Safely Navigating
Around the Facial Nerve
in Three Dimensions
John Q. Owsley, MD, FACSa,b,*, Cori A. Agarwal, MD, FACSc
KEYWORDS
 Facial  Nerve  Facelift  Anatomy  SMAS
Facial nerve injury during facelift surgery is a rare
but real occurrence, with a reported incidence
ranging from 0.5% to 2.6%.1–6 The danger zones
of the various facial nerve branches have been
well described in the literature1,2,7–16 but usually
from a two-dimensional perspective, which can
be difficult to translate to surgical technique. In
many of these classic descriptions, emphasis is
on nerve trajectory in relation to surface anatomy
and bony landmarks, with sparse and often con-
flicting information on the nerve’s transition point
between fascial planes. In the temporal region in
particular, the literature reflects confusion regard-
ing the naming of fascial planes and their relation-
ships with the frontal branch of the facial nerve.
Some of the confusion about the anatomy of the
facial fascia and the facial nerve branches can be
explained by the uncertainty of the anatomist
working with the indistinct definition of the subcu-
taneous fascias in cadavers. The superficial and
deep fascial layers in the cheek tend to be fused,
particularly in preserved cadavers. Earlier anato-
mists who wrote the standard text books were
not really concerned with the significance of the
transit of the facial nerve branches in relation to
cosmetic surgery. Only in the operating room
with live patients can the superficial and deep fas-
cial planes be readily distinguished and separated
with dissection.
In surgery, the motor nerves are sometimes
exposed but mostly remain hidden beneath the
deep facial fascia. The general course of the facial
nerve branches is known from cadaver dissection.
a
Division of Plastic Surgery, University of California, San Francisco, CA, USA
b
California Pacific Medical Center—Davies Campus, San Francisco, CA, USA
c
Division of Plastic and Reconstructive Surgery, University of Utah, Salt Lake City, UT, USA
* Corresponding author. California Pacific Medical Center—Davies Campus, 45 Castro Street, Suite 111, San
Francisco, CA 94114.
E-mail address: owsley@drjohnowsley.com (J.Q. Owsley).
Clin Plastic Surg 35 (2008) 469–477
doi:10.1016/j.cps.2008.05.011
0094-1298/08/$ – see front matter ª 2008 published by Elsevier Inc.
Where the nerves remain protected at a plane
deep to the dissection and where the nerve tran-
sits to a superficial plane in locations that dissec-
tion must and can avoid has been learned from
surgical dissection. From this clinical information,
the transit path of the facial nerve branches can
be inferred without actually exposing them to
injury.
This article describes in three-dimensional
accurate surgical terms where the facial nerve
branches are located and how they can be
protected while dissecting above and below the
superficial musculoaponeurotic system (SMAS)–
platysma plane.
Although a sub-SMAS–platysma facelift is
believed to put the facial nerve at a higher risk
for potential injury,6,17–20 the authors have found
extensive dissection of this plane to be safe if
performed with a clear understanding and respect
for the facial nerve danger zones (Fig. 1). The ana-
tomic descriptions and surgical technique are
based on the senior author’s observations from
more than 2500 SMAS–platysma facelifts.
FRONTAL BRANCH
The classic descriptions of the frontal branch of
the facial nerve by Furnas,8 and later by Pitanguy
and Ramos,7 describe the trajectory of a single
ramus in relation to the tragus and the lateral
brow. The presence of multiple frontal branch
rami and the variable region over which these
plasticsurgery.theclinics.com
rami cross the zygomatic arch was observed
470 Owsley & Agarwal
Fig. 1. Danger zones of the facial nerve. Green indi-
cates a safe area, yellow indicates where cautious
dissection is required, and red indicates where
extreme caution is necessary.
more recently by Zani and colleagues10 and
Gosain,2 who describe an area spanning nearly
two thirds of the central arch over which the rami
cross.
Although this two-dimensional frontal nerve
danger zone is well understood, reports conflict
as to the fascial level of the frontal rami as they
cross the zygomatic arch.1,21–33 Inferior to the
zygomatic arch, the frontal branch travels within
the substance of the parotid gland, deep to the
parotid–masseteric fascia, while in the temporal
region it is located within the superficial temporo-
parietal fascia close to its deep surface. Its point
of transition between deep and superficial planes
and its fascial level as it crosses the zygomatic
arch are not well described. Although Stuzin and
colleagues23 stated that the frontal branch is
located within the temporoparietal fascia as it
crosses the arch, compelling evidence shows
that it travels in a deeper plane at this location.
