , 73
m edullar y segm en t , 72
t ym pan ic segm en t , 73–74
SMAS and, 79
su rgical an not at ion for
during liposu ct ion , 211
during parot idectom y, 211–212
su rgical approach es to, 77
Facial skeleton , neurocran ium an d, 1–12
Facial soft t issue layer, SMAS an d, 104
Facial vein , 64–66, 66f
Foram en cecum , 14, 16f
Forehead
an atom y of, 139, 139f
angiogram of, 41f
blood supply of, 52f
vasculat ure of, 40, 41f
Fren ulum , 184f
Fron t al bon e
in ferior view of, 3f
orbit al par t s of, 2
squ am ou s p ar t , 1
su rgical an not at ion of, 1–2
Fron t alis, 114f
Fron t al m usculopericran ial ap, 36f
su rgical an not at ion for, 35
Fron t al sin u s, 148, 148f
agger n asi cells an d, 17
fract ures of, surgical an n ot at ion for, 4
On odi cell and, 18
un cin ate p rocess in uen cing, 17
Fron t al sin u s cran ializat ion , 148–149, 149f
Fron t al/tem poral bran ch , of facial n er ve, 79–82
dissect ion of, 81f, 83f
fascia plan e for, 82f
Fron t al t rigger point , in m igrain e h eadach es
SON, 86–89, 88f, 89t
STN, 89–90, 89t, 90f
G
Galea apon eu rot ica, 33, 34f
Geniculate ganglion segm en t
of facial n er ve, 73
in n er ear in relat ion to, 74f
Gingiva/Alveolar m u cosa, 187, 187f
Greater occipit al n er ve (GON)
clinical correlat ion , 96
com pression p oin t s an d extern al lan dm arks,
94, 95f, 95t
origin an d course of, 94
H
Hyoid bone, 197f, 200, 202f
I
In ferior carot id t riangle, 216
In ferior labial arter y, 48f, 53–54, 53f, 55f
surgical an n ot at ion for, 54
In ferior n asal con ch a. See Nasal con ch a, in ferior
In ferior n asal m eat us, 146f
In ferior ophth alm ic vein , 64
In ferior t arsal m uscle, capsulo palpebral fascia
an d, 138
In ferior tem p oral sept um , 106–107
In tern al carot id ar ter y, 25–26
segm en t classi cat ion system for, 25, 26f
In tern al jugular vein, 69
In tern al surface, of m an dible, 172–173, 173f
alveolar part , 173, 175f
con dylar process, 175
coron oid process, 174–175
ram u s, 174, 174f
surfaces an d borders, 174
In t racran ial por t ion , of facial n er ve, 72
In t ratem poral por t ion , of facial n er ve, 73
J
Jugular vein , 69
K
Keros classi cat ion
CT im ages depict ing, 16f
of eth m oid roof an d olfactor y fossa, 14
L
Labyrin th ine segm en t , of facial n er ve, 73, 74f
Lacrim al bon e, 12, 12f
Lacrim al glan d, 130
Lacrim al pu m p, 130–131
LAO. See Levator anguli oris m uscle
Lar yngeal m uscles, act ion s of, 197f
Lateral an d m edial can t h al ten don s
eyelid an d, 136
reanch oring of, 136
Index
Lateral com p ar t m en t n eck m uscles, 207–208
stern ocleidom astoid, 207–208
su rgical an n ot at ion for, 208
Lateral n asal ar ter y, 48f, 53f, 55f
su rgical an n ot at ion for, 54
Lateral orbit al oor, orbit al su rger y con siderat ion s for, 125
Lateral orbit al w all, 120
Lateral p alp ebral arter y, 48f, 52f, 58–59, 59f
Lateral pter ygoid
m an dibu lar n er ve sp at ial relat ion s, 181
side-to-side m ovem en t , 181
vascu lar sup ply an d in ner vat ion , 181
Le For t I Osteotom y, 152–153
Lesser occip it al n er ve (LON)
clin ical correlat ion , 98
com p ression p oin t s an d extern al lan dm arks,
96–97, 97f, 97t
origin an d course of, 96
Levator angu li oris m u scle (LAO), 116
Levator labii su p erioris (LLS), 115
