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198 Part VII&Facial Surgery
REFERENCE
1. Tiffany JM. The normal tear film. In: Geerling G, Brewitt H, eds. Surgery for the Dry Eye: Scientific Evidence and
Guidelines for the Clinical Management of Dry Eye Associated Ocular Surface Disease (Developments in
Ophthalmology, Book 41). 1st ed. Basel, Switzerland: Karger; 2008:1–20
ANATOMY
11. A 25-year-old male reports numbness of the left cheek and lower eyelid after blunt trauma to the left mid-
face. Physical examination reveals crepitus and bruising along the left midface. The described sensory disturbance is a result from trauma to which of the following nerves?
D. Infraorbital nerve.
The clinical vignette describes a fracture of the left maxilla. The infraorbital nerve (V2) courses along
the roof of the maxillary sinus and exits through the infraorbital foramen at approximately the level of
the medial limbus. Maxillary fractures often traverse the infraorbital foramen resulting in hypoesthesia
of the midface and lower eyelid.
The supraorbital and supratrochlear nerves originate from the ophthalmic division of the trigeminal
nerve (V1) and provide sensation to the anterior scalp and mid forehead, respectively.
The infratrochlear nerve is a division of the ophthalmic division of the trigeminal nerve (V1) and pro-
vides sensation to the upper third of the nose and medial upper eyelid.
The anterior ethmoid nerve is a division of the ophthalmic division of the trigeminal nerve (V1) and pro-
vides sensation to the nasal cavity.
1
REFERENCE
1. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg
1991;18:183
30. Face and Neck Anatomy
Jacob Nathaniel Grow, Christopher C. Surek
See Essentials of Aesthetic Surgery, pp. 372–389
SOFT TISSUE LAYERS OF THE FACE
1. Which of the following represents the most appropriate arrangement of facial layers from most superficial to
deep?
A. Skin, subcutaneous fat, mimetic muscles, superficial musculoaponeurotic system, parotidomasseteric fascia.
B. Skin, superficial musculoaponeurotic system, subcutaneous fat, mimetic muscles, parotidomasseteric fascia.
C. Skin, subcutaneous fat, superficial musculoaponeurotic system, parotidomasseteric fascia, mimetic muscles.
D. Skin, subcutaneous fat, superficial musculoaponeurotic system, mimetic muscles, parotidomasseteric fascia.
E. Skin, parotidomasseteric fascia, subcutaneous fat, superficial musculoaponeurotic system, mimetic muscles.
SOFT TISSUE LAYERS OF THE FACE
2. A patient consults for complaints primarily related to prominent nasolabial folds. This feature of facial aging
may be attributed to pseudoptosis of the nasolabial fat pad secondary to volume loss of which of the
following?
A. Malar bone.
B. Deep medial cheek compartment.
C. Prezygomatic space.
D. Suborbicularis oculi fat (SOOF).
E. Nasal ala.
SOFT TISSUE LAYERS OF THE FACE
3. While performing a rhytidectomy, you appreciate improvement of jowling. The anatomical basis for this phe-
nomenon of aging is associated with which of the following structures?
A. Orbicularis oculi muscle.
B. Modiolus.
C. Mentalis muscle.
D. Nasolabial fat pad.
E. Depressor anguli oris muscle.
SOFT TISSUE LAYERS OF THE FACE
4. Which of the following structures is not continuous with the superficial musculoaponeurotic system (SMAS)?
A. Galea.
B. Platysmal fascia.
C. Temporoparietal fascia.
D. Orbicularis fascia.
E. Parotidomasseteric fascia.
SOFT TISSUE LAYERS OF THE FACE
5. Which of the following muscles receives innervation from the facial nerve on its superficial surface?
A. Mentalis.
B. Levator labii superioris.
C. Depressor anguli oris.
D. Risorius.
E. Zygomaticus minor.
200 Part VII&Facial Surgery
SOFT TISSUE LAYERS OF THE FACE
6. During open neck rejuvenation with platysmal plication in the midline, remaining just superficial to which
layer ensures the safest plane for dissection?
