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252 PART V ORALANDMAXILLOFACIALSURGERY
SMAS
ARTERIES
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44. What is the relationship of the facial nerve to the parotideomasseteric fascia?
As the facial nerve branches leave the parotid gland, the parotideomasseteric fascia covers them. The
SMAS is located superficial to this layer.
45. What is the blood supply to the temporalis muscle and the temporalis fascia?
The muscle is supplied primarily by the anterior and posterior deep temporal arteries (branches of the
internal maxillary artery) and to a lesser extent by the superficial temporal artery.
The middle temporal artery, a branch of the superficial temporal artery, is the main supply to the fascia.
Frontalis
STF
SMAS
Platysma
Figure 23-6. Anatomy of the superficial musculoaponeurotic system (SMAS). STF, Superficial temporal fascia. (From Rees TD,
Aston SJ, Thorne CHM: Blepharoplasty and fascioplasty. In McCarthy JG, editor: Plastic surgery, Philadelphia, 1990, Saunders.)
Occipital
Posterior auricular
Superficial temporal
Supraorbital
Supratrochlear
Frontalis
Zygomatic M
Platysma
Skin
Septa
NERVES
Third occipital
Greater occipital
Lesser occipital
Auriculotemporal
Zygomaticotemporal
Supraorbital
Supratrochlear
Figure 23-7. Nerve and blood supply of the scalp. (From Welch TB, Boyne PJ: The management of traumatic scalp
injuries: report of cases, JOralMaxillofacialSurg 49:1007–1014, 1991.)
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46. What is the blood supply to the temporal fat pad?
The blood supply to the temporal fat pad is from the middle temporal artery, which is a branch of the
superficial temporal artery.
47. What is the function and foramina of the 12 cranial nerves?
See Table 23-2.
48. At what distance from the stylomastoid foramen does the facial nerve bifurcate?
The nerve bifurcates into two main trunks (the zygomatico facial and the mandibular cervical) at vari-
able distances after the nerve exits the skull, but on the average this distance is 1.3 cm.
49. At what distance from the external auditory canal does the facial nerve bifurcate?
The point of bifurcation of the facial nerve is located 1.5 to 2.8 cm inferior to the lowest concavity of
the bony external auditory canal.
50. What is the danger zone for the frontal branch of the facial nerve as it crosses the
zygomatic arch?
Thefrontalbranchofthefacialnervecrossessupercialtothezygomaticarchinanareathatlies0.8
to 3.5 cm anterior to the anterior concavity of the bony external auditory canal (an average of 2 cm
anterior to the canal). A danger zone for injuring the frontal branch of the facial nerve during surgical
Table 23-2. Cranial Nerve Components, Function, and Foramen of
NERVE COMPONENTS FUNCTION SKULL OPENING
1. Olfactory Sensory Smell Openingincribriform
2. Optic Sensory Vision Opticcanal
3. Oculomotor Motor Lifts upper eyelid; turns eyeball
4. Trochlear Motor Assists in turning eyeball down-
5. Trigeminal
• Ophthalmic
• Maxillary
• Mandibular
6. Abducent Motor Lateral rectus muscle; turns
Exit from the Cranium
Sensory Cornea,skinofforehead,scalp,
division
Sensory Skin of face over maxilla and the
division
Motor Muscles of mastication, mylohy-
division
Sensory Skin of cheek, skin over man-
plate of ethmoid
Superior orbital fissure
upward, downward, and
medially; constricts pupil;
accommodates eye
Superior orbital fissure
ward and laterally
Superior orbital fissure
eyelids, and nose; also mucous membrane of paranasal
sinuses and nasal cavity
Foramen rotundum
upper lip; teeth of upper jaw;
mucous membrane of nose, the
maxillary air sinus, and palate
Foramen ovale
oid, anterior belly of digastric,
tensor veli palatini, and tensor
tympani
dible, lower lip, and side of
head; teeth of lower jaw and
temporomandibular joint; mucous membrane of mouth and
anterior two-thirds of tongue
Superior orbital fissure
eyeball laterally
Continued on following page
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Table 23-2. Cranial Nerve Components, Function, and Foramen of
NERVE COMPONENTS FUNCTION SKULL OPENING
7. Facial Motor Muscles of face, the cheek, and
8. Vestibulocochlear
• Vestibular Sensory Position and movement of head Internal acoustic
• Cochlear Sensory Hearing
9. Glossopharyn-
10. Vagus Motor Constrictormusclesofpharynx
11. Accessory
• Cranialroot Motor Muscles of soft palate, pharynx,
• Spinalroot Motor Sternocleidomastoid and
12. Hypoglossal Motor Muscles of tongue controlling its
Adapted from Snell RS: Clinical anatomy for medical students, ed 5, Boston, 1996, Little, Brown.
