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Original Article |

Temporal Branch of the Facial Nerve and Its Relationship to Fascial Layers FREE

Seda T. Babakurban, MD; Ozcan Cakmak, MD; Simel Kendir, MD; Alaittin Elhan, PhD, MD; Vito C. Quatela, MD
[+] Author Affiliations

Author Affiliations: Department of Otorhinolaryngology, Faculty of Medicine, Başkent University, Ankara (Dr Babakurban); Department of Otorhinolaryngology, Faculty of Medicine, Acibadem University, Istanbul (Dr Cakmak), and Department of Anatomy, Faculty of Medicine, Ankara University, Ankara (Drs Kendir and Elhan), Turkey. Dr Quatela is in private practice in Rochester, New York.


Arch Facial Plast Surg. 2010;12(1):16-23. doi:10.1001/archfacial.2009.96.
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Published online

Objectives  To eliminate the inconsistency in the nomenclature, to anatomically and definitively describe the topographic relationship of the temporal branch of the facial nerve to the fascial layers and the fat pads, and to create an effective algorithm to define the safest approaches and planes for surgical procedures in this area.

Methods  The study was performed using 18 hemifacial cadaveric specimens. In 12 hemifacial specimens, the facial halves were coronally sectioned and dissected. In 6 hemifacial specimens, planar dissection was performed layer by layer.

Results  The temporal branch of the facial nerve that traversed inside the deep layers of the temporoparietal fascia and the superficial musculoaponeurotic system coursed along the zygomatic arch as 1 (14.3%), 2 (57.1%), 3 (14.3%), and 4 (14.3%) twigs in the specimens. The temporoparietal fascia had no attachment to the zygomatic arch and continued caudally as the superficial musculoaponeurotic system. Adhesions were between the temporoparietal fascia and the superficial layer of the deep temporal fascia around the zygomatic arch. In most specimens, the superficial layer of the deep temporal fascia continued as the parotideomasseterica fascia, and a deep layer abutted the posterosuperior edge of the zygomatic arch.

Conclusion  An easy and safe surgical approach in this area is to elevate the superficial layer deep to the intermediate fat pad directly on the deep layer of the deep temporal fascia descending to the periosteum along the zygomatic arch.

Figures in this Article

The temporal branch of the facial nerve has become of great importance with advanced techniques of deep-plane face-lifting, subperiosteal midface-lifting, endoscopic forehead-lifting, and interfascial dissections in craniofacial and trauma surgery. Injury to the temporal branch of the facial nerve results in cosmetic defects as a result of paralysis of the corrugator supercilii, frontalis, and orbicularis oculi muscles. Understanding the anatomy of this area and the trajectory of the temporal branch of the facial nerve is critical to preserve it from injury. Despite many studies129 in the literature, controversy remains about the topographic relationship of the fascias, the fat pads, and the temporal branch of the facial nerve and its nomenclature. The objectives of this study were to eliminate the inconsistency in the nomenclature, to anatomically and definitively describe the topographic relationship of the temporal branch of the facial nerve to the fascial layers and the fat pads, and to create an effective algorithm to define the safest approaches and planes for surgical procedures in this area.

The study was performed using 18 hemifacial specimens from fixed and fresh cadavers obtained from the Department of Anatomy, Faculty of Medicine, Ankara University, Ankara, Turkey. Before dissection, the course of the temporal branch of the facial nerve was marked on the skin of each cadaver's face. First, the Pitanguay line (connecting the lobule with one-half the distance between the superior border of the external auditory canal and the lateral canthus) was drawn, and the point at which that line bisected the zygomatic arch was marked. Two other points that were 1.5 cm anterior and 1.5 cm posterior to the first point were marked, depending on the length of the zygomatic arch. Then, second and third lines that bisected the second and third points separately were drawn from the temporal region to the cheek. These 2 coronal strips of tissue were incised down to the temporal muscle above and to the masseter muscle below, including a coronal segment of the zygomatic arch (Figure 1). The 2 sections were en bloc resected, and the anterior and posterior halves of the coronal strips were dissected under an operating microscope using magnification of ×6 to ×40. In 6 hemifacial specimens, planar dissection from the skin to the bone was performed layer by layer under the operating microscope.

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Figure 1.

Lines of the 2 coronal strips of tissue.

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The nomenclature in the literature is inconsistent for certain fascias and the fat pads of this region. Therefore, preferred names (given in the Table and in Figure 2) are used herein to avoid confusion.

Table Graphic Jump LocationTable. Naming of the Fascias and the Fat Pads in the Literature
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Figure 2.

Preferred names of the anatomic structures given in the Table. The asterisk marks where the deep layer of the deep temporal fascia (D-DTF) abuts the posterosuperior surface of the zygomatic arch (ZA) on 10 sides. The superficial layers and the deep layers of the deep temporal fascia (DTF) fuse at the anterosuperior surface of the ZA on 4 sides of the cadaveric heads. DFP indicates deep fat pad; IFP, intermediate fat pad; MM, masseter muscle; PG, parotid gland; PMF, parotideomasseterica fascia; S, skin; S-DTF, superficial layer of the DTF; SFP, superficial fat pad; SMAS, superficial musculoaponeurotic system; TM, temporal muscle; TPF, temporoparietal fascia.