Levator labii su p erioris alaeque n asi m u scle
(LLSAN), 114
Levator p alp ebrae su p erioris m uscle, 138
Ligam en t . See Ret ain ing ligam en t s, of face
Lingu al ar ter y, 50f
su rgical an n ot at ion for, 49
Lingu al m ucosa, su rface an atom y of, 188f
Lingu al vein s, 69
Liposu ct ion , facial n er ve su rgical an n ot at ion
during, 211
LLS. See Levator labii sup erioris
LLSAN. See Levator labii sup erioris alaequ e nasi
m u scle
LON. See Lesser occipit al n er ve
Loose con n ect ive t issu e, 33, 34f
Low er eyelid, surgical an n ot at ion for, 129–130
Low er lid m alposit ion , 139–140
Low er lip
angiogram of, 45f
sagit t al sect ion through , 46f
vascu lat u re of, 44–46
M
Magn et ic reson an ce im aging (MRI)
of an terior sku ll base, 15f
of facial n er ve, 77f
Malar fat p ad, SMAS an d , 101
Man dible
body of, 172, 173f
extern al su rface of, 172, 173f
in tern al su rface of, 172–173, 173f
alveolar p ar t , 173, 175f
con dylar process, 175
coron oid p rocess, 174–175
ram u s, 174, 174f
su rfaces an d bord ers, 174
lateral pter ygoid
m an dibu lar n er ve spat ial relat ion s, 181
side-to-side m ovem en t , 181
vascu lar supply an d in n er vat ion , 181
lateral view of, 185f
m an dibu lar can al an d, 175
m asseter an d, 176–177
bran ch es of, 178
in n er vat ion of, 178, 179f
in t ram u scular in n er vat ion of, 178
vascu lar supply of, 178, 178f
m ast icator y m uscles, 175–176, 176f, 177f
tem poralis m uscle ap, 178–179
m edial pter ygoid
m an dibular angle redu ct ion an d, 180–181
vascular su pply an d in n er vat ion , 180, 181f
m ovem en t s of, 195f
surgical ann ot at ion for
bone h ar vest , 172
m an dibu lar foram en iden t i cat ion , 174, 175f
tem poralis m uscle ap
fasciae of, 180
in n er vat ion , 180
vascular su pply for, 179–181, 180f
Man dible can al, an terior loop of, 173f
Man dibular angle redu ct ion , 180–181
Mandibular branch , of facial ner ve, 83–84, 83f, 84f
Man dibular can al
dam age to, 175
m an dible and, 175
Man dibular ligam ent , 109–110, 109f
Man dibular n er ve, 212f
Masseter, 176–177
bran ch es of, 178
in n er vat ion of, 178, 179f
in t ram uscu lar in n er vat ion of, 178
vascular su pply of, 178, 178f
Masseteric cut an eous ligam en t , 110
Mast icator sp ace, 29–30
Mast icator y m uscles, 175–176, 176f, 177f
tem poralis m uscle ap, 178–179
Mastoid segm en t , of facial n er ve, 76, 76f
Maxilla
body
an terior surface, 8
fron t al process, 9
m axillar y sin us, 9–10
n asal su rface, 9
orbit al surface, 8
p alat ine process, 9
p osterior surface, 8
zygom at ic process, 9
lacrim al bon e, 12, 12f
lateral view of, 9f
m edial view of, 9f
p alat ine bone
h orizon t al plate, 10
orbit al process, 11
p erp endicular p late, 10–11
p osterior view of, 10f
pyram idal p rocess, 11
sph enoidal process, 11
zygom at ic bon e, 11–12
borders of, 12
extern al view of, 11f
in tern al view of, 11f
p rocesses of, 12
su rfaces of, 12
Maxillar y ar ter y, 48f
su rgical ann ot at ion for, 56
Maxillar y fract ure, 152–153, 152f
Maxillar y n er ve, 127
Maxillar y sin us, 9–10
n asal cavit y an d, 151–152, 151f
Maxillar y vein , 66
Meat al segm ent
of facial n er ve, 73
in n er ear in relat ion to, 74f
Meckel’s cave, 27–28
Medial orbit al w all, 120
