COSMETIC

The Anatomy of the Corrugator SuperciliiMuscle: Part II. Supraorbital NerveBranching Patterns

Jeffrey E. Janis, M.D.Ashkan Ghavami, M.D.

Joshua A. Lemmon, M.D.Jason E. Leedy, M.D.

Bahman Guyuron, M.D.

Dallas, Texas; and Cleveland, Ohio

Background: This article focuses on delineation of supraorbital nerve branch-ing patterns relative to the corrugator muscle fibers and identifies four branch-ing patterns that help improve understanding of the local anatomy.Methods: Twenty-five fresh cadaver heads (50 corrugator supercilii muscles and50 supraorbital nerves) were dissected and the corrugator supercilii musclesisolated. After corrugator supercilii muscle measurement points were recordedfor part I of the study, the supraorbital nerve branches were then traced fromtheir emergence points from the orbit and dissected out to the defined topo-graphical boundaries of the muscle. Nerve branching patterns relative to themuscle fibers were analyzed, and a classification system for branching patternsrelative to the muscle was created.Results: Four types of supraorbital nerve branching patterns were found. Intype I (40 percent), only the deep supraorbital nerve division sent branches thatcoursed directly along the undersurface of the muscle. In type II (34 percent),branches emerging directly from the superficial supraorbital nerve were foundin addition to the branches from the deep division. Type III (4 percent)included discrete branches from the superficial division, but none from thedeep division. In type IV (22 percent), significant branching began morecephalad relative to the muscle and, therefore, displayed no specific relationto the muscle fibers.Conclusions: Contrary to previous reports, both the deep and superficialdivisions of the supraorbital nerve are intimately associated with corrugatorsupercilii muscle fibers. Four supraorbital nerve branching patterns fromthese divisions were found. Potential sites of supraorbital nerve compressionwere identified. This more detailed anatomical information may improve thesafety and accuracy of performing complete corrugator supercilii muscleresection. (Plast. Reconstr. Surg. 121: 233, 2008.)

In part I of this study, we reported data onthe topographical dimensions of the corru-gator supercilii muscle relative to fixed bony

landmarks.1,2 This allows for a more systematic andpredictable surgical approach to precise corruga-tor supercilii muscle resection for both foreheadrejuvenation and the surgical treatment of mi-graine headaches, which has been shown to beparamount to an optimal result.1–7

Most migraine headaches have been theorizedto be related to irritation, entrapment, and/or com-pression of peripheral nerve trigger points.8–13 Thesupraorbital and supratrochlear nerves have beenimplicated as the frontal trigger sites.8,9 This the-ory has been supported in part by the fact thatimprovement of symptoms has been demon-strated in a significant proportion of patients afterchemodenervation of the corrugator superciliimuscle by botulinum toxin type A.8–12,14–16

The supraorbital nerve and its intimate re-lationship with the corrugator supercilii muscle

From the Department of Plastic Surgery, The University ofTexas Southwestern Medical Center, and the Division ofPlastic and Reconstructive Surgery, Case Western ReserveUniversity School of Medicine.Received for publication December 3, 2006; accepted July 21,2007.Copyright ©2007 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000299260.04932.38

Disclosure: None of the authors received financialbenefit from any commercial entity in support of thisarticle.

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require further anatomical inspection. We hy-pothesize that the supraorbital nerve divisions dem-onstrate a more significant branching pattern andmuscular relationship with respect to the corrugatorsupercilii muscle than previously reported.

RELEVANT ANATOMYThe supraorbital nerve is a purely sensory

nerve that arises from the ophthalmic division(V1) of the trigeminal nerve. It exits through asupraorbital notch 90 percent of the time, but itcan also exit a true bony foramen located 1.5 cmcephalad to the supraorbital rim 10 percent of thetime.17–20 Beer et al.21 performed an extensive an-atomical study on the exit point(s) of the supraor-bital nerve and found a single exit point (eithernotch or foramen) in 84 percent of right orbitsand 82 percent of left orbits. However, in 14 per-cent of right orbits and 16 percent of left orbits,more than one exit point was found.21

