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

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.

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.

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.

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. A dotted line will be incised.

Fig. 2.

An OOM flap incorporating orbicularis branches of zygomatic nerve was created while the redundant SMAS and OOM were excised. The SMAS flap was fixed to the superior and posterior edge of the original SMAS incision.

Fig. 3.

The OOM flap (a dotted line) incorporating orbicularis branches of zygomatic nerve was transposed and placed in between the OOM and SMAS flap.

Fig. 4.

The SMAS flap was brought and fixed to the superior edge of the original OOM incision with a transverse OOM flap (a dotted line) incorporating orbicularis branches of zygomatic nerve.

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.

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.

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.