To accurately describe the path of the frontal
branch, the anatomy and terminology of the fascial
layers in the temporal region must be clarified
because the nomenclature has tremendous vari-
ability in the literature.22–34 It is well accepted
that the SMAS below the zygomatic arch is analo-
gous to and in continuity with the temporoparietal
fascia (superficial temporal fascia, galeal ex-
tension) above the arch. The plane of the
parotid–masseteric fascia below the zygomatic
arch is analogous to that of the superficial layer
of the deep temporal fascia (intermediate temporal
fascia, superficial lamina, innominate fascia)
above the arch. Whether these deeper fascial
layers are contiguous structures or are separate,
inserting on the periosteum above and below the
arch, is complicated and a matter of
debate.23,26,30,31,33
However, from a surgical perspective, these
superficial and deep layers of fascia clearly
become adherent to each other and the underlying
zygomatic arch periosteum across the central re-
gion. The level and location of the firm attachment
between the superficial and deep fascia begins at
the arch and becomes firm at the superior border
of the central arch. This firm adhesion extends
2 to 3 cm above the arch into the anterior temporal
region. This adhesion has been termed the inferior
temporal septum (Fig. 2).24,35
Because the nerve is beneath the parotid–
masseteric fascia below this area of adhesion,
and within the superficial temporoparietal fascia
above it, the transition of the frontal branch likely
occurs at some point within this area of dense
fascial adhesions. The authors believe that the
frontal branch maintains its position beneath the
continuation of the parotid–masseteric fascia,
Fig. 2. The dotted line depicts the area of adhesion
between the superficial and deep fascial layers overly-
ing and above the mid-zygomatic arch. In this region,
the frontal branch crosses between the fascial layers.
The blue dot represents the sentinel vein, routinely
encountered when separating the fascial layers in
the temporal region just before the area of adhesion
begins.

while crossing the arch at a subfascial plane over-
lying the periosteum. Recent cadaver dissection
suggests that the parotid–masseteric fascia above
the arch merges into the fibroareolar innominate
fascia that overlies the superficial layer of the
deep temporal fascia at 2 or 3 cm above the
mid-anterior arch in the area of dense interfacial
adhesion. Initially, the nerve lies just above the
insertion of the superficial layer of the deep tempo-
ral fascia into the arch. Within the area of dense
adhesion containing the innominate fascia, the
frontal branch gradually passes upward to enter
the deep surface of the superficial temporoparietal
fascia where it continues forward (Fig. 3).
In performing the senior author’s facelift opera-
tion, the SMAS is divided over the entire length
of the body of the arch to the origin of the zygoma-
ticus muscle. No frontal branch injuries have
occurred. The level of division is determined by
the point of resistance to blunt elevation of the
SMAS over the arch. The fact that the nerve
does not cross to a superficial plane until it is
above the arch is further demonstrated by the
safe performance of the high-SMAS operation, in
which the SMAS is divided along the superior bor-
der of the zygomatic arch, where the nerve is
safely protected beneath the deep fascia.36,37
Additional evidence of its deep position on the
periosteum across the arch is the high rate of
reported frontal branch injuries after subperiosteal
dissections over the arch, ranging from 11% to
20%,32,33 although refinements in technique have
allowed this rate to be reduced to just 1%.38
Protection of the facial nerve branches during
sub-SMAS elevation in the cheek is facilitated by
dissecting the sub-SMAS plane first. During
a sub-SMAS dissection of the cheek, the caudal
zygomatic arch should be approached using blunt
innominate fascia to reach the undersurface of the temporoparietal fascia. The sentinel vein is encountered
lateral and cephalad to the location of the nerve.
Safely Navigating Around the Facial Nerve 471
dissection. Over the posterior third of the zygo-
matic arch, the plane between the superficial
(SMAS) and deep fascia can be easily separated
up to and often beyond the superior arch border.
At a point 1 to 2 cm above the lateral arch in the
preauricular lateral temporal region, the deep and
superficial fascia become fused and cannot be
dissected further. This location is the transition of
the superficial temporal artery from beneath the
superficial layer of the deep temporal fascia to
reach the undersurface of the temporoparietial
fascia.
