ORIGINAL ARTICLE
Arterial anatomy of subdermal plexus of the face
Hak Chang
Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University(Received for publication on November 13, 2000)

Abstract. The subdermal plexus of the face was angiographically investigated using ten fresh cadavers
injected with a radio-opaque lead oxide-gelatin mixture over the entire body. The subdermal vessels
were unique in each region of the face, and the author classi®ed the vessels into three kinds according
to their running forms, shape of their skin territories, and arrangement of the territories. A kind of line
by anastomoses of the subdermal vessels which are mutually adjacent or by the quite elongated subdermal vessels was observed. The line depicted by those vessels almost coincided with the relaxed skintension lines. The author believes that when local ¯aps in the face are utilized, the ¯aps should bebetter designed along the line to obtain better blood supply and aesthetic outcome. (Keio J Med 50 (1):31±34, March 2001)
Key words: arterial anatomy, angiogram, face, subdermal plexus, relaxed skin tension lines

part of the subdermal plexus. Terminology of theplexus in the deep part of the dermis is controversial.
An appropriate demonstration and explanation for thesubdermal and dermal plexus have not been realized.
Recently, Imanishi et al.7 investigated the arterial
anatomy of the subdermal plexus in the lower back area
and clearly demonstrated the existence of the subdermal plexus in their preliminary report. They also
found that the subdermal plexus did not show uniform
vasculature, but it did have directionality, which must
be taken into account when raising a thin ¯ap. In thistime, the author has built upon their studies and focusedon the arterial anatomy of the face. The purpose of thestudy is to elucidate the arterial anatomy of the subdermal plexus in the face.

Introduction
Local ¯aps on the face are usually elevated above
the muscles of either facial expression or the super®cial
musculoaponeurotic system in order to prevent injury
of the facial nerve. Therefore, the blood supply to the¯aps is almost dependent upon the subdermal plexus.
To raise the ¯aps safely, a thorough understanding of¯ap vascular anatomy is imperative, however the anatomical detail of the subdermal vessels has remained
unknown. Although arterial anatomy encompassing theentire body has been angiographicaly investigated indetail, previous angiographic studies have generally
treated the skin and underlying soft tissue as a mass andtherefore were not designed to examine the subdermal
vessels.1±3
The blood vessels in the skin form some plexus. The
subdermal or cutaneous plexus is considered to be thejunction between the deep reticular portion of the dermis and the underlying subcutaneous fat tissue.4 Fromthe super®cial side of the subdermal plexus, numerous
arterioles run upward to form the dermal plexus. The
subepidermal or subpapillary plexus, the most super®cial plexus in the skin exists in the papillary-reticularborder of the dermis. Although the dermal plexus has
been considered in the reticular layer of the dermis,
some investigators5,6 didn't describe the existence ofthe plexus as being independent and considered it asMaterials and Methods
Ten fresh cadavers with ages ranging from 56 to 92
years at the time of death were studied. The cadavers
were dedicated to the Department of Anatomy, Keio
University for basic research. Four cadavers were female, and six were male. Lead oxide-gelatin mixture
was injected over the entire body.8 The skin and underlying soft tissue of the head and neck were elevated,
and the specimen was radiographed. Dissection wasperformed under the dermis and was then divided into
two layers which included the skin (including the epi-Reprint requests to: Dr. Hak Chang, Department of Plastic and Reconstructive Surgery, School of Medicine, Kyorin University, Shinkawa
6-20-2, Mitaka city, Tokyo 181-8611, Japan, e-mail: prschang@hotmail.com
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Chang H: Arterial anatomy of subdermal plexus of the faceFig. 1 Fresh cadaver arterial study of the face. The specimen
included the skin and underlying soft tissue of the head and neck.
(Left) Arteriogram of the lateral view of the right face and (Right)
Schematic picture of the skin territories. 1. super®cial temporal artery.
2. transverse facial artery. 3. zygomaticoorbital artery. 4. zygomaticotemporal artery. 5. posterior auricular artery. 6. occipital artery. 7.
infraorbital artery. 8. zygomaticofacial artery. 9. facial artery. 10. superior labial artery. 11. inferior labial artery. 12. submental artery. 13.
mental artery. 14. angular artery. 15. dorsal nasal artery. 16. supratrochlear artery. 17. supraorbital artery. 18. superior palpebral artery.
19. inferior palpebral artery.