orbit al surger y con siderat ions for, 124–125
Medial palpebral arter y, 52f, 59f
surgical an n ot at ion for, 59
Medial pter ygoid
m an dibu lar angle red uct ion an d, 180–181
vascular supply and in ner vat ion , 180, 181f
Medullar y segm ent , of facial n er ve, 72
Men t alis m u scle (MT), 117, 118f
Mid dle ear cavit y, facial n er ve in relat ion to, 75f
Mid dle skull base, 20–31, 22f, 31f
center of sph ere, sph en oid bon e an d sp h en oid
sin us, 20–23
ext racran ial st r u ct ures an terior/in ferior to
m ast icator space, 29–30
nasophar yn x, 30–31, 30f
orbit al apex an d PPF, 27–29
int racran ial st ruct ures su perior to
cavern ous sin u s, 24–25, 25f, 26f
intern al carot id arter y, 25–27
sella t u rcica an d sup rasellar region , 24
st ruct ures lling posterior aspect of
Meckel’s cave, 27
pet rous apex an d p et roclival jun ct ion , 27
Mid dle tem poral vein , 67–68
surgical an n ot at ion for, 68
Mid dle t hyroid vein s, 69
Migrain e h eadach es
path ogenesis of, 86
periph eral t rigger poin t s in
fron t al, 86–90, 88f, 89t, 90f
nasosept al, 93–94, 93f
occipit al, 94–98, 95f, 95t, 97f, 97t, 98t
tem poral, 90–93, 90f, 91t, 92f, 92t
Mim et ic m uscles, 104, 112f, 113f
an terior ch eek region of, 115–116
buccin ator, 117, 118f
ch in region an d super cial neck of, 117–118
extern al n ose region of, 114–115
facial expression m uscles and th eir act ion s,
111–112
facial layers an d, 111, 111f
foreh ead an d tem poral region of, 111–112
fron t alis, 114f
m odiolus, 118–119, 119f
MT, 117, 118f
nasalis, 115f
orbicularis oculi m uscle, 114f
perioral region of, 116–117, 117f
periorbit al region of, 112–113, 136f
risorius, 117, 117f
SMAS an d, 102
upper lip elevators, 116f
Modiolus, 118–119, 119f
Mouth , oor of, su blingual sp ace an d, 192
MRI. See Magn et ic reson an ce im aging
MT. See Men t alis m uscle
Mü ller’s m uscle, 138
Mu scu lar t riangle, 216
N
Nasal bon e
in tern al view of, 6f
n asal bridge an d bony sept um , 6–7, 7f
surgical an n ot at ion for, 7
Nasal bridge, 6–7, 7f
Nasal cavit y
an terior sku ll base form ing, 13–14
223
Index
Nasal cavit y (cont inued )
blood sup p ly of, 146–147, 146f
eth m oid sin us an d, 149–150, 149f, 150t
oor of, 142, 144f
fron t al sin u s an d , 148, 148f
in ferior n asal m eat us, 146f
lateral w all of, 143, 145f, 146
m axillar y sin u s, 151–152, 151f
m edial view of, 5f
m edial w all/n asal sept u m , 142–143, 145f
paran asal sin u ses, 148, 148t
roof of, 142
sagit t al sect ion of, 143f
sen sor y in n er vat ion of, 147–148, 147f
sp h en oid sin u s, 151, 151f
su rgical an n ot at ion for, 148–149
m axillar y fract ure, 152–153, 152f
Nasal con ch a, inferior, 8, 8f
Nasalis, 115f
Nasal root vein , 63, 65f
Nasal sept u m , 7f, 142–143, 145f
Nasojugal groove, 140
Nasolacrim al duct s, 148
open ing variat ions of, 153, 153f, 153t
Nasolacrim al in t u bat ion , 131
Nasolacrim al su rger y, su rgical an n ot at ion for,
131–132
Nasolacrim al system , 130–131, 132f
Naso-orbit al ceph alocele, 16
Nasop h ar yn x, 30–31, 30f
Nasosept al t rigger p oin t , in m igrain e headach es
clin ical correlat ion, 94
com pression p oin t s, 93, 93f
path op hysiology of, 93
Neck
ad ipose t issu e, 200, 203f
su rgical an n ot at ion for, 203
ar teries in, 212, 213f
