Anatomy of the Scalp, Temple, Face, including facelift

Powerpoint presentation of the scalp, temple, face anatomy and physiology

1. Surgical Anatomy of the Scalp, Temple, and Face

2. The Scalp Extends from external occipital protuberance and superior nuchal lines to supraorbital foramen/margin and laterally to zygomatic arch

3. Layers of the Scalp Skin - thick, contains hair follicles and sebaceous glands Connective Tissue – contains nerves, lymphatics, vascular supply Aponeurosis (Galea Aponeurotica) – Insertion site for occipitofrontalis muscle. Extends from superior nuchal line to superior temporal line, continues laterally as temporal fascia. Firmly attached to subcutaneous tissue layer, prevents stretching of scalp during surgery or gaping when lacerated Loose areolar tissue – flexible layer, important to mobility of scalp. Sometimes referred to as Danger Zone because of the ease by which infectious agents can spread to emissary veins which then drain into the dural venous sinuses within the cranium Pericranium – analogous to periosteum, contains vascular supply to underlying calvarium

4. Musculature Occipitofrontalis muscle Consists of: 2 occipital bellies Originate from the superior nuchal lines and inserts into galea Innervated by the posterior auricular branch of CN VII 2 frontal bellies Originates from galea and inserts into superior orbicularis oculi Innervated by the frontal branch of CN VII These bellies can raise the eyebrows

5. Lymphatics Located in subcutaneous layer Anterior portions drain through parotid nodes -> deep cervical and submandibular nodes Posterior to auricle drains to occipital and posterior auricular nodes

6. Vasculature Arterial supply: found in dense connective tissue layer Common carotid ECA gives rise to superficial temporal, posterior auricular, occipital, and angular arteries STA divides into frontal and parietal branches after passing over posterior aspect of zygomatic arch Frontal branch supplies anterior temple, superior to brows Parietal branch supplies parietal area Posterior auricular – originates superior to stylohyoid and digastric mm and travels superiorly to supply scalp posterior and superior to auricle Occipital artery ascends to penetrate fascia between trapezius and SCM and then on to supply superficial fascia of posterior scalp superior to nuchal line and anastomose with posterior auricular and contralateral occipital artery Inferior to nuchal line scalp is supplied by vessels that also supply trapezius and splenius capitis which originate from transverse cervical and posterior intercostal arteries

7. Venous drainage Superficial and deep drainage systems; superficial veins follow their respective arteries Frontal vein communicates with dural sinuses via parietal emissary vein found in the loose areolar layer along the lateral side of the head Pterygoid venous plexus drains deep scalp and is found between the temporalis and lateral pterygoid mm. It has a communicating vein that travels through the inferior orbital fissure to connect the cavernous sinus to the ophthalmic vein and eventually drains into maxillary vein

8. Sensory Nerve Supply V1 -> frontal nerve -> bifurcates into supratrochlear and supraorbital nerves -> anterior scalp V2 -> zygomaticotemporal -> lateral scalp V3 -> auriculotemporal nerve -> lateral scalp Lesser and greater occipital nerves supply posterior scalp

9. Scalp Blocks

10. The Temporal Branch of CN VII and the Temporal Danger Zone The temporal branch of CN VII requires special attention because of the complex anatomy involved in the temporal area It leaves the parotid and runs within the superficial temporal fascia (temporoparietal fascia/ over the zygomatic arch to innervate the frontalis It passes the arch between 8 and 35 mm anterior to the external auditory canal It has between 3 to 5 rami , with the most posterior ramus being either anterior or posterior to the superficial temporal vessels The most anterior branch is 2 cm posterior to the anterior extent of the zygomatic arch The plane of dissection in this area should be either very superficial in relation to the superficial temporal fascia, deep to the SMAS on the temporalis fascia, or within the temporal fat pad between the superficial and deep divisions of the temporalis fascia Estimating the temporal branch distribution: Draw a triangle from the earlobe to the lateral brow and lateral extent of the highest forehead crease or A point 0.5 cm below the tragus to the lateral brow and 1.5 cm above the lateral brow The Temple Surgical Approach Considerations When using a preauricular approach, incise through the superficial layer of the temporalis fascia and periosteum posterior to a point 8 mm anterior to the EAC If anterior extension is required, make it superiorly within the temporal hairline