After exiting the supraorbital rim (througheither a foramen or notch), the supraorbital nervetrunk divides into a superficial branch and a deepbranch.17,18,20 The deep division of the nerve splitsfrom the nerve trunk at the supraorbital notch in5 percent to 10 percent of patients, but it has beennoted that the deep branch can also branch outfrom a separate, more lateral foramen.17 The deepbranch has a more consistent distribution andruns deep to the frontalis in a cephalad directionbetween the galea and periosteum in the lowerhalf of the forehead to provide sensory innerva-tion to the frontoparietal scalp.17,18 Its course par-allels the temporal fusion line, traveling just me-dial to it.18 According to Knize,22 the deep divisiondoes not branch except for tiny “threadlike”strands extending to the underlying periosteum.

The superficial division divides into multiplesmaller branches that penetrate the frontalis mus-cle and pass over the muscle as they travel towardthe hairline to provide sensation to the foreheadand anterior scalp. This pattern was seen in 90percent of specimens evaluated by Knize.17,18 Whilethree types of branching patterns of the supraorbitalnerve deep branch have been described,17 thesewere not defined relative to the overlying muscula-ture and were described as always running deep toor within the galea.

On the basis of extensive intraoperative ob-servation, the senior author (B.G.) believes thereto be significant branching relative to the corru-gator supercilii muscle from both the deep andsuperficial supraorbital nerve divisions. Nerve fi-bers may be more closely associated with the cor-

rugator supercilii muscle fibers than previouslydescribed.

MATERIALS AND METHODSTwenty-five fresh cadaver heads (50 corruga-

tor muscles and 50 supraorbital nerves) were dis-sected using a cross-shaped incision centered overthe radix, with the transverse component follow-ing the eyebrow arches (Fig. 1). None of the ca-davers had previous trauma sustained to the an-atomical regions to be dissected. All dissectionswere carried out under 3.8� high loupe magni-fication. Adipocutaneous flaps were initially raisedto avoid inadvertent injury to the underlying mus-culature or avulsion of cutaneous nerve branchesfrom their nerve origins. The frontalis and de-pressor supercilii muscles were sharply dissectedoff of the corrugator supercilii muscle and ele-vated along with the skin flaps to complete theexposure. The full extent of the corrugator su-percilii muscle was delineated and meticulouslyteased off of the interdigitating orbicularis oculiand frontalis muscles (Fig. 2). Standardized mea-surements of corrugator supercilii muscle dimen-sions were taken before proceeding to the su-praorbital nerve dissection, and were reported inpart I of this study.1,2 Of note, evaluation of su-pratrochlear nerve patterns revealed consistentbranching within corrugator supercilii muscle fi-bers with no particular variations with respect tobranching patterns or nerve-muscle associations;therefore, no further microdissection of this nervewas performed.

The inferior aspect of the corrugator superciliimuscle was reflected, revealing the origin of thesupraorbital nerve trunk and its deep and super-ficial divisions, as well as their branches. Data and

Fig. 1. Cross-shaped incision. Markings indicate incision place-ment and planned flap dissection.

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observations were recorded as to the nerve fiberbranching patterns along the corrugator superciliimuscle, the plane in which they ran, and the spe-cific supraorbital nerve division from which theyoriginated. A limited neurolysis was performed,when indicated, to facilitate better delineation ofthe finer nerve branches that coursed along thecorrugator supercilii muscle. Dissection of the su-praorbital nerve branches was limited to the mostcephalad and lateral borders of the corrugatorsupercilii muscle, as only the supraorbital nervebranches associated with the corrugator musclefibers were deemed relevant for this study.These corrugator supercilii muscle brancheswere designated as superficial supraorbitalnerve– corrugator supercilii muscle (SON-SCSM)or deep supraorbital nerve– corrugator superci-lii muscle (SON-DCSM) depending on the nervedivision they arose from.