In the middle and anterior third of the arch, the
planes become densely adherent at the superior
arch border and further blunt separation is pre-
vented. When dissecting from above the arch in
the temporal region, a safe plane of easy cleavage
exists between the superficial temporoparietal fas-
cial and the deep temporal fascia, with the nerve
contained within the superficial fascia. Blunt
dissection can be performed safely and without
resistance until the area of fascial fusion is encoun-
tered in the mid and anterior temporal region,
typically 2 to 3 cm above the arch and heralded
by the sentinel vein, which runs between the two
planes in this location.
Within this area of dense interfascial adhesion,
the frontal branch rami are in jeopardy as they
cross from deep to superficial fascial planes
(see Fig. 3).24 As this area is approached, careful
subcutaneous dissection or an atraumatic subper-
iosteal approach will protect the nerves from
injury. Blind scissor subcutaneous dissection in
the temporal region and over the mid arch can
penetrate the temporoparietal fascia and result in
injury to the frontal branch. Indiscriminate applica-
tion of electrocautery can also cause frontal
branch injury.
Fig. 3. The course of the frontal
branch of the facial nerve as it
crosses the zygomatic arch. The
frontal branch emerges from
the substance of the parotid
gland and travels beneath the
parotid–masseteric fascia, then
crosses the arch at a deep plane
overlying the periosteum. Above
the arch the parotid–masseteric
fascia merges into the innomi-
nate fascia within the area of
dense adhesion between the
temporoparietal fascia and
superficial layer of the deep
temporal fascia. The frontal
branches course through the
472 Owsley & Agarwal
ZYGOMATIC BRANCH
The zygomatic branch of the facial nerve travels
forward within the cephalic portion of the parotid
gland along with the transverse facial artery.
Here, the parotid gland lies in proximity to the
zygomatic arch and the body of the zygoma and
extends into the buccal space at and sometimes
beyond the anterior superior edge of the masseter
muscle. The zygomatic branch exits the parotid
gland in association with the parotid duct at a level
deep to the parotid–masseteric fascia and travels
forward into the buccal space beneath the origin
of the zygomatic major muscle. The zygomatic
branch emanates rami to innervate the deep sur-
faces of the levator muscles and orbicularis oculi
(Fig. 4). The terminal medial branches of the zygo-
matic branch, together with crossover innervation
from the buccal branch, have primary functional
significance in terms of involuntary blink, eyelid
position, tear pump movement, and orbicularis
tone, whereas the proximal lateral branches are
responsible for voluntary tight squeezing of the
eyelid fissure.10,39–43
When dissecting in a sub-SMAS plane in the
cheek, the zygomatic branch is initially protected
by its position within the parotid gland. The area
Fig. 4. The zygomatic branch is depicted exiting the
parotid gland in association with the parotid duct at
a level deep to the parotid–masseteric fascia and trav-
eling forward into the buccal space beneath the
origin of the zygomatic major muscle. Note the trans-
verse facial artery perforator located above the zygo-
matic nerve.
of nerve vulnerability exists at the anterior–
cephalad edge of the parotid gland deep to the
origin of the zygomaticus muscle. This location
has been described as MacGregor’s patch,44
where strong ligaments run from the body of the
zygoma through the masseteric fascia, SMAS,
and subcutaneous fat and insert into the dermis.
When dissecting beneath the SMAS in this region,
careful perpendicular scissor spreading using
loupe magnification is performed to avoid damag-
ing the zygomatic branches as they exit the
parotid–masseteric fascia to pass into the buccal
space. Here, among dense perpendicular fascial
bands, a perforator from the transverse facial
artery is routinely encountered accompanied by
a zygomatic sensory nerve that supplies sensation
to the skin of the malar region (Fig. 5).45
BUCCAL BRANCH
The buccal branch rami travel within the mid-
portion of the parotid gland, which is considerably
narrower than the cephalic portion, ending 2 to
4 cm lateral to the anterior border of the masseter.
The buccal branch rami exit the parotid and travel
forward on the surface of the masseter muscle
deep to the investing masseteric fascia. At the
Fig. 5. After release of the cephalic zygomatico–mas-
seteric ligaments in a sub-SMAS plane. The dissection
extends to the zygomatic arch on the left side. A zygo-
matic branch (right arrow) is seen exiting the parotid–
masseteric fascia to enter the buccal space beneath
the zygomaticus muscle. A perforator from the trans-
verse facial artery is also visualized cephalad to the
nerve (left arrow).