su rgical an n ot at ion s, 214
cer vical fascia
layers of, 204f
su p er cial cer vical fascia, 203, 205
cer vical p lexu s, 209
cu t an eou s branch es of, 210f
cran ial n er ve in , 209–212
su rgical an n ot at ion for, 211–212
facial n er ve bran ch es in , 211–212, 211f
lym p h at ics an d , 214f
classi cat ion of, 214
su rgical an n ot at ion for, 215
m an dibular n er ve in , 212f
m u scles for, 206f, 207f
an terior com par t m en t , 208
lateral com part m en t , 207–208
m otor in n er vat ion s of, 210f
posterior com part m en t , 208
periph eral n er ves of, 209
skelet al su p port for
cer vical spin e, 200
hyoid bon e, 200
skin , 200
su bm an dibu lar glan d, 216, 217f
su rgical an n ot at ion for, 218
su rface an atom y of, 201f
t riangles of, 215–218, 215f
an terior t riangle, 216
carot id t riangle, 216
m u scu lar t riangle/in ferior carot id t riangle,
216
224
posterior t riangle, 216
su bm en t al t riangle/su prahyoid t riangle,
216
su rgical an not at ion for, 216
vascular anatom y of, 212, 213f, 214
vein s of, 68f, 69f
an terior jugular vein , 69
an terior vertebral vein , 69
deep cer vical vein , 69
in ternal jugular vein, 69
lingu al vein s, 69
m iddle thyroid vein s, 69
ph ar yngeal vein s, 69
posterior extern al jugular vein , 69
su bclavian vein , 68–69
su perior thyroid vein s, 69
su rgical an not at ion for, 214
ver tebral vein , 69
visceral st ru ct ures of, surgical an n ot at ion for,
218
Neurocran ium
eth m oid bon e
cribriform plate an d, 3f, 4
in ferior view of, 4f
labyrin th s in , 4–5
perp en dicu lar plate an d, 4
su perior view of, 4f
facial skeleton and, 1–12
fron t al bon e
in ferior view of, 3f
orbit al part s of, 2
squam ou s p ar t , 1
su rgical an not at ion of, 1–2
fron t al sin u s fract ures an d, surgical
an not at ion for, 4
tem poral bon e
in terior view of, 6f
pet rom astoid par t , 6
squam ou s p ar t , 5–6
viscerocraniu m art iculat ions an d, 2t
viscerocraniu m ossi cat ion pat tern s an d, 2t
Nose. See also Extern al n ose
angiogram of, 43f
sagit t al sect ion th rough , 44f
vasculat ure of, 42–43
O
Occipit al arter y, 49, 49f, 52f
su rgical an not at ion for, 51
Occipit al t rigger p oin t , in m igrain e h eadach es
GON, 94–96, 95f, 95t
LON, 96–98, 97f, 97t
TON, 98, 98t
Occipit al vein , 68
Occipitofron t alis m uscle (OFM), 111
Occlu sion , 197
Oculom otor t riangle, 25, 26f
OFM. See Occipitofront alis m uscle
Olfactor y fossa, Keros classi cat ion of, 14
Onodi cell, 18
Oph th alm ic arter y, 48f
su rgical an not at ion for, 58
Oph th alm ic n er ve, 126
Oral cavit y, 183
m idsagit t al p lane of, 183f
sw allow ing an d, 192–193, 195
Oral m u cosa, in n er vat ion of, 187f
Oral vest ibu le, 183–184
Orbicu laris ret ain ing ligam en t , 107
Orbit al an atom y
axial an d coron al view s of, 124f
clinical an atom y of, 120
dim ension s an d volum es, 121f
orbit al apex, 123f
orbit al bon es, 121f, 122f
addit ion al ssures, can als, an d foram in a
an d con ten t s, 120–121
lateral orbit al w all, 120
m edial orbit al w all, 120
orbit al oor, 120
orbit al rim , 120
orbit al roof, 120
orbit al w alls, 120
periorbit a and fascial t issu es, 122
sagit t al view of, 123f
surgical an n ot at ion an d, 122–123
orbit al surgical spaces an d ap proaches,
