facial anatomy

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Facial Anatomy ‫ד\"ר פרידמן טל‬ ‫כירורגיה פלסטית‬ ‫ הרופא‬-‫בי\"ח אסף‬ 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. 1

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Subcutaneous Soft Tissue  Homogenous fascial fatty layer.  Malar Fat Pad: Triangular in shape  Beneath is the SMAS. 2

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ SMAS Superficial 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. 3

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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. 4

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Parotid region Mitz 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. 5

‫תש\"ע‬/‫טבת‬/‫י\"ג‬  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. 6

‫תש\"ע‬/‫טבת‬/‫י\"ג‬  Yousif, 1994: Traction on the SMAS deepens the NLF; traction on the fascial- fatty layer lessens the fold. 7

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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. 8

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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. 9

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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 10

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 1. Depressor anguli oris, Zygomaticus minor, Orbicularis oculi. 2. Depressor labii inferioris, risorius, platysma, zygomaticus major, levator labii superioris alaeque nasi. 11

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 3. Orbicularis oris, levator labii superioris. 4. Mentalis, levator anguli oris, Buccinator. 12

‫תש\"ע‬/‫טבת‬/‫י\"ג‬  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 13

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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. 14

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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: 15

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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 16

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Facial danger zone 1  Greater auricular n.- Mckinney and Katrana: 6.5 cm below external auditory meatus  Posterior to SMAS 17

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ 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. 18

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Facial danger zone 3 marginal mandibular branch  Dingman and Grabb: The mandibular n. passes above the mandibular border- 81%- posterior to the facial a. 19

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Facial danger zone 4 Zygomatic and Buccal brances 20

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Facial danger zone 5 Supraorbital and Supratrochlear nn. 21

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Facial danger zone 6 Infraorbital n. 22

‫תש\"ע‬/‫טבת‬/‫י\"ג‬ Facial danger zone 7 Mental n. 23

‫י\"ג‪/‬טבת‪/‬תש\"ע‬ ‫‪24‬‬