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FASCIAL LAYERS AND FAT PADS

The temporoparietal fascia and the deep temporal fascia were identified on the anterior, middle, and posterior parts of each coronal strip. Above the zygomatic arch, the temporoparietal fascia was composed of multiple (3-4) layers (Figure 3 and Figure 4) that were integrated with thin fibrous septa immediately deep to the subcutaneous layer.

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Figure 3.

Coronal strips (A) and corresponding depictions (B) of the anterior (right), middle (center), and posterior (left) thirds of the specimen.

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Figure 4.

Dissection of the middle third of the coronal strip. The temporoparietal fascia (TPF) is composed of multiple layers. DFP indicates deep fat pad; IFP, intermediate fat pad; MM, masseter muscle; TM, temporal muscle; ZA, zygomatic arch.

Graphic Jump Location

The temporoparietal fascia could be easily dissected from the superficial layer of the deep temporal fascia above the zygomatic arch (Figures 5, 6, 7, and 8). Descending to the zygomatic arch, a discrete fatty layer called the superficial fat pad was encountered between the superficial layer of the deep temporal fascia and the temporoparietal fascia (Figures 3 and 5). This fat pad disappeared below the middle level of the zygomatic arch. The superficial fat pad was encountered in middle parts of all specimens. However, this fatty layer was not visible in 27.3% of posterior parts and 9.1% of anterior parts of specimens. The mean vertical lengths of the superficial temporal fat pad were 14, 20, and 25 mm, respectively, in posterior, middle, and anterior parts of specimens. Although this layer was thin (≥2 to <3 mm) in 36.3% of posterior, 36.4% of middle, and 27.3% of anterior parts of specimens, it was too thin (≥1 to <2 mm) in 27.3% of posterior, 27.3% of middle, and 27.3% of anterior parts of specimens, and was thick (≥3 to <4 mm) in 9.1% of posterior, 36.3% of middle, and 36.3% of anterior parts of specimens.

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Figure 5.

Dissection of the hemiface of a cadaver. The superficial layer of the deep temporal fascia (S-DTF) continues as the parotideomasseterica fascia (PMF). SFP indicates superficial fat pad; TB-FN, temporal branch of the facial nerve; TPF, temporoparietal fascia; ZA, zygomatic arch.

Graphic Jump Location
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Figure 6.

Dissection of the posterior third of the coronal strip. There are fibrous indentations from the temporoparietal fascia (TPF) into the superficial layer of the deep temporal fascia (S-DTF) covering the parotid gland (PG). TB-FN indicates temporal branch of the facial nerve; TFA, transverse fascial artery; TM, temporal muscle; ZA, zygomatic arch.

Graphic Jump Location
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Figure 7.

The topographic relationship of the temporoparietal fascia (TPF) to the temporal branch of the facial nerve (TB-FN). The temporal branch twigs of the facial nerve course within the TPF. D-DTF indicates deep layer of the deep temporal fascia; DFP, deep fat pad; IFP, intermediate fat pad; S-DTF, superficial layer of the DTF; TM, temporal muscle; ZA, zygomatic arch.

Graphic Jump Location
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Figure 8.

The temporal branch twigs of the facial nerve. The facial nerve traverses along the zygomatic arch as multiple twigs. PG indicates parotid gland; S-DTF, superficial layer of the deep temporal fascia; TB-FN, temporal branch of the facial nerve; TPF, temporoparietal fascia.

Graphic Jump Location

The temporoparietal fascia had no attachment to the zygomatic arch (Figures 3, 4, and 5). The temporoparietal fascia descending to the zygomatic arch lost its fascial layers and became a foamy tissue (Figures 3 and 6). The level of change varied and was observed at approximately 1 cm above the zygomatic arch in 18% of specimens (6 of 33 sides of 11 specimens), in the upper level of the zygomatic arch in 64% (21 of 33 sides of 11 specimens), and in the middle of the zygomatic arch in 18% (6 of 33 sides of 11 specimens). The fascia continued as a superficial musculoaponeurotic system (SMAS) below the zygomatic arch (Figure 3 and Figure 9). Beginning from a level between the upper edge and the middle of the zygomatic arch, tight adhesions were observed between the temporoparietal fascia and the superficial layer of the deep temporal fascia, which covered the zygomatic arch, the masseter muscle, and the parotid gland (Figure 9 and Figure 10). Below this level, the plane could only be found using sharp dissection between these layers (Figure 9). However, at the level of the parotid gland, fibrous indentations were observed from the temporoparietal fascia into the superficial layer of the deep temporal fascia covering the parotid gland (Figure 6), and no dissection plane was noted among the SMAS, the superficial layer of the deep temporal fascia, and the parotid fascia (Figure 9).

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Figure 9.