A. Infrahyoid muscle fascia.
B. Prevertebral fascia.
C. Investing deep fascia.
D. Pretracheal fascia.
E. Subcutaneous tissue.
NERVES
7. Following rhytidectomy, a patient complains of numbness at the ear lobule. Injury to which of the following is
the most likely explanation for this complication?
A. Auriculotemporal nerve.
B. Lesser occipital nerve.
C. Greater occipital nerve.
D. Great auricular nerve.
E. Arnold's nerve.
NERVES
8. Which of the following is true with regards to Pitanguy's line?
A. Anterior point is 1.5 cm lateral to tail of the brow.
B. Posterior point is 2 cm below the tragus.
C. Identifies the location of the zygomatic branch of the facial nerve.
D. Courses over the zygomatic arch at its posterior 1/3.
E. Runs parallel with the parotid duct.
NERVES
9. Following an open neck lift, a patient returns to clinic with complaints of facial asymmetry. On examination,
the patient has an elevated right commissure compared to the left on active smile. Lower lip eversion is present and symmetric. Which of the following nerves is most likely injured?
A. Right facial nerve cervical branch.
B. Left facial nerve cervical branch.
C. Right facial nerve marginal mandibular branch.
D. Left facial nerve marginal mandibular branch.
E. Bilateral facial nerve buccal branches.
FACIAL DANGER ZONES
10. A patient undergoes a deep plane facelift with undermining to the modiolus. The next day, the patient has
inability to elevate the commissure on active smile. Which of the following nerves is likely injured?
A. Supraorbital nerve.
B. Mental nerve.
C. Zygomatic branch of the facial nerve.
D. Marginal mandibular nerve.
E. Infraorbital nerve.
FACIAL DANGER ZONES
11. A patient has inability to evert the lower lip 3 days after a deep neck lift surgery. Which nerve is likely
injured?
A. Supraorbital nerve.
B. Mental nerve.
C. Buccal branch of the facial nerve.
D. Marginal mandibular nerve.
E. Infraorbital nerve.
Chapter 30&Face and Neck Anatomy 201
FACIAL DANGER ZONES
12. A 22-year-old female who is not healing postoperatively from an augmentation genioplasty has chin numb-
ness. Which nerve is likely injured?
A. Supraorbital nerve.
B. Mental nerve.
C. Buccal branch of the facial nerve.
D. Marginal mandibular nerve.
E. Infraorbital nerve.
FACIAL DANGER ZONES
13. A patient has residual numbness of the central forehead 2 months after an endoscopic browlift procedure.
Which nerve is likely affected?
A. Supraorbital nerve.
B. Mental nerve.
C. Buccal branch of the facial nerve.
D. Marginal mandibular nerve.
E. Infraorbital nerve.
VASCULAR SUPPLY
14. Which of the following is derived from the internal carotid arterial system?
A. Superficial temporal artery.
B. Facial artery.
C. Maxillary artery.
D. Supratrochlear artery.
E. Superior thyroid artery.
VASCULAR SUPPLY
15. Which of the following is true regarding the sentinel vein?
A. Located below the zygoma.
B. Found above the temporal crest.
C. Associated with the zygomatic branch of the facial nerve.
D. Branch of the zygomaticotemporal vein.
E. Remains above the inferior temporal septum.
RETAINING LIGAMENTS OF THE FACE AND NECK
16. A patient presents for improvement of periorbital facial aging. Release of which of the following is essential
to blend the lid–cheek junction?
