Facial Danger Zones

FmiuCPhtic Surgey
a Facial Danger Zones
J
Avoiding Nerve Injury in
~ a c i a~l l h r t i Surgery
c

Brooke R. Secliel, M.D.

Chairman
Department of Plastic and Reconstructive Surgery
Lahey Clinic Medical Center
Burlington, Massachusetts
Assistant Professor of Surgery
Harvard Medical School
Boston, Massachusetts

ILLUSTRATOR
Anne Beard Greene

Quahty Medical Publishing, Inc.

St. Louis, Missouri 1994
Copyrrght O 1994 by Quality Medical Publishing, Inc.

All rights reserved. Reproduction of the material herein in any form

requires the written permission of the publisher.
Printed in the United States of America.

PUBLISHER Karen Berger

PROJECTW A G E R Carolita Deter
PRODUCTION Susan Trail
BOOK DEIW Susan Trail
Diane M. Beasley
COYER D ~ I C ~ N

Quality Medical Publishing, Inc.

11970 Borrnan Drive, Suite 222
St. Louis, Missouri 63146

LIBRARY OF CONGRESS CATALOGING-tb-PUBLICKlTONDATA

Seckel, Brooke R.
Facial danger zones : avoiding nerve injury in Eacial plastic
surgery / Brooke R Seckel ;illustrator, Anne Greene.
p. Un.
Indudes bibliographical references and index.
ISBN 0-942219-59-7
1.Faceljfc-Complications-Prwention-Atlases. 2. Facial nerve-
Wounds and injurie-Prevention-Atlases. I. Title.
RD119.5.F33S43 1994
617.5'20592-dc20 93-39123
cn'
my d e Debbie
my daughter Laura and
my son Tommy
who are my ultimate joy in life
 Preface
This book is the outgrowth ofan invita-
tion by A Lee Delion, M.D., to partidpak
in a panel discussion entided ?Don't h e
Your Nerve" held at athe 1992 Annual Scien-
tific Meeting of the American Society of
Plastic and Reco~~~mcdve Surgeons in
Washinpn, D.C. I was asked to speak on
nerve injuries in aesthetic plastic surgery.
A review of the literam sdmulad fkther
interat and ultimately led to cadaver dissec-
tiom in the hbramry and exploration in the
operating xocrm in preparation for the panel.
I b e p to review not only nave injuries but
aIso the anatomic loations of the most m-
ceptible n m regions and analyx dissection
techniques to avoid injuries.
Because I b e bard certification in
neurology as well as plastic s-xy, it is not
u n d that 1 am asked to*evaluatepatients
by my plastic surgery colleagues when facial
nerve injury accm in h e course ofrhfidec-
m y surgery. I had not seen such a facial
nerve i n j q ptient for some time when,
w i d i n the span of 1 month, I was asked to
consult on three patients who had suffered
ficial m e injury during rhytideaomy.
Fortunately, d-iefirst patient had a neuro-
praxic marginal mandibular injury; however,
the next two patients had buccd and qgu-
matic branch injuries, the first two injuries of
this type I had ever seen following rhytidec-
tomy. Interestingly, both-of patients
offered the information that they had had
"composite" face lifts.When I spoke with
their surgeons, it became apparent that both
had performed extensive midface correction
using sub-submuscular aponeurotic system
dissection in the cheek area.
These latter two cases, followed by tele-
phone consultation on a third similar case,
suggested that perhaps the newer, more
extended fice-lift techniques were resulting
in more facial newe injuries. This convinced
me that this subject should be brought to the
attention of a wider audience. I therefore
approached Karen Berger with the idea of
publishing a small atlas on what I term
"facial danger zones."
I have organized the book by arbitrarily
assigning numbers in the order in which I
enter the various danger zones in the course
of face-Mi surgery; that is to say, the first
danger zone I see during dissec~onis danger
zone one followed by two, three, four, five,
six, and seven.
Out of respect for the privacy of the pa-
tients and their referring physicians, I decided
against using photographs of patients with
 Preface ~ t i ~ ~ d
facial nerve injuries. Anne Greene's drawings
depict the clinical findings in such detail that
one can easily diagnose a dinical injury from
the illustrations reproduced in the book.
Finally, major advances in the surgical
techniques for facid aging have occurred
in the past 10 years, especially with the re-
cent evolution of techniques to correct mid-
face aging. Such improvements, however,
come at the expense of safety in my opinion.
Although optimal results are desirable, these
newer advanced techniques require that
particular attention be paid to the peripheral
nerve anatomy of the face. We as plastic
surgeons must, as always, keep our patient's
safety as our first and foremost consider-
ation. Careful attention to the facial danger
zones will serve all those who perform the
newer techniques and particularly the resi-
dents and young plastic surgeons who wiU
extend and improve on these observations.
Emoh R GchI, X D .
 As all who write are keenly aware, the
publishing of a book is possible only with the
help of many people. The fact that the au-
thor's name appears on the cover of the book
in no way implies entire responsibility for its
contents. Such is the case with this book, for
many people have worked hard to bring it to
fruition.
For the past 12 years Anne Beard Greene
has translated my thoughts and words into
pictures. Her superb artistic contribution
represents a major portion ofthis book. Not
only is Anne a skilled medical artist, she is
also a learned anatomist and neuroscientist
who carefully and fastidiously researches her
drawings. She is not content to accept my
word as to the location of a nerve or vessel,
but she insists on viewing the disseaion and
checking the literature herself. Time and
again Anne has been an invaluable colleague
in all of my publishing efforts.
I owe a great debt to my predecessors
on the surgical s t a f f of the Lahey Clinic who
have set the high standards that challenge
all of us who are fortunate enough m prac-
tice surgery here. Their legacy includes the
superb editorial, medical photography, and
medical art departments under the direction
of Polly Zarolow, Rich Chevalier, and Jim
MiLlerick, respectively. These departments are
a major cornerstone on which the reputation
of Lahey Clinic is built. I gratefully acknowl-
edge the permission of Lahey Clinic to use
the copyrighted artwork in this volume.
I am truly blessed to have a warm,
caring, and competent staff. Without: them,
I could not possibly maintain a busy practice
and residency &g program in addition
to performing research and writing. My re-
search and training coordinator, Christine
Antonellis, has spent innumerable hours
helping me write and rewrite, always with
enthusiasm and a bright smile. My secretary,
Kerry Duprez; physician assistant, Lorim
Herrick; nurse, Lori Watson; assistant, Sloan
Shaunessy; and administrator, Christine
White, keep my practice running smoothly
and provide skillful and supportive patient
care. Dimitria ChakaIisj my former scrub
nurse and currently the director of our plas-
tic surgery research laboratory, handles much
of the administrative and technical details
in running our research program. My very
competent:and able surgical assistant, Lisa
Pappalardo, ensures that: operations run
smoothly. Without the expert assistance of
these people, time would not permit other
interests such as writing. My residents,
Dr. Patricia Eby and Dr. Bill Holmes, have
been of immeasurable help in performing
cadaver dissections to clarify many of the
anatomic points discussed in this book. I a m
indebted and feel most fortunate to have the
assistance of these professionals.
Karen Berger and the staff at Quality
Medical Publishing, pardcularIy Carolita
Deter, Susan Trail, Cindy Lia, Mary Stueck,
Linda Kocher, and Diane Beasley, have
brought this book to publication in a most
expeditious fashion and have been delightful
to work with. I am most impressed by their
competence, professionalism, and high stan-
dards.
Obviously, without the love and supprt
of my wife Debbie and children Laura and
Tommy, I would not have had the energy,
enthusiasm, and peace of mind to devote
myself fully to this project.
 Contents