Dissection of the middle third of the coronal strip in a fresh cadaver specimen. The superficial layer of the deep temporal fascia (S-DTF) continues across the zygomatic arch (ZA) as the parotideomasseterica fascia. The temporoparietal fascia (TPF) continues as the superficial musculoaponeurotic system (SMAS). IFP indicates intermediate fat pad; MM, masseter muscle; PG, parotid gland; SFP, superficial fat pad.

Graphic Jump Location
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Figure 10.

The topographic relationship of the temporal branch of the facial nerve (TB-FN) to the zygomatic arch (ZA). The distance between the ZA and the TB-FN piercing the fascia is 3 mm. The asterisk marks where the tissue was horizontally cut to show the relationship.

Graphic Jump Location

The deep temporal fascia lay under the superficial fat pad and covered the temporal muscle. The thick single layer of the upper part of the deep temporal fascia separated into the superficial layer and the deep layer as it descended to the zygomatic arch, and a fibrofatty tissue called the intermediate fat pad filled the space between these layers (Figures 3, 4, and 7 and Figure 11). The deep layer of the deep temporal fascia could be easily dissected from the intermediate fat pad (Figure 11). However, dissection of the superficial layer of the deep temporal fascia from the intermediate fat pad was more difficult because of extensions of a fibrous network of the fat pad and arteriovenous perforators. In 10 specimens, the layers of the deep temporal fascia did not fuse above the zygomatic arch. In these specimens, the deep layer abutted the periosteum of the posterosuperior edge of the zygomatic arch (Figure 3), and the superficial layer descended through the anterior surface of the zygomatic arch to form the parotideomasseterica fascia inferiorly (Figure 5). However, on 4 sides of the cadaveric heads, the superficial layer and the deep layer of the deep temporal fascia fused at the anterosuperior edge of the zygomatic arch and continued inferiorly as a single layer to form the parotideomasseterica fascia (Figure 2).

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Figure 11.

Dissection of the layers of the deep temporal fascia (DTF) and schematic view of surgical approaches to reach the zygomatic arch (ZA) through the intermediate fat pad (IFP). A, The deep layer of the DTF (D-DTF) can be easily dissected from the IFP. B, Three possible approaches indicated by numbers 1, 2, and 3 (see the last paragraph of the “Comment” section for a discussion). The asterisk marks the subgaleal dissection plane. A indicates artery; DFP, deep fat pad; MM, masseter muscle; S-DTF, superficial layer of the DTF; SFP, superficial fat pad; TM, temporal muscle; TPF, temporoparietal fascia; V, vein.

Graphic Jump Location

The mean vertical lengths of the intermediate fat pad were 23, 24, and 37 mm, respectively, in posterior, middle, and anterior parts of specimens. The intermediate fat layer was divided into several lobules by a fibrous network (Figure 3). There were arteries (1-2 mm in diameter) and veins (2-3 mm in diameter) in the fat pad (Figure 11). Although small vessels were common, several larger vessels were also encountered in each coronal strip at 5 to 24 mm from the zygomatic arch.

Another fat pad (called the deep fat pad) was observed between the deep temporal fascia and the temporal muscle. This layer (called the buccal fat pad) continued between the masseter muscle and the temporal muscle inferiorly (Figures 4, 7, and 11).

TEMPORAL BRANCH OF THE FACIAL NERVE

Division of the temporal branch of the facial nerve occurred in the parotid gland. The temporal branch of the facial nerve emerged from the parotid gland below the zygomatic arch (Figures 6 and 10) and traversed inside the temporoparietal fascia over the zygomatic arch (Figures 5 and 7) following the Pitanguay line. The numbers of temporal branch twigs passing over the zygomatic arch were 1 (14.3%), 2 (57.1%), 3 (14.3%), or 4 (14.3%) in the specimens (Figure 8). There was approximately 3 mm between the frontal nerve and the bone over the zygomatic arch in the fresh cadaver specimens (Figure 10). Although the frontal nerve traversed inside the deep layers of the SMAS and the temporoparietal fascia (Figure 7), no obvious dissection plane was encountered between the superficial layer of the deep temporal fascia and either the SMAS or the temporoparietal fascia surrounding the temporal branch twigs over the zygomatic arch. Above the zygomatic arch, a fat layer called the superficial fat pad was observed between the temporoparietal fascia and the deep temporal fascia, and a thin layer of the temporoparietal fascia covered the temporal branch of the facial nerve medially in all specimens (Figure 5).