11. Frontal Branch: crosses arch variable 8mm-35mm anterior EAC 1.) lateral most portion of earlobe 2.) Lateral most portion of eyebrow 3.) Lateral most point of highest forehead line 1.) 1cm inferior to tragus 2.) 1cm lateral to eyebrow

12. Layers of the face Skin Subcutaneous tissue SMAS Sub-SMAS fat Mimetic muscles Deep facial fascia (parotidomasseteric) Plane containing facial nerve, parotid duct and buccal fat pad

13. s

14. Skin Nourished by dermal plexus Leave 3-4mm of fat on under surface of flap to maintain adequate perfusion and viability Important when designing flap

15. Subcutaneous Layer Between dermis and SMAS; SAFE layer Thin in overlying mastoid/posterior auricular Retinacular cutis (small, fibrous bands that connect the dermis of the skin to the deep fascia ) originate in periosteum and terminate in dermis McGregor’s Patch over Malar regions Thickest in Nasolabial folds

16. Types of Facelifts There are several types of facelift procedures, each designed to address different areas and levels of facial aging. Here are some common types: 1. **Traditional Facelift**: This involves making incisions around the ears and possibly under the chin to lift and tighten the underlying muscles and tissues. It is effective for addressing significant sagging and deep wrinkles in the lower face and neck. 2. **SMAS Facelift**: The Superficial Musculoaponeurotic System (SMAS) facelift targets the deeper layers of the face, including the muscles and connective tissues. This technique can provide a more natural lift and is often combined with a neck lift. 3. **Cutaneous (Skin) Facelift**: This procedure focuses on removing excess skin, primarily in the neck and face, without significant manipulation of deeper tissues. It is less invasive but may not provide as dramatic results as other methods. 4. **Mid-Facelift**: This procedure targets the cheek area and lower eyelids, repositioning fat and tightening the skin to create a more youthful contour. It is suitable for those with sagging in the mid-face region. 5. **Mini Facelift**: A less invasive option, the mini facelift involves smaller incisions and is designed to address early signs of aging around the jawline and neck. It has a quicker recovery time compared to a traditional facelift. 6. **Brow Lift**: Also known as a forehead lift, this procedure elevates sagging eyebrows and smooths forehead lines. It can be combined with other facelift procedures for a more comprehensive rejuvenation. 7. **Non-Surgical Facelifts**: These include treatments like Botox, dermal fillers, and Ultherapy , which use injectables or energy-based devices to lift and tighten the skin without surgery. They are ideal for those seeking minimal downtime. 8. **MACS Lift**: A minimally invasive technique that uses sutures to lift and tighten the SMAS layer, providing a subtle lift with less recovery time. Each type of facelift has its own benefits and is chosen based on the patient's specific needs, the extent of aging, and desired outcomes.

17. SMAS Contractile fibromuscular fascia enveloping muscles of facial expression Separates subcutaneous fat from parotidomasseteric fascia Encases muscles of facial expression Transfers their movement to skin Continuous w/ Platysma below the mandible Superficial Temporal fascia above zygomatic arch Galea (encases frontalis & occipitalis) ALL motor nerves are deep to SMAS Safest to keep SMAS tightening over parotid ONLY and not extend anteriorly to avoid facial n. as it crosses masseter anteriorly under masseteric fascia major vessels and nerves are initially deep to the SMAS and smaller branches perforate it, whereas the subdermal plexus is superficial to it In Temporal region, the SMAS, the superficial temporalis fascia, and the temporoparietal fascia are synonymous

18. SMAS Fibrous septae extend from the SMAS to the dermis Transmits facial muscle contractions to the skin in 2 vectors Along the longitudinal network parallel to the skin plane Perpendicular through the fibrous septa from SMAS to dermis