122
surgical con siderat ion s for, 124–125
Orbit al apex, 27–28, 28f
Orbit al fat pads, 136, 138
dist ribut ion of, 131f
surgical an n ot at ion for, 129
Orbit al oor, 120
orbit al surger y con siderat ion s for, 124
Orbit al rim , 120
Orbit al roof, 120
Orbit al sept u m , 136
Orbit al soft t issu es
au ton om ic in n er vat ion, 128
ext raocu lar m u scles an d, 126, 127f
facial n er ve, 129f
lacrim al system an d, 130
m otor in ner vat ion an d, 127–128
opt ic n er ve, 126
orbit al fat p ad, 129
orbit al lym ph at ics, 129
orbit al n er ves
ciliar y ganglion , 126–127
m axillar y n er ve, 127
oph th alm ic n er ve, 126
sen sor y in n er vat ion an d, 126
orbit al vessels an d, 128–129
periorbit al n eurovascular st ru ct u res, 130f
surgical an n ot at ion for
low er eyelid, 129–130
orbit al fat p ad m an ip ulat ion , 129
up per eyelid, 129
t rigem inal n er ve, 128f
Orbit al w alls, 120
Oroph ar yngeal isth m u s, 192
Oroph ar yngeal m uscles, n er ve in n er vat ion an d,
194f
P
Palate, 187–188
Palat in e ar ter y, 152f
Palat in e bon e
h orizon t al plate, 10
orbit al p rocess, 11
perpen dicu lar plate, 10–11
posterior view of, 10f
pyram idal p rocess, 11
sph en oidal p rocess, 11
Palpebrom alar groove, 140
Paran asal sin uses, 10f
an terior skull base an d, 17–18
n asal cavit y an d, 148, 148t
Index
Paraver tebral m u scle, 209
Parot idectom y, facial n er ve su rgical an n ot at ion
during, 211–212
Parot id glan d
cross-sect ion from , 103f
facial n er ves in , 81f
Parot id m asseteric fascia, SMAS an d, 104
Parot id p ap illa, 184f
PCOM. See Posterior com m un icat ing ar ter y
Pericran iu m , 34
Periodon t al t issu es, 184–185
longit udin al sect ion of, 186f
ret rom olar region , 185f
Periorbit al sept u m , 107
Perip h eral bran ch es, of facial n er ve, 81f, 82f
buccal bran ch , 83, 83f, 84f
cer vical bran ch , 83f, 84, 84f
front al/tem p oral bran ch , 79–82, 83f
m an dibu lar bran ch , 83–84, 83f, 84f
zygom at ic bran ch , 82, 83f
Perip h eral t rigger p oin t , in m igrain e h eadach es,
93f
front al t rigger poin t
SON, 86–89, 88f, 89t
STN, 89–90, 89t, 90f
n asosept al t rigger poin t , 93–94, 93f
occip it al t rigger p oin t
GON, 94–96, 95f, 95t
LON, 96–98, 97f, 97t
TON, 98, 98t
tem p oral t rigger poin t
ATN, 91–93, 92f, 92t
ZTN, 90–91, 90f, 91t
Pet roclival jun ct ion , 27
Pet rou s apex, 27, 27f
Ph ar yngeal vein s, 69
Ph ar yn x, 183, 183f
sw allow ing an d, 192–193, 195
Plat ysm a au ricu lar ligam en t , 110
Plat ysm a cut an eou s ligam en t , 110
Plat ysm a m uscle
classi cat ion s of, 205
su rgical an n ot at ion for, 205
Posterior au ricu lar ar ter y, 48f, 51–52, 52f
su rgical an n ot at ion for, 52
Posterior au ricu lar vein , su rgical an n ot at ion for,
68
Posterior com m u n icat ing ar ter y (PCOM), 27
Posterior com p ar t m en t n eck m uscles
paraver tebral m u scle, 209
post vertebral m u scle, 209
t rap eziu s, 208–209
Posterior extern al jugu lar vein , 69
Posterior t riangle, 216
Post vertebral m u scle, 209
PPF. See Pter ygop alat in e fossa
Pret rach eal fascia, 205
Prever tebral fascia, 205
Prezygom at ic sp ace, 108f
Pter ygoid ven ou s p lexus, 67f
su rgical an n ot at ion s for, 66
Pter ygop alat in e fossa (PPF), 27–28, 29f