Introduction ........................................................... 1
Facial Danger Zone 1 ................................................ - 4
2 ....................................... .........12
3 ............................................... 18

7 ............................................... 44
Condusion ................................................................ 48
References ............................................................... 49
ndex ......................................................................... 51
 With today's more aggressive and deeper facial dis-
section in h e course of face-lift surgery,'-" the periph-
eral nerves of the face are more often exposed, lie doser
to the plane of dissection, and in my opinion are more
likely to be injured. Injury to one of the major facial
nerve branches creates a catastrophic an$ occasionally
irreversible facial deformity. Even patients who do
recover muscle function following injury are often left
with permanent i n v o l u n q muscle twitching or distor-
tion of the facies by contractwe and shortening of par-
tially denervated muscles. Additionally, interruption of
one of the major sensory nerves in the face can result in
permanent disability secondary to numbness or, worse,
intractable dysesthesia and pain. Thus a keen and thor-
ough understanding of the location of these nerves is of
paramount importance if injury is to be avoided.
 I have arbitrarily divided the face into seven facial
danger zones based on known anatomic locations of the
Introductw n continued
branches of the peripheral nerves of the face and the
sites where they are most susceptible to injury in the
course of facial dissection (Figs. A and B). Each of these
facial danger zones will be discussed individually with
regard to the nerve and consequence of injury, the ana-
tomic borders of the facial danger zone, and the tech-
niques for safe surgical dissection. Although the branch-
ing patterns of the nerves, particularly of the facial
nerve, may vary from individual to indrvidual, only the
most common patterns are shown in this text; the
boundaries of the danger zones include these variations.

Facial Relationship Sign of

Danger Zone Laation Nerve to SMAS Zonal Injury

6.5 un below external auditory Great auricular Posterior to Numbness of inferior

canal two thirds of ear
and adjacent cheek
and neck
Below a line drawn from 0.5 cm Temporal branch Beneath Paralysis of forehead
below m a p to 2 cm above of facial
lateral eyebrow and above
zYgoma
Midmandble 2 cm posterior to Marginal mandbu- Beneath Paralysis of lower lip
oral commissure lar branch of facial
Triangle formed by connecting Zygomatic and Beneath Paralysis of upper lip
dots on malar eminence, posk- buccal branches of and cheek
rior border of mandibular angle, facial
and oral cornmissure
Superior orbital rim above Supraorbital and Anterior to Numbness of fore-
midpupil suprandear head, upper eyelid,
nasal dorsum, scalp
1an below inferior orbital rim lnfraorbitd Anterior to Numbness of side of
below midpupil upper nose, cheek,
upper lip, lower eyelid
Midmandible below second Mmtd Anterior M Numbness of half of
premolar lower lip and chin
SMAS = submuscular aponeurotic system.
F&*a
External topographic outlines of
rhe seven facial danger zones.

Underlying nerves running through

each facial danger zone after the
slun and SMAS layer have beea
removed.
 IS, Newe and 1 includes the area in which the
Consequence of Injury great auricular nerve emerges from beneath the sterno-
cleidomastoid muscle, becomes more superficial, and is
thus most susceptible to injury. Permanent injury to this
nerve results in numbness of or,in the case of a neu-
roma, painfuI dysesthesia of the lower two thirds of the
ear and adjacent neck and cheek skin (Fig. 1A). Another
unusual but troublesome syndrome is that caused by
compression of the nerve by a nonabsorbable suture
used to plicate the platysma-SMAS to the mastoid fascia.
This can result in painfuI dysesthesia of the ear, which
can be induced by tapping the nerve at the point of
compression.
Facial danger zone 1 injury. Shaded areas repre-
sent sensory loss or dysesthesia following injury to
the great auricular nerve.
Anatomic Location Facial danger zone 1 (Fig. 1B) is best located by
first identifying the point described by McICinney and
ICatrana.I4 The patient's head is turned to the opposite
side, the stemodeidomastoid muscle is palpated, and a
straight line is dropped from the caudal edge of the
external auditory canal to a point 6.5 cm below on the
midpoint of the muscle belly. I arbitrarily define zone 1
as the area described by a circle with a radius of 3 cm
drawn around this point that includes the point of
emergence of the great auricular nerve from beneath
the sternocleidomastoid muscle at 9 cm below the exter-
nal auditory canal (Fig. 1C). The lesser occipital nerve
emerges higher and stays dong the posterior edge of
the muscle belly.
Facial danger zone 1 is centered
around a point in the middle ofthe
sternocleidomastoid musde M y
6.5 an below the mudal edge of
the external auditorv canal.

n radius of 3 cm is wed to include

the point ofemergence of the nerve
from benmth the sternodeidomas-
mid muscle, whlch is found 9 un
below the exremal auditory canal.
Surgical Dissection After the postauricular incision is made, it is helpfill
to begin the dissection superficially, just deep to the
subcutaneous fat, which is thin and superficial to the
deep cervical fascia and the sternocleidomastoid muscle.
The nerve is posterior to and superficial to the platysma-
SMAS at this point (Fig. 1D).When the ear Iobule is
pulled forward, one or two tiny postauricular branches
of the great auricular nerve can often be seen (Fig. 1E).
Identification of these branches helps establish the
proper plane for dissection inferiorly over the deep
cervical fascia and the sternocleidomastoid muscle.
 Temporal Ban&
nf racl-r Y , .'

Note that the great auricular nerve

is posterior to and not protected by
the platysrna-SMAS layer through
most of its course.

During dissection, pdmg on the

ear lobule anteriorly reveals small
terminal p ~ u r i c d a branches
r of
the great auricular nerve and pro-
Postauricular Branches
of Great Auricular N.
' vides an important due to the
proper plane of &ssection in this
External Jugular U
/ area.