RESULTSFour types of supraorbital nerve branching

patterns were found relative to the corrugator su-percilii muscle fibers (Table 1). Branching patternswere classified according to the nerve divisionsthey originated from (SON-SCSM or SON-DCSM). Itshould be noted that while the designated su-praorbital nerve division commonly sent a single

dominant corrugator-related nerve branch, finernerve fibers (seen more often from the superficialbranch of the nerve) were occasionally seen, butalways from the same division. For simplification,finer nerve branches will not be included as partof a subclassification.

In type I (40 percent), the deep supraorbitalnerve division sent a single branch that courseddirectly along the undersurface of the corrugatorsupercilii muscle (Fig. 3). In type II (34 percent),branches from the superficial supraorbital nervewere observed in addition to nerve fibers from thedeep division (Fig. 4). Type III (4 percent) dis-played discrete corrugator supercilii muscle–re-lated branches from the superficial division, butnone from the deep division (Fig. 5). Type IVdisplayed no significant branching relative to thecorrugator supercilii muscle mass (Fig. 6 showsthe absence of corrugator supercilii muscle–re-lated supraorbital nerve branching). In the typeIV pattern, branching (not related to the cor-rugator supercilii muscle fibers) was noted toarise mostly from the superficial division, butonly after it passed the most cephalad portion ofthe corrugator supercilii muscle, while the deepdivision demonstrated no branches.

When a bony notch was present, there wasoccasionally a taut fibrous band that formed the

Fig. 2. Cadaver dissection depicting extent of corrugator supercilii mus-cle delineation and skeletonization.

Table 1. Supraorbital Nerve Branching Classification

Classification Branch Origin Right Left Overall

Type I Deep division 10 9 20/50 (40%)Type II Deep and superficial division 9 8 17/50 (34%)Type III Superficial division, no deep division 1 1 2/50 (4%)Type IV* No relation to CSM 5 5 11/50 (22%)CSM, corrugator supercilii muscle.*Branching usually began more cephalad relative to the corrugator supercilii muscle mass.

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anterior border of the supraorbital nerve notchand held the nerve trunk (or divisions) against thefrontal bone. Some nerve branches were seen tobe circumferentially enveloped by corrugatormuscle fibers at some point along their course, butthis was not a consistent finding. Interestingly,the specific branch (or branches) that was as-sociated with the corrugator muscle fibers al-ways coursed parallel to or nearly parallel to thedirection of these muscle fibers. A trend wasobserved in which supraorbital nerve branchesfrom both the deep and superficial divisionsbecame progressively more superficial duringtheir course away from their bony origin. Thesesuperficial branches were commonly present atthe anatomical borders of the corrugator mus-cle, where muscular insertion points and inter-digitations occur.

DISCUSSIONSuccessful forehead rejuvenation and surgical

deactivation of frontal trigger sites of migraineheadaches both require corrugator supercilii mus-cle resection. Knowledge of the exact course of thesupraorbital nerve along the corrugator musclemay assist in a more safe and effective approach toforehead rejuvenation by coronal, transpalpebral,or endoscopic approaches.

Four patterns of supraorbital nerve branchingwere found (Fig. 7). Specific nerve branches thatwere invested by the corrugator muscle seemed torun parallel with the muscle fibers after they splitoff from the superficial and deep divisions. Thisobservation may influence corrugator superciliimuscle dissection techniques to avoid unnecessarynerve sacrifice.

In type I (40 percent) only the deep supraor-bital nerve division sent branches (SON-DCSM) that

Fig. 3. Type I supraorbital nerve branching pattern. SON-D, deepdivision of the supraorbital nerve; SON-DCSM, branching fibersfrom the deep division of supraorbital nerve; CSM, corrugator su-percilii muscle. (Below) SON-D branching was simplified for illus-tration purposes. All illustrations will demonstrate the most com-mon branching relative to the supraorbital nerve division, withonly one fiber from the respective supraorbital nerve division.

Fig. 4. Type II supraorbital nerve branching pattern. SON-S, su-perficial division of the supraorbital nerve; SON-SCSM, branch fiberfrom SON-S relevant to the corrugator supercilii muscle; CSM,corrugator supercilii muscle; SON-D, deep division of the supraor-bital nerve; SON-DCSM, branch from deep division of supraorbitalnerve.

