Surgical Anatomy of the Extraparotid

Distribution of the Facial Nerve

Leslie Bernstein, MD, DDS, Robert H. Nelson, MD

\s=b\ The peripheral, extraparotid distribu- the peripheral facial nerve branches did not dissect the auricular ramus,
tion of the clinically important branches to the craniofacial muscles that they which he may have considered un¬
of the facial nerve is described, with
supply. important. To safeguard the temporal
common variations, based on the anatom-
branch of the nerve, he recommended
ical dissection of 35 cadaver half heads. REVIEW OF THE LITERATURE
Methods are suggested for avoiding, iso- staying above the temporal root of the
Various surface landmarks are zygoma, 1.0 cm posterosuperior to the
lating, and protecting the facial nerve
branches during surgical procedures. presently used identify the facial
to anterior hairline at the zygomatic
(Arch Otolaryngol 1984;110:177-183) nerve branches. The temporal branch arch and 2.0 cm posterosuperior to the
was studied by Furnas,' who sug¬ lateral edge of the eyebrow.
gested safe areas for avoiding nerve Pitanguy and Ramos2 described a
injury. He described the temporal line starting from a point 0.5 cm below
Although the intraparotid anatomy
branch as running between the lower the tragus, that extended in the direc¬
of the facial nerve has been very
well documented, the surgical ap¬ aspect of the earlobe and the lateral tion of the brow, passing 1.5 cm above
proaches to the peripheral, extrapa¬ edge of the eyebrow. He apparently the lateral extremity of the eyebrow.
rotid branches of the facial nerve have
not been described as accurately. For
instance, anatomical textbooks and
journal articles vary greatly in dem¬
onstrating the relationship of the
temporal branch to the articular emi¬
nence of the zygomatic arch, as well as
its location in the frontotemporal
areas; illustrations of the peripheral
facial nerve branches near the buccal
fat pad and the oral commissure are
not only scarce, but no comments are
provided about anatomical varia¬
tions.
This report, based on cadaveric dis¬
sections, describes anatomical varia¬
tions of the peripheral branches of the
facial nerve that pose potential dan¬
ger from a number of surgical proce¬
dures on the face. In the course of this
study, it has also become evident that
past reports have neglected to take
notice of the precise relationships of

Accepted for publication Sept 28, 1983.

From the Department of Otorhinolaryngology,
University of California, Davis, School of Medi-
cine, Sacramento.
Read in part before the annual scientific meet-
ing of the American Academy of Otolaryngology,
Las Vegas, Sept 13, 1978.
Reprint requests to Department of Otorhino-
laryngology, UC Davis Medical Center, 4301 "X"
St, Sacramento, CA 95817 (Dr Bernstein). Fig 1.—Chief types of facial nerve branching in 350 cervicofacial halves (from Davis et al5).

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 Fig 2. Surface and bony landmarks. AHL indicates most anterior point Fig 3.—Relationship to zygomatic arch of complex of rami of temporal
of temporal hairline; HL, hairline at level of outer canthus; O, outer
—

branch of facial nerve. Anteriormost ramus averaged 2.0 cm from

canthus; A, posterior aspect of frontozygomatic suture; B, most anterior origin of arch; distance from line dropped vertically from
concave point of temporal hairline, below point AHL; AS, auricle-scalp auricle-scalp point to posteriormost ramus averaged 1.8 cm; and
junction at helix; and Z, apex of posterosuperior zygomatic orbital entire anteroposterior length of complex averaged 2.4 cm.
angle.

