Clinical Anatomy (2019)

REVIEW

Surgical Anatomy of the Marginal Mandibular

Nerve: A Systematic Review and Meta-Analysis
ALBERTO VITO MARCUZZO ,1* AZZURRA NICOLE ŠURAN-BRUNELLI,1
ELISA DAL CIN,1 STEFANIA RIGO,1 ALICE PICCINATO,1
FRANCESCA BOSCOLO NATA,1 MARGHERITA TOFANELLI,1 PAOLO BOSCOLO-RIZZO,2
VITTORIO GRILL,3 ROBERTO DI LENARDA,4 AND GIANCARLO TIRELLI1
1
ENT and Head and Neck surgery Clinic, Department of Medical, Surgical and Health Sciences,
ASUITS, Trieste, Italy
2
Department of Neurosciences, ENT Clinic and Regional Center for Head and Neck Cancer,
University of Padua, Treviso Regional Hospital, Treviso, Italy
3
Department of Life Sciences, University of Trieste, Trieste, Italy
4
Maxillofacial and Dental Clinic, Department of Medical, Surgical and Health Sciences,
ASUITS, Trieste, Italy

The high number of marginal mandibular nerve (MMN) anatomical variants have a
well-known clinical significance due to the risk of nerve injury in several surgical pro-
cedures. The aim of this study was to find and systematize the available anatomical
data concerning this nerve. The PubMed and Scopus databases were investigated in
accordance with the Preferred Reporting Items for Systematic Reviews and Meta-
analyses guidelines. All studies reporting extractable data on the origin, course, split-
ting, anastomosis and relationship of the MMN with the mandible or the facial vessels
were included. We included 28 studies analyzing 1861 halves. The MMN had one
(PP = 35% 95% CI:18–54%), two (PP =35% 95% CI:18–54%), three (PP = 18%
95% CI:0–35%), or four branches (PP = 2% 95% CI:0–8%). Anastomosis with the
great auricular nerve, transverse cervical nerve, mental nerve, and other branches of
the facial nerve were defined. The origin of the MMN in relation to the parotid and the
mandible was variable. The MMN nearly always crossed the anterior facial vein later-
ally (PP = 38% 95% CI:9–72% if single, PP = 57% 95% CI:22–90% when multiple);
its relation with other vessels was less constant. At least one branch of the MMN was
found below the inferior border of the mandible (IBM), with a PP of 39% (95%
CI:30–50%). The MMN has high anatomical variability and it is more often represen-
ted by one or two branches; its origin is frequently described at the parotid apex and
above the IBM, although in its course at least one branch often runs below the IBM.
Its most frequent anastomosis is with the buccal branch of the facial nerve. Clin.
Anat. 00:000–000, 2019. © 2019 Wiley Periodicals, Inc.

Key words: marginal nerve; marginal mandibular nerve; neck dissection

INTRODUCTION
*Correspondence to: Alberto Vito Marcuzzo, ENT and Head and
The marginal mandibular nerve (MMN) is one of the Neck surgery Clinic, Department of Medical, Surgical and Health
five extratemporal branches of the facial nerve. The facial Sciences, ASUITS–Strada di Fiume 447, Trieste CAP 34137,
Italy. E-mail: [email protected]
nerve exits through the stylomastoid foramen, gives off
secondary motor branches (to the auricular muscles, Received 25 June 2019; Revised 20 August 2019; Accepted 17
posterior belly of digastric muscle, and stylohyoid mus- September 2019
cles), and enters the posteromedial surface of the parotid Published online 00 Month 2019 in Wiley Online Library
gland (Khanfour et al., 2014). It then divides into (wileyonlinelibrary.com). DOI: 10.1002/ca.23497

© 2019 Wiley Periodicals, Inc.