anterior margin of the masseter, the buccal rami
perforate the fascia and enter the buccal fat com-
partment where they innervate the facial levator
muscles from their deep surface.
During a sub-SMAS dissection of the cheek, the
buccal branches become vulnerable at the ante-
rior extent of the parotid gland, where they can
be seen running deep to the masseteric fascia.
At the anterior margin of the masseter muscle,
a line of fibrous attachments between the masse-
teric fascia and the SMAS is encountered, which
constitute the supporting ligaments of the mid-
cheek.22,46 Once the anterior edge of the parotid
is reached, the safest and most efficient method
for separating the SMAS from the underlying mas-
seteric fascia is blunt dissection using a peanut
sponge. This blunt dissection is facilitated by
dissecting in the sub-SMAS plane before subcuta-
neous undermining. At the anterior border of the
masseter, where the buccal rami emerge from
beneath the fascia to enter the buccal space,
limited and cautious blunt dissection can be
used to accomplish adequate mobilization of the
SMAS–platysma flap (Fig. 6).
MARGINAL MANDIBULAR NERVE
The classic descriptions of the mandibular branch
of the facial nerve, most notably by Dingman and
Grabb,9 focus on nerve trajectory rather than
fascial plane.1,47–50 The mandibular branches
have been found to remain above the inferior
border of the mandible, except in 19% of cases
where they can dip 1 to 3 cm below the mandible
before crossing the anterior facial vessels.
The mandibular branch exits the caudal edge of
the parotid gland anterior to or just below the angle
Fig. 6. After exiting the mid–parotid gland, the buccal
branch rami travel deep to the masseteric fascia. At
the anterior margin of the masseter muscle, amidst
the masseteric retaining ligaments of the cheek, the
buccal rami perforate the fascia and enter the buccal
fat compartment.
Safely Navigating Around the Facial Nerve 473
of the mandible at a level deep to the parotid–
masseteric and deep cervical investing fascia. In
most instances, the nerve continues forward
above the inferior border of the mandible deep to
the masseteric fascia. In those cases in which it
exits the parotid below the inferior mandibular bor-
der, it runs anteriorly and crosses the surface of
the posterior digastric muscle and then the cap-
sule of the submandibular gland, lying deep to
the investing cervical fascia and curving a variable
distance below the mandible. The nerve pene-
trates the deep cervical fascia at the inferior border
of the mid-mandible near the anterior margin of the
masseter muscle, where it then crosses superficial
to the facial artery to enter the buccal space lying
beneath the platysma, ultimately innervating the
major lip depressors and the mentalis muscle
(Fig. 7).51
During a sub-SMAS cheek dissection, the great-
est danger zone for the marginal mandibular nerve
is in the lower anterior cheek as the buccal space
is approached. Blunt dissection using a peanut
sponge can be performed over the masseteric
fascia to mobilize the SMAS–platysma flap
adequately, but extreme caution should be used
at the lower anterior border of the masseter mus-
cle, because this is the region where the anterior
facial artery and crossing marginal mandibular
branch are encountered (Fig. 8). Injury to a low-
lying mandibular branch can occur below the man-
dible only if the dissection inadvertently extends
deep to the cervical investing fascia.
Dissection beneath the platysma in the neck
should be initiated several centimeters below the
angle of the mandible where the correct plane
can be established. The subplatysmal areolar
tissue can then be bluntly swept away from the
Fig. 7. The marginal mandibular nerve emerges from
the parotid gland at or below the angle of the mandi-
ble and runs anteriorly, remaining deep to either the
masseteric or deep cervical investing fascia. It transi-
tions to a subplatysmal plane as it crosses the facial
artery at the inferior border of the mandible.
474 Owsley & Agarwal
Fig. 8. When dissecting in a sub-SMAS plane, the mar-
ginal mandibular nerve is at greatest risk in the lower
anterior cheek as the buccal space is approached. This
location is where the nerve crosses the anterior facial
artery and travels in a more superficial subplatysma
location. The facial artery is seen pulsating near the
tip of the forceps.
platysma toward the deep cervical fascia until the
inferior border of the mandible is reached, allowing
a mandibular branch coursing below the inferior
mandible to remain protected by the deep cervical
fascia (Fig. 9). During a subcutaneous facelift
dissection along the mid-mandibular border, blind
push dissection with scissor tips, traumatic manip-
ulation of a liposuction cannula, or the misplaced
use of electrocautery can result in nerve injury, be-
cause inadvertent penetration of the platysma into
the masseteric fascia or buccal space can occur.
