י"ג/טבת/תש"ע

Facial

ד"ר פרידמן טל כירורגיה פלסטית בי"ח אסף- הרופא

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 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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SMAS Superficial 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, , triangularis, auricular posterior.  The SMAS over the parotid forms the .  A second layer of 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 region Mitz 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 , 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, alaeque nasi.

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3. Orbicularis oris, levator labii superioris.

4. , , 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-

 A thin, areolar layer that lies immediately on the surface of the facial n., anterior to the .  Analogous layers:  Neck- Cervical fascia.  Temporal region- Innominate fascia.  - 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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