2 Marcuzzo et al.

branches emerging separately from the gland in order to based on predetermined exclusion and inclusion criteria.
supply the muscles of facial expression. Although the A gray literature search including the first 200 results of
branching pattern varies widely, an upper arm, dividing the Google Scholar search engine were analyzed. Addi-
into temporal, zygomatic and buccal branches, and a tionally, we conducted a manual search using the bibli-
lower arm, splitting into marginal mandibular and cervi- ographies of reports to identify further eligible studies.
cal branches, have been described. The MMN guarantees
innervation of the depressor anguli oris, depressor labii
inferioris, mentalis, and orbicularis oris muscles. Due to Eligibility Assessment
this innervation pattern, lesion to this nerve may cause All studies that reported clear and extractable data
inability to move the lower lip downward or laterally, an on at least one of the following MMN characteristics
aesthetic deficit that has a great impact on the patient’s were included: origin of the nerve, number of bra-
perception of appearance (Qahtani et al., 2015). Such a nches, splitting of the nerve, anastomosis with other
deficit inevitably affects the patients’ quality of life and nerves or between its own branches, relation with the
can often result in legal claims (Potgieter et al., 2005). facial vessels, and position relative to the inferior bor-
The most frequent cause of lesion to the MMN is iatro- der of the mandible (IBM). Review papers, conference
genic injury during various surgical procedures, such as abstracts, letters to the editor, practice guidelines,
parotidectomy, submandibular gland excision, carotid and case reports were excluded.
endarterectomy, open reductions of mandibular angle
fractures, rhytidoplasty, submental flap harvesting and
neck dissection, particularly during dissection of peri- Data Extraction
facial nodes (Lim et al., 2006; Khanfour et al., 2014;
Tirelli and Marcuzzo, 2018). The main cause of nerve Extracted data included year of publication, coun-
injury is the lack of reliable anatomical landmarks due to try of the study, number of facial halves studied and
the high variability of the MMN. For this reason, several type of specimen. Data on anatomical variations were
surgical techniques have been adopted over the years to collected with regard to origin, course, splitting, anas-
prevent nerve injury (Potgieter et al., 2005; Al-Hayani, tomosis, and relationship of the MMN with the IBM.
2007). The Hayes-Martin maneuver has been classically Relationships with facial vessels were also noted.
described as safe in preventing nerve damage. However,
the technique is not considered oncologically safe when
Statistical Analysis
Level I must be cleared since the perifacial nodal
groups remain undissected (Tirelli et al., 2019). Although Statistical analysis was performed using the dedicated
nerve integrity monitoring (NIM) seems promising in software MetaXL version 3.0 by EpiGear International
preventing nerve injury, all authors state that a thorough Pty. Ltd. (Wilston, Queensland, Australia). A random-
understanding of the complex anatomy of the MMN is effects model of meta-analysis, chosen in view of the
crucial regardless of the surgical technique used (Tirelli heterogeneity of the studies under review, was used to
and Marcuzzo, 2018). Different anatomical variations of calculate pooled prevalence (PP) estimates. The I2 and
the MMN have been described in the literature but there χ2 test were used to measure heterogeneity among the
is no consensus on their prevalence. Considering this var- studies. Cochran’s Q indicated heterogeneity of the sam-
iability and its clinical significance, data on these anatom- ples (Cochrane Handbook) (Higgins et al., 2011). The
ical variants need to be consolidated. The aim of this 95% confidence intervals (95% CI) were calculated by
study was to systematically review the prevalence and using the “prop. test” function of the “rmeta” package
characteristics of the anatomical variations of the MMN and shown on the forest plot and described in the results
and its relationship with the surrounding structures to paragraph.
improve anatomical knowledge and help perform surgi-
cal procedures more safely.
RESULTS
MATERIALS AND METHODS Study Identification
Data Sources and Search Strategy The initial search yielded a total of 5,514 articles. The
The authors performed a systematic review in accor- results were deduplicated and screened through titles
dance with the Preferred Reporting Items for Systematic and abstracts; the exclusion criteria were then applied.
The manual bibliographic search identified 21 additional
Reviews and Meta-analyses guidelines. An extensive lit-
erature search of the PubMed and Scopus databases studies eligible for inclusion. Finally, 47 articles were
selected for detailed review; among them, 29 studies
was conducted by two independent reviewers (AVM and
ANŠB). Keywords were chosen by searching the medical were excluded for lack of data. A total of 28 studies were
subject headings (MeSH) for eponyms for the MMN. finally included in this systematic review (Fig. 1).
Keyword combinations used in the search algorithm are
shown in Figure 1. Articles not written in English were Characteristics of Included Studies
excluded. Articles were initially reviewed by evaluating
title and abstract; disparities in selection were resolved Of the 28 studies included, 24 were cadaveric stud-
through collegial discussion among the authors. All rele- ies (n = 1,463 halves) and four were surgical studies
vant studies were selected for full-text assessment (n = 398 halves), for a total of 1861 halves. Papers
 Surgical Anatomy of the Marginal Mandibular Nerve 3

marginal mandibular nerve OR marginalis mandibulae nerve OR marginal nerve ORmarginalis nerve

IDENTIFICATION
+
anatomy OR dissection ORbranches ORvariations

Records identified n = 5514

Double records excluded

SCREENING

n=813
Additional studies found with Records excluded based on
manual searching n= 21 abstract n= 4669
Case reports/reviews/fetal
study excluded n = 6

Records assessed for elegibility

ELEGIBILITY

(screened based on full texts)

n = 47

Records excluded
(incomplete data)
n= 19
INCLUDED

Eligible articles included n = 28

Cadaveric Studies n = 24 In vivo studies n = 4

Fig. 1. Flow diagram of Preferred Reporting Items for Systematic Reviews and
Meta-analyses (PRISMA) for the systematic literature search. [Color figure can be
viewed at wileyonlinelibrary.com]

showed a wide geographical distribution and the year Number of Branches and Splitting
of publication ranged from 1981 to 2016.
A total of 18 articles provided data on the number
of branches of the MMN (1,334 halves); one to four
branches of the MMN were observed.
Origin of the Marginal Mandibular Nerve in The PP of one, two, three, or four branches were
Relation to the Parotid Gland and the 35% (95% CI: 18–54%), 35% (95% CI: 18–54%),
Mandible 18% (95% CI: 0–35%), and 2% (95% CI: 0–8%),
respectively. These data indicate that the MMN is most
A total of seven articles presented data on the site of likely to have one or two branches (Table 1).
origin of the MMN in relation to the parotid gland or the
mandible (410 halves). Four studies (230 halves) pres- Nerve Anastomosis
ented data on the relation between the origin of the
MMN and the parotid gland. The PP of the MMN originat- A total of 17 articles described the presence of ner-
ing from the anterior border of the parotid was 20% vous anastomosis with the MMN, for a total of 1,097
(95% CI: 0–100%). The PP of the MMN originating from halves.
the parotid apex was 30% (95% CI: 0–100%). In the
case of multiple branches, the PP of the MMN originating Connection with the Branches of the Facial
from both the anterior border and the apex was 6% Nerve
(95% CI: 0–100%).
Four studies (230 halves) reported data about the The PP of inter-MMN anastomosis was 3% (95% CI:
origin of the MMN in relation to the mandible. The PP of 0–9%). Considering anastomosis between the MMN and
an MMN origin above the mandible was 76% (95% CI: other branches of the facial nerve, the PP of anastomosis
26–100%) and below the mandible 18% (95% CI: between the MMN and the cervical branch of the facial
0–66%). In the case of multiple branches, the PP of the nerve was 5% (95% CI: 1–13%), the PP of anastomosis
MMN originating from both above and below the mandi- between the MMN and the buccal branch of the facial
ble was 4% (95% CI: 0–36%). Based on our analysis, nerve was 20% (95% CI: 10–32%), the PP of anasto-
an MMN origin from the parotid apex and above the mosis between the MMN and the zygomatic branch of
mandible should be considered the most common vari- the facial nerve was 1% (95% CI: 0–4%). Based on our
ant, in the case of both single and multiple branches analysis, the most common anastomosis of the MMN is
(Table 1). with the buccal branch of the facial nerve (Table 2).
TABLE 1. Origin of Marginal Mandibular Nerve and Number of Branches
4 Marcuzzo et al.