A. Temporal ligamentous adhesion.
B. Supraorbital ligamentous adhesion.
C. Zygomatic osteocutaneous ligament.
D. Lateral canthal tendon.
E. Orbicularis retaining ligament.
ANTERIOR TRIANGLE OF THE NECK
17. The borders of the anterior triangle of the neck include which of the following?
A. Anterior and posterior bellies of digastric muscle, inferior border of the mandible.
B. Anterior bellies of the digastric muscles, hyoid bone.
C. Anterior border of sternocleidomastoid, inferior border of the mandible, median line of the neck.
D. Anterior border of sternocleidomastoid, anterior belly of digastr ic, median line of the neck.
E. Posterior border of sternocleidomastoid, anterior border of trapezius muscle, clavicle.
202 Part VII&Facial Surgery
Answers
SOFT TISSUE LAYERS OF THE FACE
1. Which of the following represents the most appropriate arrangement of facial layers from most superficial to
deep?
D. Skin, subcutaneous fat, superficial musculoaponeurotic system, mimetic muscles, parotidomasseteric
fascia.
The face is arranged in well-defined, concentric layers that come to define the facial architecture in concert
with underlying bone. This consistent arrangement provides not only form, but also function through the
complexities of facial movement. Most superficial is the skin, whose mobility and susceptibility to aging
varies with dermal thickness. Next, the subcutaneous tissue includes volumizing compartmentalized fat,
in addition to the retinacular cutis responsible for bridging the skin to the underlying superficial
musculoaponeurotic system (SMAS) which allows for synchronized facial movement. Following this layer
is the SMAS, continuous throughout the head and neck as it invests the mimetic muscles and therefore lies
superficial to branches of the facial nerve. Just deep to the SMAS are the layered mimetic muscles, providing
the motor for facial expression in addition to oral (speech and feeding) and periocular (protective blink)
movement. Deep facialfascia,also known as the parotidomasseteric fascia, follows as a continuation of
the superficial layer of the deep cervical fascia. Named according to the overlying structure, it includes
the parotid capsule, masseteric fascia, and deep temporal fascia. Finally, the deepest plane includes the buccal fat pad, parotid duct, facial artery/facial vein, and zygomatic and buccal branches of the facial nerve.
REFERENCE
1. Nahai F, Mejia JD, Nahai FR. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery:
Principles and Techniques. 2nd ed. New York: Thieme Publishers; 2010
1
SOFT TISSUE LAYERS OF THE FACE
2. A patient consults for complaints primarily related to prominent nasolabial folds. This feature of facial aging may
be attributed to pseudoptosis of the nasolabial fat pad secondary to volume loss of which of the following?
B. Deep medial cheek compar tment.
The subcutaneous layer of the face is composed primarily of fat, which has been shown through cadaver dissection to be divided into multiple, well-defined compartments (Fig. 30.1). Of these superficial compartments, the nasolabial fat pad lies the most medial. With time, this fat pad tends to resist deflation.
However, the deep medial cheek compartment is more susceptible to volume loss with aging. As a result,
there is gravitationally dependent descent and pseudoptosis of the more superficial nasolabial fat compartment, which accentuates the nasolabial fold.
Forehead fat:
Central
Middle
FPO
1
Periorbital fat:
Superior
Inferior
Lateral
Malar fat:
Medial
Middle
Laterotemporal
Nasolabial fat
Fig. 30.1 Superficial facial fat compartments. (Source: Soft Tissue Layers of the Face. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
Chapter 30&Face and Neck Anatomy 203
REFERENCE
1. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007;119:2219
SOFT TISSUE LAYERS OF THE FACE
3. While performing a rhytidectomy, you appreciate improvement of jowling. The anatomical basis for this phe-
nomenon of aging is associated with which of the following structures?
E. Depressor anguli oris muscle.
Effacement of the jowls is a common goal when performing rhytidectomy. Anatomically, jowling occurs as
descending tissue adherent to the overlying depressor anguli oris muscle is tethered to the mandibulocutaneous ligament, creating the appearance of hanging, deflated tissue. As a result, release of the
mandibulocutaneous ligament can be an effective method of correcting this hallmark sign of facial aging during rhytidectomy or isolated neck lift (Fig. 30.2).