Stsrnocleldomaatold M.
I
Suyicd%section Another useful anatomic relationship is the external
continued jugular vein and the great auricular nerve. When the
neck flap is dissected off the sternocleidomastoid and
platysma muscles, the location of the external jugular
vein is observed by first noting its location on the skin
surface and watching for a blue shadow anterior to the
sternocleidomastoid muscle beneath the skin flap. The
great auricular nerve will be 0.5 to 1 cm pos~eriorto the
vein at the point where the vein comes into view dur-
ing dissection (see Fig. 1E). When the pIatysrna-SMAS
layer is plicated or suz-ured to the mastoid fascia, the
newe should not be compressed by the suture. Rather
the platysma-SMAS must cover and protect: the nerve
(Fig. IF). Direct contact between suture and nerve can
create a painful compressive neuropathy of the great
auricular newe . Hamra11J2does not include plication
sutures behind the ear lobule in his composite rhytldec-
tomy technique. He tightens the platysma-SMAS in the
cheek anterior to the nerve and by excision and repair
of the platysma bands. Thus, if his technique is followed
meticulously, there should be no risk of compression of
the great auricular nerve by suture plication (Fig. 1G).
F- 1F
When the platysma-SMAS layer
is plicated to the mastoid fascia be-
hind the ear, it must be folded over
the nerve and the suture must not
\
touch or compress the nerve.

Fb. 1s
When the platysrna-SMAS is
plicated in the chgek and anterior
neck, elirmnating the need for pos-
terior plication over the mastoid
area, a possible compmsive n w -
ropathy of the great auricular nerve
is avoided.
Facial Danger Zone 2

B e Neme and Facial danger zone 2 includes the area where the
Consequence of Injuy temporal branch of the facial nerve runs under the tern-
poroparietd fascia-SMAS Iayer>15 having emerged from
beneath the parotid gland at the level of the zygoma on
its way to innervate the frontalis muscle in the forehead.
Injury to the temporal branch results in paralysis of the
frontalis muscle. Typically, orbidaris oculi function is
spared following temporal branch injury as the muscle
receives dual innervation in the form of a second nerve
supply coming from the zygomatic branches inferiorly.
Clinically, the involved side of the forehead becomes
paralyzed, with resultant ptosis of the brow, asymmetry
of the eyebrows, and an asymmetric lack of animation
on that side of the forehead (Fig. 2A).
 Facial danger zone 2 injury. The right temporal
branch of the facial nerve is damaged, resulting in
paralysis of the right frontah muscle that creates
Zone 2 a characteristic facies with unilateral brow ptosis
and asymmetric lack of animation of the involved
side of the forehead.
Temporal
Branch ol
Faci I N.
P
 Facid danger zone 2 is best localized by drawing
a line from a point 0.5 an below the t r a p to a point
2 cm above the lateral eyebrow.16,17 A second line is
drawn along the zygoma to the lateral orbital rim.
A third line is then dropped from the point above the
eyebrow through the lateral end of the eyebrow to the
zygoma. These three lines define a triangle (Figs. 2B
and 2C) in which the temporal branch ofthe facial
nerve lies on the undersurface of the temporoparietai
fascia-SMAS layer and is more likely to be injured.
Facial danger zone 2 is outlined by
drawing a h e 0.5 m below the
t r a p to a point 2 crn above the
lateral eyebrow, drawing a second
line on the zygoma to the lateral
orbital rim, and connecting these
two lines with a third line.

F&. 2C
Course of the temporal branch of
the facial nerve above the zygoma.
 The temporal branch of the facial nerve emerges
from beneath the parotid gland to run on the under-
surface of the temporoparietal fascia-SMAS layer. Thus
dissection may be carried out deep to the temporopari-
eta1 fascia-SMAS layer or judiciously subcutaneously
above his layer but not immediately beneath the tern-
poroparietal fascia-SMAS layer. Safe dissection in facial
danger zone 2 requires that the surgeon develop a
ccmesotemporalis,"as described by Marino.18
This plane is developed by dissecting the subtem-
poroparietal fascia-SMAS layer from the scalp toward
the supraorbital rim down to the level of the zygoma
and hssecting the supra-SMAS layer subcutaneously in
the cheek from the mandibular ramus up to the zygoma
(Fig. 2D). The point at which these two planes meet
reveals the SMAS layer, or mesotemporalis, in which
the temporal branch of the facial nerve resides and this
branch can, on occasion, be seen running just inferior
to the frontal branch of the superficial tempord artery.
Exposure and identification of the mesotemporalis will
help avoid injury to this nerve.
In subperiosteal rhytidectomy or other procedures
in which tissues are to be elevated from their attachment
to the zygoma, the superficial layer of the deep temporal
fascia can be incised to enter the superficial temporal
fat pad within this space, and dissection can proceed
inferiorly and anteriorly with less chance of injuring the
frontal b r a n ~ h ~(Fig.
y ~ ~2E).
~

& for anterior dissection beneath the
LOO^^ Arsolar Tisaus
'smporo-parietal Famcla
(SM~S)
ssp Temporal Fascia:
Supsrficlal Lever
~tmp Layer
rontal Branch 01
Supsrficisl Temporal A
ramporal Branch of Facial N.
I -2ygomatic Arch
Surgical exposure of the meso-
temporalls conraining the temporal
branch of the facial nerve during
the course of rhytidectomy and
coronal brow lift. The scissors are
deep to the superficial layer of the
deep temporal fascia, a safe plane
temporal branch. The supeficial
temporal fat pad is a useful land-
mark in determining the proper
plant.9
Cross section through facial dan-
ger zone 2 showing the temporal
branch of the facial nerve and the
frontal branches of the superficial
ternpod artery on the undersur-
face of the ternproparid fmia-
SMAS layer. Note the superficial
temporal fat pad beneath the super-
ficial layer of the deep temporal
fascia. Thls plane can be dissected
to elevate the SMAS off the zygo-
ma without injuring the tmnp0rd
branch of the faaal nerve.
Facia6 Dander Zone 3

17ie Neme and Facial danger zone 3 includes the marginal mandib-
Consequence of Injury ular branch of the facial nerve at a point in its course
where it is most vulnerable anteriorly as the platysrna-
SMAS layer thins and the nerve courses superiorly to
innervate the depressor an@ Injury
oris rnu~cle.~~J~
to this nerve creates a noticeable and extremely distress-
ing deformity, especially when the patient smiles. Dur-
ing grimacing the denervated depressor an& oris mus-
cle cannot pull the corner of the mouth and lower lip
down, resdting in an inability to show the lower teeth
on the affected side (Flg. 3A). At rest the tone in the
normally innervated zygomaticus muscles is unopposed
because the denervated depressor angdi oris muscle
lacks tone, and the corner of the mouth is p d e d up so
that at rest the lower lip rides high over the teeth in a
unilateral "pout. "
 This patient, who has a right marginal mandibular
branch injury, is grimacing in an attempt to show
the lower teeth. The right lower lip rides up over
the lower teeth and cannot be pulled down. Be

r-
certain the patient is not contracting the plarysma
Zone 3
muscle, whch in some cases assists the depressor
an& oris musde in pulling the lip inferiorly.