Origin in relation to the Origin in relation

parotid gland N (%) to the mandible N (%) No. of branches N (%)
Both from the Both above
anterior border and below
From the and the apex the mandible
No. of anterior From the (multiple (multiple
Author Year Country halves border apex branches) Above Below branches) 1 2 3 4
Cadaveric studies
Rossell-Perry 2016 Perù 64 ND ND ND ND ND ND 58 (91) 6 (9) 0 (0) 0 (0)
Yang et al. 2016 Korea 29 ND ND ND ND ND ND 16 (55) 11 (38) 2 (7) 0 (0)
Davies et al. 2016 UK 31 ND ND ND ND ND ND 1 (3) 14 (45) 15 (48) 1 (3)
Atif et al. 2014 Pakistan 100 95 (95) ND 5 (5) ND ND ND 74 (74) 20 (20) 6 (6) 0 (0)
Baur et al. 2014 USA 96 ND ND ND 39 (41) 57 (59) 0 (0) ND ND ND ND
Khanfour et al. 2014 Egypt 30 0 (0) 21 (70) 9 (30) ND ND ND 11 (37) 13 (43) 6 (20) 0 (0)
Karapinar et al. 2013 Turkey 44 ND ND ND 44 (100) 0 (0) 0 (0) 16 (36) 28 (63) 0 (0) 0 (0)
Farahvash and 2012 Iran 42 ND ND ND ND ND ND 40 (96) ND ND ND
Yaghoobi
Batra et al. 2010 India 50 ND 44 (88) ND ND ND ND 2 (4) 6 (12) 42a (84)
Tzafetta and 2010 USA 10 ND ND ND ND ND ND 0 (0) 7 (70) 3 (30) 0 (0)
Terzis
Kim et al. 2009 Korea 85 ND ND ND ND ND ND 24 (28) 44 (52) 15 (18) 2 (2)
Al-Hayani 2007 Saudi 50 6 (12) ND ND 14 (28) 22 (44) 14 (28) 16 (32) 20 (40) 14 (28) 0 (0)
Arabia
Woltmann 2006 Brazil 45 ND ND ND ND ND ND 14 (31) 27 (60) 4 (9) 0 (0)
and Sgrott
Zani et al. 2003 Brazil 300 ND ND ND ND ND ND 30 (10) 63 (21) 174 (58) 33 (11)
Basar et al. 1998 Turkey 40 ND ND ND 40 (100) 0 (0) 0 (0) 14 (35) 24 (59) 1 (3) 1 (3)
Savary et al. 1997 France 22 ND ND ND ND ND ND 0 (0) 6 (27) 16 (73) 0 (0)
Wang et al. 1991 China 120 ND ND ND ND ND ND 38 (32) 60 (50) 16 (13) 4 (3)
Ziarah et al. 1981 UK 70 ND ND ND ND ND ND 25 (36) 37 (53) 8 (11) 0 (0)
In vivo studies
Balagopal et al. 2012 India 202 ND ND ND ND ND ND 161 (79) 26 (13) 14 (7) 1 (1)
Pooled prevalence 20 30 6 76 18 4 35 35 18 2
Cochran test Q = 310; I2 = 99 Q = 157; I2 = 98 Q = 758; I2 = 98

N, number; ND, not described.

a
More than two branches; no additional information.
TABLE 2. Anastomoses Between Marginal Mandibular Nerve and Other Nervous Structures

Prevalence of anastomoses Prevalence of anastomoses with

with facial nerve N (%) other nerves N (%)
Great Cervical
No. of Cervical Buccal Inter Zygomatic auricular Transverse Mental
Author Year Country halves branch branch MMN branch Nerve Nerve Nerve
Cadaveric studies
Khanfour et al. 2014 Egypt 30 ND 12 (40) 16 (54) ND 1 (3) 1 (3) ND
Mitsukawa et al. 2013 Japan 25 0 (0) 0 (0) 0 (0) ND ND ND ND
Karapinar et al. 2013 Turkey 44 0 2 (5) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Farahvash and 2012 Iran 42 5 (12) 7 (17) ND ND ND ND ND
Yaghoobi.
Batra et al. 2010 India 50 0 (0) 6 (12) 0 (0) ND ND ND 14 (28)
Tzafetta and Terzis 2010 USA 10 ND 5 (50) ND ND ND ND ND
Kim et al. 2009 Korea 85 3 (4) 20 (24) 12 (4) ND ND ND ND
Salinas et al. 2009 USA 20 6 (30) ND ND ND ND 1 (5) ND
Hwang et al. 2007 Korea 23 ND ND ND ND ND ND 23 (100)
Saylam et al. 2006 Turkey 60 ND 2 (3) ND 2 (3) ND ND ND
Woltmann and 2006 Brazil 45 10 (22) 19 (42) ND ND ND ND ND
Sgrott
Zani et al. 2003 Brazil 300 ND 78 (26) ND ND ND ND ND
Savary et al. 1997 France 22 6 (27) 11 (50) 6 (27) ND ND ND ND
Wang et al. 1991 China 120 14 (12) 72 (60) ND ND ND ND ND
Ziarah et al. 1981 UK 110 13 (12) 9 (8) ND ND ND ND ND
In vivo studies
Brennan et al. 2017 UK 86 ND ND ND ND ND 1 (1) ND
Brennan et al. 2010 UK 25 ND ND ND ND 2 (8) ND ND

Pooled prevalence 5 20 3 1 2 2 12
Cochran test Q = 181; I2 = 93 Q = 184; I2 = 97

MMN, marginal mandibular nerve; ND, not described; N, number.

Surgical Anatomy of the Marginal Mandibular Nerve
5
 6 Marcuzzo et al.