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coursed directly along the undersurface of thecorrugator supercilii muscle. Distinct branches(SON-SCSM) emerging directly from the superficialsupraorbital nerve were found in addition to thosearising from the deep division in type II (34 per-cent). In type III (4 percent), nerve patterns in-cluded discrete branches from the superficialdivision (SON-SCSM), but none from the deep di-vision. In type IV (22 percent), significant branch-ing occurred at a more cephalad location withrespect to the corrugator supercilii mass; there-fore, no branches specific to the corrugator mus-cle fibers were observed. Therefore, 74 percent ofthe time (types I and II), a corrugator muscle–related supraorbital nerve branch was shown toarise from the deep division, while 22 percent(type IV) of the time, no direct correlation be-tween the supraorbital nerve and the corrugatorsupercilii muscle exists.

Although supraorbital nerve branches werenot seen to perforate all the way through the cor-

rugator supercilii muscle fibers, they did changetheir direction as they coursed further from theirrespective parent supraorbital nerve division(s),taking on a slightly more parallel orientation withrespect to the corrugator muscle fibers.

Detailed knowledge of the potential sites ofnerve compression may be as important in thetreatment of migraine headaches as it has been inupper extremity. Interestingly, whenever a su-praorbital nerve notch was seen, there was occa-sionally a fibrous band located anterior to thenerve trunk, which constrained it against the bonynotch. Most often, the supraorbital nerve had al-ready split into its deep and superficial divisions asit emerged from this point. This band could po-tentiate further nerve irritation and/or compres-sion, regardless of the reason.

Fig. 5. Type III supraorbital nerve branching pattern. SON-S,superficial division of the supraorbital nerve; SON-SCSM, branchfrom the superficial division of the supraorbital nerve; CSM,corrugator supercilii muscle; SON-D, deep division of the su-praorbital nerve.

Fig. 6. Type IV supraorbital nerve branching pattern. (Above)Note the change in orientation. Represented view is lookingdown at the retracted corrugator supercilii muscle from a ceph-alad-to-caudal direction. (Above and below) Branching from thesuperficial division of the supraorbital nerve starts more cepha-lad relative to the corrugator supercilii muscle than other branch-ing patterns. SON-S, superficial division of the supraorbital nerve;CSM, corrugator supercilii muscle; SON-D, deep division of thesupraorbital nerve.

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Immediately cephalad to this point is the in-ferior free border of the corrugator supercilii mus-cle and, laterally, the inferolateral interdigitationwith the orbicularis oculi muscle. The free borderof the corrugator supercilii muscle is surroundedby a galeal fat “glide plane,”22 and nerve compres-sion here may be less common due to the amplesoft-tissue cushion, unless there has been priorinflammation or trauma.23 However, the locationof the deep division of the supraorbital nerve atthe site of corrugator supercilii muscle–orbicu-laris oculi interdigitation may be more susceptibleto nerve compression, particularly with repetitivemuscle contraction and increased muscle bulk.This can be observed clinically when the corruga-tor supercilii muscle contracts, as the mediallydirected pull of the muscle translates to the or-bicularis oculi beyond the temporal fusion line.

Overall, the deep division may be more sus-ceptible to compression at the lower portion of thefrontal bone, where it travels against the perios-teum to eventually course more medial to thetemporal fusion line. Any branches that arise fromthe more adherent portion of the deep supraor-bital nerve division must, by necessity, changetheir course to a more superficial one as they

course along the more superficially located cor-rugator supercilii muscle fibers. This deviationand change of plane from the firmly attacheddeep division is the next potential site of nervecompression.

Moving toward the hairline, another possiblesite of supraorbital nerve (and supratrochlearnerve) compression is the muscular interdigita-tion(s) of the corrugator supercilii muscle with thefrontalis and medial orbicularis oculi muscles.Nerve branches may be compressed between thevertically oriented frontalis and orbicularis fibersand the nearly transversely oriented corrugatormuscle fibers, where opposing muscular forcesmay create torqueing forces on any of the nervefibers.