They posed this line as representing facial nerve patterns within

or adja¬ frontalis muscle on recovery from the
the trajectory of the temporal branch cent to the parotid gland (Fig 1); anesthetic. During the operation, the
of the facial nerve. They also however, they did not attempt to cor¬ anterior auricular ramus of the tem¬
described the frontal branch of the relate their patterns with surface poral branch had been severed. It was
superficial temporal artery at the lev¬ landmarks. Dingman and Grabb6 considered that an anatomical varia¬
el of the lateral border of the frontalis described the course of the mandibu¬ tion must have accounted for the inju¬
muscle as the point of entry of the lar branch of the facial nerve in rela¬ ry·
temporal branch of the facial nerve tionship to the lower edge of the man¬ EXPERIMENTAL MODEL
into this muscle. dible. Posterior to the facial artery,
Correia and Zani3 combined the the mandibular branch was found to Thirty-five white adult cadaver half
heads were used in the dissection of the
observations of Fumas and of Pitan- pass above the lower border of the facial nerveand adjacent structures. Iden¬
guy and Ramos to locate the temporal mandible in 81% of the specimens. In tifying points noted in Fig 2 were used to
branch of the facial nerve between the other 19%, one or more rami of relate the surface anatomy to underlying
two diverging lines that extend from the mandibular branch formed a soft tissues and to skeletal landmarks.
the region of the earlobe, one to the downward arc, whose lowest point Equivalent identification pins were driven
lateral end of the eyebrow and the extended up to 1.0 cm below the infe¬ through the skin into the facial skeleton to
other to the lateral end of the highest rior border of the mandible. Anterior maintain these landmarks after the over¬
forehead crease. Like Furnas and to the facial artery, all of the rami of lying soft tissues were dissected. In this
way, no landmarks were lost and relation¬
Pitanguy and Ramos, Correia and the mandibular branch were found to
ships between superficial and deep struc¬
Zani disregarded the auricular ramus be above the lower border of the man¬
tures were accurately maintained. The dis¬
of the temporal branch of the facial dible in all of the specimens. sections were done in layers, except for the
nerve in their dissections. Our interest in reexamining these parotid gland—the parotid fascia and the
McCormack et al4 and Davis et al5 studies was stimulated when a pa¬ superficial lobe of the gland were removed
collectively reviewed 350 cervicofacial tient, who had undergone a superficial as one unit. The original position of the
halves and categorized six types of parotidectomy, had paralysis of the facial nerve was maintained at all times.

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 few cases, this included the orbital
Measurements Between Anatomical Landmarks (Centimeters)
extension of the zygomaticus major
Landmarks Average Median Range muscle superiorly. From the lateral
Posterior auricular ramus of cranial nerve
1.0-2.5
edge of the eyebrow, the orbicularis
VII, auricle-scalp junction 2.0
oculi muscle extended posterosuperi-
Superficial temporal vessels, point HL' 2.0
Superficial temporal vessels, auricle-scalp
orly on an average of 2.2 cm (median,
junction 2.0 1.0-2.4 2.0 cm; range, 1.5 to 3.6 cm). Relevant
Posterior auricular ramus of cranial nerve branches of the facial nerve lie deep to
VII. point HL 1.8 these muscle fibers.
Width of temporal nerve rami across
zygomatic arch 2.2 1.5-3.3 Temporal Branch of Facial Nerve
Anterior ramus of temporal branch of cranial
nerve VII, anterior origin of zygomatic arch 2.0 1.5-3.3 There were usually four rami from
Posterior ramus of temporal branch of the temporal branch of the facial
cranial nerve VII, vertical line of nerve that crossed the zygomatic
auricle-scalp point 1.8 1.9 1.0-2.5
arch. Rarely, three or five rami were
level with the outer canthus of the eye.
HL indicates hairline on a
present. These four rami were evenly
distributed over the articular emi¬
nence, or middle third, of the zygo¬
matic arch, with the posterior-most
ramus variably at or behind the poste¬
rior notch of the articular eminence,
but always anterior to the superficial
temporal vessels (Fig 3). Surgical dis¬
section must, therefore, be behind the
superficial temporal vessels to avoid
injuring the nerve, or else, through a
plane that is deep to the superficial
temporal fascia. The posterior auricu¬
lar ramus of the temporal nerve
branch was 1.8 cm from the auricle-
scalp junction (Table).
A point at the anterior hairline on a
level with the outer canthus of the
eye, point HL, consistently marks a
junction between the posterior and
middle rami of the temporal branch of
the nerve. The patterns of the posteri¬
or and middle rami in this area may
Fig 4.—Classification of divisions of temporal branch of facial nerve. Type I (13%) indicates
contribution by middle ramus to posterior ramus; type II (35%), posterior ramus is major be classified on the basis of their
contributor to middle ramus; type III (13%), no posterior contribution; and type IV (39%), equal distribution (Fig 4). The majority
contributions between posterior and middle rami. were found to branch above and poste¬
rior to point HL. Figure 4 shows four
The bony landmarks were exposed by sec¬ a larger number of types V and VI. identifiable patterns as follows: type I
tioning the overlying facial nerve and the Types V and VI are the complex (13%), contribution by the middle
surrounding soft tissues in blocks and by branching nerve patterns that, as will ramus to the posterior ramus; type II
measuring constant bony landmarks that be seen, have great importance.
could be related to the facial nerve.
(35%), the posterior ramus is the
Temporofrontal Area major contributor to the middle
RESULTS ramus; type III (13%), no posterior
Intraparotid Dissection The dissections disclosed the mus¬ contribution found; and type IV (39% )
Figure 1 shows the classification of culature to be variable in the lower equal contributions between the pos¬
Davis et al5 of the patterns of branch¬ temporoparietal area. The lateral terior and middle rami.
ing of the facial nerve. In our dissec¬ junction of the frontalis muscle with The temporofrontal branches of the
tions, we encountered the following the orbicularis oculi muscle varied at superficial temporal vessels were on
incidence of this classification: type I, the level of the zygomaticofrontal an average 2.0 cm posterosuperior to