TABLE 3A Relationship of Marginal Mandibular Nerve with Facial Vessels

One Ramus
Retromandibular Anterior facial Crossing of MMN with
vein N (%) vein N (%) Facial artery N (%) the facial pedicle N (%)
At the lower
No. of Both Above the border of the Below the
Author Year Country halves Superficial Deep Superficial Deep (Splitting) Superficial Deep Plexus mandible mandible mandible
Cadaveric studies
Rossell-Perry 2016 Peru 64 ND ND 58 (100) 0 (0) 0 (0) 58 (100) 0 (0) 0 (0) ND ND ND
Atif et al. 2014 Pakistan 100 ND ND ND ND ND 74 (100) 0 (0) 0 (0) ND ND ND
Khanfour et al. 2014 Egypt 30 ND ND 11 (100) 0 (0) 0 (0) 11 (100) 0 (0) 0 (0) ND ND ND
Karapinar et al. 2013 Turkey 44 ND ND ND ND ND 16 (100) 0 (0) 0 (0) ND ND ND
Hazani et al. 2011 USA 18 ND ND ND ND ND 18 (100)a 0 (0) ND ND ND ND
Batra et al. 2010 India 50 ND ND 2 (4) 0 (0) 0 (0) 2 (4) 0 (0) 0 (0) ND ND ND
Kim et al. 2009 Korea 85 53 (83)a 11 (17)a ND ND ND ND ND ND ND ND ND
Al-Hayani 2007 Saudi 50 ND ND ND ND ND 16 (100) 0 (0) 0 (0) ND ND ND
Arabia
Basar et al. 1998 Turkey 40 ND ND ND ND ND 14 (100) 0 (0) 0 (0) 12 (86) 0 (0) 2 (14)
Savary et al. 1997 France 22 ND ND ND ND ND ND ND ND ND ND ND
Wang et al. 1991 China 120 120 (100) 0 38 (100) 0 (0) 0 (0) 38 (100) 0 (0) 0 (0) ND ND ND
Ziarah et al. 1981 UK 70 ND ND 25 (100) 0 (0) 0 (0) ND ND 2 (8) ND ND ND
In vivo studies
Balagopal et al. 2012 India 202 ND ND ND ND ND ND ND ND 22 (11) 42 (21) 97 (48)
Pooled prevalence 88 4 38 0 0 36 2 3 20 8 24
2 2 2 2
Cochran test Q = 76; I = 99 Q = 130; I = 97 Q = 324; I = 98 Q = 36; I = 97

MMN, marginal mandibular nerve; N, number; ND, not described.

a
Data not divided in one or multiple branches.
TABLE 3B Relationship of Marginal Mandibular Nerve with Facial Vessels

Multiple rami
Crossing of MMN with
Anterior facial vein N (%) Facial artery N (%) the facial pedicle N (%)
Some Some
branches branches At the Different
superficial superficial lower level
All All some All All some Above border Below depending
No. of branches branches branches branches branches branches the of the the on the
Author Year Country halves superficial deep deep superficial deep deep Plexus mandible mandible mandible branch
Cadaveric
studies
Rossell-Perry 2016 Peru 64 6 (100) 0 (0) 0 (0) 6 (100) 0 (0) 0 (0) 0 (0) ND ND ND ND
Atif et al. 2014 Pakistan 100 ND ND ND 26 (100) 0 (0) 0 (0) 0 (0) ND ND ND ND
Khanfour 2014 Egypt 30 19 (100) 0 (0) 0 (0) 17 (89) 0 (0) 2 (11) 0 (0) ND ND ND ND
et al.
Karapinar 2013 Turkey 44 ND 1 (4) ND 28 (100) 0 (0) 0 (0) 0 (0) ND ND ND ND
et al.
Hazani et al. 2011 USA 18 ND ND ND ND ND ND ND ND ND ND ND
Batra et al. 2010 India 50 48 (100) 0 (0) 0 (0) 48 (96) 0 (0) 0 (0) 0 (0) ND ND ND ND
Kim et al. 2009 Korea 85 ND ND ND 36 (42)a 3 (4)a 46 (54)a ND ND ND ND ND
Al-Hayani 2007 Saudi 50 ND ND ND ND ND ND ND ND ND ND ND
Arabia
Basar et al. 1998 Turkey 40 ND ND ND 25 (96) 0 (0) 1 (4) 0 (0) 22 (85) 0 (0) 4 (15) 0 (0)
Savary et al. 1997 France 22 22 (100) 0 (0) 0 (0) 0 (0) 5 (23) 5 (23) 12 (54) ND ND ND ND
Wang et al. 1991 China 120 76 (95) 0 (0) 4 (5) 66 (83) 2 (2) 12 (15) 0 (0) ND ND ND ND
Ziarah et al. 1981 UK 70 45 (100) 0 (0) 0 (0) ND ND ND ND ND ND ND ND
In vivo studies
Balagopal 2012 India 202 ND ND ND ND ND ND ND 0 (0) 0 (0) 2 (1) 38 (19)
et al.
Pooled prevalence 57 1 1 44 2 7 2 2 1 1 1
Cochran test Q = 266; I2 = 98 Q = 189; I2 = 96 Q = 95; I2 = 87

MMN, marginal mandibular nerve; N, number; ND, not described.

a
Data not divided in one or multiple branches.
Surgical Anatomy of the Marginal Mandibular Nerve
7
8 Marcuzzo et al.

n° of Halves in wich at least 1

Author Year Country n° of Halves branch lie belowe the
mandible n (%)
Prevalence Prev (95% CI) % Weight
Cadaveric studies
Rossel-Perry et al. 2016 Perù 64 20 (34) 0.31 (0,20 – 0.43) 5.4
Yang et al. 2016 Korea 29 16 (55) 0.55 (0.37 – 0.73) 4.9
Davies et al. 2015 UK 31 30 (97) 0.97 (0.87 – 1.00) 5.0
Atif et al. 2014 Pakistan 100 26 (26) 0.26 (0.18 – 0.35) 5.5
Baur et al. 2014 USA 96 25 (26) 0.26 (0.18 – 0.35) 5.5
Khanfour et al. 2014 Egypt 30 3 (10) 0.10 (0.01 – 0.24) 5.0
Karapinar et al. 2013 Turkey 44 0 (0) 0.00 (0.00 – 0.04) 5.2
Batra et al. 2010 India 50 16 (32) 0.32 (0.20 – 0.46) 5.3
Tzafetta et al. 2010 USA 10 3 (30) 0.30 (0.05 – 0.62) 3.9
Weerapant et al. 2010 Thailand 49 28(49) 0.57 (0.43 – 0.17) 5.3
Kim et al. 2009 Korea 85 24 (29) 0.28 (0.19 – 0.38) 5.5
Al-Hayani et al. 2007 Saudi Arabia 50 22(44) 0.44 (0.30 – 0.58) 5.3
Woltmann et al. 2006 Brazil 45 19 (43) 0.42 (0.28 – 0.57) 5.2
Zani et al. 2003 Brazil 300 180 (60) 0.60 (0.54 – 0.65) 5.7
Basar et al. 1997 Turkey 38 6 (16) 0.16 (0.06 – 0.29) 5.1
Wang et al. 1991 China 120 40 (33) 0.33 (0.25 – 0.42) 5.6
Ziarah et al. 1981 UK 110 58 (53) 0.53 (0.43 – 0.62) 5.6
In vivo studies
Balagopal et al. 2012 India 202 121 (60) 0.60 (0.53 – 0.67) 5.7
Nason et al. 2007 Saudi Arabia 85 54(64) 0.64 (0.53 – 0.73) 5.5