CONCLUSIONSClarification of the nerve-muscle interac-

tions between the corrugator supercilii muscleand supraorbital nerve has been established.While classification systems are sometimes dif-ficult to apply to the clinical setting, recognitionof the various supraorbital nerve branching pat-terns and their frequency may assist the surgeonin safer and more systematic corrugator muscle

Fig. 7. Summary of supraorbital nerve branching pattern classification. (Left) Type I supraorbitalnerve branching pattern, the most common type (enlarged). (Right) Types II through IV. SON-S,superficial division of the supraorbital nerve; SON-SCSM, branch from the superficial division of thesupraorbital nerve; SON-D, deep division of the supraorbital nerve; SON-DCSM, branch from thedeep division of the supraorbital nerve.

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dissection/resection techniques for foreheadrejuvenation and migraine surgery.

From part II, we can conclude that (1) su-praorbital nerve compression implicated in mi-graine etiology may exist at specific points alongthe supraorbital nerve path in relation to the cor-rugator supercilii muscle and its anatomical bor-ders; (2) 78 percent of the time, supraorbital nervebranching begins closer to the supraorbital nervebony origin, allowing for more significant invest-ment by the corrugator supercilii muscle; (3) 22percent of the time, no supraorbital nerve branch-ing relative to the corrugator supercilii musclecould be established, since branching occurredmore cephalad relative to the bulk of the corru-gator muscle; (4) while some corrugator superciliimuscle fibers were noted to encircle branches ofthe supraorbital nerve, none actually perforatedthrough the muscle, and supraorbital nerve bonyexits that included a notch sometimes demon-strated a firm fibrous band that served as the an-terior constraint of the nerve, limiting its mobilityat the bony notch.

Interestingly, the distribution frequency ofsupraorbital nerve branching relative to the cor-rugator supercilii muscle seems to correlate withthe success rate of migraine treatment by com-plete corrugator resection.8 A study by Guyuronet al.8 showed complete or significant amelio-ration of migraine headaches in 79.5 percent ofpatients after corrugator resection. This is sim-ilar to the 78 percent supraorbital nerve branch-ing frequency (types I, II, and III) found in thecurrent study, in which the supraorbital nerveand corrugator supercilii muscle are closely as-sociated. It is plausible that those patients whodo not experience a significant improvement inmigraine headaches may exhibit type IV su-praorbital nerve branching, in which nervebranches and corrugator muscle fibers are notintimately related.

Future studies may serve to further delineatecorrelations among specific branching patterns,anatomical points of compression, and migraineheadache symptomatology.

Jeffrey E. Janis, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical Center1801 Inwood Road

Dallas, Texas 75390-9132Jeffrey.Janis@utsouthwestern.edu

ACKNOWLEDGMENTSThe authors thank Rod J. Rohrich, M.D., for his

generosity in donating the cadaver specimens used in

this study. They also extend their deep appreciation toKim A. Hoggatt-Krumwiede and Holly Smith for theirtalent and assistance with the images used in thisstudy.

REFERENCES1. Ghavami, A., Janis, J. E., Lemmon, J. A., Leedy, J. E., and

Guyuron, B. The corrugator supercilii muscle: An anatomicreappraisal. Presented at the American Society for AestheticPlastic Surgery/Aesthetic Society Education and ResearchFoundation Annual Meeting (Gaspar W. Anastasi Award Pre-sentation), Orlando, Fla., April 23, 2006.

2. Janis, J. E., Ghavami, A., Lemmon, J. A., Leedy, J. E., andGuyuron, B. The anatomy of the corrugator supercilii mus-cle: Part I. Corrugator topography. Plast. Reconstr. Surg. 120:1647, 2007.

3. Guyuron, B. Endoscopic forehead rejuvenation: Limita-tions, flaws, and rewards. Plast. Reconstr. Surg. 117: 1121,2006.

4. Guyuron, B., Michelow, B. J., and Thomas, T. Corrugatorsupercilii muscle resection through blepharoplasty incision.Plast. Reconstr. Surg. 95: 691, 1995.