Exit from the Cranium—(continued)
Sensory Taste from anterior two-thirds
Secretomotor
parasympathetic
geal assists
swallowing
Motor Stylopharyngeus muscle:
Secretomotor
parasympathetic
Sensory Generalsensationandtastefrom
Sensory Taste from epiglottis and val-
scalp; stapedius muscle of
middle ear; stylohyoid;
posterior belly of digastric
of tongue; floor of mouth and
palate
Submandibular and sublingual
salivary glands, the lacrimal
gland, and glands of nose and
palate
Parotid salivary gland Jugularforamen
posterior third of tongue and
pharynx; carotid sinus and
carotid body
and intrinsic muscles of
larynx; involuntary muscles
of trachea and bronchi, heart,
and alimentary tract from
pharynx to splenic flexure of
colon; liver and pancreas
lecula and afferent fibers from
structures named above
and larynx
trapezius muscles
shape and movement (except
palatoglossus)
Internal acoustic
meatus, facial
canal, stylomastoid
foramen
meatus
Jugularforamen
Jugularforamen
Hypoglossalcanal
procedures in the temporal and preauricular regions is located between two parallel lines drawn in
the temporal region. The anterior line is drawn from the inferior attachment of the earlobe to the most
lateral extension of the eyebrow. The posterior line is drawn from a midpoint on the tragus of the ear
to the most superior forehead crease of the forehead, or at least 2 cm from the first line or 2 cm above
the supraorbital regions.
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51. What is the danger zone for the marginal mandibular branch of the facial nerve?
The mandibular branch of the facial nerve courses in an area where incisions to approach the
mandible and mandibular condyle are commonly placed. Accordingly, this area is considered a danger
zone for injury to this branch. The zone is located between the inferior border of the mandible and a
line in the retromandibular and submandibular region. This line extends from anterior to posterior and
is 2 cm (1 thumb-breadth) behind the gonion and posterior border of the ascending ramus, 2 cm below
the gonion, extending forward 2 cm below the inferior border of the mandible as far anteriorly to the
level of the second premolar tooth. The anterior border of the zone is located at the intersection of two
lines: a horizontal line 2 cm below and parallel to the inferior border of the body of the mandible, and
another along the long axis of the lower second premolar.
52. How can the main trunk of the facial nerve be located during a parotidectomy?
As the facial nerve trunk travels from the stylomastoid foramen to the parotid gland, it passes anterior
to the posterior belly of the digastric muscle, lateral to the styloid process and the external carotid
artery, and posterior to the facial vein. Start a parotidectomy by mobilizing the tail of the parotid superiorly and retracting the anterior border of the sternocleidomastoid laterally, to identify the posterior
belly of the digastric muscle. Follow this muscle superiorly toward its insertion at the mastoid tip.
After bluntly separating the parotid from its attachment to the cartilage of the external auditory canal,
the tragal pointer (outer surface of the external auditory cartilage) comes into view. The facial nerve
trunk lies approximately 1 cm deep and slightly anteroinferior to the tragal pointer.
53. What are the branches of the facial nerve?
The facial nerve trunk has six major branches: temporal, zygomatic, buccal, mandibular, cervical, and
auricular. The auricular branch comes off before the facial nerve turns into the parotid body, and innervates the superior auricular, posterior auricular, and occipitalis muscles, as well as provides sensation
to the area behind the earlobe. Within the parotid, the facial nerve divides into two main branches, the
temporofacial and cervicofacial, which further divide into the temporal, zygomatic, buccal, mandibular,
and cervical branches. The stylohyoid and posterior digastric are other minor branches of the nerve.
