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Original Article

Anat Cell Biol 2023; 56(3): 313-321

Published online September 30, 2023

https://doi.org/10.5115/acb.23.040

Copyright © Korean Association of ANATOMISTS.

Anatomical knowledge of zygomatico-buccal plexus in a cadaveric study

Sukanya Uruwan1 , Chalermquan Rungsawang2 , Tawiwan Sareebot3 , Tanvaa Tansatit1,2

1Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 2Preclinical Department, Faculty of Medicine, Siam University, Bangkok, 3Department of Biomedical Engineering, College of Health Sciences, Christian University of Thailand, Nakhonpathom, Thailand

Correspondence to:Tanvaa Tansatit
Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
E-mail: Tansatitphumyoo@gmail.com

Received: February 7, 2023; Revised: March 17, 2023; Accepted: March 21, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The details of the facial nerve pattern were clearly explained in the parotid gland (PG), lateral area of the face, and periorbital areas to prevent the unexpected outcome of medical intervention. However, it remains unclear whether information about the zygomatico-buccal plexus (ZBP) in the masseteric and buccal regions. Therefore, this study aimed to help clinicians avoid this ZBP injury by predicting their common location. This study was conducted in forty-two hemifaces of twenty-nine embalmed cadavers by conventional dissection. The characteristics of the buccal branch (BB) and the ZBP were investigated in the mid-face region. The results presented that the BB gave 2–5 branches to emerge from the PG. According to the masseteric and buccal regions, the BB were arranged into ZBP in three patterns including an incomplete loop (11.9%), a single-loop (31.0%), and a multi-loop (57.1%). The mean distance and diameter of the medial line of the ZBP at the corner of the mouth level were 31.6 (6.7) and 1.5 (0.6) mm respectively, while at the alar base level were 22.5 (4.3) and 1.1 (0.6) mm respectively. Moreover, the angular nerve arose from the superior portion of the ZBP at the alar base level. The BB formed a multiloop mostly and showed a constant medial line of ZBP in an area approximately 30 mm lateral to the corner of the mouth, and 20 mm lateral to the alar base. Therefore, it is recommended that physicians should be very careful when performing facial rejuvenation in the mid-face region.

Keywords: Buccal branch, Zygomatico-buccal plexus, Facial rejuvenation

An arborization pattern of the buccal branch (BB) of the facial nerve has the most complexity and variability. The main branch of the BB originated from the temporo-facial or/and cervicofacial division(s) within the parotid gland (PG) [1]. There are 1–5 sub-branches of the BB that appear at the anterior border of the PG under the parotidomasseteric fascia or the superficial musculoaponeurotic system (SMAS) and travel medially to supply the facial muscles in the mid-face and lower face regions [2-5]. Frequently, the BB is described together with the zygomatic branch (ZB) as the zygomatico-buccal branch in maxillofacial surgery. Moreover, the ZB is identified if it is superficially located to the zygomatic bone, while the BB is inferiorly located to the zygomatic bone [6-10]. Although the BB is divided into many sub-branches, temporary facial dysfunction can occur in both nasal and oral areas such as nasal obstruction, poor oral efficacy, or defective facial expression [11, 12]. Furthermore, the BB was immolated in parotidectomy, bringing about the weakness of zygomaticotemporal division in 9% and cervico-mandibular nerve in 43% [13]. Recently, the facial paralysis resulting from the BB injury was found in maxillofacial trauma at approximately 88% [14]. Consequently, the absolute information about the BB and its relationship to the soft tissue is indispensable for surgical and non-surgical interventions [9].

In several literatures, the Davis classification is used to explain the detail of the facial nerve pattern in the PG and lateral area of the face to prevent the unexpected outcome of medical intervention [6, 15-21]. Moreover, the periorbital nerve pattern was described recently [22]. However, it remains unclear whether information about the zygomatico-buccal plexus (ZBP) in the masseteric and buccal regions. Therefore, the purpose of this study was to help clinicians avoid this ZBP injury by prediction of their common location. To achieve the purpose, the anatomical detail of the ZBP in the masseteric and buccal regions was investigated by using cadaveric dissection.

