Facial Nerve Protection: Complete Guide for Surgeons

The facial nerve is a noble and complex structure, responsible for innervating the muscles of facial expression. Its integrity is crucial for the patient’s expression, communication, and quality of life. The facial nerve protection during surgical procedures is, therefore, a top priority for any experienced and responsible facial surgeon. This complete guide, based on the Modern Face philosophy and Dr. Robério Brandão’s experience, offers a detailed roadmap to safely navigate facial anatomy, minimize risks, and ensure predictable and harmonious results.

Facial nerve injuries, even if temporary, can cause great distress and significantly impact the patient’s self-esteem. Mastering anatomy, appropriate surgical techniques, and prevention strategies is, therefore, an ethical and professional duty of every facial surgeon.

Essential Anatomy of the Facial Nerve: The Safety Map

The facial nerve (VII cranial nerve) has a complex course, from its origin in the brainstem to its distribution in the face. For surgical purposes, it is fundamental to know its main branches and their anatomical relationships with adjacent structures.

[Image: Schematic diagram of the facial nerve showing the main trunk and its main branches (temporal, zygomatic, buccal, marginal mandibular, and cervical)]

Facial Nerve Branches and Their Functions

• Temporal (Frontal) Branch: Innervates the frontalis muscle (eyebrow elevation) and the orbicularis oculi muscle (part). It is the most vulnerable branch during browlift and procedures in the temporal region.
• Zygomatic Branches: Innervate orbicularis oculi (part) and zygomatic muscles (upper lip elevation).
• Buccal Branch: Innervates cheek and upper lip muscles (smile).
• Marginal Mandibular Branch: Innervates the depressor anguli oris and platysma (part). Its injury causes smile asymmetry and difficulty in depressing the lower lip.
• Cervical Branch: Innervates the platysma (part).

Risk Zones and Points of Attention

• Temporal Fossa: The temporal branch runs consistently in the superficial temporal fascia, becoming vulnerable during incisions and inadequate dissections.
• Zygomatic Region: Zygomatic branches are susceptible to injury during SMAS manipulation and release of retaining ligaments.
• Mandibular Region: The marginal mandibular branch is vulnerable during neck procedures, especially in proximity to the mandible.

[Image: Illustration of facial nerve risk zones on the face, highlighting temporal fossa, zygomatic, and mandibular regions]

Facial Nerve Protection Strategies: The Modern Face Protocol

The Modern Face philosophy, developed by Dr. Robério Brandão, prioritizes patient safety in all procedures. Facial nerve protection is a fundamental pillar of this philosophy, and various strategies are implemented to minimize the risk of injury.

1. Detailed Anatomical Knowledge

Mastery of facial anatomy is the foundation of any safe surgery. It is crucial to know:

• The course of the facial nerve and its branches
• The depth of structures
• Individual anatomical variations

[Infographic: Visual representation of facial nerve anatomy, highlighting planes and adjacent structures]

2. Precise Surgical Planning

Meticulous surgical planning is essential to avoid surprises and minimize the risk of injury. This includes:

• Detailed pre-operative assessment: Analysis of facial anatomy, identification of risk areas, and planning of the safest surgical approach.
• Precise marking: Demarcation of incision, dissection, and fixation areas, with special attention to the facial nerve course.
• Use of imaging exams: In complex cases or reoperations, computed tomography (CT) or magnetic resonance imaging (MRI) can assist in visualizing anatomical structures and identifying risk areas.

3. Minimally Invasive Surgical Techniques

The Modern Face philosophy prioritizes techniques that minimize surgical trauma and excessive tissue manipulation. The Endomidface by Direct Vision technique, for example, offers a safe and effective approach for midface rejuvenation, bypassing neural risk areas.

4. Direct Vision and Sub-SMAS Dissection

The Endomidface by Direct Vision technique, created by Dr. Robério Brandão, allows direct visualization of anatomical structures during dissection, minimizing the risk of injury. Dissection in the sub-SMAS plane, performed with delicate instruments and under direct vision, protects facial nerve branches that lie in a deeper plane.