54. How do the facial muscles of expression receive their innervation?
All facial muscles except the mentalis, levator angularis superioris, and buccinator receive their
innervationalongtheirdeepsurfaces.However,becausethesethreemusclesarelocateddeepwithin
the facial soft tissue and lie deep to the plane of the facial nerve, they receive their innervation along
their superficial surfaces. All other facial muscles of expression are located superficial to the plane of
the facial nerve and thus receive their innervation along their deep or posterior surfaces. For example,
the platysma, orbicularis oculi, and zygomaticus major and minor are situated superficial to the level
of the facial nerve.
55. What is the relationship of the frontal branch of the facial nerve to the SMAS and
temporoparietal fascia?
Inferior to the zygomatic arch, the frontal branch of the facial nerve travels deep to the SMAS. As it
crosses over the zygomatic arch it becomes very superficial. At this point, it is sandwiched between
the periosteum (extension of the temporal fascia) and the temporoparietal fascia (extension of the
SMAS). Superior to the zygomatic arch, the frontal branch of the facial nerve travels within or on the
undersurface of the temporoparietal fascia, but superficial to the outer layer of the temporal fascia.
56. How do the frontal and mandibular branches of the facial nerve differ from other
facial branches?
Crossovercommunicationbetweenthefrontalbranchandadjacentbranchesandbetweenthe
mandibularbranchandadjacentbranchesisonlyabout15%.Crossoveramongtheotherbranchesis
approximately70%.Injurytoeitherthefrontalormandibularbranchesleadstomoremarkeddecit
compared with the results of injury to the other branches.
57. What is the relationship of the frontal and mandibular branch courses of the facial
nerve?
The frontal branch of the facial nerve crosses the zygomatic arch deep to the SMAS and in the tempo-
ral region deep to the temporoparietal fascia (superficial temporal fascia). The nerve usually lies within
2 cm from the lateral border of the eyebrow and enters the frontalis muscle from its deep surface.
The mandibular branch courses within 2 cm of the inferior border of the mandible, posterior to
the facial artery. The mandibular branch is at risk during an anterior dissection because in this area, it
becomes more superficial. It lies deep to the platysma and superficial to the facial artery.
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58. How do you evaluate the five branches of the facial nerve during a physical
exam?
Test each of the five branches of the nerve in the following manner:
• Cervical:Contracttheplatysmamuscles.
• Marginalmandibular:Whistleorpuckerthelips.
• Buccal:Smileorshowteeth.
• Zygomatic:Squeezeeyesshuttightly.
• Temporal:Raiseeyebrows.
59. What are the most common causes of facial nerve paralysis?
Facial nerve paralysis, which may be unilateral or bilateral, can be a manifestation of any of several
disease processes. These diseases can be idiopathic, neoplastic, traumatic, infectious, or congenital.
The paralysis can also result from a systemic/metabolic process (Box 23-1).
60. What is the anatomy of taste sensory function?
Taste sensory function from the anterior part of the tongue is carried along the chorda tympani of the
trigeminal nerve through the submandibular ganglion to reach the facial nerve. From the posterior or
pharyngeal part of the tongue, taste sensation is carried along the glossopharyngeal nerve, through
the pterygopalatine ganglion, to the major petrosal nerve, and then the facial nerve. From the palatal
region, the sensation is carried via the palatine nerves, which also pass through the pterygopalatine
ganglion to ultimately reach the facial nerve.
Along with the facial nerve, taste fibers reach the tractus solitarius, which is concerned with
visceral function, including taste. Some textbooks state that taste fibers from the posterior part of the
tongue reach the tractus solitarius directly by the glossopharyngeal nerve.