Earlobe ligament
Mastoid-cutaneous
ligaments
Submandibular platysma
retaining ligaments
Medial sternomastoid–
Posterior border of
sternomastoid muscle
Lateral sternomastoid–
cutaneous ligaments
1
Platysma-auricular
ligaments
Platysma-mandibular
ligaments
Mandibular ligament
Submental ligaments
Paramedian platysma
retaining ligaments
Hyoid ligament
Medial platysma–cutaneous
filaments
Skin crease–platysma
filaments
Clavicular-cutaneous ligaments
Fig. 30.2 Retaining ligaments and filaments of the neck. (Source: Retaining Ligaments of the Neck. In: Feldman J, ed.
Neck Lift. 1st Edition. New York: Thieme; 2006.)
REFERENCE
1. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to
rhytidectomy and aging. Plast Reconstr Surg 1992;89:441
SOFT TISSUE LAYERS OF THE FACE
4. Which of the following structures is not continuous with the superficial musculoaponeurotic system (SMAS)?
E. Parotidomasseteric fascia.
The superficial musculoaponeurotic system (SMAS) is a continuous layer throughout the face and neck and a
vital component to facial aesthetic anatomy. An upward extension of the cervical fascia, the SMAS is
204 Part VII&Facial Surgery
continuous with the galea in the scalp, temporoparietal fascia in the temple, and the platysma in the neck. It
may be further divided into a fixed portion located more laterally over the parotid gland and a mobile portion
anteriorly over the mimetic muscles that allows surgical manipulation during rhytidectomy. Of note, the neurovascular structures, particularly the branches of the facial nerve, lie deep to the SMAS, making it an important layer to identify when performing any procedures on the face. The parotidomasseteric fascia is located
deeper to the SMAS as part of the deep facial fascia, including the deep temporal fascia, deep cervical fascia,
and parotid fascia.
1
REFERENCE
1. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast
Reconstr Surg 1976;58:80
SOFT TISSUE LAYERS OF THE FACE
5. Which of the following muscles receives innervation from the facial nerve on its superficial surface?
A. Mentalis.
Mimetic muscles are responsible for the highly complex and coordinated movements of the face. This contributes not only to facial expression but also the functions of speech and feeding (orbicularis oris muscle) as
well as protection of the globe (orbicularis oculi muscle). There are four described layers of these facial
muscles. Clinically relevant, the first three layers receive innervation from the facial nerve on their deep
surfaces, while the deepest layer of muscles are innervated on their superficial surface. This deepest layer
is composed of the mentalis, levator anguli oris, and buccinator muscles (MLB).
1
REFERENCE
1. Freilinger G, Gruber H, Happal W, et al. Surgical anatomy of the mimic muscle system and the facial nerve:importance for reconstructive and aesthetic surgery. Plast Reconstr Surg 1987;80:686
SOFT TISSUE LAYERS OF THE FACE
6. During open neck rejuvenation with platysmal plication in the midline, remaining just superficial to which
layer ensures the safest plane for dissection?
C. Investing deep fascia.
The layers of the neck tend to be a challenging topic. When operating in this region, awareness of the various
layers is critical to avoid damage to vital structures that are abundant in the area. Following dissection
through the subcutaneous tissue, which can have various degrees of adiposity, the platysma and superficial
neck fascia are encountered. Of note, this layer is continuous with the superficial muscular aponeurotic system (SMAS) above the jawline. The superficial fascia of the neck is also continuous with the deep thoracic
fascia covering the pectoralis major and deltoid muscles and fuses laterally with investing deep fascia of the
sternocleidomastoid and trapezius muscles. Next is the investing deep fascia, also known as the superficial
layer of the deep cervical fascia, which is the most superficial layer of the deep cervical fascia. Clinically relevant, no vital structures are present superficial to this layer in the midline, allowing for a safeplane
ofdissection deep to the platysma muscle. The infrahyoid muscle fascia is located deeper, investing the sternohyoid, omohyoid, sternothyroid, and thyrohyoid muscles. Visceral fascia includes the pretracheal fascia
covering the larynx and trachea, which also invests the thyroid gland. The deepest layer, the prevertebral
fascia, invests the vertebral column and forms the floor of the posterior triangle of the neck.