CERVICAL BRANCH
The cervical branch exits the parotid gland at its
caudal border at or below the angle of the
Fig. 9. Dissection beneath the SMAS and platysma
with preservation of a tissue bridge over the inferior
edge of the mandible to protect the mandibular and
cervical branches. In the neck, the platysma has been
elevated from the deep cervical fascia to the level of
the inferior mandibular border. The marginal mandib-
ular branch is located deep to the masseteric and
deep cervical investing fascia in this location.
mandible. It immediately penetrates the deep cer-
vical fascia, protected by adjacent interfascial
fibrous bands, and travels within the fibroareolar
connective tissue to the undersurface of the
platysma, where it arborizes and sends principle
branches anteriorly and caudally (see Fig. 9;
Figs. 10 and 11).
When dissecting beneath the SMAS and platys-
ma, the cervical branch is at greatest risk anterior
to the angle of the mandible, where it emerges
from the parotid gland. Dissection at the inferior
border of the mandible, in front of the angle, at
a level deep to the platysma should be performed
carefully, using only blunt dissection and gentle
vertical scissor spreading to obtain adequate
mobility of the SMAS–platysma flap.
The danger zones for the cervical branch and
the mandibular branch are adjacent and can be
treated as a single zone during a SMAS–platysma
facelift. This area, depicted in red in Fig. 1, encom-
passes the angle of the mandible laterally, a line
1 cm above and parallel to the inferior border of
the mandible cephalically, a line 2 cm below and
parallel to the mandibular border caudally, and
the oral commissure medially. To achieve ade-
quate mobilization of the SMAS–platysma flap,
fascial attachments running between the platysma
and deep fascia in this zone will often need to be
released to some degree. Once the sub-SMAS
plane has been developed in the cheek and the
subplatysmal plane has been established in the
neck, the mandibular border can be cautiously
approached using a peanut sponge to extend the
planes of dissection toward the mandibular border
from above and below. In doing so, a mobile soft
Fig. 10. The cervical branch exits the parotid gland at
or below the angle of the mandible and immediately
penetrates the deep cervical fascia to travel on the
undersurface of the platysma, where it arborizes.

tissue bridge is preserved to protect the path of
the mandibular and cervical nerve branches, as
seen in Figs. 9 and 11.
DISCUSSION
Although much literature discusses the anatomy
and injury of the facial nerve branches, the fascial
plane of the nerves, particularly where they change
from one plane to another, is rarely emphasized
and often contradictory. All five motor branches of
the facial nerve exit from the peripheral margin of
the parotid gland, lying deep to the parotid fascia,
which continues as the masseteric fascia, which
is in continuity with the deep temporal fascia above
and the investing deep cervical fascia below.
Only one branch, the cervical, immediately
penetrates the deep fascia after exiting the parotid
gland and travels to the undersurface of the
platysma, which it innervates. The other branches
continue beneath the deep fascia for a variable
distance after exiting the parotid gland before
they pass to a more superficial plane or enter the
buccal space to reach their respective target mus-
cles. For the frontal branches, this point is above
the mid-anterior zygomatic arch, where they cross
to a more superficial location to run within the
Fig. 11. The cervical branches can often be seen cours-
ing upwards within the fibrous bands between the
parotid–masseteric fascia and platysma in the region
anterior to the mandibular angle. The cervical branch
extends forward on the undersurface of the platysma,
which it innervates (arrows).
Safely Navigating Around the Facial Nerve 475
temporoparietal fascia. For the zygomatic, buccal,
and most mandibular branches, this transition
occurs at the anterior border of the masseter mus-
cle, where they exit from beneath the masseteric
fascia to enter the buccal space. In cases where
the mandibular nerve arcs below the mandibular
border, it pierces the deep cervical fascia just
before crossing the border of the mandible and
the anterior facial artery, after which it runs
beneath the platysma in the buccal space before
innervating the lip depressor muscles.
Because of its early transition from beneath the
deep fascia to a subplatysmal plane, the cervical
branch is the motor branch most susceptible to
injury during a facelift. Fortunately, cervical branch
injury is usually inconsequential and therefore has
not been a major concern during facelift surgery.