61. What is the anatomy of the zygoma?
The zygoma is a pyramidal bone of the midface. Its anterior convexity gives prominence to the malar
eminence of the cheek, and its posterior concavity contributes to the shape of the temporal fossa. The
zygoma forms the superolateral and superoanterior portions of the maxillary sinus. It articulates with
Box 23-1. Causes of Facial Nerve Paralysis
Idiopathic
Bell’spalsy
Recurrentfacialpalsy
Melkersson-Rosenthalsyndrome
Neoplasia
Cholesteatoma
Facial neuroma
Glomusjugulareortympanicum
Carcinoma(primaryormetastatic)
Schwannoma of lower cranial nerves
Meningioma
Histiocytosis
Rhabdomyosarcoma
Leukemia
Trauma
Temporal bone fractures*
Birth trauma
Facial contusions/lacerations
Penetrating wounds to face and temporal bone
Iatrogenic injury
* May present as bilateral facial paralysis.
ModiedfromCokerNJ:Acuteparalysisofthefacialnerve.InBaileyBJ,editor:Head and neck surgery—otolaryngology, Philadel-
phia,1993,J.B.Lippincott.
Infection
Herpeszosteroticus(Ramsay-Huntsyndrome)
Otitismediawitheffusion
Acute suppurative otitis media
Coalescentmastoiditis
Chronicotitismedia
Malignant otitis externa
(Pseudomonas osteomyelitis)
Tuberculosis
Lyme disease*
AIDS
Infectious mononucleosis
Congenital
Compressioninjury
Moebius syndrome*
Lower lip paralysis
Metabolic and Systemic
Pregnancy
Diabetes mellitus
Sarcoidosis*
Guillain-Barrésyndrome*
Autoimmune disorders
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the frontal, temporal, maxillary, and sphenoid bones. Superolaterally, the frontal process of the zygoma
articulates with the zygomatic process of the frontal bone and forms the lateral orbital wall along with
its intraorbital articulation with the sphenoid bone. The temporal process of the zygoma articulates
posterolaterally with the zygomatic process of the temporal bone to make the zygomatic arch. The
broad articulation inferiorly and medially with the maxilla forms the infraorbital rim and lateral part of
the orbital floor. Superiorly and inferiorly, such articulation forms the zygomaticomaxillary buttress, the
major buttressing structure between the midface and the cranium.
62. With which bones does the zygoma articulate?
Greaterwingofthesphenoidandfrontal,temporal,andmaxillarybones.
THE NECK
63. What are the contents of the carotid sheath?
The carotid sheath contains the carotid artery, the jugular vein, and the vagus nerve. Within the carotid
sheath,thevagusnerve(CNX)liesposteriortothecommoncarotidarteryandinternaljugularvein.
64. How many branches does the external carotid artery give off? What are they?
The external carotid artery branches from the common carotid artery at the level of the upper border
of the thyroid cartilage to be the principal artery supplying the anterior aspect of the neck, face, scalp,
oral and nasal cavities, bones of the skull, and dura mater. Note that the orbit and its contents are
the only structures that are not supplied by the external carotid. There are eight branches (order of
appearance from inferior to superior): (1) the superior thyroid, (2) the ascending pharyngeal, (3) the
lingual, (4) the facial, (5) the occipital, (6) the posterior auricular, (7) the internal maxillary, and (8) the
superficial temporal.
65. What are the sources for the blood and nerve supply to the sternocleidomastoid
muscle (SCM)?
ThebloodsupplytotheSCMisprovidedfromtwosources.Thesuperiorthyroidarterysuppliesthe
middle third of the muscle, whereas the occipital artery branches supply the remainder of the muscle.
Thenervesupplyisfromthespinalaccessory(cranialnerve[CN]XI)andfromC2andC3.
66. What is the course of the facial artery in the submandibular triangle?
The facial artery passes from behind and medial to the submandibular gland, up and over the gland,
to emerge from the submandibular space laterally. It then proceeds into the face at the level of the
anterior border of the masseter muscle. Thus the facial artery may or may not be encountered in
the incision and removal of the gland, and therefore may not require removal, but would have to
be located during dissection by pinpointing the two lymph nodes, which overlie it at the level of the
inferior border of the mandible.
Superior and deep to these lymph nodes is the marginal mandibular branch of the facial nerve.