19. SMAS of upper face derived from sphincter colli profundus SMAS of lower face derived from primitive platysma Direct bony insertions Lack bony insertions Includes parotid fascia Upper Division: The frontalis muscle, the superficial temporal fascia, the orbicularis oculi muscle, the elevators of the lip, and the orbicularis oris muscle. Lower division: true platysma and its fascia, the risorius muscle, the depressor anguli oris muscle, and the posterior auricular muscle. The muscles derived from primitive platysma have limited bony insertions in contradistinction to those derived from the sphincter colli profundus .

20. subSMAS Discontinuity of SMAS at the level of the zygoma because of attachments of the various fascial layers at the arch Continuous with Galea Tempoparietal Fascia (contains CN VII above zygoma) Superficial cervical fascia Superficial to important anatomy Parotidomasseteric fascia (preauricular area) Parotid duct Greater Auricular nerve Facial Nerve External Jugular Buccal fat pad Facial artery & vein Anteriorly becomes thin and discontinuous in cheek area

21. Lower face Facial n. branches are deep to the SMAS and enter the muscles of facial expression on their undersurface. This is true, with the exception of the deep facial muscles: the levator anguli oris , the buccinator, and the mentalis, which are all innervated on their surface. Vessels and sensory nerves originate deep to the SMAS and their terminal branches run with it superficially. Upper Face important neurovascular structures arise from their deeper origins and course within the SMAS. The infratrochlear and supratrochlear neurovascular pedicles lie within the SMAS over the frontalis muscle.

22. Sub-SMAS

23. stay superficial to SMAS don’t have to worry about blood vessels & facial n. stay superficial to SMAS will avoid CN VII & most of the vasculature from superficial to deep : cutaneous nerves, SMAS, facial n & branches, parotid fascia

24. Deep Fascia + Deep temporal fascia Deep Facial fascia (parotidomasseteric) Deep Cervical Fascia

25. Vasculature Superficial Temporal Artery Terminal branch of External carotid Arise in parotid; emerge anterior EAC and posterior to condylar head Lies w/in Temporoparietal fascia as approach zygomatic arch Transverse facial artery branches inferior to arch: supply lateral canthus Supply superficial temporal fat pad (penetrates superficial layer of deep temporalis fascia) Terminal Branches Anterior: anastomose w/ supraorbital & supratrochlear Posterior: Parietal skull

26. Superficial Temporal Artery Mean diameter at Zygomatic arch 2.73 +/- 0.51mm Frontal branch often larger than parietal (however not always) Frontal branch: ~11.5cm long w/ average number of perforators to deep plane = 1.3 Temporal Branch: ~11.4cm long w/ average 1.34 perforators to deep plane Bifurcation Above the arch 20/27 (74%) On the arch 6/27 (22.22%) No bifurcation (continue as frontal br) 1/27 Tayfur et al. reported branched below arch in 40% of cadaveric halves studied

27. Greater Auricular Nerve Sensory innervation to ear and lateral cheek Branches of C2 & C3 Just deep to superficial fascia of neck Runs just deep to superficial fascia overlying SCM, behind EJV

28. Greater Auricular Nerve 6.5cm inferior to caudal end of EAC at lateral border of SCM (Erb’s Point) Safe once cephalad to ear lobe and can dissect deeper CN XI exits posterior to SCM at Erb’s point Erb’s point: where Cervical Plexus emerges from posterior of SCM/ CN XI and Greater auricular nn emerge Cutaneous branches Transvers cervical Greater Auricular Lesser Occipital Supraclavicular Most commonly injured nerve in Rhytidectomy (5% - permanent injury) Stay in SubQ plane inferior to lobe to avoid nerve injury