Marginal
/
Mandibular
Branch of
Faclal N.
anatomic Location Facial danger zone 3 is best described by drawing
a point on the middle of the mandibular body 2 cm
posterior to the oral cornrnissure and drawing a circle
with a radius of 2 crn around this pointz1J2(Fig. 3B).
This process defines a circular area, facial danger zone 3,
in which the platysma-SMAS thins, exposing the mar-
ginal mandibular branch to injury. The anterior facial
artery and vein also cross this zone and are susceptible
to injury (Fig. 3C).
 ?F
$ .-<:
. +
&&. 3 8
2.0 crn @ Facial danger zone 3 is defined by
i a point drawn on the midmandible
at a leveI 2 un posterior to the oral
cornmisswe and a circle drawn
with a r d u s of 2 cm around this
point.

Fi.3C
Note the proximiry of the anterior
facial artery and vkn to the mar-
grnal mandbular branch of the
facial nerve, which easily explains
the injury to this nerve seen after
attempting to cauterize a bleechg
vt ~
M. ~ ~ ~ *
point in these vessels. Facial danger

t-
, \Uargmal Mandibular
Branch of Farlal N. zone 3 includes the rnatginal man-
dibular branch of the facial nerve.
' ~ a c l a l ".+A.
 Injury to the nerve in facial danger zone 3 occurs
most commonly during the course of subcutaneous dis-
section in this area either from above beneath the cheek
flap or from below through a submental incision, typi-
cally when trying to develop a communication between
these two areas to permit smooth redraping of skin
along the inferior mandibular border.
The marginal mandibular branch of the facial nerve
in facial danger zone 3 can be injured easily by the elec-
trocautery while attempting to control bleeding from
the facial vein or less often from the facial artery. The
facial artery and vein lie immediately medial (deep) and
adjacent to the marginal mandibular branch of the facial
nerve; therefore the electrocautery current can be con-
ducted to the nerve, causing damage (Fig. 3D).
Thus adequate lighting and good retraction are
needed to ensure accurate visualization of any bleeding
vessel so that the nerve is not injured during ligation or
cautery.
Posterior to the facial artery and vein the platysma-
SMAS layer is thicker, which provides greater protection
for the marginal mandibular branch of the facial nerve
during dissection in the subcutaneous plane. During
composite rhpdectomy or an extended SMAS dissec-
tion, one has to keep the subplatysma-SMAS dissection
superior to the mandible and use direct vision to avoid
injuring the marginal mandibular branch of the facial
nerve (see Figs. 4F and 4G).
 Cross-section4 view through facial
danger zone 3 showing the margi-
Mandible nal mandrbdar branch of the facial
nerve running adjacent and super-
ficial to the facial artery and vein.
Note the thinning of
SMAS layer near its inse
the depressor anguh oris
and thus the loss of promuon
Pmrotld Bland the nerve, artery, and vein.
I

Yarglnml Mandibular
Branch or Faclal N.
parotld Fascia (SMAS)
Facial Danger Zone 4

Facial danger zone 4 indudes the zygomatic and

buccal branches of the facial nerve, which are superficial
to and r a t on Bichat's fat pad. Injury to these nerves
can result in paralysis of the zygomaticus major and
minor muscles and levator labii superioris alaeque nasi
muscle, causing the upper lip and oral cornmissure on
the affected side to sag. Sagging of the upper lip on the
affected side creates considerable asymmetry at rest. The
deformity is most apparent, however, when the patient
smiles. The unopposed action of the normal zygomati-
cus major and minor muscles on the opposite side pulls
the mouth toward the normal side and creates a dis-
torted appearance (Fig. 4A).
Fortunately, the zygomatic and buccal branches
interconnect freely; thus paralysis is usually not perma-
nent, although many patients have a permanent involun-
tary twitch or contraction of the affected muscle follow-
ing partial nerve injury. Permanent paralysis of these
muscles can occur, however, and when it does, the
deformity is severe and d i f f ~ dtto correct.
 F-&.4A
Facial danger zone 4 injury. When the patient
smiles, the paralyzed right side ofthe mouth does
not elevate. To many people the normal con-
tracting side looks distorted and the lay person
would assume that the a b n o d t y was on the
left side when, in fact, the a b n o d t y is on the
right side.

Branches
of Facial
 Facial danger zone 4 is located deep to the phtysma-
S W S and parotid f a c i a and should be at: risk only dur-
ing composite rhyttdectomy and extended sub-SMAS
dissection in the cheek. This space is triangular and is
anterior to the parotid gland, superior to the mandibular
body, posterior to the zygomaticus major muscle, and
superficial to the masseter muscle and Bichafs fat pad.
Preoperatively, this zone can be estimated by pal-
pating the highest point of the rnalar eminence md the
posterior border of the mandibular angle and by placing
a dot over each of these two bony points and a third
dot over the oral commissure. A triangle is then drawn
connecting these three dots and defining a triangular
space bordered anteriorly by the zygomaticus major
muscle, inferiorly by the mandible, and posteriorly by
the parotid gland (Figs. 443 and 4C).

7 ~ l e h a t ' s Fat Pad
Jucgrl Bmmhml 01FOUI=I
'Pmmtid Ouct
Maasstor
Fb, 4B
Facial danger zone 4 is deep to the
parotid fka-SMAS. It may be
outlined by placing a mark on the
highest point of the mdar emi-
nence, another on the mandibular
angle, and a thitd mark at the oral
commissure. These three marks are
conneed to form a triangle.
Facial danger zone 4 is bounded
by the parotid gland, zygomaticus
major muscle, and mandible and
includes the zygornatic and buccal A
branches of tbe fiual nerve as well
as the parotid duct and the branches
of the facial artery and vein. Nore
u. that the m a r g d mandibular branch
passes bri* through the inferior
portion of facial danger zone 4.
27
Anatomic Locution Our cadaver dissections reveal that facial danger
continued zone 4 is the area in which the zygomatic and buccal
branches and parotid duct are no longer protected by
the parotid gland and thus are more susceptible to
i n j W 3 (Figs. 413 and 4E).

Injury to the zygomatic and buccal branches should

occur only when the plane of dissection is beneath the
SMAS. Thus this type of injury would typicdy occur
only in the more invasive face-lift procedures such as
extended sub-SMAS or composite rhytldectorny11J2
techniques. In the typical subcutaneous face-lift dissec-
tion these nerve branches remain protected by the
SMAS and should not be subject to injury.
Cadaver dissection of facial danger
zone 4 with slun removed from
cheek and SMAS layer left intact.

