Facelift-related Anatomy

(1)

CHAPTER 12

12

tant are nervus infraorbitalis (from n. maxillaris), n. mentalis (from n. mandibularis), nn. supratrochle- ares and supraorbitales (from n. ophtalmicus), the greater auricular nerve, and the transverse cutaneous nerve of neck. The motor nerve of the face is the facial nerve, the seventh cephalic nerve, and n. oculomoto- rius, the third cephalic nerve, is responsible for move- ments of the eyes.

The facial skin is in certain points fixed with strips of firm connecting tissue to the periosteum. We call these formations retaining ligaments. They are not elastic and do not follow the sagging of the skin. That is why they cause dimples in the soft tissue of the face with advanced ageing. We have to detach some of them to obtain a smooth surface of the skin when we perform rejuvenating surgeries. If we can do it blindly it will not bleed. Otherwise, we have to do some elec- trocoagulation. If those connecting ligaments do not reach the periosteal layer, we speak of false retaining ligaments.

Bryan Mendelson from Australia had a splendid idea to compare the retaining ligaments with trees. In this way their inflexibility becomes understandable for everybody.

We detach the first three ligaments regularly when performing facelift surgery, and last three we resect seldom (Fig. 12.5).

“Anatomia clavis et clavis medicinae”, said Gabriele Fallopio, Italian pioneer of anatomy. It is the key and helm of the whole medicine. Profound knowledge of anatomic variations is the prerequisite for any physi- cian who is thinking of becoming a surgeon. We will pay attention especially to the topographic anatomy of the face.

Epidermis – the upper layer of the skin – renews itself. In babies this process is completed within 7 days; in our 70s, it takes 4–6 weeks. Below is the corium, which is connected to the epidermis with collagen and elastic fibres like a rubber layer. It allows the flexibility of the skin. Losing collagen and elastic fibres, our skin becomes wrinkled.

Between skin and bone there are fat layers, muscles, fascias, nerves, vessels, ligaments, glands, and lymph nodes. Muscles of the face have not only attachments to the bone, but also to the skin. Musculus orbicularis oris and mm. orbiculares oculi are circu- lar muscles which have no attachments to the bone and are most important for the countenance. M. orbicularis oculi is, after the myocardium, the most active muscle of the human body – it contracts every 4 s when we are awake. In 16 h our eyes are closed for 23 min.

There are sensory and motor nerves of the face. For local anaesthesia of sensory nerves the most impor-

Facelift-related Anatomy

Dimitrije E. Panfilov

Fig. 12.1. High-grade magnification of the surface of the skin (Science Photo Library)

(2)

53 12 Facelift-related Anatomy

Fig. 12.2. Topography of muscles of the face and branches of the facial nerve. 1 Temporal branches of the facial nerve, 2 frontal branches of the facial nerve, 3 zygomatic branches of the facial nerve, 4 buccal branches of the facial nerve, 5 marginal man- dibular branch of the facial nerve, 6 transverse nerve of the neck, 7 frontal part of the epicranial frontooccipital muscle,

8 temporal muscle, 9 orbicularis occuli muscle, 10 masse- ter muscle, 11 greater zygomatic muscle, 12 lesser zygomatic muscle, 13 buccinator muscle, 14 risorius muscle, 15 orbicu- laris oris muscle, 16 depressor anguli oris muscle, 17 mentalis muscle, 18 platysma

(3)

54

Fig. 12.3. Topography of facial vessels. 1 Parietal branches of superficial temporal artery and vein, 2 frontal branches of su- perficial temporal artery and vein, 3 transverse facial artery and vein, 4 maxillary artery (and vein), 5 facial artery and vein,

6 angular branch of facial artery and vein, 7 submental vein (and artery), 8 posterior external iugular vein, 9 external iu- gular vein

(4)