9%; type II, 9%; type III, 25%; type suture line. The orbicularis oculi mus¬ point HL, and anterior to the auricle-
IV, 19%; type V, 22%; and type VI, cle extended posteriorly over the zygo¬ scalp junction by 1.7 cm (Table). The
16%. Although the number of our matic arch for an average of 3.6 cm major posterior auricular ramus of
specimens was smaller than that of (median distance, 3.8 cm; range, 2.4 to the temporal nerve branch was poste¬
the Davis group, our group contained 5.0 cm) from the outer canthus. In a rior or posterosuperior to point HL on

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 an average 1.8 cm (Table). Rarely does
the facial nerve branch lie superiorly
to the temporofrontal vessels. Ac¬
cordingly, working superior and pos¬
terior to these vessels should avoid
the temporal branch of the facial
nerve.
The anterior temporal hairline usu¬
ally marks the lateral aspect of the
frontalis muscle. Therefore, medial to
this point, the facial nerve is always
deep to the frontalis muscle.
The frontozygomatic suture line
consistently marked the prominent
ending of the lateral edge of the eye¬
brow, although some heavy male
brows curve downward to the level of
the outer canthus. The frontal and
orbital rami of the temporal branch of
Fig 5.—Composite drawings, made from cadavers, showing auriculotemporal nerve rami to
the facial nerve consistently ran facial nerve. Left, Facial and auriculotemporal neurovascular loops around superficial temporal
toward the lateral edge of the eyebrow and transverse facial vessels. Right, Interrupted arrow points to dangerous blind dissection.
at the frontozygomatic suture line. Dotted line shows point of greatest danger from iatrogenic sectioning of facial nerve branches.
Continuous arrow points to dissection that protects facial nerve (see text).
Using these landmarks, and by stay¬
ing 2.0 to 2.5 cm behind point HL, and
no farther anterior than 1.0 cm from
the auricle-scalp point, the temporal
branch of the facial nerve should be
avoided.

The Temporomandibular Joint

and the Zygomatic Arch
Across the zygomatic arch, the
entire complex of temporal nerve
rami measures 2.4 cm from the anteri¬
or to the most posterior ramus (Fig 3;