The SMAS layer has been dissected

off ficid danger zone 4 and the
buccat and zygomatic facial nerve
branches marked with india ink
Note that the parotid gland is the
posterior border of facial danger
zone 4.
Surgical Dissection The deeper sub-SMAS rhytideaomy procedures can,
continud however, t x pehnned with minimat risk of injury to
the zygomatic and buccal branches. The b e d SMAS
and parotid fascia layer is incised below the zygoma and
in front ofthe ear and is carefdy dissected as a unit off
the parotid gland (Fig. &). In composite rhytidectomy
the SMAS incision is made anterior to the parotid and
the platysma-SMAS branches are elevated using the
vehcal. spreadq te&nique1lJ2(Fig. 4G). This latter
maneuver is probably best left to more experienced sur-
I geons since too deep an initial incision could cause a
zone 4 nerve injury.
With either technique, as the &seaion reaches the
anmior border of the parotid gland, the scissors can be
turned in a gentle vertical spreadq motion to &sect
the SMAS carefully off the zygomatic and buccal neme
branches, masseter muscle, parotid d q and Bichat's fat
pad. h the anterior segment of hcid danger zone 4 the
lama1 portion of the zygomaticus major muscle comes
inm view.The zygomatic branches are most superficial
just before running underneath the superior portion of
the zygomaticus major muscle near the muscle's origin
from the zygoma, and injury is most likely to occur
here. In most patients a small branch from the superior
ramus of the zygomsttic branch rum above the zyp-
maticus major muscle to innervate h e inferior portion
of the orbidark oculi.
 A$-*/Biehst's Fat Pad
Zygomatlcus Yalor Y.
Zmrnatle Branch-
,

BYAS- Platymma

c I
F&. 4F
Surgical exposure of G a l danger -
zone 4. Note the lateral border of
the zygomaticus major muscIe near
its o r i p from the malar eminence
and the dangerously superfid
course of the zygomatic branches
before their innervation of this
muscle.

Zygomatlc Branch 01 Faclal N.

\

Temporal Brmneh

The exposure during composite

rhpdectomy is shown in which the
6uccai Branch orbicularis dmusde is elevated
as well as the platysma muscle,
creating a bipedide musculocuta-
neous flap. l1 Note that the parotid
fascia-SMAS is incised along the
anterior lmrder of the parotid,
which involves a greater risk in
terms of buccal and zygomaac
branch injuries than incision of the
parotid fascia more posteriorly.
I
Marginal Mandibular
., Branch 01 Facial H.
Surgical Bisection This small branch is easily disrupted in the course
continued of dissection in facial danger zone 4. However, the
orbicularis oculi muscle receives innervation from the
temporal branch of the facial nerve as well; thus com-
plete orbicularis oculi palsy is unusual. Typically, full
orbicularis muli palsy is only seen in patients with total
proximal facial nerve lesions such as occur following
section of the facial nerve trunk in the: facid canal during
removal of an acoustic neuroma. Barton13and Hamra"
recommend piercing the platysma-SMAS at the lateral
border of the zygomaticus major muscle to carry the
dissection into the subcutaneous plane superficial to the
muscle to disrupt the connections of the SMAS to the
nasolabial fold and to free the ptotic cheek fat pad for
redraping superiorly and laterally (Figs. 4H and 41).
This maneuver must be performed carefully under direa
vision because dissection beneath the zygomaticus major
muscle near its origin can easily injure the zygomatic
branches of the facial nerve.
Facial danger zone 4 can be entered safely, however,
with careful. dissection under direa vision. Blind dssec-
tion, forcell or injudicious sharp dissection, and blind
use of the electrocautery are to be avoided in this area.
Failure to observe these guidelines may result in paraly-
sis of the upper lip, a potentially debilitating complica-
tion.
 Cross section through the cheek
fat pad demonsmting why dis-
section from the sub-SMAS loca-
Naaolsbiml F O I ~ tion has to be directed superficially
through the SMAS on top of the
zygomaticus major and minor mu-
-Z ~ g o m a t l ~ u a
Mlnor M. des so that the fat pad can be re-

I Zygomaticus
Malor M.
draped superiorly and laterally to
correct ptosis of the malar fat pad.
Redrapq could also be a c h w d
- cheek Fat Pad using only a subcumneous dissec-
tion, but all attachments to the
nasolabial fold must be disruptd.

Cross section through ficiaI danger

zone 4 showing the relation of the
platysma-SMAS, parotid Eascia,
buccal branches of the facial nerve,
Ytarssmr M. and facial artery and vein.
I Faclal V.+A.

I 6 u c ~ a lBranch
Platysma-SMAS of Faclal N.
FaciaC Danger Zone 5'

me %erne and FaciaI danger zone 5 includes both the supraorbital

Consequence of Injury and supratrochlear nerves, which are branches of the
first division of the trigeminal nerve (cranial nerve V) .
Both of these nerves are susceptible to injury as they
emerge from the bony foramina where they are more
adherent and less easily moved or stretched.
Although the supraorbital nerve courses deep to
the corngator muscle, the supratrochlear nerve actually
courses through the muscle. One can readily see that: the
supratrochlear nerve can be easily cut during section of
the cormgator muscle, a common treatment for "frown
lines" during h e course of a coronal brow lift. Injury
to these nerves results in numbness or, in the case of a
neuroma, painfui dysesthesia of the medial forehead,
scalp, upper eyelid, and nasal dorsum3 (Fig. 5A).
 F&.5A
Danger zone 5 injury creates numbness of the
upper eyelid and forehead in the supratrochlear
and supraorbid nerve btribution.
Zone 5
 Facial danger zone 5 is best localtzed by identifying
the supraorbital foramen, which can be palpated along
the supraorbital rim, usually directly above the
midpupilZ2(Figs. 5 B and 5C). After this point has been
marked, a circle with a radius of 1.5 cm is drawn around
the point. This circle defines facial danger zone 5 and
encompasses both the supratrochlear and supraorbital
nerves. When a vertical line is dropped through the
supraorbital foramen, the midpupil, and down to the
second manhbular premolar, a line can be drawn
through the infraorbital and mental foramina, making
subsequent localization of facial danger zones 6 and 7
much easier.22
 Frontalle M. -
Supraorbital M
-.
Supratrochlsar H.-
Facial danger zone 5.The supraor-
b i d foramen is palpated, and a line
Procerua M.-
Corrugator H.- is dropped through the midpupil
and the second mmdbular pm-
molar. This line will run through or
near the supraorbital, mfraorbiml,
and mental foramina.20Facial danger
zone 5 is defined by a circle with a
radus of 1.5 cm drawn around the
supraorbital foramen.

- Frontalis M.

- Supretrochlssr N.
erus N.
rugator M.
bicularis Ocull Y.