R
Ram u s, 174, 174f
Ret ain ing ligam en t s, of face
foreh ead an d tem p oral region , 106f, 107t
in ferior tem p oral sept u m , 106–107
su p erior tem poral sept um , 106
supraorbit al ligam entous adh esion, 107
tem poral ligam en tous adhesion , 106
m iddle an d low er facial region , 107, 108t
m an dibular ligam en t , 109–110, 109f
m asseteric cu t an eous ligam en t , 110
p lat ysm a auricular ligam en t , 110
p lat ysm a cut an eous ligam en t , 110
p rezygom at ic space, 108f
zygom at ic ligam en t , 109
p eriorbit al region , 107t, 108f
orbicularis ret ain ing ligam en t , 107
p eriorbit al sept u m , 107
tear t rough ligam en t , 107
SMAS an d, 104–110
Ret rom and ibular vein , 66
Risoriu s, 117, 117f
S
Scalp
blood circu lat ion m orph ology of, 34–35, 35t
ap, surgical an n ot at ion for, 35
layers of, 34f
loose con n ect ive t issu e an d, 33, 34f
subcut an eous fat layer an d, 33
vein s of, 67f
m iddle tem poral vein, 67–68
occip it al vein , 68
p osterior au ricular vein , 68
super cial tem poral vein , 67
Sella t u rcica, 24, 24f
Sen sor y n er ves, 86
m igrain e t rigger poin t s an d, 87f
sum m ar y, 98
Skull
an terior base of, 13–18, 14f, 15f
an terior view of, 3f
m iddle base of, 22f, 24–31, 25f, 26f, 31f
Sku ll-base injur y, 14
SMAS. See Sup er cial m u sculo ap on eurot ic
system
SOF. See Su perior orbit al ssure
Soft t issue
galea apon eu rot ica, 33
layered st ru ct ure ch aracterist ics of, 35–36
loose con n ect ive t issu e, 33
p ericran ium , 34
surgical ann ot at ion for, 35
in tem poral region, 35–36
SON. See Su praorbit al n er ve
Sph en oid bon e, 20–23, 21f
Sph en oid sin u s, 20–23, 23f, 151, 151f
Stern ocleidom astoid, 207–208
surgical ann ot at ion for, 208
STN. See Sup rat rochlear n er ve
St rap m uscles, of th e n eck, 208
Su bclavian vein , 68–69
Su bcu t an eous fat layer
scalp an d, 33
SMAS an d, 101
Su bdural p lexus, 45f
Su blingu al space, oor of m outh an d, 192
Su bm an dibu lar glan d, 216, 217f
surgical ann ot at ion for, 218
Su bm en t al ar ter y, surgical an not at ion for, 53
Su bm en t al t riangle, 216
Su per cial m usculoapon eu rot ic system (SMAS),
33, 105f
facial ner ve an d, 79
facial soft t issue layer an d, 104
h istologic n dings of
low er eyelid, 103–104, 104f
parot id area to ch eek region , 103, 103f
tem poral region , 103, 103f
m alar fat pad an d, 101
m im et ic m uscles an d, 102
parot id m asseteric fascia an d, 104
parot id region dissect ion of, 102f
ret ain ing ligam en t s an d, 104–110
subcut aneou s fat layer and , 101
Super cial tem poral ar ter y, 48f, 52f, 56–58, 60f
course an d branch es of, 57f
over an terior tem poralis, 179–180, 179f
surgical an n ot at ion for, 57–58
Super cial tem poral fascial ap, su rgical
an n ot at ion for, 38
Super cial tem poral vein , 67
Superior labial arter y, 53f, 55f
surgical an n ot at ion for, 54
Superior oph th alm ic vein , 64
Superior orbit al ssure (SOF), 28, 120
Superior tem poral sept u m , 106
Superior thyroid ar ter y, 50f
origin of, 51f
surgical an n ot at ion for, 49
Superior thyroid veins, 69
Suprahyoid t riangle, 216
Supraorbit al arter y, 48f, 60–61, 60f
surgical an n ot at ion for, 61
Supraorbit al ligam en tou s adh esion , 107
Supraorbit al n er ve (SON)