5. Knize, D. M. Transpalpebral approach to the corrugatorsupercilii and procerus muscles. Plast. Reconstr. Surg. 95: 52,1995.

6. Walden, J. L., Brown, C. C., Klapper, A. J., Chia, C. T., andAston, S. J. An anatomical comparison of transpalpebral,endoscopic, and coronal approaches to demonstrate expo-sure and extent of brow depressor muscle resection. Plast.Reconstr. Surg. 116: 1479, 2005.

7. Guyuron, B. An anatomical comparison of transpalpebral,endoscopic, and coronal approaches to demonstrate expo-sure and extent of brow depressor muscle resection (Dis-cussion). Plast. Reconstr. Surg. 116: 1488, 2005.

8. Guyuron, B., Varghai, A., Michelow, B. J., Thomas, T., andDavis, J. Corrugator supercilii muscle resection and migraineheadaches. Plast. Reconstr. Surg. 106: 429, 2000.

9. Guyuron, B., Kriegler, J. S., Davis, J., and Amini, S. B. Com-prehensive surgical treatment of migraine headaches. Plast.Reconstr. Surg. 115: 1, 2005.

10. Mosser, S. W., Guyuron, B., Janis, J. E., and Rohrich, R. J. Theanatomy of the greater occipital nerve: Implications for theetiology of migraine headaches. Plast. Reconstr. Surg. 113: 693,2004.

11. Dash, K. S., Janis, J. E., and Guyuron, B. The lesser and thirdoccipital nerves and migraine headaches. Plast. Reconstr. Surg.115: 1752, 2005.

12. Totonchi, A., Pashmini, N., and Guyuron, B. The zygomat-icotemporal branch of the trigeminal nerve: An anatomicalstudy. Plast. Reconstr. Surg. 115: 273, 2005.

13. Austad, E. D. Comprehensive surgical treatment of mi-graine headaches (Discussion). Plast. Reconstr. Surg. 115:1759, 2005.

14. Binder, W. J., Brin, M. F., Blitzer A., Schoenrock, L. D., andPogoda, J. M. Botulinum toxin A (BTX-A) for the treatmentof migraine headaches: An open-label study. Otolaryngol.Head Neck Surg. 123: 669, 2000.

15. Dodick, D. W. Botulinum neurotoxin for the treatment ofmigraine and other primary headache disorders: Frombench to bedside. Headache 43(Suppl. 1): S25, 2003.

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16. Mathew, N. T., and Kaup, A. O. The use of botulinum toxintype A in headache treatment. Curr. Treat. Options Neurol. 4:365, 2002.

17. Knize, D. M. The Forehead and Temporal Fossa: Anatomy andTechnique. Philadelphia: Lippincott Williams & Wilkins, 2001.Pp. 28–44.

18. Knize, D. M. A study of the supraorbital nerve. Plast. Reconstr.Surg. 96: 564, 1995.

19. Cuzalina, A. L., and Holmes, J. D. A simple and reliablelandmark for identification of the supraorbital nerve in sur-gery of the forehead: An in vivo anatomical study. J. OralMaxillofac. Surg. 63: 25, 2005.

20. Williams, P. L., Warwick, R., Dyson, M., and Bannister, L. H.(Eds.). Gray’s Anatomy, 37th Ed. London: Churchill Living-stone, 1989. P. 1100.

21. Beer, G. M., Putz, R., Mager, K., Schumaker, M., andKeil, W. Variations of the frontal exit of the supraorbitalnerve: An anatomic study. Plast. Reconstr. Surg. 102: 334,1998.

22. Knize, D. M. Muscles that act on glabellar skin: A closer look.Plast. Reconstr. Surg. 105: 350, 2000.

23. Ramirez, O. M., and Pozner, J. N. Endoscopically assistedsupraorbital nerve neurolysis and correction of eyebrowasymmetry. Plast. Reconstr. Surg. 100: 755, 1997.

Online CME CollectionsThis partial list of titles in the developing archive of CME article collections is available online at www.PRSJournal.com. These articles are suitable to use as study guides for board certification, to help readers refamiliarizethemselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old can be taken for CMEcredit.

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