Despite many studies, controversy remains about the topography of the temporoparietal fascia, which comprises a fascial layer just under the subcutaneous tissue in the temporal region extending to the parietal region.1 After description of the SMAS of the face by Mitz and Peyronie,2 the temporoparietal fascia was recognized as important to the temporal branch of the facial nerve. These authors stated that the SMAS was a fibromuscular network located between the facial muscles and the dermis. According to their observations, the SMAS “crosses in front of the zygomatic arch and belongs to the temporozygomatic SMAS”2(p85) and is independent of the parotid fascia. In 1988, Hing et al3 noted that the temporoparietal fascia was attached to the zygomatic arch. In 1989, Stuzin et al4 demonstrated in cadaver dissections that the temporoparietal fascia continued as the SMAS across the zygomatic arch but was not in anatomic continuity with the periosteum of the zygomatic arch. However, Gosain et al5 claimed that the SMAS was not in anatomic continuity with the temporoparietal fascia. Gassner et al6 supported the finding by Gosain et al and stated that the SMAS and the temporoparietal fascia were in corresponding anatomic layers but lost their anatomic continuity when they fused with the zygomatic arch. In contrast, Campiglio and Candiani7 and Coscarella et al8 claimed that the temporoparietal fascia abutted the zygomatic arch and comprised the parotideomasseterica fascia below the zygomatic arch. Our results agree with the observation by Stuzin et al4 that the temporoparietal fascia had no attachment to the zygomatic arch. Our findings are consistent with most studies4,911 in the literature reporting that the temporoparietal fascia continues as the SMAS below the zygomatic arch. However, we demonstrate herein that the temporoparietal fascia becomes a foamy tissue between the upper level of the zygomatic arch and approximately 1 cm above the zygomatic arch. We also show that there are adhesions between the temporoparietal fascia and the superficial layer of the deep temporal fascia between the upper and middle levels of the zygomatic arch. Because of the fusion, elevation requires sharp dissection between these layers; this could endanger the temporal branch of the facial nerve, which is protected by only a thin layer of spongiosis-type temporoparietal fascia or SMAS over the zygomatic arch. However, we observed fibrous indentations from the SMAS into the superficial layer of the deep temporal fascia covering the parotid gland, which could reflect fusion of the SMAS and the parotid fascia to form a single layer.

Tellioğlu et al12 reported that the temporoparietal fascia was composed of inner and outer parts. They stated that the outer layer extended as the SMAS below the zygomatic arch. The inner layer blended with the superficial layer of the deep temporal fascia on the zygomatic arch and continued to the masseteric fascia. Hata13 disagreed with their findings, arguing that the outer layer of the fascia was “temporoparietalis” and that the inner part of the fascia was the “loose areolar layer” or the “subgaleal fascia.” Beheiry and Abdel-Hamid10 demonstrated that the temporoparietal fascia splits into the superficial layer and the deep layer and that the superficial layer splits into 2 other layers in the lower half of the temporal muscle. We show herein that the temporoparietal fascia is composed of multiple fascial layers that are integrated with thin fibrous septa.

The deep temporal fascia is a dense uniform aponeurotic layer covering the temporal muscle.1 There is agreement that the deep temporal fascia is a single layer attached along the length of the superotemporal line, where it blends with the periosteum14,15 and splits into the superficial and deep lamina above the level of the zygomatic arch.4,7,8,10,11,14,1620 However, it is controversial where the deep temporal fascia splits and where and if its layers abut the zygomatic arch or continue as the masseteric fascia over the zygomatic arch. Yaşargil et al21 demonstrated that the deep temporal fascia is divided into 2 layers at the orbital level. According to them, the superficial layer and the deep layer of the fascia that are attached to the lateral and medial borders of the zygomatic arch are separated by an intermediate fat layer. Stuzin et al4 subsequently showed that the deep temporal fascia splits into 2 layers below the supero-orbital margin. They documented that the superficial layer of the deep temporal fascia is attached to the superior margin of the zygomatic arch, overlies the periosteum of the zygomatic arch, and blends with the parotideomasseterica fascia. Salas et al9 argued that the deep layer of the deep temporal fascia is attached to the posterosuperior margin of the zygomatic arch, continues along the deep surface of the zygomatic arch, and blends with the “posteromasseteric fascia.” Ramirez et al19 found that the deep layer and the superficial layer of the deep temporal fascia fuse at 1 cm above the zygomatic arch and are attached to the superficial surface of the zygomatic arch, blending with the attachment to the fascia of the masseter muscle. Ammirati et al20 reported that 2 layers of this fascia are attached to the anterior portion of the zygomatic arch and continue with the parotideomasseterica fascia below the zygomatic arch. Campiglio and Candiani7 noted that the temporal muscle fascia split into 2 sheets at 5 cm above the zygomatic arch, with the superficial sheet abutting the anterior surface of the zygomatic arch and the deep sheet abutting the posterior surface of the zygomatic arch. These 2 fascial layers were fused in the anterior and posterior thirds of the zygomatic arch but were separated by a fat pad in the middle. Similarly, Hwang and Kim22 demonstrated that the superficial layer and the deep layer of the deep temporal fascia fused and abutted the superior margin of the zygomatic arch in 18 dissections (56%) and abutted the superolateral surface in 14 dissections (44%). Coscarella et al8 and Beheiry and Abdel-Hamid10 reported that the fascia of the temporal muscle split into 2 layers at 1 to 2 cm above the zygomatic arch or over the lower half of the temporal muscle, and the superficial fascia attached to the lateral side of the zygomatic arch. The deep fascia abutted the medial side of the zygomatic arch. In contrast, Accioli de Vasconcellos et al11 found that the deep temporal fascia was independent of the zygomatic arch (like the temporoparietal fascia) and continued caudally as the masseter muscle fascia. Our results are in agreement with the observations of all of these studies that the deep temporal fascia splits into the superficial layer and the deep layer. However, our findings demonstrate that the point where the fascia splits differs at the anterior, middle, and posterior portions of the zygomatic arch because of the fat pad between the layers of the fascia. We also show that the layers of the deep temporal fascia do not fuse above the zygomatic arch, but the 2 layers could be seen as a single layer if a cross-section was obtained near the lateral orbital rim. In most of our specimens, the superficial layer continues as the parotideomasseterica fascia, and the deep layer abuts the posterosuperior edge of the zygomatic arch. However, the superficial layer and the deep layer of the deep temporal fascia continued together across the zygomatic arch as the parotideomasseterica fascia in 27% of specimens (9 of 33 sides of 11 specimens).