clin ical correlat ion, 88–89
com pression poin t s an d extern al lan dm arks,
89t
CSM, 87–88
su praorbit al n otch , 87, 88f
origin an d cou rse of, 86–87
Supraorbit al n otch, 87, 88f
Supraorbit al vein , su rgical an n ot at ion for, 63
Suprasellar region , 24
Suprat roch lear arter y, 40, 48f
sagit t al sect ion of, 42f
surgical an n ot at ion for, 60
Suprat roch lear n er ve (STN)
clin ical correlat ion, 90
com pression poin t s an d extern al lan dm arks,
89–90, 89t, 90f
origin an d cou rse of, 89
Suprat roch lear vein , 63
Surgical an n ot at ion
for carot id sh eath , 205
for cer vical spin e, 200
for deep tem poral fascia ap , 38
for digast ric m uscle, 208
eth m oid sin us surger y, 150–151
for eyelid, 136, 138
low er lid m alposit ion , 139–140
m alar region , 140
nasojugal groove, 140
palpebrom alar groove, 140
for face an d n eck ar teries, 214
angular ar ter y, 55
dorsal n asal arter y, 61
extern al carot id arter y, 49
inferior labial ar ter y, 54
lateral n asal ar ter y, 54
lingual ar ter y, 49
m axillar y ar ter y, 56
m edial palp ebral arter y, 59
225
Index
Surgical an n ot at ion (cont inued )
occip it al ar ter y, 51
oph th alm ic ar ter y, 58
posterior auricular ar ter y, 52
su bm en t al arter y, 53
su p er cial tem poral ar ter y, 57–58
su p erior labial ar ter y, 54
su p erior thyroid ar ter y, 49
su p raorbit al arter y, 61
su p rat roch lear arter y, 60
of fron t al bon e, 1–2
for fron t al m usculopericranial ap , 35
for fron t al sin us fract ures, 4
du ring liposu ct ion , 211
for low er eyelid , 129–130
for m an dible bon e har vest , 172
m an dibular foram en iden t i cat ion an d, 174,
175f
for m axillar y fract ure, 152–153, 152f
for m iddle tem p oral vein , 68
for n asal bon e, 7
for n asal cavit y, 148–149
for n asolacrim al su rger y, 131–132
for n eck
ad ipose t issu e, 203
cran ial n er ve in , 211–212
lym p h at ics in , 215
su bm an dibu lar glan d, 218
t riangles of, 216
vein s, 214
visceral st ru ct u res, 218
for orbit al an atom y, 122–123
for orbit al fat p ad m an ipu lat ion , 129
du ring p arot idectom y, 211–212
for plat ysm a m uscle, 205
for posterior au ricu lar vein , 68
for pter ygoid ven ous plexus, 66
for scalp ap , 35
for soft t issu e, 35
for stern ocleidom astoid, 208
for sup er cial tem poral fascial ap, 38
for sup raorbit al vein , 63
for tem p oralis m uscle ap, 38
for tem p oralis m uscle- p ericran ial ap, 38
for t rapeziu s, 208–209
for up per eyelid, 129
Sw allow ing
hyoid bon e du ring, 197f
m ech an ism of, 198f
cheek m ovem en t during, 195f
oral cavit y p h ase en ding, 195
ph ar yngeal ph ase begin n ing, 195
ph ar yngeal ph ase en ding, 196–197
prep arator y ph ase, 193–194
oral cavit y an d p h ar yn x du ring, 192–193
sch em at ic diagram of, 193f
T
Tarsus, conju n ct iva an d, 138
Tear t rough ligam en t , 107
Teeth , 184–185
aesth et ic region of, 198, 198f, 199f
longit udin al sect ion of, 186f
occlu sion of, 197
su rface design at ion of, 186f
Tem poral bon e
in ferior view of, 6f
pet rom astoid p ar t , 6
226
squ am ou s p ar t of, 5–6
Tem poralis m uscle ap , 37f, 178–179, 179f
fasciae of, 180
in n er vat ion , 180
su rgical an not at ion for, 38
vascular supply for, 179–181
arter y, 179
su per cial tem poral arter y, 179–180, 180f