Table). The distance from the anterior

origin of the arch to the most anterior
ramus of the temporal nerve branch
averages 2.0 cm (Table). This anterior
ramus was never more than 0.3 cm in
front of the anterior notch of the
articular eminence of the zygomatic
arch at its inferior border. The dis¬
tance from a line dropped vertically
from the auricle-scalp point to the
posterior ramus averages 1.8 cm (Fig Fig 6.—Classification of anastomoses of buccal rami. Top left, Buccal-buccal (19%); buccal
3; Table). subdivisions unite. Top right, Zygomatic-buccal (72%); zygomatic and buccal divisions unite.
Without displacing any of the nerve Bottom, Buccal-zygomatic marginal mandibular (9%); marginal mandibular rami join superior
divisions. Circled areas represent buccal nerve (CN-V) or marginal mandibular nerve (CN-VII)
rami, exposure of the temporoman¬ anastomoses with buccal facial nerve rami. Cross-hatching represents buccal fat pad and its
dibular joint is safe as long as any infratemporal extension.
deep incision over the zygomatic arch
does not extend more than 1.0 cm tional anterior subperiosteal eleva¬ rami, surgical dissection for elevation
beyond the posterior edge of the zygo¬ tion and reflection of the lateral tem¬ of a skin flap should be superficial to
matic arch, or the auricle-scalp point. poromandibular ligament. The latter the orbicularis oculi muscle under
This 1.0-cm incision also usually displaces the temporal branch of the which these nerves run.
avoids the superficial temporal ves¬ facial nerve forward and downward The auriculotemporal nerve was
sels. This incision not only provides and actually acts as a protective cush¬ found to send two to four branches to
sufficient room for incising the zygo¬ ion for it during surgery. On the other the facial nerve. Three or four such
matic periosteum but also for addi- hand, to avoid injury to the zygomatic branches were identified in our Davis

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 Fig 7.—Fasciai analysis. Relation of facial nerve to regional fascia in forehead, and temporo-
zygomatic and buccal areas. Section at bottom right shows relationship of buccal nerve branch
to muscular modiolus and buccal fat pad.

types IV, V, and VI patterns. These The facial nerve can be mobilized temporal nerve. The intimate associa¬
complex auriculotemporal nerve rami by cutting the connecting
1.5 to 2.0 cm tion between a neural loop and its
may join the facial nerve at its main rami from the auriculotemporal penetrating vessels, complicated by
trunk, or at its temporal or zygomatic nerve. If the facial nerve is dissected the underlying auriculotemporal
branches. These auriculotemporal within the parotid gland and its adja¬ rami, may produce moderate fixation
rami are grouped into superior and cent areas superiorly, these anasto- of the nerve in some instances. More¬
inferior divisions. The upper division motic rami may be seen by tenting the over, forward dissection of the nerve
is on an average of 2.5 cm (median, 2.5 facial nerve laterally (Fig 5)."° If, in may be difficult because of the trans¬
cm; range, 2.0 to 3.5 cm) below the the surgical approach to the temporo- verse facial vessels that overlie the
superior border of the zygomatic arch, mandibular joint, the facial nerve is nerve distally. Figure 5 shows a nerve
just behind the condylar process of not exposed, the dissection may be loop around the transverse facial ves¬
the mandible. The lower division is on maximized by catting the auriculo¬ sels where the auriculotemporal
an average 3.1 cm (median, 3.3 cm; temporal nerve fibers as they cross branch joins the facial nerve. To pro¬
range, 3.0 to 3.8 cm) below the superi¬ medial to lateral, so that the undis- ceed with the dissection safely, it is
or edge of the zygomatic arch. Its sected facial nerve may be retracted recommended that the superficial
lowest ramus was always found anas¬ 1.0 to 2.0 cm laterally and forward portion of the loop of the nerve be
tomosing with the facial nerve below with minimal tension. dissected forward, and that the ves¬
the take-off of the most posterior Neurovascular loops were often sels be carefully isolated from the
auricular ramus of the temporal found in the complex Davis types, facial nerve before clamping them.
branch of the nerve. The upper auric¬ usually at the upper part of the poste¬ Only thus might the unsuspected deep
ulotemporal rami joined at the zygo¬ rior border of the mandible, where the portion of the loop be recognized.
matic or temporal branches of the facial nerve curves laterally and
facial nerve. The transverse facial and superficially at an acute angle. Unless Mimetic Modiolus
and Buccal Fat Pad
superficial temporal veins and arte¬ dissected carefully, the facial nerve
ries were always found to be looped by was easily subject to injury at the Several muscles of facial expression
the auriculotemporal rami. anastomotic loops with the auriculo- meet at the labiobuccal junction, the