Overall 0.39 (0.30 - 0.50) 100.0

Q= 280,56, p=0,00, I2=94%

Fig. 2. Forest plots for the relationship of the marginal mandibular nerve with the
inferior border of the mandible. [Color figure can be viewed at wileyonlinelibrary.com]

Connection with Other Nerves Relationship with Facial Vessels

Anastomosis between the MMN and the great A total of seven articles presented data on the MMN
auricular nerve had a PP of 2% (95% CI: 0–17%); relationships with the facial vessels (895 halves). Rela-
the PP of anastomosis between the MMN and the tion with the retromandibular vein (RV) was described in
transverse cervical nerve was 2% (95% CI: 0–17%) two papers (205 halves): the PP of the MMN passing
and that of anastomosis between the MMN and the superficially to the RV was 88% (95% CI: 28–100%),
mental nerve was 12% (95% CI: 0–39%; Table 2). while that of the nerve crossing the RV deeply was 4%

Fig. 3. Most frequent anatomical variants of the marginal mandibular nerve. Note:
(a) parotid gland; (b) marginal mandibular nerve; (c) buccal branch of the facial
nerve; (d) facial vessels; (e) mandible; (f) masseter muscle; (g) depressor anguli
oris muscle; (h) depressor labii muscle; (i) mentalis muscle; (l) orbicularis oris mus-
cle; c.n., cranial nerve; IBM, inferior border of the mandible; PP, pooled prevalence.
[Color figure can be viewed at wileyonlinelibrary.com]
 Surgical Anatomy of the Marginal Mandibular Nerve 9

(95% CI: 0–54%). Seven papers (356 specimens) neck cancer surgeons to guarantee an adequate
described the MMN crossing the anterior facial vein remaining quality of life (Gobbo et al., 2016; Tirelli et al.,
(AFV): the MMN was found to cross laterally to the AVF 2018a). The incidence of injury to the MMN varies
with a PP of 38% (95% CI: 9–72%) when only one depending on the surgical procedure: 5.6–16.3% after
branch was described, and with a PP of 57% (95% CI: parotidectomy and up to 23% after neck dis-
22–90%) when multiple rami were reported. The rela- section (Nason et al., 2007; Batstone et al., 2009). Vari-
tionship with the facial artery (FA) was less constant and ous techniques have been reported to protect the nerve
described in 11 papers (583 halves). Eight of these from injury especially during neck dissection, and the
reported that the MMN crosses the FA superficially in all Hayes-Martin maneuver is certainly the most effective
cases in which only one branch was described and well known: it consists in ligating the facial vein at
(PP = 36%, 95% CI: 12–65%). In the case of multiple two finger breadths below the mandible and retracting
branches, our data found a PP of 44% (95% CI: the superficial cervical fascia and subplatysmal plane,
24–65%) for the MMN crossing the FA superficially, a PP which is elevated and reflected superiorly. However, this
of 2% (95% CI 0–10%) for the MMN crossing the FA technique cannot be considered oncologically safe and
deeply, and a PP of 7% (95% CI: 0–19%) for the MMN should be avoided in neck dissection due to the risk of
splitting and crossing the FA both superficially and leaving undissected perimarginal nodes (Tirelli and
deeply. The MMN was also described to form a neural Marcuzzo, 2018). Many authors have studied and
plexus around the artery (PP = 2%, 95% CI: 0–10%). described different anatomical landmarks that could help
Only two papers described the point at which the MMN surgeons in identifying the course of the MMN or “danger
crosses the FA, for a total of 242 halves. When the MMN zones” where the nerve is at greater risk of being injured
had only one branch it could cross the FA above the IBM (Potgieter et al., 2005; Hazani et al., 2011; Atif et al.,
(PP = 20%, 95% CI: 0–72%), below the mandible 2014; Baur et al., 2014; Qahtani et al., 2015; Davies
(PP = 24%, 95% CI: 0–78%) or at the IBM (PP = 8%, et al., 2016; Rossell-Perry, 2016; Yang et al., 2016;
95% CI: 0–50%). In specimens with multiple branches Zhong and Ashwell, 2016). Qathani et al. measured the
the crossing point was above the mandible with a PP of distance from the angle of the mandible and the lowest
2% (95% CI: 0–4%), below the mandible with a PP of point of the nerve with respect to the inferior edge of the
1% (95% CI: 0–3%), never at the IBM with a PP of 1% mandible, whereas Zhong et al. concluded that the angle
(95% CI: 0–2%), and at different levels of crossing of the mandible is the preferred landmark given that this
depending on the branch evaluated, with a PP of 1% osseous structure can be vividly appreciated by light pal-
(95% CI: 0–4%; Table 3a–3b). pation on the face (Qahtani et al., 2015; Zhong and
Ashwell, 2016). Baur et al. described five landmarks in
the mandible (the gonion, the posterior border of the
Relationship with the Mandible antegonial notch, the superior arc of the antegonial
notch, the anterior border of the antegonial notch, and
Relationship of the MMN with the mandible was evalu- the facial artery), four of which are osseous, concluding
ated in 20 studies (1,588 halves). This relation is highly that relating the MMN to identifiable palpable anatomical
variable, as at least one MMN branch was found below landmarks helps the surgeon identify and protect the
the mandible in 0–97% of the halves analyzed, with a PP nerve (Baur et al., 2014). Moreover, Hazani et al. mea-
of 39% (95% CI: 30–50%) (Figs. 2 and 3). sured the distance from the masseteric tuberosity to the
mental midline, concluding that the nerve can be
DISCUSSION predicted to cross the facial artery approximately 3 cm
anterior to the masseteric tuberosity, or one-fourth of
Identification and preservation of the MMN remains the distance from the masseteric tuberosity to the men-
an important step in head and neck surgery. The risk of tal midline (Hazani et al., 2011). Seckel was the first to
iatrogenic injury is due to variability in the number of describe a “danger zone” specific for MMN: this is a criti-
nerve branches, the varying positions, and the crossing cal 2 cm wide circular area from a point on the middle of
of the IBM (Al-Hayani, 2007; Batra et al., 2010). the mandibular body 2 cm posterior to the oral commis-
MMN injury has been reported after parotidectomy, exci- sure (Seckel, 1994). Likewise, Rossell-Perry et al.
sion of the submandibular gland, neck dissection, described the “marginal branch triangle” defined by the
rhytidectomy, liposuction, open reduction of mandibular lateral commissure of the mouth, the base of the mas-
fractures, carotid endarterectomy, and reconstructive toid apophysis and the anterior border of the extracellu-
procedures confined to the submandibular region. Nerve lar matrix muscle (platysma muscle) where the
injury results in weakness or complete loss of innerva- probability of finding the nerve is higher (Rossell-Perry,
tion of the circumoral musculature, leading to asymme- 2016). A different approach consisted in identifying
try of facial expression and imbalance of the lower lip, “safety zones” where the surgeon can operate ideally
more noticeable in dynamics. This significant aesthetic free of danger for the MMN: for example, Gulses et al.
deformity, with flattening of the lower lip and the inability defined a triangular area delimited by a trago-basal line,
to move it laterally or downward, has a great impact on a cantho-gonial line, and the line of the border of the
the patient’s quality of life and self-appearance and mandible (Gulses et al., 2012). Similarly, Yang et al.
might lead to legal claims (Batstone et al., 2009; Qahtani evaluated the distance from the MMN to several land-
et al., 2015). Beyond its importance in aesthetic and marks and found that the IBM in the submental area
functional surgery, this factor should not be neglected 4.5 cm anterior to the gonion constitutes a surgical safe
also in oncological surgery, as it is essential for head and zone (Yang et al., 2016).
10 Marcuzzo et al.