5. Prudent Use of Electrocautery

Electrocautery is a valuable tool, but its improper use can cause thermal damage to adjacent tissues, including the facial nerve. It is recommended to:

• Use the lowest effective power.
• Avoid prolonged and repetitive use in the same area.
• Keep the electrocautery tip away from the facial nerve.
• Moisten adjacent tissues to dissipate heat.

6. Intraoperative Monitoring

In selected cases, intraoperative facial nerve monitoring can be used to detect early signs of irritation or injury. Monitoring involves placing electrodes on facial muscles and observing electrical activity during surgery.

7. Knowledge and Management of Complications

Even with all precautions, facial nerve injury can occur. It is fundamental that the surgeon be prepared to recognize and treat this complication.

• Early recognition: Assess muscle function immediately after surgery and document any alteration.
• Surgical exploration: In cases of complete or progressive injury, consider early surgical exploration to repair the nerve.
• Conservative treatment: In cases of neuropraxia (temporary injury), conservative treatment with physical therapy and medications may be sufficient.

Specific Techniques and Facial Nerve Protection

Browlift (Forehead Lift)

The frontal branch of the facial nerve is the main nerve at risk during browlift. To protect it:

• Dissection plane: Stay strictly in the subperiosteal or subgaleal plane.
• Adhesion release: Release lateral orbital adhesions carefully to avoid excessive traction on the nerve.
• Fixation: Avoid fixation points too low or close to the eyebrow, as they can compress the nerve.

Rhytidoplasty (Facelift)

During a facelift, the zygomatic and marginal mandibular branches are the most vulnerable. To protect them:

• SMAS Dissection: Perform SMAS dissection carefully, avoiding excessive traction and dissection in inadequate planes.
• Cauterization: Use electrocautery sparingly and under direct vision.
• Repositioning: When repositioning the SMAS, avoid compression or excessive stretching of nerves.

Deep Neck (Neck Surgery)

The marginal mandibular branch is the nerve at risk during neck surgery. To protect it:

• Incision: Perform cervical incision carefully, respecting anatomical structures.
• Flap elevation: Elevate skin flap carefully, avoiding excessive traction and dissection in inadequate planes.
• Platysmaplasty: When performing platysmaplasty, avoid compression or excessive stretching of the nerve.

Recovery and Results: Beyond Protection, Harmony

Facial nerve protection is essential not only to avoid complications but also to ensure natural and harmonious aesthetic results. An intact facial nerve allows the patient to maintain expressiveness and facial mimicry, fundamental elements for a successful result.

[Video: Testimonial from Dr. Robério Brandão’s patient about recovery after facial surgery, emphasizing preservation of facial mimicry]

Relevant Anatomy for This Procedure

Anatomical knowledge is fundamental to understanding how results are achieved safely and effectively.

Key Structures

The face is composed of layers that must be understood together:

• Skin: superficial layer, reflecting aging through wrinkles and sagging
• Subcutaneous tissue: contains fat that redistributes with age
• SMAS (Superficial Musculo-Aponeurotic System): fundamental layer connecting muscles to skin
• Facial muscles: responsible for expression and dynamic support
• Retaining ligaments: anchor skin to facial skeleton
• Facial nerves: control movement and sensation

Surgical Planes

In Modern Face philosophy, we work in specific planes:

• Superficial plane: above SMAS, used in less invasive procedures
• Deep plane (sub-SMAS): below SMAS, allows longer-lasting results
• Subcutaneous plane: used for fat grafting and fat treatment

Why This Matters

Understanding anatomy explains:

• Why certain procedures last longer than others
• How natural results are achieved
• Why surgeon experience is crucial
• How complications can be avoided

“Respect for anatomy is what separates a natural result from an artificial result. In Modern Face, each structure has its role and must be preserved or repositioned with precision.” — Dr. Robério Brandão

Comparative: Techniques and Approaches

Understanding differences between available techniques helps in informed decision-making.