In most patients, loss of platysma function has
no effect on the lip depressors.
However, in approximately 2% of the popula-
tion, typically those who exhibit a ‘‘full denture
smile’’52 in whom the cervical branch probably
innervates the depressor anguli oris in continuity
with the platysma, the platysma is a contributing
lip depressor, and injury to the cervical branch of
the facial nerve results in ‘‘pseudo-paralysis of
the marginal mandibular nerve.’’53 The authors
suspect that many if not most of the marginal man-
dibular nerve injuries reported in the literature
actually represent pseudo-paralysis caused by
platysmal dysfunction secondary to cervical
branch injury. They observed this in their own
series of 2000 consecutive cases, in which all but
one case of lip depressor weakness after a facelift
were caused by a cervical nerve injury rather than
a mandibular nerve injury.54
Clinical distinction between these injuries may
be difficult because of variable overlapping func-
tion and interconnections of nerve supply to the
lip depressors. Injury to the marginal mandibular
nerve typically causes paralysis of the depressor
labii inferioris, depressor anguli oris, and mentalis
muscles, resulting in an inability to move the lower
lip downward and laterally and to evert the vermil-
ion border of the lower lip. The deformity appears
as an elevation of the lip on the affected side and
a relative retraction downward on the normal
side. Mentalis function has only recently been
acknowledged to distinguish cervical branch injury
from marginal mandibular dysfunction. The pres-
ence of lower lip eversion indicates a functioning
mentalis and therefore suggests an intact mandib-
ular branch. In the authors’ experience, cervical
branch injury is always associated with spontane-
ous recovery without special treatment.
In multiple anatomy texts and surgical articles,
the course of the marginal mandibular branch of
476 Owsley & Agarwal
the facial nerve is described as ‘‘running deep to
the platysma,’’ with warnings against dissecting
in a subplatysmal plane within 3 cm of the inferior
border of the mandible.1,48,49,55–57 This description
differs from the authors’ observations in live
SMAS–platysma facelift dissections, in which the
mandibular branch is never visualized in the neck
but courses beneath the deep cervical fascia until
it crosses the anterior facial vessels in the mid-
mandible.
This discrepancy has several explanations.
In cadaver dissections, the deep cervical fascia,
which is less distinct and harder to appreciate
than platysma muscle fibers, may have simply
not been recognized. Additionally, what were
believed to be mandibular branches traveling on
the undersurface of the platysma in the lateral
mandibular location may have been cervical
branches. During live facelift dissections, the
authors have observed that cervical branches of
the facial nerve are frequently visualized in the
areolar tissue and on the undersurface of the pla-
tysma just anterior to the mandibular angle
(see Fig. 11). The marginal mandibular nerve has
never been encountered in this location, because
it is beneath the masseteric or deep cervical fas-
cia. By recognizing this, dissection can be safely
performed beneath the platysma up to the angle
of the mandible, as long as the subplatysmal plane
has been well established caudally and a blunt
technique of sweeping the deep tissues from the
undersurface of the platysma is used.
REFERENCES
1. Baker DC, Conley J. Avoiding facial nerve injuries in
rhytidectomy: anatomic variations and pitfalls. Plast
Reconstr Surg 1979;64:781.
2. Gosain AK. Surgical anatomy of the facial nerve. Clin
Plast Surg 1995;222:241.
3. Cohen SR, Webster RC. Primary rhytidectomy—
complications of the procedure and anesthetic.
Laryngoscope 1983;93:654.
4. Castanares S. Facial nerve paralyses coincident
with, or subsequent to, rhytidectomy. Plast Reconstr
Surg 1974;54:637.
5. Owsley JQ. Platysma-fascial rhytidectomy: a prelimi-
nary report. Plast Reconstr Surg 1977;60:843.
6. Rees TD, Aston SJ. A clinical evaluation of the re-
sults of submusculo-aponeurotic dissection and fix-
ation in face lifts. Plast Reconstr Surg 1977;60:851.
7. Pitanguy I, Ramos AS. The frontal branch of the
facial nerve: the importance of its variations in face
lifting. Plast Reconstr Surg 1966;38:352.
8. Furnas DW. Landmarks for the trunk and the tempor-
ofacial division of the facial nerve. Br J Surg 1965;
52:694.