F&. 5C
Lateral view of facial danger zone 5.
 hjury to the supratrochlear and supraorbital nerves
within facial danger zone 5 occurs typically when a
coronal brow lift is performed either alone or in con-
junction with a lower face lift. When the coronal brow
flap is dissected, the subtemporoparietal fascia-SMAS
or supraperiosteal plane is entered and the coronal flap
is turned down using either the electrocautery or sharp
dissection.
The surgeon must obsenre the undersurface of the
coronal brow flap (i.e., the undersurface of the tern-
poroparietal fascia-SMAS layer in this region) for the
supraorbital nerve and the accompanying vascular pedi-
cle. This nerve and vascular pedicle are prominent at,
about the junction between the lateral third and the
middle third of the coronal brow flap (Fig. 5D). As the
dissection approaches the supraorbital rim, the surgeon
must be carefid not to injure these nerves as they exit
their respective foramina. Furthermore, when excising
a thin layer of frontalis muscle during the course of
dissection, the surgeon should attempt to leave a small
island of temporoparietal fascia-SMAS and frontalis
muscle with. the accompanying nerve and vessel intact at
the junction of the lateral and medial third of tke coro-
nal flap on each side.
Only the SMAS and frontalis muscle should be ex-
cised. Removal of any of the subcutaneous fat from this
region will resdt in a serious contour deformity. For
this reason, many authors only score the undersurface of
 Corrugator I
f-ipratrochlear N.

s,.or bit., ..
Surgical exposure of the supraor-
bital and supratrochlear nerves be-
neath the corond brow flap. The
nerve and vascular pedrcle are left
undisturbed on the undersurface of
the temporoparied fascia-SMAS.
The corrugator muscle has been
resected, revealing the supratroch-
lear nerve.

the frontalis muscle and do not remove muscle or the

SMAS layer.
In the course of dissecting the corrugator muscles,
the surgeon should be careful to avoid injury to the su-
pratrochlear nerve. The supratrochlear newe runs within
the fibers of the conugator muscle, and only by careful
dissection of these muscle fibers under direct vision can
the supratrochlear newe be preserved, although, frankly,
in many cases it is impossible to preserve this nerve.
After the corrugator muscles are dissected and the elec-
trocautery is used for cutting,the uninjured supratroch-
lear nerve can frequently be visualized, and the supraor-
bital nerve should be seen running lateral to the cormga-
;;'G.'

tor muscle.
Facial Danger Zone 6

me Newe and Facial danger zone 6 includes the infraorbital nerve,

Cowequence of Injuy which is a branch of the second division of the trigem-
inal nerve (cranial nerve V). Injury to this nerve creates
numbness of the lateral nose, cheek, upper lip, and
inferior eyelid24(Fig. 6A). This numbness can interfere
with a patient's ability to eat. An even worse scenario is
a painful neurorna that can cause symptoms resembling
tic douloureux. The aygomatic branches of the facid
nerve aIso run through this area to innervate the levator
labii superioris muscle.
 Fb. 6A
Injury to the infraorbital nerve results in numb-
ness or hypesrhesia of the inferior eyelid, cheek,
lateral nose, and upper lip.

Zone 6
Anatomic Location Facial danger zone 6 can be identified by approxi-
mating the infraorbital foramen in the following man-
ner. First, the midpupil and the second manhbular
premolar are identified along a vertical line running
through the supraorbital foramen, and a point on the
anterior maxilla 1 cm below the infraorbital rim is pal-
pated along this Iine to approximate the location of the
infraorbital foramen. A circle with a radius of 1.5 cm
is drawn around this point to include h e infraorbital
foramen (Figs. 6B and 6C).

Injury to the nerves in facial danger zone 6 is un-

likely to occur in the typical subcutaneous or sub-SMAS
face lift. However, the extended subperiosteal face lift
involves dissection in the subperiosteal plane on the
anterior maxilla, and thus the infraorbital nerve and
the zygomatic branches of the facial nerve can be in-
jured. Ths nerve may also be injured in the course of
rhinoplasty, injection of local anesthetic, and midface
advancement surgery.
 Fg. 6%
Facial danger zone 6 is descrikd by
a circle with a 1.5 cm radius around
the infraorbital foramen, which lies
Orblculsrla Ocull M.- 1 cm below the inferior orbital rim
Levator Lsblt Buaarlorls
- along the h e down through the
Alasaus Nssl H.
Heaalls M.
Lavator Labli Supsrlorls M-.
- midpupil and second mandibular
premolar.
J zygomatlc Branch of F a ~ l a N
l .-

zygomaticus Major + Minor ~ m .

Depressor Semi M.
3
I n l r w r b I t n l U-

Orbiculatls Orle M.

Lwntor Labii Suwrlorls

Alneque Nasl M.
-Neanlis M.
-Zygomatic Branch
of Fncial H.
-tnlraorbital N.
Zygomatlcus
+
Major Minor M.
'Dsarsssor Septi H.
%Orblcularls Oria Y.

F&.6C
Lateral view of facial danger zone 6 .
Facial Danger Zone 7

Facial danger zone 7 includes the mental nerve,

which is a sensory branch of the third division of the
trigemid llerve (cranial nerve V). Injury to this nerve
results in numbness in one half of the mucosal and
cutaneous surfaces of the lower lip and chin24(Fig. 7A).
A mental nerve injury is a serious clinical condition since
patients may have difficulty holding food in their mout-h
and can inadvertently bite their lower lip during chew-
ing. Patients who play a wind instrument may not be
able to do so after injury.
 Facial danger zone 7 injury produces numbness
and hypesthesia on both external and internal
surfaces of half of the lower lip and &.

Zone 7
Anatomic Location The mental foramen exits the midmandible below
the second mandibular premolar and in line with the
previously drawn line extending from the supraorbital
foramen through the midpupil. On an anteroposterior
roentgenographic view this foramen is in line with the
supraorbital foramen and the infraorbital foramen
(Figs. 7B and 7C).

Injury to this nerve occurs most commonly in the

course of chin implantation surgery when dissecting a
subperiosted or preperiosteal plane, through either a
buccal or submental incision. Hamra's chin procedurell
is performed medial to the foramen, and if done exactly
as he describes, should not produce mental nerve injury.
 Facial danger zone 7 is described
by a circle with a radius of 1.5 cm
around the mentd foramen, which
lies on the midmanhble below the
second premolar along the line
drawn through the supraorbital
foramen, midpupil, and infraorbital
foramen.

Oiblcularls Orls Y.
Dsgrsssor Angull Orla , ,M
.
Osarsssor Labll lnfmrlorls M-.
c
2.d. Ma ndlbuhr
Premolar

Marglnel Mandlbular Branch

of Facial N.
Ysntalie M
-.

F&.7C
Lateral view of facial danger zone 7.