A valuable aid for avoiding nerve injury is the to have more than one branch (Savary et al., 1997;
intraoperative use of NIM. Although its use during Tzafetta and Terzis, 2010). Farahvash and Yaghoobi
parotidectomy is still debated, it seems to be helpful described the nerve as one branch in 96% of cases
for recognition of the nerve in the nodal dissection of and Rossell-Perry reported a similar result in 91% of
level Ib (Makeieff et al., 2005; Tirelli et al., 2018b). cases (Farahvash and Yaghoobi, 2012; Rossell-Perry,
NIM is not the standard of care during thyroid and 2016). This discrepancy could be explained by the
parathyroid surgery, so that the most crucial factor in diversity in innervation between different ethnic
nerve preservation is the surgical technique (Horne groups. In fact, as Farahvash suggested, this finding
et al., 2007). Overall, it is widely accepted that there could be related to the minimal animation of the lower
are no reliable anatomical landmarks that can estab- lip and neck in Persian individuals due to the inactivity
lish the course of the MMN. An accurate and precise of some muscles when speaking Farsi as compared to
knowledge of MMN anatomy and connections is European languages (Farahvash and Yaghoobi,
essential for its safe identification and preservation. 2012). Moreover, it must be noted that not all studies
Few authors investigated the point of origin of the identified and described all four branches of the
MMN, described as the site in which the nerve is found nerve. The variability of the branching pattern of the
to emerge either in relation to the anterior border of MMN and especially its anastomosis with its own bra-
the parotid gland or to its apex—data regarding the nches or with other nerves can explain why, despite
origin and course of the mandibular branch are highly an evident injury, a limited extent of lower lip paraly-
heterogeneous, and do not allow for definitive conclu- sis can be noted in some cases (Savary et al., 1997;
sions. For Khanfour the nerve never emerged from Khanfour et al., 2014). Several studies showed
the anterior border of the gland, while for Atif the ori- peripheral communications between the MMN and
gin of the nerve was found anterior to its border in other branches of the facial nerve. The most fre-
almost all of the specimens dissected (Atif et al., quently described anastomoses of the MMN were with
2014; Khanfour et al., 2014). Considering the mandi- the buccal branch of the facial nerve (Tzafetta and
ble both Basar and Karapinar reported similar results, Terzis, 2010), while communications between the
as in all their specimens the MMN was found to arise MMN and other nerves such as the great auricular
above the mandible (Basar et al., 1998; Karapinar nerve, the zygomatic branch of the facial nerve, the
et al., 2013). On the contrary, in the majority of sub- mental nerve and the transverse cervical nerve were
jects analyzed by Baur et al., the MMN originated infe- less frequent (Salinas et al., 2009; Brennan et al.,
rior to the border of the mandible and then coursed 2010; Hwang et al., 2007), though not always investi-
above it (Baur et al., 2014). gated. Despite the fact that this meta-analysis has
The apex of the parotid gland, described in Gray’s illustrated the presence of various anastomotic bra-
standard text as the lower part of the gland with vari- nches for the MMN, which could be an advantage in
able extent to the carotid triangle, is relatively easy to surgical practice, the MMN is one of the less anasto-
identify during neck dissection or in other surgical pro- motic branches of the facial nerve. De Bonnecaze
cedures in the submandibular area and in many proce- et al. recently analyzed the variability of facial muscle
dures involving the mandible or the face. Nevertheless, innervation and density of communicating branches
the literature shows that it should not be considered a of the facial nerve during anatomical dissection and
safe landmark for identifying the MMN origin. The larg- electrostimulation. The study showed that there are
est study addressing this aspect is the one by Atif et al. multiple communication branches between the zygo-
who performed 100 dissections of the MMN and the matic, buccal, and frontal branches but the communi-
parotid area, showing that the nerve emerged from the cating branches between the MMN and cervical
anterior border of the gland in 95% of the cases while it branches are less common. Additionally, the depres-
never emerged only from the apex (Atif et al., 2014). sor anguli oris and depressor labii inferioris muscles
These results are consistent with those of Al-Hayani (and platysma) exhibited the “weakest” accessory
et al. who reported that the MMN emerged only from innervation by the MMN (and cervical branches,
the anterior edge of the gland. However, it should be respectively) emphasizing that close attention must
emphasized that the origin in relation to the parotid be paid to the frontal and MMN branches during
was investigated by this study in only six cases (Al- parotid surgery since they showed the fewest com-
Hayani, 2007). In contrast, Khanfour et al. and Batra municating branches (De Bonnecaze et al., 2019).. As
et al. described the origin of the MMN from the parotid seen before, various anatomical landmarks have been
apex in 70 and 88% of cases, respectively (Batra reviewed to allow a safer surgical procedure in the
et al., 2010; Khanfour et al., 2014). Although our final submandibular region. The FA and the IBM are often
analysis shows the PP of the MMN originating from the reported as useful landmarks to identify the MMN,
parotid apex was only 30% (95% CI: 0–100%). This since both can be easily felt by palpation and there-
is one of the least explored variables in the included fore have a practical importance for the surgeon. Par-
studies and its role should be studied more in detail. ticularly, the pulsation of the FA can be easily
Contrary to the general belief that the MMN has a sin- palpated and felt by the surgeon at the inferior angle
gle branch, our meta-analysis shows that the single- of the masseter muscle. Different studies have evalu-
branch variant is as frequent as the two-branch vari- ated the relationship of the MMN with the FA, but the
ant. However, it should be noted that in some studies results were inconsistent: our meta-analysis shows
the main prevalence remains that of a single-branch that the MMN lay superficially to the FA in most cases,
nerve, while in two studies the MMN was always found especially when the nerve has one branch. In two
 Surgical Anatomy of the Marginal Mandibular Nerve 11