29. Temporoparietal Fascia Superficial Temporal Artery and Facial nerve lie in Temporoparietal Fascia Loose connective tissue separates temporoparietal Fascia from Fascia of Temporalis muscle Temporalis Fascia splits several centimeters above arch to encase temporal Fat Pad Transition from Sub-Temporoparietal fascial plane/sub-SMAS to subcutaneous as move from temporal area to cheek protects facial nerve Frontal branch of CN VII is anterior and inferior to frontal branch of STA (preservation of vessel protects CN VII)

30. Frontalis . No bony attachments, arises from occipitofrontalis muscles aponeurosis and terminate s on the skin and dermal tissue of the anterior forehead and brow. The muscle runs in a vertical direction, and as such, contraction will result in horizontal forehead rhytids above the brow level. Corrugator supercilii . A ttaches to the orbital rim medially and inserts with the frontalis on the skin laterally. Contraction of this muscle produces vertical rhytids known as “frown lines” in the glabella and lower median forehead. Procerus . attaches to the facial aponeurosis overlying the nasal bones and insert s on the skin of the eyebrow and lower forehead. Contraction of this muscle produces horizontal rhytids over the nasal dorsum, or “glabellar lines”. Orbicularis Oculi . broad, flat muscle that encircles the palpebral fissure. Includes 3 parts, orbital portion, preseptal, and pretarsal portions. Muscles of the Upper Face

31. Nasalis . arises from the maxilla and sends fibers over the nasal dorsum to decussate in the midline at an aponeurosis at the bridge of the nose. The muscle functions to open the nasal aperture and valve during exercise or deep inspiration. Excess contraction can cause “bunny scrunch lines” on the nasal dorsum. Levator Labii Superioris Alaeque Nasi. arises from the upper part of the frontal process of the maxilla and passes obliquely to insert on the upper lip, blending with the orbicularis. Contraction deepens the nasolabial fold, dilates nasal ala, and everts the upper lip. Levator Labii Superioris. arises from the inferior orbital margin and inserts into the upper lip . Contraction raises and everts the upper lip and deepens the nasolabial fold. Zygomaticus Minor. a rises from the lateral surface of the zygoma and inserts into the muscular slip of the upper lip, just lateral to the levator labii superioris. Contraction causes elevation of the upper lip, also contributes to nasolabial fold. Zygomaticus major. This muscle runs from the zygomatic bone to the modiolus, blending with the orbicularis oris. Contraction draws the angle of the mouth upward, such as in laughing. Muscles of the Midface

32. Levator Anguli Oris . a rises from the canine fossa and inserts on the lateral commissure, known as the modiolus. The modiolus is a dense, fibromuscular interface of the muscles contributing to oral commissure movement and function by acting as a scaffold for muscles to pull on. Buccinator. forms the lateral border of the oral cavity between the alveolar ridge of the maxilla and mandible. It originates on the stylomandibular rhaphe and inserts into the orbicularis sling. Orbicularis Oris. comprised of two parts: par peripherals, a circular sling attached to each commissure at the modiolus; and pars marginalis, deep to vermillion border and mucosal lip. Muscles of the Midface

33. Depressor Labii Inferioris . arises from the mandible and inserts on the skin and mucosa of the lower lip, medial to the mental foramen. Contraction draws the lip downward and everts the lip. Depressor Anguli Oris. o riginates at the mental tubercle on the mandible, lateral to the mental foramen, and inserts on the lateral lower lip and modiolus. Contraction causes the angle of the lower lip to depress and open the mouth. Increased use can cause radially oriented lower lip rhytids, known as “marionette lines.” Mentalis. arises from the mandible and inserts on the skin of chin, inferior to its origin. Thus, contraction pulls the chin and lip upwards and wrinkles the chin. Overuse may account for a “poppy chin” pincushioning effect on the mentum. Platysma. broad, sheetlike muscle arises from the fascia over the upper chest and clavicle and extends over the anterolateral neck to meet in the midline at the lower chin margin. The muscle then extends laterally over the mandible body to attach to the lateral lower lip and subdermal tissue of the lower face. With increasingage, ptosis of the muscle, skin laxity, and thinning of subcutaneous tissues create platysmal banding as a cosmetic issue in some patients. Muscles of the Lower Face and Neck