Orblculnris Orls k

Mental N.
Depressor Lnbii Infsrlorls tA
Msntalls Y.
-Yarglnal Mandibular Branch
of Faclal M.
Dsprasoor Angull Oris M.
 Serious permanent injury to the peripherd newes
of the face during the course of a routine subcutaneous
or limited SMAS pIication face lift is, fortunately, un-
common, with an average incidence of 0.8% and 0.196,
re~pectively.~~ In fact, if the surgeon dissects only in the
subcutaneous plane and does not penetrate the SMAS
layer, then it should be impossible to damage the motor
branches of the facial nerves (see Fig. 1D).
Techniques involving extended dissection beneath
the SMAS Iayers in the cheek and the temporoparietal
fascia-SMAS layer in the forehead, however, place the
zygomatic, buccal, and temporal branches of the facial
nerve closer to the plane of dissection. Although those
who originated these techniques may not have noticed
increased numbers of nerve injuries, I have little doubt
that zone 4 (zygomatic and buccal branch) and zone 2
(temporal branch) facial nerve injuries will occur more
frequently as less experienced surgeons adopt these new
advanced techniques. Furthermore, subperiosteal face
lifting with elevation of the periosteum of the anterior
maxilla carries a higher risk of zone 6 infraorbital nerve
injury. Hopefully, the popularization of these advanced
techniques will stimulate a renewed interest in the de-
tailed anatomy of the peripheral nerves in the face and
significant nerve injuries will be avoided.
 '1. Tmsim P.Face Ming- and frond rhytidectomy- [abstl.
- - InEly I
JF,4. Transactions of the Seventh International Congress of
Plastic Surgery- Rio de Janeiro: 19811, p 393.
2. -1ey JQJr. SMAS-plarysma face hft. P h t Reconstr Surg
71:573,1983.
3. Hamra ST. The tri-plane face lift dissection. Ann Plast Surg
12:268, 1984.
4.Lemmon ML. SuprGcial fascia rhytidectomy: A restoration of
[r the SMAS with control of the cervicomental angle. Clin Plast
I
I Surg 1044-9,1983,
5. JostG, Wassef M, L e e Y. Subfascia1 lifting. Aesrhe~cPlast
Surg 11:163,1987.
6. Rsmrez OM, Maillard GF,Musolas A. The extended subperi-
m osreal face lift: A defutive soft-tissue remodeling for facial re-
juvenation. Plast Reconstr Surg 88 :227,1991.
7. Hinderer UT, Urdolagoitia F, Vildmda R The blephamperi-
arbimpJasty: Anatomical basis. A m Plast Surg 18:437,1987.
8. ~ s & k i s JM,
Rumley TO, C a m a r p A. Subperiosteal approach
as an improved concept for correction of h e aging face. Plast
Recom Surg 82:383,1988.
8.Stuzin Jh4,Wagstr~mL, Kawamoto HXC,Wolfe SA. h a m m y
of the frontal branch of the facial nerve: The signhcance of the
temporal fat pad. Plast Reconstr Surg 83:265, 1989.
10. Rudolph R.Depth of the facial nerve in face lift dissections.
Plast Reconstr Surg 85 :537,1990.
11, Hamra ST. The deep-plane rhytidmmy. Plast Reconstr Surg
8653, 1990.
12. Hamra ST. Composite Rhytideaomy. St. Louis: Quality Medi-
a l Publishmg, 1993.
13. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast
RBconstr Surg 90:601,1992.
14, McKimey P,R a w DJ. Prevention of injury to the great
auricular nerve during rhytidedomy. P h t Reconstr Surg 66:
675,1980.
15. Liebman EP, Webster RC,Berger AS, DellaVecchia M.The
frontalis nerve in the tempord brow lifr.Arch Otolaryngol
I 108:232,1982.
Keferences continued

16. Pitanguy I, Rarnos AS. The frontal branch of the facial nerve:
The importance of its variations in face lifting. Plast Reconstr
Surg 38:352,1966.
17. Bernstein L, Nelson RH. Surgical anatomy of the extraparotid
distribution of rhe facial nerve. Arch Otolaryngol 110:177,
1984.
18. Marino H. The forehead lift: Some hints to secure better re-
sults. Aesthetic Plast Surg 1:251, 1977.
19. Baker DC, Conley J. Avoiding facial nerve injuries in rhyti-
dectomy : Anatomical variations and pitfalls. Plast Reconsrr
Surg 64:781,1979.
20. Nelson DW, Gingrass W. Anatomy of the mandibular
branches of the facial nerve. Plast Reconstr Surg 44:479, 1979.
21. Liebman El?, Webster RC, Gaul JR, Griffin T.The margLnal
rnandbular nerve in rhytidectomy and liposuction surgery.
Arch Otolaryngol Head Neck Surg 114:179, 1988.
22. Larrabee WF Jr, Makielskt KH. Surgical Anatomy of the Face.
New York: Raven Press, 1993.
23. SecIrel BR, Eby PL, Holrnes WH. Topographicaf landmarks
of the buccal and zygomatic branches of the facial nerve: An
anatomical study of clinical importance (in preparation).
24. Costas PD, Heatley G,Sedcel BR. Norrnd sensation of human
face and neck. Plast Reconsu Surg (in press).
25. Barton FE Jr. The aging face: Rhytidectomy adjunctive proce-
dures. Sekcred Readings Plasc Surg 6:19,1991.
 ~ndex
A D
Acoustic neuroma, removal of, facial danger
zone 4 and, 32-33
Anatomic location
of facial danger zone 1,6-7
official danger zone 2, 14-15
of facial danger zone 3,20-21
of facial danger zone 4,26-29
offacial danger zone 5,36-37
offacial danger zone 6,42-43
of facial danger zone 7,4647
Anterior facial artery, facial danger zone 3
and, 20-21
Anterior facial vein, facial danger zone 3
and, 20-21
Anricular nerve, great; see Great auricular
m e
B ptosis of, facial danger zone 2 and, 12-13
Bichat's fat pad, facial danger zone 4 and,
24-25, 30-31.
Bipdicle mmusculcm~ne~us flap,facial
danger zone 4 and, 30-31
Buccal branch of facial nerve, facial danger
zone 4 and, 2,24-25,28-33
C anterior, ficial danger zone 3 and, 20-21
Cheek, numbnas of
facial danger zone 1 and, 2, 4-5
facial danger zone 6 and, 2 , 4 0 4 1
Chin, numbness of, facial danger zone 7
and, 44-45
Composite rhpdectomy
facial danger zone I and, 10
facial danger zone 3 and, 22-23
hcid danger w n e 4 and,26-31
Coronal brow,&I facial danger zone 5 and,
34-35, 38
Cormgator muscle, facial danger zone 5
and, 34-35,38-39
Cranial nerve V
f a c d h i g e r zone 5 and, 3435
facial danger zone 7 and, 4445
a--
Depressor angul~oris muscle, facial danger
zone 3 and, 18-19,23
Diss~tion,surgical; see Surgical dissection
B numbness of, facial danger zone 5 and,
Ear, inferior two thirds of, numbness of,
facial danger zone 1 and, 2,4-5
Electrocautery, injury to marginal mandibu-
lar branch by, Facial danger zone 3
and, 22-23
Extended sub-SMAS dissection, facial dan-
ger zone 4 and, 26-29
External jugular vein, facial danger zone 1
and, 10-11
Eyebrows
asymmetry of, facial danger wne 2 and,
12-13
Eyelid
lower, facial danger zone 6 and, 4041
upper, numbness of, facial danger zone 5
and, 2,34-35
P J
Facial artery
facial danger zone 3 and, 22-23
facial danger zone 4 and, 32-33
Facial nerve
buccal branch of,kcid danger zone 4
- an4 2,24-25,28-33
facial danger zone 4 and, 32-33
marginal mandibular branch of,facial
danger zone 3 and, 2, 18-23,27
temporal branch of
f a d danger zone 2 and,2, 12-13,
14-17
hdal danger zone 4 and, 32-33
zygornatic branch of
faaal danger zone 2 and, 12-13
facial danger zone 4 and, 2,2425,
28-33
facial danger zone 6 and, 40-43
Facial vein
anterior, facial danger zone 3 and, 20-21
facial danger zone 3 and, 22-23
facial danger zone 4 and, 32-33
Forehead
2,34-35
paralysis of,facid daiger zone 2 and,
2,12-13
Frontal branches of superficial temporal
artery, facial danger zone 2 and, 16-17
Fronralis muscle, facial danger zone 2 and,
12-13
Great auriculat nerve
compression of, by suture phcation, facial
danger zone 1 and, 4 5 , 10-11
ficial danger mne 1 and, 2,4-11
I
Infraorbiral nerve, facial danger zone 6 and,
2,40-43
Jugular vein, external, facial danger zone 1.
and, 10-11
Lesser occipital nerve, facial danger zone 1
and, 6-7
h t o r labii superioris alaeque nasi muscle
facial danger zone 4 and, 24-25
Edcial danger zone 6 and, 40-41
Lip
lower
numbness of, facial danger zone 7 and,
2,u-45
paralysis of, facial danger zone 3 and,
2, 18-19
numbness of, facial danger zone 6 and,
2,4041
paralysis of,facial danger zone 4 and,
2,24-25,32-33