Kim and Matic16 observed that a fibrous network divides the intermediate fat pad into lobules and that there is a dual arterial supply to the intermediate fat pad from perforators originating from the middle and deep temporal arteries, which pierce the superficial layer and the deep layer of the deep temporal fascia. Our study confirms that the intermediate fat pad is divided into several lobules by a fibrous network and that there are vessels inside the fat pad, especially at 5 to 24 mm from the zygomatic arch. We also show that perforators are more common between the intermediate fat pad and the superficial layer and the deep layer of the deep temporal fascia.

Researchers have called attention to the number of temporal branch twigs at the level of the zygomatic arch. Gosain et al23 demonstrated that 2 to 4 rami of the temporal branch of the facial nerve cross the zygomatic arch. Zani et al24 noted that the temporal branch of the facial nerve is composed of 1 twig in 28% of cases, 2 twigs in 32% of cases, 3 twigs in 16% of cases, and 4 twigs in 4% of cases at the level of the zygomatic arch. Ammirati et al20 showed that the temporal branch of the facial nerve is divided into anterior, middle, and posterior rami after piercing the parotideomasseterica fascia. In our study, the temporal branch of the facial nerve traversed along the zygomatic arch as 1 twig in 14.3%, as 2 twigs in 57.1%, as 3 twigs in 14.3%, and as 4 twigs in 14.3% of specimens.

Various approaches have been described for a safe surgical dissection around the temporal branch of the facial nerve and the zygomatic arch. Researchers7,8,11,14,20 have observed that the temporal branch of the facial nerve courses within the superficial fat pad. Because of this finding, Coscarella et al8 proposed submuscular dissection (deep to the temporal muscle) or subfascial dissection (deep to the deep temporal fascia layer). In contrast, other authors4,9,12,18 have noted the temporal branch of the facial nerve in the deepest temporoparietal fascia above the zygomatic arch. Beheiry and Abdel-Hamid10 reported that the temporal branch of the facial nerve coursed first between the layers of the superficial lamina of the temporoparietal fascia and then coursed between the deep layer and the superficial layer of the temporoparietal fascia. Consistent with these findings, Salas et al9 and Yaşargil et al21 recommended interfascial dissection. Ammirati et al20 showed that terminal twigs of the temporal branch of the facial nerve penetrated the temporoparietal fascia at different levels. They cautioned against mistaking the superficial fat pad for the intermediate fat pad and endangering the temporal branch of the facial nerve by interfacial dissection and instead recommended deeper dissection to preserve the facial nerve. In contrast, Stuzin et al4 claimed that a safe surgical plane is ensured by beginning dissection in the superficial fat pad of the temporal region and by deepening the dissection at 2 cm above the zygomatic arch into the intermediate temporal fat pad to expose the zygomatic arch. Ramirez et al19 reported in 1991 that there was no structure between the periosteum of the zygomatic arch and the temporoparietal fascia. Therefore, they suggested that subgaleal dissection should be deepened through the layers of the deep temporal fascia at about 3 cm above the zygomatic arch and that subperiosteal dissection should be performed at the level of and along the entire length of the zygomatic arch. In 2002, Ramirez25 described some changes in his surgical technique, noting that the zygomatic arch could be entered at 2 to 3 mm above the superior border of the zygomatic arch. As part of their midface-lift technique, Quatela and Olney published the recommendation “to elevate deep to the intermediate fat pad directly on the deep layer of the deep temporal fascia and then deep to the periosteum.”17(p217) Krayenbühl et al14 suggested that subgaleal fascia dissection can be performed up to the adhesions between the temporoparietal fascia and the deep temporal fascia and that interfacial or interlaminar dissection (between the 2 lamina of the deep temporal fascia) or subfascial dissection could then be performed to protect the facial nerve.