9. Dingman RO, Grabb WC. Surgical anatomy of the
mandibular ramus of the facial nerve based on the
dissection of 100 facial halves. Plast Reconstr Surg
1962;29:266.
10. Zani R, Fadul R, Dias Da Rocha MA, et al. Facial
nerve in rhytidoplasty: anatomic study of its trajec-
tory in the overlying skin and the most common sites
of injury. Ann Plast Surg 2003;51:236.
11. Gosain AK, Sewall SR, Yousif NJ. The temporal
branch of the facial nerve: how reliably can we pre-
dict its path? Plast Reconstr Surg 1997;99:1224.
12. Seckel BR. Facial danger zones: avoiding nerve
injury in facial plastic surgery. St. Louis (MO): Quality
Medical Publishers; 1994.
13. Myckatyn TM, MacKinnon SE. A review of facial
nerve anatomy. Seminars in plastic surgery. Facial
Paralysis 2004;18(1):5.
14. Wilhemi BJ, Mowlavi A, Neumeister MW. The safe
face lift with bony anatomic landmarks to elevate
the SMAS. Plast Reconstr Surg 2003;111:1723.
15. Owsley JQ. SMAS-platysma face lift. Plast Reconstr
Surg 1983;71:573.
16. Owsley JQ. SMAS-platysma face lift: a bidirectional
cervicofacial rhytidectomy. Clin Plast Surg 1983;10:
429.
17. Baker DC. Editorial: deep dissection rhytidectomy:
a plea for caution. Plast Reconstr Surg 1994;93:
1498.
18. Beeson WH. Extended posterior rhytidectomy.
Facial Plast Surg Clin North Am 1993;1:215.
19. Adamson PA, Moran ML. Complications of cervico-
facial rhytidectomy. Facial Plast Surg Clin North
Am 1993;1:262.
20. Baker DC. Complications of cervicofacial rhytidec-
tomy. Clin Plast Surg 1983;10:543.
21. Bernstein L, Nelson RH. Surgical anatomy of the
extraparotid distribution of the facial nerve. Arch
Otolaryngol 1984;110:177.
22. Stuzin JM, Baker TJ, Gordon HL. The relationship of
the superficial and deep facial fascias: relevance to
rhytidectomy and facial aging. Plast Reconstr Surg
1992;89:441.
23. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anat-
omy of the frontal branch of the facial nerve: the
significance of the temporal fat pad. Plast Reconstr
Surg 1989;83:265.
24. Salas E, Ziyal IM, Bejjani GK, et al. Anatomy of the
frontotemporal branch of the facial nerve and indica-
tions for interfacial dissection. Neurosurgery 1998;
43:563.
25. Ammirati M, Spallone A, Ma J, et al. An anatomico-
microsurgical study of the temporal branch of the
facial nerve. Neurosurgery 1993;33:1038.
26. Abul-Hussan HS, von Drasek Ascher G, Acland RD.
Surgical anatomy and blood supply of the fascial
layers of the temporal region. Plast Reconstr Surg
1986;77:17.

27. Krayenbuhl N, Isolan GR, Hafez A, et al. The rela-
tionship of the fronto-temporal branches of the facial
nerve to the fascias of the temporal region: a litera-
ture review applied to practical anatomic dissection.
Neurosurg Rev 2007;30:8.
28. Campiglio GL, Ponzielli G, Di Leo A, et al. Anatomi-
cal study of the temporal fascia and fat pads.
Minerva Stomatol 1999;48:71.
29. Campiglio GL, Candiani P. Anatomical study on the
temporal fascial layers and their relationships with
the facial nerve. Aesthetic Plast Surg 1997;21:69.
30. Hwang K, Kim DJ. Attachment of the deep temporal
fascia to the zygomatic arch: an anatomic study.
J Craniofac Surg 1999;10:342.
31. Accioli de Vasconcellos JJ, Britto JA, Henin D, et al.
The fascial planes of the temple and face: an
en-bloc anatomical study and a plea for consis-
tency. Br J Plast Surg 2003;56:623.
32. Moss CJ, Mendelson BC, Taylor GI. surgical anatomy
of the ligamentous attachments in the temple and peri-
orbital regions. Plast Reconstr Surg 2000;105:1475.