studies, with a single-branched or multiple-branched variables such as those dependent on the ethnicity of
MMN, a neural plexus was found around the FA the individuals have already been described. As for
(Ziarah et al., 1981; Savary et al., 1997). Although other factors such as age, it could be said that in indi-
inconsistently investigated, a more constant result viduals with lax and atrophic tissues such as in older
was found in the relationship between the AFV and people, the branches of the MMN could run lower than
the MMN: the nerve lay superficial to the vein in most in young people, although the literature denies this
cases. The point at which the MMN crosses the FA in hypothesis (Tirelli et al., 2018a).
relation to the IBM was investigated by two authors
only, both in vivo and in cadaveric studies, and
showed high heterogeneity (Basar et al., 1998; Bal- CONCLUSIONS
agopal et al., 2012). The relationship between the Our overall results demonstrated that the MMN has a
MMN and the RV was explored by two studies as the high variability in almost its entire path and that adja-
RV lies in the same fascial plane as the facial nerve cent anatomical structures do not represent safe land-
and can be used as an anatomical landmark for the marks to identify its course. The only constant seems to
surgeon (Wang et al., 1991). Both Kim and Wang be its relationship with the AFV to which it almost
described the MMN course as lateral to the RV in most always runs superficially. The FA and IBM are not safe
of their dissected specimens (Wang et al., 1991; Kim landmarks for identifying the MMN course. The MMN
et al., 2009). Some studies showed how the MMN lay origin is frequently described at the parotid apex and
above the level of the mandible remaining superficial above the IBM, although in its course at least one
to the FA, while others described it as coursing below branch often runs below the IBM (PP = 39%). The MMN
it (Basar et al., 1998; Zani et al., 2003; Nason et al., more often exhibits one or two branches, more rarely
2007; Atif et al., 2014). As Weerapant suggests, there three or four. Its most frequent anastomosis is with the
might be differences in the distance from the MMN buccal branch of the facial nerve; anastomosis with the
and the IBM among the different types of specimen mental nerve, great auricular nerve, transverse cervical
analyzed: the distance between the MMN and the IBM nerve and with the cervical and zygomatic branch of the
may change in the stiff and contracted tissues of facial nerve are reported more rarely. The present find-
embalmed cadavers as compared to fresh specimens ings can help surgeons in their daily practice to reduce
(Weerapant et al., 2010). This data should be taken possible damage to the MMN in various procedures
into account and caution should be used when per- involving the head and neck region.
forming the incision relying on the two-finger-breadth
line landmark from the IBM (Davies et al., 2016). Fur-
thermore, it should be evaluated that during neck dis- CONFLICT OF INTEREST
section the course and position of the MMN will
inevitably differ because of extension of the neck and None.
traction of the investing layer of the deep fascia
(Balagopal et al., 2012). As seen in the studies ana-
lyzed, there is high variability in the relationship REFERENCES
between the MMN and the IBM and results cannot be
standardized. Given that the surgeon’s goal is to pre- Al-Hayani A. 2007. Anatomical localisation of the marginal mandibu-
lar branch of the facial nerve. Folia Morphol 66:307–313.
dict the risk of damaging the nerve in procedures
Atif S, Ghumman NU, Rcs FDS, Yasser F, Warraich RA. 2014. Marginal
involving a submandibular incision, we believe that mandibular nerve and its relation with lower border of mandible
the presence of at least one MMN branch under the and facial artery. Pak Oral Dent J 34:11–13.
margin of the mandible (PP: 39%. 95% CI: 30–50%) Balagopal PG, George NA, Sebastian P. 2012. Anatomic variations of
is the finding that must be underlined. the marginal mandibular nerve. Indian J Surg Oncol 3:8–11.
Basar R, Sargon MF, Tekdemir Y, Elhan A. 1998. The marginal man-
dibular branch of the facial nerve. Surg Radiol Anat 19:311–314.
LIMITATIONS Batra AP, Mahajan A, Gupta K. 2010. Marginal mandibular branch of
The present meta-analysis could be limited by the the facial nerve: an anatomical study. Indian J Plast Surg 43:
60–64.
fact that the dissection technique (incision and head
Batstone MD, Scott B, Lowe D, Rogers SN. 2009. Marginal mandibu-
position) is not always identical or described in all stud- lar nerve injury during neck dissection and its impact on patient
ies; in some cases, this could vary from surgeon to sur- perception of appearance. Head Neck 31:673–678.
geon. We included both cadaveric and in vivo studies, Baur DA, Kaiser AC, Leech BN, Landers MA, Altay MA, Quereshy FA.
although in a certain number of papers there is no spe- 2014. The marginal mandibular nerve in relation to the inferior
cific information on the types of specimen dissected border of the mandible. J Oral Maxillofac Surg 72:2221–2226.
when both embalmed and fresh cadavers are used. It Brennan PA, Elhamshary AS, Alam P, Anand R, Ammar M. 2017.
should, however, be specified that the difference in Short communication. Anastomosis between the transverse cervi-
specimen does not affect most of the factors analyzed cal nerve and marginal mandibular nerve: how often does it
occur? Br J Oral Maxillofac Surg 55:293–295.
in this meta-analysis, such as the origin, number of bra-
Brennan PA, Gholmy M, Ounnas H, Zaki GA, Puxeddu R, Standring S.
nches, anastomosis and relations with the vessels. On 2010. Communication of the anterior branch of the great auricular
the other hand, the type of specimen could affect the nerve with the marginal mandibular nerve: a prospective study of
relationship between the MMN and the IBM. In our opin- 25 neck dissections. Br J Oral Maxillofac Surg 48:431–433.
ion, the heterogeneity among the individuals studied Davies JC, Ravichandiran M, Agur AM, Fattah A. 2016. Evaluation of
does not represent a limiting factor and potential clinically relevant landmarks of the marginal mandibular branch
12 Marcuzzo et al.