This study was approved with certificate of exemption No. 055/2021; IRB No. 0880/64 by the Institutional Review Board of the Faculty of Medicine Chulalongkorn University, Bangkok, Thailand. Forty-two hemifaces of twenty-nine embalmed cadavers, 15 males and 14 females with an average age of 79.0 (12.9) years, were conducted by conventional dissection. Moreover, the adult embalmed cadavers have been completely preserved and were injected with red latex into the common carotid artery. The characteristics of the BB and ZBP were investigated in the mid-face region.

Begin with, the cadavers were carefully dissected with layer by layers technique according to the facial tissue layers; skin, subcutaneous, SMAS, and sub-SMAS layers. Then, the number and origin of the BB were recorded at sub-SMAS layer. The location and diameter of the emerging point of the BB at the anterior border of the PG were investigated to correlate with the Frankfort’s horizontal line (FHL) and the anterior tragal line as the X and Y-axis, respectively (Fig. 1). After that, the relationship between the BB and parotid duct (PD) was recorded.

Figure 1. The location of the emerging point of the BB is sporadically distributed throughout the anterior border of the PG. Then, it branched and arranged into the ZBP in masseteric and buccal regions, and presented the medial line of the ZBP branched into small twigs to innervate muscles around the mouth and nose. BB, buccal branch; ZBP, zygomatico-buccal plexus; TB, temporal branch; ZB, zygomatic branch; BB1, first buccal branch; BB2, second buccal branch; BB3, third buccal branch; MMB, marginal mandibular branch; CB, cervical branch; AN, angular nerve; PG, parotid gland; PD, parotid duct; MM, masseter muscle; LLS, levator labii superioris muscle; OO, orbicularis oculi muscle; OOr, orbicularis oris muscle; DAO, depressor anguli oris muscle; red arrowhead, the medial line of the ZBP; yellow arrowhead, small twigs of the BB; blue arrow, ZB gave branch to connect the BB; FHL, Frankfort’s horizontal line; midFHL, midpoint of the FHL; ATL, anterior tragal line; red circle, emerging point of the BB.

After the BB passed through the vertical line perpendicular to the midpoint of FHL (midFHL) into buccal and infra-orbital regions, the origin and pattern of the ZBP were collected. The area of investigation was; superior: supra-alar crease, inferior: horizontal line from the corner of the mouth, lateral: vertical line at midFHL, and medial: vertical line at the corner of the mouth (Fig. 2). For positioning of the ZBP, the horizontal distance (parallel to the FHL) from the corner of the mouth and alar base were measured to the medial line of the ZBP. Moreover, the relationship between the ZBP and facial vein was recorded.

Figure 2. The area for investigation the pattern of ZBP (red area). ZBP, zygomatico-buccal plexus; SAC, supra-alar crest; CM, the corner of the mouth; midFHL, midpoint of the Frankfort’s horizontal line. TB, temporal branch; ZB, zygomatic branch; BB1, first buccal branch; BB2, second buccal branch; BB3, third buccal branch; PG, parotid gland; PD, parotid duct; LLS, levator labii superioris muscle; OO, orbicularis oculi muscle; OOr, orbicularis oris muscle; red arrowhead, the medial line of the ZBP.

The collected data of this study were analyzed by using IBM SPSS Statistics for Windows, Version 23.0 (IBM Co.). The descriptive statistics comprising frequency, percentage, mean, and standard deviation were adopted to present the characteristics of the BB and the ZBP.

The buccal branch of the facial nerve

The characteristics of the BB are summarized in Table 1. The results showed that the number of BB was 2–5 branches that emerged at the anterior border of the PG (Fig. 1). This nerve mostly originated from both temporo-facial and cervico-facial divisions (CFDs) in 88.1%. Moreover, the location of the emerging point of the BB was sporadically distributed throughout the anterior border of the PG superficial to the masseter muscle (MM). The mean distance of the emerging point was 29.7 (6.6) mm on the x-axis, whereas the nerves were distributed approximately 20%–30% in each 10 mm from 20–50 mm in the vertical distance perpendicular to the FHL. Furthermore, the mean diameter of the BB at the emerging point was 1.2 (0.6) mm, and the maximal diameter was approximately 5 mm.