dermis and dermis), and the subcutaneous adiposetissue. The super®cial specimen including the skin withthe various amount of the subdermal fat tissue was alsoradiographed. The stem vessels for the subdermal plexus
were determined, and the structure of the subdermal
plexus was observed.
Results
The blood supply of the face was provided by manybranches of the internal and external carotid artery.
Angiographic study revealed the rich anastomotic vascular networks that occur in the scalp between theoccipital, posterior auricular, and super®cial temporal
branches of the external carotid artery and the supratrochlear, and supraorbital, and dorsal nasal branchesof the internal carotid artery (Fig. 1). The subdermal
plexuses are formed by the terminal portions of thesebranches (Fig. 2).
The vessels forming the subdermal plexus wereunique in each region of the face. Upon analysis, thosevessels appeared to be grouped into three kinds (Fig.
3). In the cheek, lower lip, jaw and posterior neck, threeor four subdermal vessels which had branched off froma subcutaneous perforator were considerable in length.
Each skin territory of the subdermal vessels showed anelliptical shape, and those territories were arranged in a
spoke-like fashion (Fig. 3, Left). In the parietal, frontal,
palpebral, posterior auricular regions, nasal alar, nasal
dorsum, and upper lip, the subdermal vessels were alsoquite elongated. Each skin territory of the subdermal
vessels showed a further long elliptical shape or a large
elliptical shape, and those territories were arranged

Fig. 2 Arteriogram of the super®cial layer which includes the epidermis and dermis of the face. The subdermal plexuses were demonstrated. The ear includes a whole layer.

Fig. 3 Three kinds of the subdermal vessels. The vascular territory
for one subdermal vessel is depicted by an enclosed circle. The scale isa one-centimeter long. (Left) Vessels showing an elliptical skin territory arranged in a spoke-like fashion. (Center) Vessels showing an
elliptical skin territory arranged parallel. (Right) Vessels showing asmall and circular skin territory.

parallel (Fig. 3, Center). In the occipital, temporal
regions, red lip, nasal tip, and eyebrow, the subdermal
vessels radiated at the subdermal layer and theirbranches were running short way. Each skin territory of
the subdermal vessels was small and circular in shape(Fig. 3, Right). Although there were differences in thedistribution of the three kinds of the subdermal vessels
among individuals, a typical distribution was shown inFig. 4A.
On the other hand, a kind of line appeared partiallyby relatively large anastomoses of the adjacent subdermal vessels or by the quite elongated subdermal
vessels themselves. The lines were longitudinal in themidline of the anterior face, horizontal in the cheek,palpebral, mental and lateral regions to the eyebrow,and oblique, in the nasolabial fold and jaw. A schematic
drawing of these lines was shown in Fig. 4B.
Discussion
In this study systemic injection of lead oxide mixture
was used for analysis of the arterial circulation in freshKeio J Med 2001; 50 (1): 31±34A33BFig. 4 A) Distribution of the three kinds of the subdermal vessels.
Dark gray area: Vessels showing an elliptical skin territory arranged
in a spoke-like fashion. Light gray area: Vessels showing an ellipticalskin territory arranged parallel. Black area: Vessels showing a smalland circular skin territory. B) Lines by the subdermal vessels.

Fig. 5 Distribution of the three kinds of the subdermal vessels byWhetzel and Mathes. Dark gray, Light gray and Black areas show thesame meaning in the ®gure 4A. White area: type of the subdermal
vessels is uncertain.