Posterior to the nodes is the facial vein. Because the vein is lateral to the gland, it is often necessary
to ligate and cut this vessel during the dissection to remove the gland.
67. What is the relationship of the lingual nerve to Wharton’s duct?
Thesubmandibulargland,orWharton’sduct,isabout5cminlength,anditslumenis2to4mmin
diameter. It runs anteriorly above the mylohyoid muscle and on the lateral surface of the hyoglossus
and genioglossus muscles. At first, the duct lies below the lingual nerve. Then, as the lingual nerve
descends, it crosses lateral to the duct. As the duct and lingual nerve pass below the sublingual gland,
the lingual nerve passes below the duct and crosses it medially. As the nerve continues toward the
genioglossus, the duct continues anteriorly and medially. The duct loops from below upward beneath
the lingual nerve at the level of the third molar and then crosses above the lingual nerve at about the
level of the second molar. Thus, the nerve loops almost completely around the duct (Fig. 23-8).
68. What are the relationships and the course of the hypoglossal nerves in the submandibular triangle?
The hypoglossal nerve emerges from the hypoglossal canal and passes laterally between the internal
jugular vein and the internal and external carotid arteries. It then descends steeply and crosses the
stylohyoid and posterior belly of the digastric muscles on their medial surfaces. The hypoglossal nerve
courses forward and upward on the lateral surface of the hyoglossus muscle and is accompanied
by branches of the sublingual vein entering the oral cavity at the posterior border of the mylohyoid
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Superficial temporal vessels
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Inner layer of
temporalis fascia
Temporalis muscle
temporal fascia
Zygomatic arch
Facial nerve braches
and auriculotemporal nerve
Superficial temporal fascia
Figure 23-8. Cross-sectionshowingthelevelofdissectionofthecoronalapinthetemporalregion. (From Bell WH:
Modern practice in orthognathic and reconstructive surgery, vol 2, Philadelphia, 1992, Saunders.)
Bone
Outer layer of
T
Skin
muscle,slightlyabovethedigastrictendon.Here,beneaththetongue,thenervecurvesforwardand
upward on the lateral surface of the genioglossus muscle, splitting into several branches that go into
the substance of the tongue. These branches supply all extrinsic and intrinsic muscles of the tongue
exceptthepalatoglossus,whichissuppliedbyCNXIviaCNX.
69. What are the boundaries and significance of Lesser’s triangle?
The triangle is made up by the angle between the tendon of the digastric muscle inferiorly, the
hypoglossal nerve superiorly, and the posterior border of the mylohyoid muscle. The hyoglossal and
mylohyoid muscles form the floor of this triangle. This triangle is useful in localization and ligation of
the artery that lies at the inner surface (beneath) of the hyoglossus muscle deep to the floor of the
triangle.
THE MUSCLES OF MASTICATION AND
TEMPOROMANDIBULAR JOINT
70. What are the muscles of mastication?
The muscles of mastication can be divided into two groups: primary muscles of mastication
and accessory muscles of mastication. Primary muscles of mastication include the temporalis,
masseter, and pterygoideus (medial and lateral). Accessory muscles of mastication include the
suprahyoid group, infrahyoid group, and platysma. The suprahyoid group includes the digastric,
mylohyoid, geniohyoid, and stylohyoid muscles. The infrahyoid group includes the sternohyoid,
thyrohyoid, and omohyoid.
71. How do these muscles act to perform the function of mastication?
The muscles of mastication act most of the time as a group during functional movement of the jaw.
For example, jaw closing is a coordinated function of the elevator muscles, which are the masseter,
medial pterygoid, and temporalis muscles. The jaw closing is a function of the lateral pterygoid and the
suprahyoid muscles. The protrusion is a function of the masseter, medial pterygoid, and lateral pterygoid muscles, whereas retrusion is a function of the digastric and temporalis muscles. The infrahyoid
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muscles help in the opening of the mouth by fixing the hyoid bone as a stable structure so when the
suprahyoid muscles contract, they are able to participate in depressing the anterior portion of the
mandible, thus opening the mouth.