Table 1 . The characteristics of the buccal branch of the facial nerve

CharacteristicsValueMean (SD)MinMax
Number (n=42)3.1 (0.8)25
210 (23.8)
320 (47.6)
410 (23.8)
52 (4.8)
Origin (n=42)
Main trunk1 (2.4)
Temporo-facial division4 (9.5)
Both division37 (88.1)
Location of the emerging point of BB correlated to FHL
All (n=130)Distance (x, y)29.7 (6.6), –29.9 (13.2)13.3, –2.248.3, –57.2
Diameter1.2 (0.6)0.45.2
Below FHL 0.1–10.0 mmDistance (x, y)32.4 (6.4), –6.4 (2.4)20.1, –2.238.7, –9.1
6 (4.6)Diameter1.6 (0.4)0.92.0
Below FHL 10.1–20.0 mmDistance (x, y)33.6 (5.2), –15.1 (2.7)23.5, –10.543.0, –19.9
30 (23.1)Diameter1.4 (0.6)0.43.4
Below FHL 20.1–30.0 mmDistance (x, y)32.0 (4.4), –24.4 (2.6)25.1, –20.241.5, –29.6
26 (20.0)Diameter1.5 (0.9)0.65.2
Below FHL 30.1–40.0 mmDistance (x, y)27.7 (7.1), –35.3 (2.7)15.8, –30.648.3, –39.9
38 (29.2)Diameter1.1 (0.4)0.42.2
Below FHL 40.1–50.0 mmDistance (x, y)24.5 (4.8), –45.2 (2.5)13.3, –40.432.6, –49.6
21 (16.2)Diameter1.00 (0.4)0.42.1
Below FHL >50.1 mmDistance (x, y)29.0 (7.3), –52.9 (2.1)15.7, –50.238.9, –57.2
9 (6.9)Diameter0.8 (0.2)0.51.2
Location of course of BB at MidFHLin vertical distance
All (n=148)Distance33.7 (12.0)11.970.4
Diameter1.3 (0.6)0.44.6
Below MidFHL 10.1–20.0 mmDistance16.4 (2.2)11.919.4
24 (16.2)Diameter1.5 (0.6)0.62.7
Below MidFHL 20.1–30.0 mmDistance24.9 (2.9)20.229.6
31 (21.0)Diameter1.5 (0.7)0.64.5
Below MidFHL 30.1–40.0 mmDistance34.7 (2.7)30.739.9
49 (33.1)Diameter1.2 (0.7)0.44.6
Below MidFHL 40.1–50.0 mmDistance44.3 (3.2)40.249.8
29 (19.6)Diameter1.0 (0.5)0.42.6
Below MidFHL >50.1 mmDistance55.4 (4.5)50.370.4
15 (10.1)Diameter1.00 (0.3)0.51.7
The relationship between BB and parotid duct (n=148)
Above34 (23.0)
Crossing32 (21.6)
Below82 (55.4)

Values are presented as number (%). BB, buccal branch; FHL, Frankfort’s horizontal line; MidFHL, midpoint of FHL; Min, minimum; Max, maximum.



As the BB passed through the vertical line perpendicular to the midFHL point into the buccal region, some BB gave smaller branches and also distributed throughout the MM (Fig. 1). The mean of vertical distance and diameter of the BB at the midFHL were 33.7 (12.0) and 1.3 (0.6) mm respectively. Moreover, the BB was distributed approximately 20%–30% in each 10 mm from 10–50 mm in the vertical distance perpendicular to the midFHL also. After that, the BB is extremely close to the PD and crossed the duct at 21.6%. Interestingly, the BB was arranged to form a plexus superficially to the PD and buccal fat pad at both masseteric and buccal regions, and initiated to branch as small twigs to innervate the facial muscles, especially zygomaticus major muscle. The buccal plexus is known as the ZBP. Moreover, the lowest branch of the BB traveled medially and located above the MM and deep to the buccal fat pad noticeably to innervate the buccinator muscle, while the ZBP was superficial to the buccal fat pad.