human cadaver.8 In comparison to local injection, systemic injection produces sharp radiographs with highcontrast and detail.
This study showed that the structure of the subdermal plexus was angiographically varied in eachregion of the face. The vascular territories de®ned byeach subdermal plexus anastomose with one anotherto form the continuous vascular networks. Those connections between the territories were formed by
reduced caliber, choke anstomoses, in the face and thescalp area as described by Houseman, et al.9 True
anastomoses (i.e. the connection without change in caliber) have not been seen between the territories of the
facial skin in this study.
Angiographically distinct three patterns of the subdermal vascularization were observed in the head andneck area. A typical distribution of vascular pattern wasobtained, but there were differences in the distribution
among the cadavers. Although characteristics of thesubdermal vessels were almost consistent from region
to region, the size of each vascular territory varies.
Mapping of the subdermal vascular territory can bemade by comparing several specimens.
Previous studies have not demonstrated a variety
of detail in the subdermal vessels.1,10±13 However,Whetzel and Mathes14 identi®ed three different groupsof the vascular territories by macroscopic subdermal
dissection. The transverse facial territory was suppliedby one or two subcutaneous perforators whichbranched upon reaching the subdermal plexus intolarge and long terminal branches. The submental territory was also supplied predominantly by one perforator
that characteristically branched three to four times tosupply separate subcutaneous islands of dermis. The
musculocutaneous blood supply in the anterior facereached the dermis by means of hundreds of small perforators that terminated in a ®ne reticular patterncharacterized by the labial artery territories. The fasciocutaneous supply to the scalp was also characterized
by a dense subdermal vascular plexus supplied by hundreds of small subcutaneous perforators. The distribution of the subdermal vessels described by Whetzel andMathes14 was depicted in Fig. 5, although they did notrefer to many regions in the face and scalp. In thisstudy, all the areas in the face were angiographicallyinvestigated and it was found that the subdermal vessels
were divided into three different distinct groups as
Whetzel and Mathes had pointed out. However, there
were many differences between the author's ®ndings
and their's (See Figs. 4A and 5). Different level of subdermal dissection while preparing the specimens may
contribute to the differences. The skin was separated
just below the dermis in this study while the specimens
were excised in the subdermal plane by Whetzel andMathes. As a result of the difference in dissectional
planes, the subdermal vessels may show different morphology even within the same region.
This study provides additional data that local skin¯aps in the face include the subdermal vessels along the¯ap and there is a possibility of thinning of the ¯aps.
The midline forehead ¯ap1,15 can be raised on a narrow
pedicle which includes two supratrochlear and dorsal
nasal arteries. Although the ¯ap is elevated in the subgaleal plane at the proximal portion, thinning of the¯ap is possible in the upper half of the forehead. The
frontalis muscle and the subcutaneous tissue beneaththe dermis may be removed from the distal half of the¯ap because the numerous ®ne branches of the arteries
lie in the subdermal layer, which was demonstratedin Fig. 2. The nasolabial ¯ap1,15 is generally marked

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Chang H: Arterial anatomy of subdermal plexus of the facea local ¯ap with a large length to width ratios is elevated in the face, the long axis of the ¯ap should betterbe designed along Kraissl's lines in order to incorporate
the subdermal vessels in the ¯ap.

Fig. 6Kraissl's line (left) and Langer's cleavage line (right).

over the nasolabial fold and dependent on the numerous subdermal branches given off by the facial, angularartery and dorsal nasal artery. Those branches are also
illustrated in Fig. 2 and they run parallel to the source
arteries in the subdermal plane of the nasolabial fold.
The lateral orbital ¯ap16 is the subcutaneously-pedicled¯ap and includes the skin between the lateral orbital
wall and auricle. The ¯ap is based on the branches ofthe zygomaticofacial artery. In the arteriogram of theskin specimen we demonstrated that the rich subdermal
vascular networks exist in the area lateral and inferior
to the eyelid which are contributed by the branchesof the zygomaticofacial, the zygomaticoorbital and thetransverse facial artery. The ¯ap may be raised foreyelid or socket reconstruction as the subcutaneouslypedicled ¯ap inferomedially or superomedially.
The subdermal plexus presented a kind of line byanastomoses with neighboring vessels or by an elongated pathway of the subdermal vessels themselves.
This line is considered to be equal to a kind of anaxiality in a previous study.7 The surface of the skin andits deeper structure show various ``skin lines''. Skincreases, ¯exure lines and papillary ridge etc are externally visible skin lines, and Langer's cleavage lines andKraissl's lines are detectable after manipulation orincision17 (Fig. 6). Among these lines, Kraissl's lines(relaxed skin tension lines) are applied to minimize
postoperative scarring in the ®eld of plastic surgery.
The lines by the subdermal vessels approximately coincided with Kraissl's lines except for the forehead area.
These anatomic data play an important role when
designing incisions or raising local ¯aps. Local ¯aps on
the face are usually designed as preventing suture lines
from standing out, and blood supply to the ¯aps is not
usually taken in account. Local skin ¯aps in the headand neck may be raised safely due to the high density ofthe subdermal plexus of the face. This study shows thata rich subdermal anastomosis of vessels provides thesuperb blood supply to these ¯aps. In conclusion, when

Acknowledgments: I wish to express my gratitude to Dr. Tatsuo
Nakajima of the Department of Plastic and Reconstructive Surgery,
School of Medicine, Keio University for his valuable advice. I also
gratefully acknowledge the help of Dr. Hideo Nakajima of the Department of Plastic and Reconstructive Surgery and Dr. Nobuaki
Imanishi and Dr. Sadakazu Aiso of the Department of Anatomy,
School of Medicine, Keio University for their useful information andtechnical advice.

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