72. What is the origin and insertion of each of the muscles of mastication?
With few exceptions, for a skeletal muscle to perform its function, it must originate from a fixed struc-
ture in the skeleton and insert into another, mobile part. This rule applies to all muscles of mastication,
except for the suprahyoid muscle group (as described previously).
Masseter
Origin: superficial belly from the lower border of the zygomatic arch and the zygomatic process of the maxilla.
The deep belly from the posterior third and medial surface of the inferior border of the zygomatic arch.
Insertion: the angle and inferior half of the lateral surface of the ramus of the mandible. The deep portion
(belly) of the muscle inserts onto the lateral surface of the coronoid process and superior half of the ramus.
Medial Pterygoid
Origin: medial surface of the lateral pterygoid plate and pyramidal process of the palatine bone. A small
belly of the muscle arises from the lateral surface of the pyramidal process and tuberosity of the maxilla.
Insertion: inferior and posterior part of the medial surface of the ramus and angle of the mandible.
teMPoralis
Origin: the temporal fossa of the temporal bone.
Insertion: medial surface, apex, and anterior border of the coronoid process of the mandible.
lateral Pterygoid
Origin: the superior belly arises from the inferior part of the lateral surface of the greater wing of the
sphenoid and from the infratemporal fossa. The inferior belly arises from the lateral surface of the lateral
pterygoid plate.
Insertion: the superior belly inserts into the anterior margin of the articular disc. The inferior belly inserts
into a depression on the anterior portion of the neck of the condyle.
digastric
Origin: digastric fossa of the medial side of the lower border of the mandible close to the symphysis. The
posterior belly of the muscle arises from the mastoid notch of the temporal bone. Both bellies are united by
an intermediate tendon that is connected to the hyoid bone by a loop of fibrous tissue.
The other suprahyoid muscle group originates from different parts of the medial surface of the
mandible and inserts into the hyoid bone. The exception is the stylohyoid muscle, which arises from the
temporal bone and inserts on the body of the hyoid bone.
Ofnoteisthattheoriginandinsertionofthesuprahyoidgroup(exceptstylohyoidmuscle)arefroma
mobileoriginandinsertion.However,becausetheinfrahyoidmusclegroupfunctionstostabilizethehyoid
bone during mastication, this bone becomes static, allowing the mandible to move when the suprahyoid
muscles contract. Inversely, during swallowing, the suprahyoid muscles stabilize the hyoid bone, allowing
for swallowing action to be completed with the contraction of the infrahyoid muscles.
73. How many origins and insertions does each masticatory muscle have?
For each muscle of mastication, there are two insertions and two origins.
74. What is the function of the lateral pterygoid muscle?
The lateral pterygoid muscle is triangular in shape and runs in a slightly inferior and posterior
horizontal direction. The muscle has superior and inferior heads. The superior head arises from
the infratemporal surface of the greater wing of the sphenoid and inserts into the articular capsule
and disc. The function of the superior head is to stabilize the condyle and disc during closing
movement.
The inferior head originates from the lateral surface of the lateral pterygoid plate and inserts
into the pterygoid fovea of the neck of the condyle. The inferior head aids in translation of the condyle
over the articular eminence during opening of the mouth.
75. Which muscles make up the pterygomandibular raphe?
The buccinator muscle anteriorly and the superior constrictor of the pharynx posteriorly make up the
pterygomandibular raphe.
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76. What are the muscles of the soft palate?
The soft palate is formed by three pair of muscles, all of which fuse at the midline: the uvulus muscle,
which runs along the uvula on each side of the midline forming almost one muscle; the levator
palatine muscle extending across the midline and forming an arch-shape configuration within the soft
palate; and the tensor veli palatine, which loops around the hamulus fusing with the tensor muscle of
the opposite side and forming an aponeurosis at the midline.
77. What class of joint is the temporomandibular joint?
The temporomandibular joint is classified as a diarthrodial joint. It has both features of diarthrodial
joints which are ginglymus (hinge) and arthrodia (gliding) types. The articular surfaces of the fossa and
the condyle are covered by nonvascular fibrous tissue that contains some cartilage cells, designated
as fibrocartilage. Because of the incongruity between the articular surfaces of the joint (the mandibular condyle and the glenoid fossa and articular eminence), the joint is subdivided into an upper and
lower compartments by a fibrous oval articular disc, the meniscus.