The ZBP

The characteristics of the ZBP were explained in Table 2. The present study revealed that the BB branched and arranged into the plexus, so the ZBP truly originated from the BB. Surprisingly, the pattern of ZBP could be divided into 3 patterns including incomplete loop, single-loop, and multi-loop patterns. Firstly, an incomplete loop was arranged from 3–4 branches of the BB and connected together as a medial line after passing through the anterior border of the MM. Then, the medial line of the ZBP branched into small twigs to innervate muscles around the mouth and nose. Secondly, a single loop was arranged from several branches but ostensibly observed as a big single loop. Lastly, a multiloop was the BB branched and connected to the plexus which could be observed more than 2 loops (Fig. 3). Furthermore, the mean distance and diameter of the medial line of the ZBP at the corner of the mouth level were 31.6 (6.7) and 1.5 (0.6) mm respectively, while at the alar base level were 22.5 (4.3) and 1.1 (0.6) mm respectively. Meanwhile, the relationship between the medial line of the ZBP and facial vein was observed at the corner of the mouth and alar base levels. The results presented that the ZBP positioned superficial to the facial vein at the corner, and located deep to the facial vein at the alar base level because the facial vein changed to locate in a superficial plane at the alar base level. Moreover, the angular nerve arose from the superior portion of the ZBP at the alar base level. It located under the levator labii superioris muscle (LLS), then penetrated the LLS to embed in the nasolabial fat locating superiorly to the LLS (Fig. 4).

Figure 3. Three patterns of the ZBP; incomplete (A, a), single (B, b), and multi-loop patterns (C, c). ZBP, zygomatico-buccal plexus; SAC, supra-alar crest; CM, corner of the mouth; PD, parotid duct; FA, facial artery; FV, facial vein; red arrowhead, ZBP; BB1, first buccal branch; BB2, second buccal branch; BB3, third buccal branch; LLS, levator labii superioris muscle; OOr, orbicularis oris muscle; ZMj, zygomaticus major muscle.

Figure 4. The origin and location of the AN that arose from superior part of the ZBP. ZBP, zygomatico-buccal plexus; AN, angular nerve; PD, parotid duct; LLS, levator labii superioris muscle; OO, orbicularis oculi muscle; red arrowhead, the origin of the AN; FV, facial vein; FA, facial artery.

Table 2 . The characteristics of the ZBP

CharacteristicsValueMean (SD)MinMax
Pattern of ZBP (n=42)
Incomplete loop5 (11.9)
Single loop13 (31.0)
Multiloop24 (57.1)
Location of medial line of ZBP (n=42)
At corner of the mouthDistance (x, y)31.6 (6.7), 4.1 (5.3)17.7, 044.3, 15.9
Diameter1.5 (0.6)0.63.6
At alar baseDistance (x)22.5 (4.3)13.731.3
Diameter1.1 (0.6)0.53.2

Values are presented as number (%). ZBP, zygomatico-buccal plexus; Min, minimum; Max, maximum.


The present study concentrated on the detail of the BB and ZBP in the mid-face region to pointedly explain the complicated anatomical information. The comparison of the characteristics of the buccal branch of the facial nerve was summarized in Table 3. The result presented that most of the BB originated from both temporo-facial and CFDs and had 2–5 branches at the anterior border of the PG. The findings suggested that the BB was rather constantly distributed in the area between anterior border of the PG and midFHL. On the contrary, it became very complex and unstable after passing through midFHL for the reason that the BB branched and arranged into the ZBP. Although the ZBP was formed by several BB branches. In some cases, the ZB gave branches to connect with the BB also. As a result, term of ZBP was still used in this study. Furthermore, many literatures defined the upper BB as the lower ZB in medical surgery [1, 2, 23, 24]. In addition, Ye et al. [25] reported that the lowermost zygomatic ramus connected with the upper BB to arrange into the ZBP.