Fig. 12.4. Frontal view of facial anatomy: muscles, nerves and vessels. 1 Frontalis muscle, 2 superciliary corrugator muscle, 3 procerus muscle, 4 supraorbital nerve, 5 supratrochlear nerve, 6 frontal branch of facial nerve, 7 orbicularis oculi mus- cle, 8 zygomatic branch of facial nerve, 9 infraorbital nerve, 10 buccal branches of facial nerve, 11 parotid gland, 12 de- pressor muscle of septum, 13 masseter muscle, 14 buccinator muscle, 15 depressor anguli oris muscle (resected), 16 orbicu- laris oris muscle, 17 mentalis nerve, 18 mentalis muscle, 19 de-

pressor labii inferioris muscle (of lower lip), 20 mental branch of inferior alveolar artery, 21 risorius muscle, 22 parotid duct, 23 levator anguli oris muscle, 24 retromandibular artery and vein, 25 levator labii superior muscle, 26 nasal muscle, 27 an- gular artery and vein, 28 parietal branch of superficial tempo- ral artery and vein, 29 temporal branch of superficial tempo- ral artery and vein, 30 frontal branch of superficial temporal artery and vein

(5)

56

Fig. 12.5. a Retaining ligaments. b Botanic comparison with a tree rooted in the earth. c Retaining ligaments as fibrous supporting tissue connecting skin to the bone. d With advanced ageing, they show increased laxity and sagging of the skin

When we perform surgery we have to handle the human tissue with awe. We have to respect the fact that one squeeze of the forceps can destroy millions of cells. Our operating technique has to be gentle and respectful. If we act in this way we will have best pos- sible healing and scar formations.

As a generous gesture, Walter Thiel, the superb Austrian anatomist from Graz, has allowed us to re- produce nine of his excellent cadaveric studies from his remarkable work Photographic Atlas of Practical

Anatomy published by Springer. I am sure that many young plastic surgeons to whom this book is ad- dressed will benefit from these extremely precise works and I am deeply thankful to Walter Thiel for his generosity.

Bibliography

Please see the general bibliography at the end of this book.

(6)

Fig. 12.5. e Facial retaining ligaments: the first three ligaments we detouch regularly performing facelift surgery, and last three we resect seldom. 1 Zygomatic ligament, 2 Platysma-

auricula ligament (false), 3 Masseteric cutaneous ligament (false), 4 Orbital retaining ligament, 5 Buccal-maxillary re- taining ligament (false), 6 Mandibular retaining ligament

(7)

58

Fig. 12.6. a McGregor’s malar patch produces a dimple in age- ing cheeks. b McGregor’s malar patch – zygomatic retaining ligament is a very firm formation. c Buccal branches of facial nerve visible below elevated superficial musculo-aponeurotic system (SMAS) flap – indicated with a white triangle. d Huge SMAS flap divided into three leaves. e Elevated tricuspidal

SMAS flap. f Bichat’s buccal fat pad expulsed through the SMAS layer. g Fascia Loré below the preauricular incision is very firm and suitable for fixation of the SMAS flap, not pro- voking ear distortion. h A branch of the greater auricular nerve appears some 5 cm below the earlobe

(8)

Fig. 12.7. Retro- and subauricular region with m. sternocleidomastoideus and plexus cervicalis

(9)

60

Fig. 12.8. Supra-SMAS and supraplatysmal layer

(10)

Fig. 12.9. Parotid gland, branches of facial nerve with following vessels and supraplatysmal layer

(11)

62

Fig. 12.10. Parotid gland with rami zygomatici et buccales nervi facialis and subplatysmal ramus marginalis mandibularis

(12)

Fig. 12.11. All six branches of n. facialis branching below the parotid gland: ramus temporalis, ramus frontalis, ramus zygomati- cus, ramus buccalis, ramus marginalis mandibularis, ramus colli

(13)

64

Fig. 12.12. Periosteal plane of the face

(14)

Fig. 12.15. Septum orbitale

Fig. 12.14. Musculus temporalis and musculus frontalis. Arcus marginalis in-between

Fig. 12.13. Rami temporales et frontales n. facialis are following the vessels with the same names