In light of our findings and the results of the studies reviewed herein, 3 approaches may be used to reach the zygomatic arch through the intermediate fat pad. The dissection plane is incised down to the periosteum (subperiosteal) on the zygomatic arch in all 3 approaches (Figure 11). The first approach is a subgaleal dissection (superficial to the superficial layer of the deep temporal fascia), deepening into the intermediate fat pad just above the zygomatic arch. Our study demonstrates that the temporal branch of the facial nerve is covered by a thin layer of the temporoparietal fascia above the zygomatic arch and that there is a superficial fat pad between the temporoparietal fascia and the superficial layer of the deep temporal fascia. However, our study also shows that this fat pad disappears and that adhesions are observed at the dissection plane beyond the upper edge of the zygomatic arch. Our findings suggest that continuous dissection on the subgaleal plane to the upper edge of the zygomatic arch is safe and easy. Beyond this level, subgaleal dissection carries the risk of injury to the temporal branch of the facial nerve. Therefore, the surgeon will need to continue deep dissection to at least a few millimeters above the zygomatic arch. The second approach begins with subgaleal dissection as in the first approach but deepens into the intermediate fat pad at 1 to 2 cm above the zygomatic arch. Our study shows that there are widespread vessels in the intermediate fat pad located 5 to 24 mm from the zygomatic arch. Although dissection using this approach would be safer than the first approach, more bleeding may occur. The third approach is to dissect the deep layer of the deep temporal fascia (deep to the intermediate fat pad) beginning from the division point of the layers of the deep temporal fascia. Our study shows that the intermediate fat pad can be easily dissected from the deep layer of the deep temporal fascia and that only a few small vessels are encountered along the dissection plane. Our results suggest that this approach is as safe as the second approach in terms of injury to the temporal branch of the facial nerve but that less bleeding and disruption of the fat pad occur compared with the second approach.

Correspondence: Ozcan Cakmak, MD, Acibadem University, Department of Otorhinolaryngology, Acibadem Kadikoy Hospital, Tekin Sokak, No. 8, Acibadem, Kadikoy, Istanbul, Turkey 34718 (ozcan.cakmak@gmail.com).

Accepted for Publication: July 14, 2009.

Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Babakurban, Cakmak, and Quatela. Acquisition of data: Babakurban, Cakmak, Kendir, and Elhan. Analysis and interpretation of data: Babakurban, Cakmak, Kendir, and Quatela. Drafting of the manuscript: Babakurban, Cakmak, Kendir, and Elhan. Critical revision of the manuscript for important intellectual content: Cakmak, Kendir, and Quatela. Statistical analysis: Babakurban. Administrative, technical, and material support: Cakmak, Elhan, and Quatela. Study supervision: Cakmak, Elhan, and Quatela.

Financial Disclosure: None reported.

Previous Presentation: This study was presented and awarded the best poster in the field of facial plastic surgery at the First Meeting of the European Academy of Otorhinolaryngology & Head and Neck Surgery in Collaboration With the European Federation of Oto-Rhino-Laryngological Societies; June, 28, 2009; Mannheim, Germany.

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Accioli de Vasconcellos  JJBritto  JAHenin  DVacher  C The fascial planes of the temple and face: an en-bloc anatomical study and a plea for consistency. Br J Plast Surg 2003;56 (7) 623- 629
PubMed
Tellioğlu  ATTekdemir  IErdemli  EATüccar  EUlusoy  G Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications. Plast Reconstr Surg 2000;105 (1) 40- 45
PubMed
Hata  Y Is it true that the temporoparietal fascia has two layered structures? Plast Reconstr Surg 2001;107 (5) 1309- 1310
PubMed
Krayenbühl  NIsolan  GRHafez  AYaşargil  MG The relationship of the fronto-temporal branches of the facial nerve to the fascias of the temporal region: a literature review applied to practical anatomical dissection. Neurosurg Rev 2007;30 (1) 8- 15
PubMed
Standring  S Gray's Anatomy: The Anatomical Basis of Clinical Practice. 39th ed. Edinburgh, Scotland Elsevier Churchill Livingstone2008;
Kim  SMatic  DB The anatomy of temporal hollowing: the superficial temporal fat pad. J Craniofac Surg 2005;16 (5) 760- 763
PubMed
Quatela  VCOlney  DR Management of the midface. Facial Plast Surg Clin North Am 2006;14 (3) 213- 220
PubMed
Sabini  PWayne  IQuatela  VC Anatomical guides to precisely localize the frontal branch of the facial nerve. Arch Facial Plast Surg 2003;5 (2) 150- 152
PubMed
Ramirez  OMMaillard  GFMusolas  A The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation. Plast Reconstr Surg 1991;88 (2) 227- 238
PubMed
Ammirati  MSpallone  AMa  JCheatham  MBecker  D An anatomicosurgical study of the temporal branch of the facial nerve. Neurosurgery 1993;33 (6) 1038- 1044
PubMed
Yaşargil  MGReichman  MVKubik  S Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy: technical article. J Neurosurg 1987;67 (3) 463- 466
PubMed
Hwang  KKim  DJ Attachment of the deep temporal fascia to the zygomatic arch: an anatomic study. J Craniofac Surg 1999;10 (4) 342- 345
PubMed
Gosain  AKSewall  SRYousif  NJ The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg 1997;99 (5) 1224- 1236
PubMed
Zani  RFadul  R  JrDa Rocha  MASantos  RAAlves  MCFerreira  LM Facial nerve in rhytidoplasty: anatomic study of its trajectory in the overlying skin and the most common sites of injury. Ann Plast Surg 2003;51 (3) 236- 242
PubMed
Ramirez  OM Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 2002;109 (1) 329- 349
PubMed
Abul-Hassan  HSvon Drasek Ascher  GAcland  RD Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77 (1) 17- 28
PubMed
Casanova  RCavalcante  DGrotting  JCVasconez  LOPsillakis  JM Anatomic basis for vascularised outer-table calvarial bone flaps. Plast Reconstr Surg 1986;78 (3) 300- 308
Tolhurst  DECarstens  MGreco  RHurwitz  D The surgical anatomy of the scalp. Plast Reconstr Surg 1991;87 (4) 603- 614
PubMed
Wen  HTde Oliveira  ETedeschi  HAndrade  FC  JrRhoton  AL The pterional approach: surgical anatomy, operative technique, and rationale. Oper Tech Neurosurg 2001;4 (2) 60- 7210.1053/otns.2001.25567

