The frontal branch of the facial nerve across the zygomatic arch: Anatomical relevanceof the high-SMAS technique

Background: The frontal branch has a defined course along the Pitanguy line from tragus to lateral brow, although its depth along this line is controversial. The high-superficial musculoaponeurotic system (SMAS) face-lift technique divides the SMAS above the arch, which conflicts with previous descriptions of the frontal nerve depth. This anatomical study defines the depth and fascial boundaries of the frontal branch of the facial nerve over the zygomatic arch. Methods: Eight fresh cadaver heads were included in the study, with bilateral facial nerves studied (n = 16). The proximal frontal branches were isolated and then sectioned in full-thickness tissue blocks over a 5-cm distance over the zygomatic arch. The tissue blocks were evaluated histologically for the depth and fascial planes surrounding the frontal nerve. A dissection video accompanies this article. Results: The frontal branch of the facial nerve was identified in each tissue section and its fascial boundaries were easily identified using epidermis and periosteum as reference points. The frontal branch coursed under a separate fascial plane, the parotid-temporal fascia, which was deep to the SMAS as it coursed to the zygomatic arch and remained within this deep fascia over the arch. The frontal branch was intact and protected by the parotid-temporal fascia after a high-SMAS face lift. Conclusions: The frontal branch of the facial nerve is protected by a deep layer of fascia, termed the parotid-temporal fascia, which is separate from the SMAS as it travels over the zygomatic arch. Division of the SMAS above the arch in a high-SMAS face lift is safe using the technique described in this study.