34. Which of the following can occur following placement of a tissue expander in the scalp? A. Epidermal hypoplasia B. Increase in dermal thickness C. Atrophy of fat D. Hyperplasia of skeletal muscle Answer: C Rationale: Following placement of a tissue expander in the body, the following histologic changes occur: thickened epidermis, decrease in thickness of dermis, no changes in hair follicles or sebaceous glands, decrease in thickness of skeletal muscle, increase in capillaries, and fat atrophy.

35. The coronal incision used in an open forehead lifts is best used in a: A. male patient with medium forehead hairline. B. female patient with medium forehead hairline. C. male patient with high hairline. D. female patient with high hairline. Answer: B Rationale: Coronal brow lift is one of the earliest procedures for brow and forehead lifting. An incision is made in the scalp hair (the incision is made beveled parallel to the hair follicles, but could still lead to hair loss) 1-3 cm behind the hairline. Dissection is performed in a subgaleal or subperiosteal plane, which then connects to a lateral subtemporoparietal plane dissection. Scalp tissue excision is done to elevate the brows. The coronal incision is best indicated for females or non-balding males with a medium to low forehead hairline. Trichophytic or pretrichial incisions are best used on patients with high forehead hairlines, where further lengthening of the forehead/hairline is undesirable. The pretrichial incision is made in front of the hairline and leaves a scar on the forehead in front of the hairline. In contrast, the trichophytic incision is made just behind the hairline; it is beveled so that the follicles in front of the hairline survive, and hair grows to camouflage the incision scar. Generally, it is advisable to avoid visible scalp incisions in balding males (medium to high forehead lines), and endoscopic procedures are usually the best choice in these cases.

36. Injury to branches of the facial nerve (C.N. VII) during the preauricular approach to the temporomandibular joint most commonly involves the: A. zygomatic which lie a mean 2 cm anterior to the preauricular crease. B. temporal which lie a mean 2 cm anterior to the preauricular crease. C. zygomatic which lie a mean 2 cm anterior to the bony external auditory canal. D. temporal which lie a mean 2 cm anterior to the bony external auditory canal. Answer: D Rationale: The most posterior temporal branches lie anterior to the post-glenoid tubercle. Their location was measured as 0.8 – 3.5 cm (mean 2.0 cm) and more recently measured at 2.12 cm ± 0.21 cm (range, 1.68 to 2.49 cm); from the anterior margin of the bony external auditory canal. The zygomatic branches are inferior and anterior to the surgical field and much less likely to be injured in the approach to the TMJ.

37. This 50 year-old female wishes to enhance her cervico-facial appearance with face lift surgery. Which of the following surgical techniques is the best option? A. Subcutaneous B. Composite C. Mini-lift D. Endoscopic Answer: B Rationale: The various procedures available for rhytidectomy can be classified anatomically according to the depth of dissection from skin down to periosteum. A skin only face-lift is the simplest procedure, but is usually not indicated. The SMAS face-lift involves surgery to both the SMAS and the skin. This can be achieved by either reconstituting the SMAS after removing a strip of redundant preauricular skin or by SMAS plication alone. The degree of the SMAS flap elevation is variable from none, to a small amount, to extended sub SMAS elevation to the lateral edge of the zygomaticus major muscle in the face. In the mini-lift, the skin incision is limited and the SMAS is plicated with a series of sutures at the lower face and neck area. In a deep plane face lift, the dissection is in a plane below the malar fat pad. A composite facelift adds the dissection of SMAS flap of the inferior portion of the orbicularis oculi to the dissection of the deep plane. The subperiosteal facelift elevates the periosteum off the zygomatic arch and the anterior face of the maxilla in order to reposition the whole unit superiorly. SMAS face lit procedures need to be individualized; In this specific patient, a subcutaneous facelift will not address underlying skeletal deformities, ptotic deep soft tissue structures or change the skin texture. A mini-facelift technique will not address cervical area and malar fat pad region predictably. An endoscopic face-lift option will not improve skin texture, and will release periosteal connections with the superficial soft tissues enhancing just the upper facial and midfacial areas. Best results are expected with use of a composite rhytidectomy incorporating multiplanar dissections and SMAS procedures, which will give better control of soft tissues and provide longer lasting results.