1
REFERENCE
1. Feldman JJ. Surgical anatomy of the neck. In: Feldman JJ, ed. Neck Lift. New York: Thieme Publishers; 2006
NERVES
7. Following rhytidectomy, a patient complains of numbness at the ear lobule. Injury to which of the following is
the most likely explanation for this complication?
D. Great auricular nerve.
Innervation of the ear is well defined and derived primarily from the cervical plexus. The great auricular nerve
(C2–C3) is responsible for innervation of the lobule and majority of the helix, consistently identified at
McKinney's point 6.5 cm inferior to the external auditory canal overlyingthesternocleidomastoidmusclerunning
with the external jugular vein. Ozturk et al describe an additional topographic landmark where the nerve is
Chapter 30&Face and Neck Anatomy 205
consistently found.1This consists of a vertical line perpendicular to the Frankfort's horizontal plane bisecting the lobule of the ear and another line extending from the mid-lobule posteriorly at a 30-degree angle.
Given its location and superficial course, it is prone to injury during surgical rejuvenation of the face andneck. The auriculotemporal nerve, a branch of the mandibular division of the trigeminal nerve (V3), runs
just anterior to the ear with the superficial temporal vessels and is responsible for sensationof the helical
root and tragus primarily. The lesser occipital and greater occipital nerves (C2) provide sensation more
posteriorly with the lesser providing some innervation at the postauricular fold. Arnold's nerve, a branch
of CN X, is responsible for sensation within the ear at the external auditory canal lining.
REFERENCE
1. Ozturk CN, Ozturk C, Huettner F, Drake RL, Zins JE. A failsafe method to avoid injury to the great auricular nerve.
Aesthetic Surg Journal 2014;34:16–21
NERVES
8. Which of the following is true with regards to Pitanguy's line?
A. Anterior point is 1.5 cm lateral to tail of the brow.
One of the long-standing topographic landmarks for the frontal branch of the facial nerve is Pitanguy's line
(Fig. 30.3). The line is formed by connecting a point 1.5 cm lateral to the tail of the brow to a point 0.5
cm below the tragus. This intersects with the middle third of the zygomatic arch, at which point the frontal branch of the facial nerve also crosses over the arch. In the temple region, the frontal branch is located
just deep to or within temporoparietal fascia and continues to course superoanteriorly to innervate the
frontalis muscle. Be cognizant that there are typically three to five rami of the frontal branch of the facial
1
nerve.
Pitanguy line
Tail of
eyebrow
1.5 cm
Frontal or
temporal branch
0.5 cm
Fig. 30.3 Frontal branch course. (Source: Motor Innervation: Facial Nerve. In: Janis J, ed. Essentials of Aesthetic Surgery.
1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve pseudo-paralysis” in
patients undergoing face lift. Plast Reconstr Surg 2003;111:2414
NERVES
9. Following an open neck lift, a patient returns to clinic with complaints of facial asymmetry. On examination,
the patient has an elevated right commissure compared to the left on active smile. Lower lip eversion is present and symmetric. Which of the following nerves is most likely injured?
A. Right facial nerve cervical branch.
In this clinical scenario, the right commissure appears higher than the left while smiling due to weakened
active lip depression from an injury to the right facial nerve cervical branch. As a result, there is more unopposed lip elevation on the right compared to the left, giving the illusion that the lower side is the injured side.