78. What are the sources of the blood and nerve supply to the temporomandibular
joint (TMJ)?
ThemajorarterialsupplytotheTMJisderivedfromthesupercialtemporalarteryandfromthe
maxillary artery posteriorly, and from smaller masseteric, posterior deep temporal, and lateral pterygoid arteries anteriorly. The venous drainage is through a diffuse plexus around the capsule and rich
venous channels that drain the retrodiscal tissue.
The nerve supply is from the auriculotemporal nerve, which provides the principal sensory
innervationtotheTMJ.Thenervegivesofftwoorthreebranches,whichenterthecapsuleinferiorly,
medially, and laterally. The masseteric nerve also innervates the capsule from the frontal and medial
sidesofthejoint.TheposteriordeeptemporalnervesuppliestheTMJlaterallyandanteriorly.
SURGICAL ANATOMY
79. What is the retromandibular approach?
This approach is useful for procedures involving the ramus and areas on or near the condylar neck/
head.Theincisionbegins0.5cmbelowtheearlobeandcontinues3.0to3.5cminferiorly,approximately
2 cm posterior to the ramus. In some patients, this may limit the direct proximity of the skin incision to
the mandible, which is one of the main advantages of this technique. Accordingly, some surgeons recommend placement of the incision more anteriorly at the posterior ramus, just below the earlobe. The
deeper dissection of this approach is carried out bluntly through the parotid gland in an anteromedial
direction (in the anticipated direction of the facial nerve) toward the posterior border of the mandible.
The facial nerve, if identified, is avoided and deeper dissection is continued until the pterygomasseteric sling is identified and incised. The submasseteric dissection is continued to expose the ramus
and condyle as needed.
80. Where should the skin incision be placed during a submandibular approach to
avoid the mandibular branch of the facial nerve?
ThesubmandibularapproachisoftenreferredtoastheRisdonapproach.Itmaybeusedtoaccessthe
mandibular angle, ramus, condyle, inferior border of the mandibular body, and submandibular gland.
The exact location of the skin incision differs, mostly due to the disagreement over the course of the
marginal mandibular branch of the facial nerve.
DingmanandGrabbshowed,in192patients,thatthisbranchisbelowtheinferiorborderofthe
mandible, posterior to where the nerve crosses the facial artery. Anterior to that point, the facial nerve
isabovetheinferiorborderin100%ofpatients.Inanotherstudy,ZiarahandAtkinsonfoundthatin
53%ofpatientsthemarginalmandibleofthefacialnerveisbelowtheinferiorborderofthemandible,
posteriortothefacialvessels,andin6%thisnervecontinuestobebelowtheinferiorborderanterior
to the facial vessels.
Based on these findings, and to err well on the safe side, the recommended placement of the
submandibularincisionis1.5to2.0cm(athumb-breadth)belowtheinferiorborderofthemandible.
81. In a patient with a 3-cm vertical laceration of the anterior border of the masseter
muscle, what findings are likely?
In such an injury there is a likelihood for paralysis of the frontalis, orbicularis oculi, nasalis muscles, and
orbicularis oris. The paralysis of these muscles is due to severance of the frontal, zygomatic, and buccal
branches of the facial nerve, respectively. The parotid duct and the parotid gland may also be involved.
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82. What are the structures involved in resection of the mandible from midramus to
the mental foramen?
Compositeresectionofthebodyofthemandibleusuallyinvolvesremovalofbone,muscles,glands,
lymph nodes, and vessels. The muscles involved are the masseter, medial pterygoid, platysma,
mylohyoid, buccinator, depressor anguli oris, depressor labii inferioris, superior pharyngeal constrictor,
and a small portion of the temporalis. The submandibular gland, sublingual glands, and submandibular
lymph nodes surrounding superficial and deep cervical nodes also are removed, depending on the
extent of the resection. The facial artery, anterior facial vein, and marginal mandibular branch of the
facial nerve also are occasionally removed.
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