33. Psillakis JM, Rumley TO, Camargos A. Subperiosteal
approach as an improved concept for correction of
the aging face. Plast Reconstr Surg 1988;82:383.
34. Ramirez OM, Maillard GM, Musolas A. The extended
subperiosteal face lift: a definitive soft-tissue remod-
eling for facial rejuvenation. Plast Reconstr Surg
1991;88:227.
35. Casanova R, Cavalcante D, Grotting JC, et al. Ana-
tomic basis for vascularized outer-table calvarial
bone flaps. Plast Reconstr Surg 1986;78:301.
36. Connell BF, Semlacher RA. Contemporary deep
layer facial rejuvenation. Plast Reconstr Surg 1997;
100:1513.
37. Alpert B, Nahai F. Protecting the facial nerve frontal
branch in the ‘‘high SMAS’’ face lift operation. Pre-
sented at the American Society for Aesthetic Plastic
Surgery Meeting. Vancouver, WA. April 2004.
38. Heinrichs H, Kaidi AA. Subperiosteal face lift: a 200-
case, 4-year review. Plast Reconstr Surg 1998;102:
843.
39. McCord CD. Innervation of the orbicularis oculi mus-
cle. Presented at the New Horizons In Cosmetic Sur-
gery Symposium. Palm Springs, CA. February 2005.
40. McCord S, Codner M, Nahai F, et al. Letter: analysis
of the nerve branches to the orbicularis oculi muscle
of the lower eyelid in fresh cadavers. Plast Reconstr
Surg 2006;118:556.
41. DiFrancesco LM, Anjema CM, Codner MA, et al.
Evaluation of conventional subciliary incision used
in blepharoplasty: preoperative and postoperative
videography and electromyography findings. Plast
Reconstr Surg 2005;116:632.
Safely Navigating Around the Facial Nerve 477
42. Lowe JB, Cohen M, Hunter J, et al. Analysis of the
nerve branches to the orbicularis oculi muscle of
the lower eyelid in fresh cadavers. Plast Reconstr
Surg 2005;116:1743.
43. Ramirez OM, Santamaria R. Spatial orientation of
motor innervation to the lower orbicularis oculi mus-
cle. Aesthetic Surgery Journal 2000;20:107.
44. Furnas D. The retaining ligaments of the cheek. Plast
Reconstr Surg 1989;83:11.
45. Whetzel TP, Mathes SJ. Arterial anatomy of the face:
an analysis of vascular territories and perforating
cutaneous vessels. Plast Reconstr Surg 1992;89:
591.
46. Ruess W, Owsley JQ. The anatomy of the skin and
fascial layers of the face in aesthetic surgery. Clin
Plast Surg 1987;14:677.
47. Skandalakis JE, Gray SW, Rowe JS. Surgical anat-
omy of the submandibular triangle. Am Surg 1979;
45:590.
48. Conley J, Baker DC. Paralysis of the mandibular
branch of the facial nerve. Plast Reconstr Surg
1982;70:569.
49. Liebman EP, Webster RC, Gaul JR, et al. The
marginal mandibular nerve in rhytidectomy and lipo-
suction surgery. Arch Otolaryngol Head Neck Surg
1988;114:179.
50. Nelson DW, Gingrass RP. Anatomy of the mandibu-
lar branches of the facial nerve. Plast Reconstr
Surg 1979;64:479.
51. Owsley JQ. Aesthetic facial surgery. Philadelphia:
W.B. Saunders Company; 1994.
52. Rubin LR. The anatomy of a smile: its importance in
the treatment of facial paralysis. Plast Reconstr Surg
1974;53:384.
53. Ellenbogen R. Pseudo-paralysis of the mandibular
branch of the facial nerve after platysmal face-lift op-
eration. Plast Reconstr Surg 1979;63:364.
54. 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.
55. Singer DP, Sullivan PK. Submandibular gland I: an
anatomic evaluation and surgical approach to sub-
mandibular gland resection for facial rejuvenation.
Plast Reconstr Surg 2003;112:1150.
56. Codner MA, Nahai F. Submandibular gland I: an
anatomic evaluation and surgical approach to
submandibular gland resection for facial rejuvena-
tion. Discussion. Plast Reconstr Surg 2003;112:
1155.
57. Smith AD, Elahi MM, Kawamoto HK, et al. Excision of
the submandibular gland by an intraoral approach.
Plast Reconstr Surg 2000;105:2092.