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 modiolus, located approximately 1.0 specimens and may be grouped into ance or strict exposure may prevent
cm posterior to the oral commissure. three types (Fig 6): (1) zygomatic- accidental injury.
In many individuals, this junction buccal (72% ), in which the zygomatic The frontalis and the superior part
produces a dimple with smiling. Ligh- and buccal divisions join; (2) buccal- of the orbicularis oculi muscles may
toller" and others1213 have described buccal type (19%), in which only be mobilized as one unit. This fact can
the variability of the muscles contrib¬ buccal divisions anastomose; and (3) protect the temporal branch of the
uting to the modiolus, such as the buccal-zygomatic-mandibular anasto¬ facial nerve from injury, since it lies
buccinator, orbicularis oris, triangu- moses (9%). This third type is associ¬ deep to these muscles and superficial
laris, caninus, platysma, risorius, and ated with complex Davis branching to the loose subaponeurotic space.
zygomaticus major. The risorius is a patterns. Lightoller" showed that the frontalis
variable muscle that is sometimes Davis, as well as Dingman and muscle has three submuscular fasciai
absent, especially in black individuals. Grabb,6 described a 6% incidence of layers, whereas the temporalis has
It may be formed from the platysma the mandibular branch contributing three supramuscular fasciai layers
or from the zygomaticus major.13 to the labiobuccal area, especially in (Figure 7, A and B). Accordingly, the
Likewise, its nerve supply is variable. the Davis type VI patterns, while Con¬ facial nerve lies superior to the tem¬
Thus, if it is platysmal in origin, this ley14 reported a 12% incidence of man¬ poralis fascia, but deep to the fronta¬
muscle is innervated from the man¬ dibular contribution. In our series, 9% lis fascia.
dibular branch; and, if it originates contributed mandibular rami, one To avoid injury to the facial nerve,
from the zygomaticus major muscle, third of the contributions occurring Pitanguy and Ramos,2 Correia and
it is supplied from the buccal behind the facial vein at the lower one Zani,3 and Gleason16 suggested dis¬
branches of the facial nerve. Our dis¬ third of the buccinator muscle, near secting superficially to the level of the
sections demonstrated this well. its mandibular insertion. In several of facial nerve in the brow, forehead, and
The buccal fat pad has a very thin our Davis type VI specimens, the riso¬ scalp; deep to the frontal branch of
overlying lateral fascia, which may be rius, buccinator, and modiolar mus¬ the superficial temporal vessels; and
contributed to by the risorius or by its cles were innervated by the mandibu¬ subaponeurotic dissection above the
degenerated fasciai remnant. This lar rami or by their anastomoses with temporal vessels. Gleason's16 alopecia
attenuation produces a laxity of fascia the second junction of the buccal complication rate of 10% disclosed the
over the fat pad and minimal protec¬ branch. Davis types IV and V speci¬ risks thus involved. These risks may
tion for the facial nerve. mens send a branch to the buccal be best minimized by staying above
The buccal and zygomatic branches branch proximally near the take-off the deepest layer of temporalis fascia
of the facial nerve were found by of the main mandibular branch. and supraperiosteally below the fron¬
Davis to divide 2.0 cm beyond the The parotid duct was found to be talis and orbicularis oculi muscles.
anterior edge of the parotid gland overlaid with zygomatic rami. The Injury to the facial nerve branches
before supplying the labiobuccal mus¬ duct is displaced anteriorly by the fat near the temporal vessels is more
cles. Davis' classification of facial pad and often must swing anterome- likely, however, since we found great
nerve branching was based on dissec¬ dially to penetrate the junction of the variability to the course of these ves¬
tions up to the anterior border of the upper and middle thirds of the bucci¬ sels in relation to the temporal
masseter and, sometimes, to the buc¬ nator muscle, in order to enter the branches of the facial nerve posterior¬
cal fascia. Our dissections continued buccal cavity. We found the parotid ly. Anteriorly, the facial nerve
under the labiobuccal muscles to the duct to dip medially 0.5 to 1.0 cm branches to the frontalis muscle
deep aspect of the buccinator muscle anteriorly to the masseter muscle. assumed a deep relationship to the
below the facial artery and vein. The buccal nerve (CNVV) sends rami temporal vessels; however, the nerve
Because of this extended dissection, to anastomose with the facial nerve branches to the superolateral part of
analysis of our dissections disclosed a deep to the modiolar area and the the frontalis and to the auricular
persistent double-junction anasto- anterior buccal space (Fig 7, D). The muscles were posterior to the tempo¬
motic pattern (Fig 6). The first branch buccal nerve passes under the facial ral vessels. This may be explained by
occurs at the posterior aspect of the vein and gives off three to four the fact that superolaterally, adjacent
buccal fat pad, anterior to the masse¬ branches that ramify with the facial to the coronal suture line, the fronta¬
ter muscle. The second branching nerve, two thirds anterior to the facial lis muscle extends to a higher level
anastomosis lies under the modiolus vein, and one third above and posteri¬ and its nerve supply must therefore
and overlaps the anterior aspect of or to the vein. All of these rami join follow.
the buccal fat pad. Contributions from the facial nerve below the level of the Inferior to the zygoma, the subcuta¬
the zygomatic branch of the nerve oral commissure. neous panniculus adiposus becomes
descend downward, while the buccal thicker, with looser fibrous septal
branches cross transversely or up¬ Fasciai Analysis connections to the parotideomasseter-
ward. These junctions lie within the Figure 7 demonstrates the impor¬ ic fascia (Fig 7, C). The facial nerve is
buccal fascia and/or under the mimet¬ tance of regional fasciai analysis.15 safe within the parotid gland if dis¬
ic perimysium. This double-junction Based on this knowledge, protection of section is superficial to this thick fas¬
configuration was found in all of our the facial nerve by means of avoid- cia. However, the supra-aponeurotic