vein s, 179
Tem poralis m uscle-pericranial ap , 38f
su rgical an not at ion for, 38
Tem poral ligam en tous adh esion , 106
Tem poral region , blood circu lat ion m orph ology
of, 36–37, 38t
Tem poral t rigger poin t , in m igrain e headach es
ATN, 91–93, 92f, 92t
ZTN, 90–91, 90f, 91t
Tem porom an dibular join t (TMJ), 172
Tem poropariet al fascial ap, 180. See Super cial
tem poral fascial ap
Th ird occipit al n er ve (TON)
clin ical correlat ion , 98
com pression poin t s an d extern al lan dm arks,
98, 98t
origin an d course, 98
TMJ. See Tem porom and ibular join t
TON. See Third occipit al n er ve
Tongue, 188–189, 191
n er ves and vessels of, 190f
papillae of, 189f
Trap ezius, surgical an n ot at ion for, 208–209
Triangle, 215–218, 215f
an terior, 216
carot id, 216
m u scular/inferior carot id, 216
ocu lom otor, 25, 26f
posterior, 216
su bm en t al/suprahyoid, 216
su rgical an not at ion for, 216
Trigem in al n er ve, 128f
Tym pan ic segm ent , of facial n er ve, 73–74
U
Upp er eyelid
angiogram of, 42f
layers of, 134, 135f
sagit t al sect ion th rough , 43f
su rgical an not at ion for, 129
vasculat ure of, 40–42
Upp er lip
angiogram of, 43f
elevators, 116f
sagit t al sect ion th rough , 44f
vasculat ure of, 42–43
V
Vasculat u re, of facial region s, 40–46
angiogram of, 41f
ch eek, 43–44
angiogram of, 44f
su bdural plexu s of, 45f
foreh ead, 40, 41f
low er lip, 44–46
angiogram of, 45f
sagit t al sect ion th rough , 46f
n ose an d upper lip, 42–43
angiogram of, 43f
sagit t al sect ion th rough , 44f
up per eyelid, 40–42
angiogram of, 42f
sagit t al sect ion th rough, 43f
Vein s
of th e face
angu lar vein , 63, 66f
ar terioven ogram of, 64f
com m on p at tern of, 65f
facial vein , 64–66, 66f
in ferior oph th alm ic vein , 64
m axillar y vein, 66
n asal root vein , 63, 65f
pter ygoid ven ous plexu s, 66, 67f
ret rom an dibu lar vein , 66
superior oph th alm ic vein , 64
supraorbit al vein , 63
suprat rochlear vein , 63
of th e n eck, 68f, 69f
an terior jugu lar vein , 69
an terior ver tebral vein , 69
deep cer vical vein , 69
in tern al jugu lar vein , 69
lingual vein s, 69
m iddle thyroid vein s, 69
ph ar yngeal veins, 69
posterior extern al jugular vein , 69
subclavian vein , 68–69
superior thyroid vein s, 69
vertebral vein , 69
of th e scalp, 67f
m iddle tem poral vein , 67–68
occipit al vein, 68
posterior auricular vein , 68
super cial tem poral vein, 67
Veloph ar yngeal m u scles, 196f
Ver tebral ar ter y, 202f
Ver tebral vein, 69
Viscerocran iu m , 2t
in ferior n asal con ch a, 8, 8f
m axilla
body, 8–10
lacrim al bon e, 12, 12f
palat in e bon e, 10–11, 10f
zygom at ic bone, 11–12, 11f
n asal bon e, 6f
n asal bridge an d bony sept u m , 6–7, 7f
surgical an n ot at ion for, 7
ossi cat ion pat tern s of, 2t
vom er, 7–8, 8f
Vom er, 7–8, 8f
Z
ZTN. See Zygom at icotem p oral n er ve
Zygom at ic bon e, 11–12
borders of, 12
extern al view of, 11f
in tern al view of, 11f
processes of, 12
surfaces of, 12
Zygom at ic bran ch , of facial n er ve, 82, 83f
Zygom at ic ligam en t , 109
Zygom at icotem poral n er ve (ZTN)
com pression p oin t s an d extern al lan dm arks,
90–91, 90f, 91t
tem poral fossa, 90
tem poralis m uscle/deep tem poral fascia,
91
origin an d course of, 90