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  • Conceptualizing superficial anatomy as a three-dimensional layered system helps understand the course and location of important neurovascular structures as they travel in a stepwise pattern in and between the muscular, bony, and fascial planes to reach their terminal areas of supply and innervation.

  • When approaching anatomically susceptible regions (“danger zones”), understanding the depth, course, and relation of these structures as they traverse anatomical boundaries provides the key to successful surgery.

image Beginner Tips

  • Striated muscles of the face (muscles of facial expression) produce movement of the overlying soft tissue by creating tension transmitted by fibrous strands (retinacula) that connect the SMAS to the skin.

  • Facial nerve branches, while generally protected by the SMAS, are surgically vulnerable as they reach areas of transition along their course toward their final destination.

  • The forehead and temple are functionally related to the scalp and through SMAS can easily glide over the skull.

image Expert Tips

  • The internal carotid artery via its ophthalmic branch supplies a central triangular area including the eyes, superior nose, and central portion of the forehead.

  • The angular artery and vein cross the medial canthal tendon and contribute to an important site of anastomosis just superior to the tendon between branches of the external carotid (facial artery) and internal carotid (ophthalmic artery).

  • Nasal blood supply is mainly from the angular artery externally and the sphenopalatine artery internally, with smaller contributions from the superior labial and ophthalmic arteries.

  • The parotid gland is contained within a shiny, tight fascial sheath (the parotid fascia), which helps differentiate it from fat.

image Don’t Forget!

  • The key area of anastomosis between the external and internal carotid arteries is located above the medial canthal tendon where the angular artery communicates with the dorsal nasal branch of the ophthalmic artery.

  • Both the facial artery and the marginal branch of the facial nerve lie deep to the fibers of the platysma.

image Pitfalls and Cautions

  • Erb’s point, located 6 cm below the midpoint of a line connecting the angle of the mandible with the mastoid process, provides a landmark for the exit point of the superficial cervical nerves and the accessory nerve (cranial nerve XI).

  • The mandibular branch of the facial nerve crosses over the facial artery about 5 to 10 mm above the point at which the facial artery crosses the mandible.


Understanding fundamental anatomy is crucial before embarking on any skin surgery—or any interventional procedure. Although head and neck anatomy is more subtle and complex than that of the trunk and extremities, even those restricting their practice to nonfacial areas need to understand the complex interactions between tissue planes in order to yield the best possible results—and confer the lowest possible risk of adverse events. Importantly, the head and neck display significant variation in skin thickness, texture, color, amount of subcutaneous ...

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