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 fascia and nerve unit between the to cause facial weakness or even 3. The posterior rami of the tempo¬
scalp over the superior one half of the paralysis. The generous nerve anasto¬ ral branch of the facial nerve are
temporal fossa and the parotideomas- mosis in this area may preclude com¬ variable and sometimes contribute to
seteric fascia is a site for easy injury plete paralysis, but partial facial the frontalis muscle.
to the facial nerve, especially over the asymmetry on intense emotion is a 4. The temporal rami overlie the
thin area above the zygomatic arch, possible complication. articular eminence of the zygomatic
where the four rami of the temporal arch and never extend anterior to the
branch of the facial nerve have yet to CONCLUSIONS articular eminence more than 0.5 cm.
anastomose superficially in the tem¬ This report, based on careful and 5. The facial nerve may be mobi¬
poral fossa. precise dissection of 35 adult cadaver lized 1.0 to 2.0 cm laterally by cutting
Our dissections again pointed to the half heads, has shown the following: the auriculotemporal nerve rami to
weak fascia and muscle overlying the 1. The temporal branch of the the facial nerve within or medial to
buccal space in white subjects. There facial nerve lies within an area the parotid gland.
are individuals who advocate buccal bounded by a line from the earlobe to 6. The facial nerve has a double-
fat excision in certain patients having the lateral edge of the eyebrow inferi¬ branching anastomotic pattern over¬
face-lifts. However, it is almost orly and a second line from the tragus lying the buccal fat pad.
impossible to bluntly dissect the buc¬ to the lateral coronal suture just 7. The mandibular branch of the
cal fat without traumatizing the above and behind the highest fore¬ facial nerve contributed to the buccal
facial nerve branches, which begin head crease. anastomosis in 9% of our specimens.
their first main junctional anastomo¬ 2. The temporofrontal branches of 8. Knowledge of the aforemen¬
sis between the buccal fat pad and the the superficial temporal vessels mark tioned and of the regional fasciai
muscular layer (Fig 7, D). Trimming the posterior boundary of the tempo¬ anatomy should help to protect the
fat, with the possiblity of including ral branches of the facial nerve in the facial nerve from surgical injury.
adjacent nerve branches, seems likely temporal fossa.

References

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