facial anatomyand facial bones; the sphincter colli profundus: frontalis, periorbital, zygomaticus,...

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Facial Anatomy

ר פרידמן טל"ד

כירורגיה פלסטית

הרופא -ח אסף"בי

Anatomy of the facial soft tissues

Five layers of critical anatomy:

1. Skin

2. Subcutaneous fat

3. Supereficial Musculoaponeurotic system

(SMAS)/ muscle layer.

4. Deep Fascia

5. Facial n.

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Subcutaneous Soft Tissue

Homogenous fascial fatty layer.

Malar Fat Pad: Triangular in shape

Beneath is the SMAS.

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SMASSuperficial musculoaponeurotic system

“A tissue plane that is composed of fibrous or

muscular tissue, lies in direct continuity with the

platysma, and lacks direct bone insertion”.

SMAS

History Henry Gray, 1859

Skoog, 1974- Plication and flap suspension in facelift.

Mitz and Peyronie, 1976- Detailed anatomic description of

the SMAS in the parotid and cheek area :

1.The SMAS was continuous with the frontalis m.

2. Continuous with the platysma m. inferiorly.

3. Motor n. run deep to the SMAS.

4. Sensory n. are superficial.

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Jost and Levet, 1984-

The SMAS is the remnant of the primitive platysma muscle; true platysma, risorius, triangularis, auricular posterior.

The SMAS over the parotid forms the parotid fascia.

A second layer of facial muscles located deep to the SMAS , oriented vertically and attached to the skull and facial bones; The sphincter colli profundus: frontalis, periorbital, zygomaticus, and quadratus labii inferioris.

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Parotid regionMitz and Peyronie, 1976:

The SMAS anterior to the tragus is particularly

dense.

Jost and Levet, 1984:

Impossible to separate the SMAS from the deep

parotid fascia.

Zygomatic and Temporal regions

Mitz and Peyronie, 1976: The SMAS tightly

adhered to the zygoma.

The fascial layer in the temple, the

temporoparietalis fascia, is continuous with the

posterior portion of the frontalis m.

Jost and Levet, 1984: The SMAS ends at the level

of the zygoma, and does not join the frontalis m.

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Stuzin: Three fascial layers in the temporal

area: Temporoparietal fascia, Superficial

layer of deep temporal fascia, and the deep

layer of of the DTF.

Nasolabial fold

Mitz and Peyronie, 1976: The NLF as a cutaneous

depression where the SMAS ends.

Pensler, 1985: The superficial fascia in the upper

lip is continuous with the cheek SMAS through

the NLF.

Barton, 1992: The SMAS in the anterior cheek is

the nesting fascia for the muscles of the upper lip;

Lateral traction on the SMAS would have little

effect on the medial cheek skin.

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Yousif, 1994: Traction on the SMAS

deepens the NLF; traction on the fascial-

fatty layer lessens the fold.

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SMAS

S.Aston: It is fibrous, muscular, or fatty,

depending on the location in the face:

A single, heterogenous layer: Galea-

Frontalis- Temporoparital fascia- SMAS-

Orbicularis oculi- Orbicularis oris-

Platysma.

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Retaining ligaments of the

cheek

Furnas: Described 4 ls., that support the soft

tissue of the face:

Zygomatic (McGregor’s patch), Mandibular

retaining ligaments in the cheek: from the

periosteum to affix the skin.

Anterior Platyma- cutaneous l.,

Platysma- Auricular l.

Stuzin:

2 types of retaining ll:

1. Osteocutaneous ll.:Zyg, Man. l.l.

2. Fascial connections: Parotid- cut.l, Masseteric-

cut.l.

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The zygomatic ll., Stuzin: Fixate the malar

pad to the underlying zygomatic

eminence in the youthful face.

Masseteric Cutaneous ls., Stuzin, Baker,

and Gordon:

– Fibroelastic septi that extends between the

superficial and deep facial fascia along the

anterior margin of the masseter m.

– Provides support to the SMAS- platysma in

the midface.

Mimetic Muscles

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1. Depressor anguli oris, Zygomaticus minor,

Orbicularis oculi.

2. Depressor labii inferioris, risorius,

platysma, zygomaticus major, levator labii

superioris alaeque nasi.

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3. Orbicularis oris, levator labii superioris.

4. Mentalis, levator anguli oris, Buccinator.

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The innervation of the ms.

of the first 3 layers is from

their deep surface.

The deepest group is

innervated from the

superficial surface.

The platysma muscle

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The platysma m.

Size: 8*12 cm

Origin: Fascia over the upper parts of the

pectoralis major and deltoid.

Insertion: Skin and subcutaneous tissue of the

lower face.

Has no bony insertions!

Pattern of circulation: type II:

Dominant pedicle: submental a.

Minor a: suprasternal a.

Nerve supply:

Motor: cervical branch, VII.

Sensory: transverse cervical n.

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The platysma m.

Vistnes and Souther, 1979:

61%- Decussated from the level of the

hyoid

39%- No decussation- “Turket globbler”

deformity.

Cardoso de Castro, 1980: Three different

conformations:

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Parotid- Masseteric fascia

A thin, areolar layer that lies immediately

on the surface of the facial n., anterior to the

parotid gland.

Analogous layers:

Neck- Cervical fascia.

Temporal region- Innominate fascia.

Scalp- Subgaleal fascia.

Facial n.

Facial danger zones

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Facial danger zone 1

Greater auricular n.- Mckinney and

Katrana: 6.5 cm below external auditory

meatus

Posterior to SMAS

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Facial danger zone 2

Frontal branch of VII A line from 0.5 cm below

the tragus to 1.5

above the lateral

end of eyebrow.

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Facial danger zone 3

marginal mandibular branch

Dingman and Grabb: The mandibular n.

passes above the mandibular border- 81%-

posterior to the facial a.

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Facial danger zone 4

Zygomatic and Buccal

brances

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Facial danger zone 5

Supraorbital and Supratrochlear nn.

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Facial danger zone 6

Infraorbital n.

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Facial danger zone 7

Mental n.

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