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Anatomical Variation of Zygomatic Nerve Branches around Zygomaticus Major Muscle in Facelift

Ryu, Min-Hee, MD*; Kahng, David, MD

Plastic and Reconstructive Surgery – Global Open: February 2017 - Volume 5 - Issue 2 - p e1241
doi: 10.1097/GOX.0000000000001241

From the *Nanjing Medical University Friendship Plastic Surgery Hospital, Beijing, China; and David Kahng’s Plastic Surgery Clinic, Los Angeles, Calif.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Min-Hee Ryu, MD, Friendship Plastic Surgery Hospital, Nanjing Medical University, No. 109 Nongguangli, Chaoyang District, Beijing City 100021, China, E-mail:,

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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To improve midfacial soft-tissue sagging, it is sometimes necessary to release the zygomatic and upper masseteric retaining ligaments in the sub-superficial musculoaponeurotic system (SMAS) plane. Release of these ligaments needs to be done carefully to avoid any injuries to the branches of the facial nerve. Some of the zygomatic branches run toward the zygomaticus major muscle and are located deep to the fascia and pass deep under a third of the zygomaticus major muscle.1,2 However, anatomical variations of the zygomatic branches were found. This is a case of the anatomic variations of the zygomatic branches seen unilaterally in a single patient undergoing a facelift.

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A healthy 66-year-old female patient underwent a facelift procedure (Fig. 1).

Fig. 1.

Fig. 1.

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After the zygomatic and upper masseteric retaining ligaments were released in the sub-SMAS plane, an anatomical variation of the zygomatic branches was identified lateral to the origin of the zygomatic major muscle only on the left side. The branches penetrated from the deep fascia about 1 cm lateral to the origin of the zygomaticus major muscle; one ramus innervated orbicularis oculi muscle and the other ramus passed superficially above the upper third of the muscle. On the right side, this was not seen. The main zygomatic retaining ligaments are located immediately lateral to the origin of the zygomaticus major muscle. The zygomatic branches are usually located deep to the deep fascia in the lateral area of the muscle and pass deep under a third of the muscle. Therefore, the branches are protected while the retaining ligaments are dissected in the sub-SMAS plane. However, in this patient, the risk of the zygomatic branch injury is higher, so blunt dissection, adequate vertical traction of the SMAS flap, and the use of tumescent solution are needed to visually differentiate between the retaining ligaments and the nerve branches to avoid any injury.3

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We should be aware of this unique case where the variation was only seen unilaterally. Particular care must be taken when dissection is performed to release the retaining ligaments. We hope this case can contribute to avoiding nerve injuries in facelift procedures.

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1. Alghoul M, Bitik O, McBride J, et al. Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the Sub-SMAS danger zone. Plast Reconstr Surg. 2013;131:245e–252e.
2. Mendelson BC, Muzaffar AR, Adams WP Jr.. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–896; discussion 897.
3. Ryu MH, Moon VA. High superficial musculoaponeurotic system facelift with finger-assisted facial spaces dissection for Asian patients. Aesthet Surg J. 2015;35:1–8.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.