In addition, active lip eversion is solely dependent upon the marginal mandibular nerve, which is intact in
206 Part VII&Facial Surgery
this case which eliminates this as a possibility. Of note, avoiding dissection within 2 cm of the lower mandibular border helps protect against injury to the marginal mandibular nerve. Although unilateral injury to
the buccal branch may result in impaired elevation of the commissure on the affected side, bilateral involvement is rare and would not manifest with asymmetry. Injuries to the cervical branch of the facial nerve tend
to recover over time with conservative management.
1
REFERENCE
1. Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve pseudo-paralysis” in
patients undergoing face lift. Plast Reconstr Surg 2003;111:2414
FACIAL DANGER ZONES
10. A patient undergoes a deep plane facelift with undermining to the modiolus. The next day, the patient has
inability to elevate the commissure on active smile. Which of the following nerves is likely injured?
C. Zygomatic branch of the facial nerve.
The zygomatic branch of the facial nerve innervates the muscles that control the movement of the upper lip,
including the muscles responsible for elevating the corner of the mouth (commissure) during smiling.
Injury to this nerve can result in difficulty elevating the commissure and lead to a drooping or asymmetric
smile on the affected side (Fig. 30.4).
1
Temporal branches
of facial nerve
5
2
6
4
1
7
Supraorbital/
supratrochlear nerves
Infraorbital nerve
Zygomatic and
buccal branches of
facial nerve
Marginal mandibular
branch of facial nerve
Mental nerve
Great auricular nerve
Fig. 30.4 Facial danger zones: motor and sensory nerves. (Source: Facial Danger Zones. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Nahai F, Mejia JD, Nahai FR. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery:
Principles and Techniques. 2nd ed. New York: Thieme Publishers; 2010
FACIAL DANGER ZONES
11. A patient has inability to evert the lower lip 3 days after a deep neck lift surgery. Which nerve is likely
injured?
D. Marginal mandibular nerve.
The marginal mandibular nerve is a branch of the facial nerve (cranial nerve VII) that provides innervation
to the muscles responsible for controlling the movement of the lower lip, including the depressor anguli
oris muscle. Inability to evert the lower lip indicates dysfunction of this nerve, which can occur due to
injury during surgery or as a result of swelling and inflammation in the surgical area (Fig. 30.5).
1
Chapter 30&Face and Neck Anatomy 207
Temporal branches
of facial nerve
5
2
6
4
1
3
7
Supraorbital/
supratrochlear nerves
Infraorbital nerve
Zygomatic and
buccal branches of
facial nerve
Marginal mandibular
branch of facial nerve
Mental nerve
Great auricular nerve
Fig. 30.5 Facial danger zones: motor and sensory nerves. (Source: Facial Danger Zones. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Nahai F, Mejia JD, Nahai FR. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery:
Principles and Techniques. 2nd ed. New York: Thieme Publishers; 2010
FACIAL DANGER ZONES
12. A 22-year-old female who is not healing postoperatively from an augmentation genioplasty has chin numb-
ness. Which nerve is likely injured?
B. Mental nerve.
The mental nerve is a branch of the trigeminal nerve (cranial nerve V) that provides sensory innervation to
the chin and lower lip. It runs along the lower jaw and can be affected during genioplasty surgery, leading to
numbness and altered sensation in the area. Nerve injury can result from the surgical procedure itself, pressure, stretching, or other factors that may have affected the nerve during surgery (Fig. 30.6).
1
Temporal branches
of facial nerve
5
2
6
4
1
3
7
Supraorbital/
supratrochlear nerves
Infraorbital nerve
Zygomatic and
buccal branches of
facial nerve
Marginal mandibular
branch of facial nerve
Mental nerve
Great auricular nerve
Fig. 30.6 Facial danger zones: motor and sensory nerves. (Source: Facial Danger Zones. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Nahai F, Mejia JD, Nahai FR. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery:
Principles and Techniques. 2nd ed. New York: Thieme Publishers; 2010