Figures

Place holder to copy figure label and caption
Figure 1.

Lines of the 2 coronal strips of tissue.

Graphic Jump Location
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Figure 2.

Preferred names of the anatomic structures given in the Table. The asterisk marks where the deep layer of the deep temporal fascia (D-DTF) abuts the posterosuperior surface of the zygomatic arch (ZA) on 10 sides. The superficial layers and the deep layers of the deep temporal fascia (DTF) fuse at the anterosuperior surface of the ZA on 4 sides of the cadaveric heads. DFP indicates deep fat pad; IFP, intermediate fat pad; MM, masseter muscle; PG, parotid gland; PMF, parotideomasseterica fascia; S, skin; S-DTF, superficial layer of the DTF; SFP, superficial fat pad; SMAS, superficial musculoaponeurotic system; TM, temporal muscle; TPF, temporoparietal fascia.

Graphic Jump Location
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Figure 3.

Coronal strips (A) and corresponding depictions (B) of the anterior (right), middle (center), and posterior (left) thirds of the specimen.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Dissection of the middle third of the coronal strip. The temporoparietal fascia (TPF) is composed of multiple layers. DFP indicates deep fat pad; IFP, intermediate fat pad; MM, masseter muscle; TM, temporal muscle; ZA, zygomatic arch.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Dissection of the hemiface of a cadaver. The superficial layer of the deep temporal fascia (S-DTF) continues as the parotideomasseterica fascia (PMF). SFP indicates superficial fat pad; TB-FN, temporal branch of the facial nerve; TPF, temporoparietal fascia; ZA, zygomatic arch.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Dissection of the posterior third of the coronal strip. There are fibrous indentations from the temporoparietal fascia (TPF) into the superficial layer of the deep temporal fascia (S-DTF) covering the parotid gland (PG). TB-FN indicates temporal branch of the facial nerve; TFA, transverse fascial artery; TM, temporal muscle; ZA, zygomatic arch.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

The topographic relationship of the temporoparietal fascia (TPF) to the temporal branch of the facial nerve (TB-FN). The temporal branch twigs of the facial nerve course within the TPF. D-DTF indicates deep layer of the deep temporal fascia; DFP, deep fat pad; IFP, intermediate fat pad; S-DTF, superficial layer of the DTF; TM, temporal muscle; ZA, zygomatic arch.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

The temporal branch twigs of the facial nerve. The facial nerve traverses along the zygomatic arch as multiple twigs. PG indicates parotid gland; S-DTF, superficial layer of the deep temporal fascia; TB-FN, temporal branch of the facial nerve; TPF, temporoparietal fascia.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 9.

Dissection of the middle third of the coronal strip in a fresh cadaver specimen. The superficial layer of the deep temporal fascia (S-DTF) continues across the zygomatic arch (ZA) as the parotideomasseterica fascia. The temporoparietal fascia (TPF) continues as the superficial musculoaponeurotic system (SMAS). IFP indicates intermediate fat pad; MM, masseter muscle; PG, parotid gland; SFP, superficial fat pad.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 10.

The topographic relationship of the temporal branch of the facial nerve (TB-FN) to the zygomatic arch (ZA). The distance between the ZA and the TB-FN piercing the fascia is 3 mm. The asterisk marks where the tissue was horizontally cut to show the relationship.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 11.

Dissection of the layers of the deep temporal fascia (DTF) and schematic view of surgical approaches to reach the zygomatic arch (ZA) through the intermediate fat pad (IFP). A, The deep layer of the DTF (D-DTF) can be easily dissected from the IFP. B, Three possible approaches indicated by numbers 1, 2, and 3 (see the last paragraph of the “Comment” section for a discussion). The asterisk marks the subgaleal dissection plane. A indicates artery; DFP, deep fat pad; MM, masseter muscle; S-DTF, superficial layer of the DTF; SFP, superficial fat pad; TM, temporal muscle; TPF, temporoparietal fascia; V, vein.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable. Naming of the Fascias and the Fat Pads in the Literature

