Secondary Logo

Share this article on:

Preserving Orbicularis Branches of the Zygomatic Nerve with the Orbicularis Oculi Muscle—Superficial Musculoaponeurotic System Flap Complex in Facelift Surgery

Ryu, Min-Hee, MD*; Kahng, David, MD; Khoo, Lee Seng, MD; Lao, William Wei-Kai, MD

Plastic and Reconstructive Surgery – Global Open: October 2018 - Volume 6 - Issue 10 - p e1961
doi: 10.1097/GOX.0000000000001961
Ideas and Innovations
Taiwan

Summary: The orbicularis oculi muscle (OOM) is sometimes incorporated with the superficial musculoaponeurotic system (SMAS) flap to provide a stronger flap. While elevating the OOM flap, it is important to avoid injury to the orbicularis branches of the zygomatic nerve. When the orbicularis branches of the zygomatic nerve are identified during the OOM-SMAS flap elevation, a transverse OOM flap was created to preserve the nerve. Postoperative follow-up was 12 months. There was no functional impairment of the OOM in the follow-up period. There are anatomical variations of the orbicularis branches of the zygomatic nerve. When it is identified, a transverse OOM flap incorporating it can be raised to avoid inadvertent injury. Using this method, good results were achieved with virtually no complications.

From the *The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Beijing, China

Cara Plastic Surgery and Laser Center, Los Angeles, Calif.

Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Published online 4 October 2018.

Received for publication May 31, 2018; accepted August 7, 2018.

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, Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Beijing, China, No. 109 Nongguangli, Chaoyang District, Beijing City, China 100021, E-mail: psryuminhee@gmail.com

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.

Back to Top | Article Outline

BACKGROUND

The superficial musculoaponeurotic system (SMAS) flap in the malar region can be thin and may tear easily, making it difficult to securely fix it during facelift surgery. The orbicularis oculi muscle (OOM) is sometimes incorporated with the SMAS flap to provide a more robust flap. While elevating the OOM flap, it is important to avoid injury to the orbicularis branches of the zygomatic nerve. When the orbicularis branches of the zygomatic nerve are identified during the OOM-SMAS flap elevation, a transverse OOM flap is created to preserve the nerves.

Back to Top | Article Outline

METHODS

A 54-year-old lady with no known medical illness underwent a high SMAS facelift with finger-assisted facial spaces dissection.1 , 2 Although the zygomatic and upper masseteric retaining ligaments were released in the sub-SMAS plane, the orbicularis branches of the zygomatic nerve were identified about 1.5 cm lateral to the origin of the zygomaticus major muscle on the right side (Fig. 1). An OOM flap incorporating the orbicularis branches of the zygomatic nerve was made after excising the redundant SMAS and OOM (Fig. 2). It was then transposed and sandwiched in between the OOM and SMAS flap (Fig. 3). The SMAS flap was brought out and fixed to the edges of the original SMAS and OOM incision with a transverse OOM flap incorporated into it (Fig. 4).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Back to Top | Article Outline

RESULTS

The orbicularis branches of the zygomatic nerve were identified only on the right side of this patient and not encountered on the left side. Postoperative follow-up was 12 months. No functional impairment of the OOM was noted during the follow-up period.

Back to Top | Article Outline

DISCUSSION

There are anatomical variations of orbicularis branches with regard to location, number, and thickness.2–7 When the SMAS flap is elevated during facelift surgery, it is sometimes encountered. In my cases, it is less than 10%. Several strategies can be employed to preserve these nerve branches. If 1 or 2 branches are identified, an island flap incorporating the nerves branches can be designed. In this case, we described multiple branches with variable destinations were identified. To preserve all branches, a transverse OOM flap was designed. It is also possible to design other suitable local flaps incorporating branches based on varying location, number, and thickness of the nerves. This flap is then repositioned or sandwiched between the original layer of the edges of the SMAS and the elevated SMAS. This maneuver and technique does not have a deleterious effect on the lifting and fixation of sagging tissues because of the narrow width and dimensions of the raised flap.

Back to Top | Article Outline

CONCLUSIONS

There are anatomical variations of the orbicularis branches of the zygomatic nerve.2–7 When multiple branches are identified, a transverse OOM flap incorporated as an OOM-SMAS flap complex can be used to avoid inadvertent injury to these important nerves. Damage to the orbicularis branches of the zygomatic nerve may cause unnatural facial animation and atrophy of muscles around the periorbital region. The OOM-SMAS flap complex allows the surgeon to redrape and reposition the sagging tissues during facelift surgery without causing any collateral damage to the orbicularis branches of the zygomatic nerve.

Back to Top | Article Outline

REFERENCES

1. 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.
2. Ryu MH, Moon VA, Yin W. The inclusion of orbicularis oculi muscle in the SMAS flap in Asian facelift: anatomical consideration of orbicularis muscle and zygomaticus major muscle. Aesthetic Plast Surg. 2018;42:471–478.
3. Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg. 2008;35:569–603, vi.
4. Ryu MH, Kahng D. Anatomical variation of zygomatic nerve branches around zygomaticus major muscle in facelift. Plast Reconstr Surg Glob Open. 2017;5:e1241.
5. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–896; discussion 897.
6. Hwang K. Surgical anatomy of the facial nerve relating to facial rejuvenation surgery. J Craniofac Surg. 2014;25:1476–1481.
7. 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.
Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.