Marginal mandibular branch of facial m m ,
facial. danger zone 3 and, 2,18-23,27 facial danger zonc 4 and, '30-33
Mental nerve, facial dilnger zone 7 and, Orbidark oculi
2,4445
Mesotemporalis,facial danger zone 2 and,
16-17
M d m e o u s h p , bipedide, fafial
danger zone 4 and, 30-31
Nasal dorsum,numbness of,facial danger
mne 5 and, 2,3435
N e m and conscquencc of injury
facial danger zone 1 an4 4-5
facial danger zone 2 and, 12-13
facial dilnger zone 3 and, 18-19
facial danger zone 4 and, 24-25
facial danger zone 5 and, 34-35
facial danger mne 6 and,40-41
facial danger zone 7and, 4-4-45
Neuroma
acousric, removal of, facial d a n p zont 4
and, 32-33
causing symptoms resembhg tic dou-
l o r n , hcial danger wne 6 and,
40-41
Nox,upper, side of, numbness of, facial
ckqm zone 6 and, 2,4041
Numbness
of cheek, E a d danger zone 6 and,
2,4041
of chin, facial danger zone 7 and, 4445
of forchcad, facial danger zone 5 and,
2,34-35
of haK of lower Iip, facial danger zone 7
and, 2,4445
of inferior two thirds dear and adja-
cent cheek, facial dar& zone 1 and,
2,4-5
of lower eyelid, facial danger zone 6 and,
40-41
of nasal do-, facial danger mne 5 and,
2,34-35
of side of upper nose, facial danger zone 6
and, 2,M-41
of upper eyelid, facial danger zone 5 and,
2,34-35
of upper lip, facial danger mnc 6 and,
2,4041
Occipital ncm, Icsser, fadal danger zone 1
and, 6-7
Orbicularis oculi r u d e
facial danger zone 2 and, 12-13
my, facial danger mm 4
an4 32-33
Paralysis
of forehead, facial danger zone 2 and,
2,12-13
of lower lip, facial danger zone 3 and,
2, 18-19
of upper lip, facial danger mne 4 and,
2,2425,32-33
Parotid duct, facial danger zone 4 and,
28-31
Parotid gland
facial dangcr zone 2 and, 12-13,16-17
facial danger zone 4 and, 26-31
Platysrna muscle, facial danger mne 1 and,
10-11
Plarysma-SMAS layer
facial danger zone 1 ad, 8-1 1
facial danger zone 3 and, 18-23
facial danger zone 4 and, 26-27,32-33
Ptosis of eyebrow, facial danger zone 2 and,
12-13
Rhytidecmmy
comP0s;te; see Cornpire rhyddectomy
subperimttal, facial danger zone 2 and,
16-17
WAS; sct Submuscular apo~lcuroticsystem
Sternocleidomastoid mwle, faaal danger
zone 1 and, 4 1 1
Submuscular aponeurotic system (SMAS), 2
facial danger zone 2 and, 16-17
Subperkisreal rhycidectomy, facial danger
zone 2 and, 16-17
Subplatysma-SMAS layer, facial danger wne
3 and, 22-23
Subtempomparietalfascia= layer,
facial danger zone 2 and, 16-17
Superfiaal temporal artery, frontd branches
of, fiaal danger zone 2 an4 16-17
Supraorbital ntrve, facial danger zone 5 and,
2,34?39
Supra-SMAS layer, facial dangcr zone 2 and,
16-17
Supratrofhlcarnerve, Eafial danger zone 5
and, 2,34-39
surgical disKdon
in facial danger zone 1, 8-11
in facial danger zone 2, 16-17
in facial danger zone 3,22-23
in f a d danger zone 4 28-33
in f a d danger zone 5,38-39
in facial danger zone 4 4 2
in facial danger m e 7,%
Sumre plication, comprtssionof great
auricular nerve by, facial danger m e
1 and, 4-5, 10-11
Temporal b d of facial nerve
facial danger zone 2 and,2,12-17
ficial danger zone 4 and, 32-33
Tcmpomparietal fascia-SW layer, facial
danger zone 2 and, 12-17
Tic dodo- ncuroma causing sympmm
resembling, facial dangcr zone 6 and,
4-41
Trigeminat nerve
hcd danger zone 5 and,34-35
facial danger zone 7 and,4-4-45
U w r N d , numbness of, FaEial danger
zone 5 and, 2,34-35
upper lip
numbness of, facial h g w zone 6 and,
2,40-41
pd+ of, facial danger zone 4 and,
524-25,32-33
Upper nose, side of, numbness of, facial
danger zone 6 and, 2, -1
Vertical spreading technique, facial danger
mne 4 and, 30-31
Zygnrna
facial danger zone 2 and, 16-17
facial danger mne 4 and, 3&31.
Zygomatic branch of facial nerve
facial danger zone 2 and, 12-13
f a d danger zone 4 and, 2,24-25,28-33
facial danger zone 6 and, 40-43
Zygomaticus major irmsde
facial danger zone 3 and, 18-19
ficial dangcr zone 4 and, 24-33
Zygomaricus minor mu&
facial danger zone 3 and, 18-19
f a d danger zone 4 and, 24-25