Table 3 . Comparison of the characteristics of the buccal branch of the facial nerve

Present study
(2023)
Liu et al.
(2010) [3]
Dhiwakar and Khan (2016) [13]Eltohami et al.
(2019) [26]
Ahmed et al.
(2015) [4]
Hwang et al.
(2005) [27]
Tsai et al.
(2019) [29]
Bendella et al.
(2017) [1]
SampleThai embalmed adult cadavers (n=42)Chinese fresh adult cadavers (n=12)Cases of parotidectomy (n=104)40 cadavers, 10 patients (unilateral) (n=90)Embalmed adult cadavers (n=20)Korean embalmed cadavers (n=19)Taiwanese adult cadavers (n=35)95 cadavers (n=158)
Origin
Main trunk1 (2.4)-15 (14.4)-----
TFD4 (9.5)-8 (7.7)----
CFD--68 (65.4)78.9%----
Both37 (88.1)--21.1%----
Multiple--13 (12.5)-----
Number of branches
1-1 (8.3)---3 to 5 (mean 3.6±0.6)1 to 5 (mean 2.5±1.2)-
210 (23.8)4 (33.3)--50.0%-
320 (47.6)7 (58.3)--30.0%-
410 (23.8)---10.0%-
52 (4.8)---10.0%-
The relationship between BB and PD
Above34 (23.0)-----The number of intersections between the BB and the PD was 1 point (20%), 2 points (37%), 3 points (23%), 4 points (16%), and 5 points (6%).The BB related to the PD and formed plexus around the PD
Crossing32 (21.6)11 (91.7)----
Below82 (55.4)-----
BB formIncomplete loop 5 (11.9)----Type I superficially to the buccal fat pad 14 (73.7)
Single loop 13 (31.0)----
Multiloop 24 (57.1)----Type II penetration to the buccal fat pad 5 (26.3)

Values are presented as number (%). TFD, temporo-facial division; CFD, cervico-facial division; BB, buccal branch; PD, parotid duct.



Liu et al. [3] found that the BB gave 1–3 rami in 8.3%, 33.3%, and 58.3% respectively, and located superiorly to the PD was 10.3 (5.1) mm., and inferiorly to the PD was 10.8 (5.0) mm. Besides, the diameter of the nearest buccal branch to the PD was 1.6 (0.4) mm. Additionally, the mean length of the BB was 37.9 (7.3) mm, and the diameter of the BB was 1.0 (0.4) mm [21]. It innervated the zygomaticus, orbicularis oris and LLSs which responded to lip movement and blowing. Furthermore, the BB originated from the temporo-facial division (TFD) in 7.7%, the CFD in 65.4%, main bifurcation in 14.4%, and multiple origins in 12.5% [13]. Nonetheless, Eltohami et al. [26] reported that the BB originated from the CFD and both divisions in 78.9% and 21.1% respectively, but none of the BB originated from the TFD. Besides, Dhiwakar and Khan [13] suggested that the BB normally arose from the CFD.

Additionally, Ahmed et al. [4] explained that the BB were positioned both superior and inferior to the PD. The BB mostly presented with multiple rami including 2 branches in 50.0%, 3 branches in 30.0%, 4 branches in 10.0%, and 5 branches in 10.0% of specimens. In addition, the location of the BB was classified into 2 types correlated to the buccal fat pad; type I referred to the course of the nerve crossing superficially to the buccal fat pad, and type II referred to the course of the nerve penetration to the buccal fat pad. These nerve crossed superficially to the buccal fat pad in 73.7% and penetrated to the buccal fat pad in 26.3% [27].

