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Know anatomy of upper third of the face before performing surgery

Article-Know anatomy of upper third of the face before performing surgery

Key iconKey Points

  • In brow surgery, top of temporalis muscle must be 'freed-up' to allow adequate stability
  • Deep branch of supraorbital nerve most susceptible to injury during endoscopic brow lift
  • Candidates for lower eyelid surgery may be better candidates for midface lifting, fat grafting or cheek implants

Tulsa, Okla. — It's crucial to be very familiar with the anatomy of the upper third of the face before performing any surgery in that area, says a member of the board of the American Academy of Cosmetic Surgery (AACS).

"Anywhere you are doing surgery on the body, you have to know the anatomy inside and out," says Angelo Cuzalina, M.D., D.D.S., a maxillofacial surgeon and surgeon who is certified by the American Board of Cosmetic Surgery, and who serves as treasurer for the AACS.

"The face has the most compact anatomy of any place on the human body," Dr. Cuzalina said in an interview at the annual meeting of the 2009 American Association of Oral and Maxillofacial Surgeons. "There is a lot to consider. If you are going to do surgery and have as few complications as possible, the anatomy is critical to understand."

Dr. Cuzalina, who is in private practice at Tulsa Surgical Arts in Tulsa, Okla., notes the top of the temporalis muscle has to be "freed up" in brow surgery for adequate stability.

"The thing you need to know is that there are several muscles that help elevate or depress the brow," Dr. Cuzalina says. "The frontalis is the only elevator of the brow. Therefore, care must be taken to avoid damage to the frontalis muscle while still being able to selectively transect portions of the four main depressor muscles of the brow."

The corrugator supercilii muscle is intimately involved with the supraorbital nerve and the supratrochlear nerve, Dr. Cuzalina notes.

"Selective and cautious ablation of portions of this muscle is required to avoid damage to these sensory nerves," he says.

Of note, there are two branches of the supraorbital nerve: a deep branch and a superficial branch. The deep branch, which supplies the posterior scalp, is most susceptible to injury during an endoscopic brow lift procedure.

The motor nerves and fascia are both key to consider when performing a brow lift. "When you see the shiny fascia over the temporalis muscle, that is where you want to be," Dr. Cuzalina says. "The frontal branch of the facial nerve has multiple branches by the time it reaches the frontalis muscle. Care must be taken, however, to avoid overstretching the temporal tissue and to be well below the temporoparietal fascia in this area. Performing blepharoplasty requires just as much anatomical knowledge to avoid problems, particularly anything that may create a chronically dry eye."

Incisions too deep along the tarsus can damage both the levator and the orbicularis oculi. "Basic knowledge of location of the orbital septum related to the levator aponeurosis will help prevent damage to the muscle (levator) that is elevating the eye," he says. "Lower eyelid surgery is where more surgeons get into trouble than any other in the upper facial third."

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