References

Arinci  KElhan  A Anatomi. Vol 1.2nd ed. Ankara, Turkey Güneş Kitabevi Ltd Şti2006;
Mitz  VPeyronie  M The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58 (1) 80- 88
PubMed
Hing  DNBuncke  HAlpert  BS Use of the temporoparietal free fascial flap in the upper extremity. Plast Reconstr Surg 1988;81 (4) 534- 544
PubMed
Stuzin  JMWagstrom  LKawamoto  HKWolfe  SA Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg 1989;83 (2) 265- 271
PubMed
Gosain  AKYousif  NJMadiedo  GLarson  DLMatloub  HSSanger  JR Surgical anatomy of the SMAS: a reinvestigation. Plast Reconstr Surg 1993;92 (7) 1254- 1265
PubMed
Gassner  HGRafii  AYoung  AMurakami  CMoe  KSLarrabee  WF  Jr Surgical anatomy of the face: implications for modern face-lift techniques. Arch Facial Plast Surg 2008;10 (1) 9- 19
PubMed
Campiglio  GLCandiani  P Anatomical study on the temporal fascial layers and their relationships with the facial nerve. Aesthetic Plast Surg 1997;21 (2) 69- 74
PubMed
Coscarella  EVishteh  AGSpetzler  RFSeoane  EZabramski  JM Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontal branch of the facial nerve: technical note. J Neurosurg 2000;92 (5) 877- 880
PubMed
Salas  EZiyal  IMBejjani  GKSekhar  LN Anatomy of the frontotemporal branch of the facial nerve and indications for interfascial dissection. Neurosurgery 1998;43 (3) 563- 569
PubMed
Beheiry  EEAbdel-Hamid  FA An anatomical study of the temporal fascia and related temporal pads of fat. Plast Reconstr Surg 2007;119 (1) 136- 144
PubMed
Accioli de Vasconcellos  JJBritto  JAHenin  DVacher  C The fascial planes of the temple and face: an en-bloc anatomical study and a plea for consistency. Br J Plast Surg 2003;56 (7) 623- 629
PubMed
Tellioğlu  ATTekdemir  IErdemli  EATüccar  EUlusoy  G Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications. Plast Reconstr Surg 2000;105 (1) 40- 45
PubMed
Hata  Y Is it true that the temporoparietal fascia has two layered structures? Plast Reconstr Surg 2001;107 (5) 1309- 1310
PubMed
Krayenbühl  NIsolan  GRHafez  AYaşargil  MG The relationship of the fronto-temporal branches of the facial nerve to the fascias of the temporal region: a literature review applied to practical anatomical dissection. Neurosurg Rev 2007;30 (1) 8- 15
PubMed
Standring  S Gray's Anatomy: The Anatomical Basis of Clinical Practice. 39th ed. Edinburgh, Scotland Elsevier Churchill Livingstone2008;
Kim  SMatic  DB The anatomy of temporal hollowing: the superficial temporal fat pad. J Craniofac Surg 2005;16 (5) 760- 763
PubMed
Quatela  VCOlney  DR Management of the midface. Facial Plast Surg Clin North Am 2006;14 (3) 213- 220
PubMed
Sabini  PWayne  IQuatela  VC Anatomical guides to precisely localize the frontal branch of the facial nerve. Arch Facial Plast Surg 2003;5 (2) 150- 152
PubMed
Ramirez  OMMaillard  GFMusolas  A The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation. Plast Reconstr Surg 1991;88 (2) 227- 238
PubMed
Ammirati  MSpallone  AMa  JCheatham  MBecker  D An anatomicosurgical study of the temporal branch of the facial nerve. Neurosurgery 1993;33 (6) 1038- 1044
PubMed
Yaşargil  MGReichman  MVKubik  S Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy: technical article. J Neurosurg 1987;67 (3) 463- 466
PubMed
Hwang  KKim  DJ Attachment of the deep temporal fascia to the zygomatic arch: an anatomic study. J Craniofac Surg 1999;10 (4) 342- 345
PubMed
Gosain  AKSewall  SRYousif  NJ The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg 1997;99 (5) 1224- 1236
PubMed
Zani  RFadul  R  JrDa Rocha  MASantos  RAAlves  MCFerreira  LM Facial nerve in rhytidoplasty: anatomic study of its trajectory in the overlying skin and the most common sites of injury. Ann Plast Surg 2003;51 (3) 236- 242
PubMed
Ramirez  OM Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 2002;109 (1) 329- 349
PubMed
Abul-Hassan  HSvon Drasek Ascher  GAcland  RD Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77 (1) 17- 28
PubMed
Casanova  RCavalcante  DGrotting  JCVasconez  LOPsillakis  JM Anatomic basis for vascularised outer-table calvarial bone flaps. Plast Reconstr Surg 1986;78 (3) 300- 308
Tolhurst  DECarstens  MGreco  RHurwitz  D The surgical anatomy of the scalp. Plast Reconstr Surg 1991;87 (4) 603- 614
PubMed
Wen  HTde Oliveira  ETedeschi  HAndrade  FC  JrRhoton  AL The pterional approach: surgical anatomy, operative technique, and rationale. Oper Tech Neurosurg 2001;4 (2) 60- 7210.1053/otns.2001.25567

Correspondence

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