In a previous study, the pattern of the facial nerve branches was classified into several patterns [1, 17, 19-21, 28]. Our study exclusively focused on the ZBP pattern. The results illustrated that the ZBP was positioned under the SMAS, but superficial to the PD and buccal fat pat at both masseteric and buccal regions. Moreover, it formed a multi-loop pattern in 57.1% (Fig. 2). It was possible that the BB injury could be occurred in these regions during facial surgery or parotidectomy. In the same way, the complex arrangement of the BB related to the PD was firstly classified at the anterior of the PG by Tsai et al. [29]. The results presented that the BB is located superiorly or/and inferiorly to the PD. These nerves crossed the duct in several points. Additionally, the number of intersections between the BB and the PD was 1 point (20%), 2 points (37%), 3 points (23%), 4 points (16%), and 5 points (6%). Similarly, Bendella et al. [1] summarized the attribute of the facial nerve to prevent the complications that might be occurred in head and neck surgery. They explained that the BB related to the PD and formed plexus around the PD, but it was referred in terms of the facial parotid plexus [1]. Moreover, the BB traveled superficially at the lateral side of the corner of the mouth at approximately 20 mm; as a result, the BB could be damaged. However, this plexus was different from the infraorbital plexus, because it was merely arranged from several branches of the BB, while an infraorbital plexus was arranged by the BB with the superior labial branches of the infraorbital nerve [1].

Surprisingly, the finding demonstrated that the medial border of the ZBP at the buccal region forms a constant line along the nasolabial fold. After that, it branched small twigs to innervate facial muscles. It is assumed that the cadavers were injected with red latex into the artery, therefore, the nerves could be clearly observed. Then, the medial line was carefully dissected by using the small artery for following the course of these nerves. The present study is the first study to inspect the medial line of the facial nerve correlated to the anatomical landmarks such as the corner of the mouth and the alar base, and the relationship between the nerves and the facial vein. Our findings suggests that the possibility that several branches of the BB do not separate individual branches, but each the BB was located harmoniously as nerve plexus, and formed a medial line at approximately 30 and 20 mm far from the corner of the mouth, and alar base respectively. After that the plexus gave small twigs to innervate muscles. These could conceivably describe why the BB has a low rate of transient weakness after nerve injury.

Although, the anatomical knowledge of the facial nerve has been investigated in widely, the facial nerve injury can occur in a several conditions such as trauma, parotidectomy, rhytidectomy or nonsurgical inventions [12, 30]. Moreover, facial rejuvenation has increased each year so the anatomical knowledge of the face is essential to avoid complication. Thread lift procedure is one minimally invasive technique to correct facial soft tissue sagging. Although, thread lift procedure was performed in subcutaneous layer, the facial nerve damage can occur in this procedure [31]. The data imply that the ZBP are located deep to SMAS layer. Consequently, when the thread lift procedure was performed in the mid-face region, the thread should not be performed closely SMAS or within sub-SMAS. In addition, the BB was distributed anteriorly to the PG and medially traveled superficial to the buccal fat pad for facial expression muscle innervation. This factor will probably cause the highest rate of BB paralysis after trauma at the mid-face region [14]. Moreover, Tsai et al. [32] recommended that thread lift procedure should performed in the deep plane of the face because the tread traveled under the buccal fat pad to avoid the BB injury.

In conclusion, the precise detail of the BB and ZBP were investigated by the cadaveric dissection. These provide the anatomical information that can both prevent and predict unexpected outcomes in the medical intervention in the mid-face region. Interestingly, the finding revealed that the BB was distributed approximately 20%–30% in each 10 mm from 10–50 mm in the vertical distance perpendicular to the midFHL and arranged into ZBP anterior to the midFHL. It formed a multiloop mostly and showed a constant medial line of ZBP in an area 30 mm lateral to the corner of the mouth, and 20 mm lateral to the alar base. Therefore, it is recommended that physicians should be very careful when performing facial rejuvenation at the region anteriorly to midFHL to prevent injury of the BB.

We would like to express my deepest gratitude to the cadaver who sacrificed their body for medical education. This research was supported by the 100th Anniversary Chulalongkorn University Fund for Doctoral Scholarship.

Conceptualization: SU, TT. Data acquisition: SU, CR. Data analysis or interpretation: SU, TS. Drafting of the manuscript: SU. Critical revision of the manuscript: SU, TS, TT. Approval of the final version of the manuscript: all authors.

No potential conflict of interest relevant to this article was reported.

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