38. The procedure which trims and secures the posterior border of the superficial musculoaponeurotic system (SMAS)-platysma muscle layer in a face-lift procedure is best termed: A. imbrication. B. involution. C. placation. D. transposition. Answer: A Rationale: With the current trend toward limited undermining in facelift surgery, identification and effective use of the SMAS layer is pivotal for success and longevity of rhytidectomy. This layer, initially described by Mitz and Peryonie in 1976, includes the superficial temporal fascia superiorly, and extends into the superficial surface of the platysma muscle inferorly. It lies external to the parotid capsule, and contains varying amounts of fat. After development of skin and SMAS flaps, the SMAS layer can be manipulated by either plication (suturing and folding without excision) or imbrication (excision and repositioning) or a combination of both procedures.

39. The nerve most commonly injured in face lift procedures is the: A. buccal. B. spinal accessory. C. greater auricular. D. marginal mandibular. Answer: C Rationale: Injury to the facial serve causing paralysis is rare, and reported only to occur in 0.53 to 2.6% of patients. Eighty-five percent of motor nerve injuries resolve spontaneously, and results of surgical repair are unpredictable and not very encouraging. Injury to the greater auricular nerve is most common and occurs in up to 7% of patients. Temporary neuropraxia usually resolves in 2-4 months, and causes numbness/paresthesia around the inferior portion of the ear and surrounding skin. Transection of the great auricular nerve is best treated with immediate microanastomosis.

40. A 5cm full thickness scalp avulsion down to the cranium is best treated by a: A. split thickness skin graft. B. full thickness skin graft. C. split thickness skin graft placed over bur holes made in the outer table. D. rotation-advancement flap. Answer: D Rationale: Exposed cortical cranial bone will not accept skin grafts. Rotational-advancement flaps with multiple galeal releasing incisions parallel to the long axis of the flap will provide adequate coverage in most instances.

41. Your preoperative esthetic evaluation of a patient reveals brow ptosis, and an upper eyelid crease which is more than 12 mm above the upper eyelid margin with lid ptosis. This patient is best treated by: A. transcutaneous upper eyelid blepharoplasty and brow lift. B. brow lift only, but only via a coronal approach. C. levator aponeurosis or Muller’s muscle surgery and brow lift. D. transconjunctival upper eyelid blepharoplasty and brow lift. Answer: C Rationale: Transcutaneous blepharoplasty does not correct eyelid retraction, and occasionally will worsen the condition due to skin removal. Brow lift procedures will correct brow ptosis, but not lid ptosis. Surgery of the muscles of the upper eyelid is often performed to correct lid ptosis. Lid ptosis must be evaluated and corrected prior to a blepharoplasty procedure. A transconjunctival blepharoplasty will not correct eyelid retraction.

42. Macgregor’s patch refers to an area adjacent to the: A. sternocleidomastoid and ear lobule, where important nerves are found. B. zygomatic arch and prominence where a plexus of vessels is found. C. antegonial notch and inferior mandible where the facial artery is found. D. the preauricular area where the facial nerve crosses the zygomatic arch. Answer: B Rationale: McGregor's patch is also known as the bloody gulch. It is named after the strong zygomatico-dermal fibrous attachments that often present as skin dimpling or retraction. It is also important because a plexus of vessels supplied by the facial artery and transverse cervical artery becomes superficial in this area. Damage to these vessels can create bleeding during development of the skin muscle flap in face-lift procedures. Additionally, the buccal nerve lies just deep to this danger zone, and the zygomatic branch of the facial nerve becomes more superficial in this area.