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ע"תש/טבת/ג"י
1
Facial Anatomy
ר פרידמן טל"ד
כירורגיה פלסטית
הרופא -ח אסף"בי
Anatomy of the facial soft tissues
Five layers of critical anatomy:
1. Skin
2. Subcutaneous fat
3. Supereficial Musculoaponeurotic system
(SMAS)/ muscle layer.
4. Deep Fascia
5. Facial n.
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Subcutaneous Soft Tissue
Homogenous fascial fatty layer.
Malar Fat Pad: Triangular in shape
Beneath is the SMAS.
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SMASSuperficial musculoaponeurotic system
“A tissue plane that is composed of fibrous or
muscular tissue, lies in direct continuity with the
platysma, and lacks direct bone insertion”.
SMAS
History Henry Gray, 1859
Skoog, 1974- Plication and flap suspension in facelift.
Mitz and Peyronie, 1976- Detailed anatomic description of
the SMAS in the parotid and cheek area :
1.The SMAS was continuous with the frontalis m.
2. Continuous with the platysma m. inferiorly.
3. Motor n. run deep to the SMAS.
4. Sensory n. are superficial.
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Jost and Levet, 1984-
The SMAS is the remnant of the primitive platysma muscle; true platysma, risorius, triangularis, auricular posterior.
The SMAS over the parotid forms the parotid fascia.
A second layer of facial muscles located deep to the SMAS , oriented vertically and attached to the skull and facial bones; The sphincter colli profundus: frontalis, periorbital, zygomaticus, and quadratus labii inferioris.
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Parotid regionMitz and Peyronie, 1976:
The SMAS anterior to the tragus is particularly
dense.
Jost and Levet, 1984:
Impossible to separate the SMAS from the deep
parotid fascia.
Zygomatic and Temporal regions
Mitz and Peyronie, 1976: The SMAS tightly
adhered to the zygoma.
The fascial layer in the temple, the
temporoparietalis fascia, is continuous with the
posterior portion of the frontalis m.
Jost and Levet, 1984: The SMAS ends at the level
of the zygoma, and does not join the frontalis m.
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Stuzin: Three fascial layers in the temporal
area: Temporoparietal fascia, Superficial
layer of deep temporal fascia, and the deep
layer of of the DTF.
Nasolabial fold
Mitz and Peyronie, 1976: The NLF as a cutaneous
depression where the SMAS ends.
Pensler, 1985: The superficial fascia in the upper
lip is continuous with the cheek SMAS through
the NLF.
Barton, 1992: The SMAS in the anterior cheek is
the nesting fascia for the muscles of the upper lip;
Lateral traction on the SMAS would have little
effect on the medial cheek skin.
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Yousif, 1994: Traction on the SMAS
deepens the NLF; traction on the fascial-
fatty layer lessens the fold.
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SMAS
S.Aston: It is fibrous, muscular, or fatty,
depending on the location in the face:
A single, heterogenous layer: Galea-
Frontalis- Temporoparital fascia- SMAS-
Orbicularis oculi- Orbicularis oris-
Platysma.
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Retaining ligaments of the
cheek
Furnas: Described 4 ls., that support the soft
tissue of the face:
Zygomatic (McGregor’s patch), Mandibular
retaining ligaments in the cheek: from the
periosteum to affix the skin.
Anterior Platyma- cutaneous l.,
Platysma- Auricular l.
Stuzin:
2 types of retaining ll:
1. Osteocutaneous ll.:Zyg, Man. l.l.
2. Fascial connections: Parotid- cut.l, Masseteric-
cut.l.
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The zygomatic ll., Stuzin: Fixate the malar
pad to the underlying zygomatic
eminence in the youthful face.
Masseteric Cutaneous ls., Stuzin, Baker,
and Gordon:
– Fibroelastic septi that extends between the
superficial and deep facial fascia along the
anterior margin of the masseter m.
– Provides support to the SMAS- platysma in
the midface.
Mimetic Muscles
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1. Depressor anguli oris, Zygomaticus minor,
Orbicularis oculi.
2. Depressor labii inferioris, risorius,
platysma, zygomaticus major, levator labii
superioris alaeque nasi.
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3. Orbicularis oris, levator labii superioris.
4. Mentalis, levator anguli oris, Buccinator.
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The innervation of the ms.
of the first 3 layers is from
their deep surface.
The deepest group is
innervated from the
superficial surface.
The platysma muscle
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The platysma m.
Size: 8*12 cm
Origin: Fascia over the upper parts of the
pectoralis major and deltoid.
Insertion: Skin and subcutaneous tissue of the
lower face.
Has no bony insertions!
Pattern of circulation: type II:
Dominant pedicle: submental a.
Minor a: suprasternal a.
Nerve supply:
Motor: cervical branch, VII.
Sensory: transverse cervical n.
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The platysma m.
Vistnes and Souther, 1979:
61%- Decussated from the level of the
hyoid
39%- No decussation- “Turket globbler”
deformity.
Cardoso de Castro, 1980: Three different
conformations:
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Parotid- Masseteric fascia
A thin, areolar layer that lies immediately
on the surface of the facial n., anterior to the
parotid gland.
Analogous layers:
Neck- Cervical fascia.
Temporal region- Innominate fascia.
Scalp- Subgaleal fascia.
Facial n.
Facial danger zones
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Facial danger zone 1
Greater auricular n.- Mckinney and
Katrana: 6.5 cm below external auditory
meatus
Posterior to SMAS
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Facial danger zone 2
Frontal branch of VII A line from 0.5 cm below
the tragus to 1.5
above the lateral
end of eyebrow.
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Facial danger zone 3
marginal mandibular branch
Dingman and Grabb: The mandibular n.
passes above the mandibular border- 81%-
posterior to the facial a.
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Facial danger zone 4
Zygomatic and Buccal
brances
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Facial danger zone 5
Supraorbital and Supratrochlear nn.
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Facial danger zone 6
Infraorbital n.
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Facial danger zone 7
Mental n.
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