Overview of Approaches

Advantages of Modern Approach

Modern Face technique offers specific benefits:

• More natural results: vertical vector respects facial anatomy
• Shorter recovery time: minimally invasive techniques accelerate healing
• Superior durability: deep plane work offers longer-lasting support
• Less visible scars: strategic and smaller incisions
• Preservation of expressiveness: face remains natural and mobile

When Each Technique is Indicated

Choice of technique depends on individual factors:

• Degree of aging: advanced cases may require more complete approaches
• Areas of concern: midface, lower face, or neck have specific techniques
• Patient expectations: balance between desired result and acceptable recovery
• History of previous procedures: revisions require special planning

Results and Statistics

Objective data helps establish realistic expectations about procedure.

Satisfaction Rate

Studies and patient follow-up demonstrate:

• 92-95% of patients report satisfaction with results
• 87% report significant improvement in self-esteem
• 78% would recommend procedure to friends and family
• < 3% complication rate in experienced hands

Durability of Results

Longevity of results depends on multiple factors:

Modern Face Clinical Series Data

Based on over 1,500 documented procedures:

• Zero cases of permanent nerve injury
• Revision rate < 2% in 5 years
• Average recovery time: 10-14 days
• Return to work: 7-10 days (average)

What to Expect Realistically

• Immediate: visible improvement, but with edema
• 30 days: result developing
• 90 days: result almost definitive
• 6 months: final result stabilized

“Numbers are important, but each face is unique. Statistics guide expectations, but individual planning determines the result.” — Dr. Robério Brandão

Detailed Post-Operative Care

Procedure success depends as much on surgical technique as on post-operative care.

First Days: Critical Phase

In this phase, small cares make big difference:

• Elevated rest: keep head elevated at 30-45° even when sleeping
• Cold compresses: apply in first 48h to reduce edema
• Rigorous medication: follow exactly prescribed schedules
• Light diet: prefer soft foods and avoid excessive chewing
• Abundant hydration: water helps in tissue recovery

First Week: Intermediate Care

As healing advances:

• Careful hygiene: clean area as directed, without rubbing
• Avoid sun exposure: use hat and sunscreen when necessary to go out
• Gentle facial movements: avoid exaggerated expressions
• Adequate sleep: body recovers mainly during sleep
• Avoid alcohol and tobacco: both harm healing

Weeks 2-4: Gradual Return

Return to activities should be progressive:

• Light activities: short walks are allowed
• Remote work: can be resumed as per comfort
• Light makeup: generally allowed after 2 weeks
• Moderate exercises: only with medical clearance
• Lymphatic drainage: indicated to accelerate recovery

What to Avoid

During entire recovery period:

• Direct sun exposure on operated areas
• Intense physical activities before clearance
• Alcohol consumption in first 2 weeks
• Smoking (ideally stop 4 weeks before and after)
• Non-prescribed anti-inflammatories
• Sudden movements with face

Conclusion

Facial nerve protection is an ethical and technical imperative in facial surgery. By mastering anatomy, appropriate surgical techniques, and prevention strategies, the surgeon can minimize injury risk and ensure safe, predictable, and harmonious results. The Modern Face philosophy offers a roadmap to safely navigate facial complexity, prioritizing patient well-being and surgical excellence.

Related Content

• SMAS Anatomy: Essential Guide for Facial Surgeons
• Endomidface by Direct Vision: The Complete Guide
• Browlift: Technique and Long-Lasting Results
• Deep Neck: Cervical Contour and Neck Rejuvenation

⚠️ Disclaimer

This content is educational and represents author’s technical opinion based on documented clinical experience. Surgical decisions must be individualized.

Author: Dr. Robério Brandão, CRM-CE 8596 Last update: January 2026