of the facial nerve: a three-dimensional study with application to Qahtani KAL, Mlynarek A, Adamis J, Harris J, Seikaly H, Islam T.
avoiding facial nerve palsy. Clin Anat 29:151–156. 2015. Intraoperative localization of the marginal mandibular
De Bonnecaze G, Vergez S, Chaput B, Vairel B, Serrano E, nerve: a landmark study. BMC Res Notes 27:382
Chantalat E, Chaynes P. 2019. Variability in facial-muscle innerva- Rossell-Perry P. 2016. The marginal branch triangle : anatomic refer-
tion: a comparative study based on electrostimulation and ana- ence for its location and preservation during cosmetic surgery. Br
tomical dissection. Clin Anat 32:169–175. J Plast Surg 69:387–394.
Farahvash MR, Yaghoobi A. 2012. The extratemporal facial nerve and Salinas NL, Jackson OH, Dunham BP, Bartlett SP. 2009. Anatomical
its branches: analysis of 42 hemifacial dissections in fresh Persian dissection and modified Sihler stain of the lower branches of the
( Iranian ) cadavers. Aesthet Surg J 33:201–208. facial nerve. Plast Reconstr Surg 124:1905–1915.
Gobbo M, Bullo F, Perinetti G, Gatto A, Ottaviani G, Biasotto M, Savary V, Robert R, Rogez JM, Armstrong O, Leborgne J. 1997. The
Tirelli G. 2016. Diagnostic and therapeutic features associated mandibular marginal ramus of the facial nerve. Surg Radiol Anat
with modification of quality-of-life’s outcomes between one and 19:69–72.
six months after major surgery for head and neck cancer. Braz J Saylam C, Ucerler H, Orhan M, Ozek C. 2006. Anatomic landmarks of
Otorhinolaryngol 82:548–557. the buccal branches of the facial nerve. Surg Radiol Anat 28:
Gulses A, Kilic C, Sencimen M. 2012. Determination of a safety zone 462–468.
for transbuccal trocar placement: an anatomical study. Int J Oral Seckel BR. 1994. Facial danger zones: avoiding nerve injury in facial
Maxillofac Surg 41:930–933. plastic surgery. Can J Plast Surg 2:59–66.
Hazani R, Chowdhry S, Wilhelmi BJ. 2011. Bony anatomic landmarks Tirelli G, Bergamini PR, Scardoni A, Gatto A, Boscolo Nata F,
to avoid injury to the marginal mandibular nerve. Aesthet Surg J Marcuzzo AV. 2018a. Intraoperative monitoring of marginal man-
31:286–289. dibular nerve during neck dissection. Head Neck 40:1016–1023.
Higgins PT, Green S, Shuster JJ. 2011. Review: Cochrane handbook Tirelli G, Gatto A, Bonini P, Tofanelli M, Arnez ZM, Piccinato A. 2018b.
for systematic reviews for interventions. Editors Res Syn Meth 2: Prognostic indicators of improved survival and quality of life in
243–293. surgically treated oral cancer. Oral Surg Oral Med Oral Pathol Oral
Horne SK, Gal TJ, Brennan JA. 2007. Prevalence and patterns of Radiol 126:31–40.
intraoperative nerve monitoring for thyroidectomy. Otolaryngol Tirelli G, Gatto A, Marcuzzo AV. 2019. Perimarginal lymph nodes: an
Head Neck Surg 136:952–956. undervalued entity in oral cancer. Eur Arch Otorhinolaryngol 276:
Hwang K, Jin S, Park JH, Kim DJ, Chung IH. 2007. Relation of mental 1147.
nerve with mandibular branch of the facial nerve. J Craniofac Surg Tirelli G, Marcuzzo AV. 2018. Lymph nodes of the perimandibular area
18:165–168. and the hazard of the Hayes Martin maneuver in neck dissection.
Karapinar U, Kilic C, Cetin B, Saglam O, Dursun E, Durmus M. 2013. Otolaryngol Head Neck Surg 159:692–697.
The course of the marginal mandibular branch of the facial nerve Tzafetta K, Terzis JK. 2010. Essays on the facial nerve: part
in adult cadavers. Saudi Med J 34:364–368. I. microanatomy. Plast Reconstr Surg 125:879–889.
Khanfour AA, Sayed E, Mohamed A. 2014. Marginal mandibular branch Wang TM, Lin CL, Kuo KJ, Shih C. 1991. Surgical anatomy of the
of the facial nerve: an anatomical study. Alex J Med 50:131–138. mandibular ramus of the facial nerve in Chinese adults. Acta Anat
Kim D, Kim D, Nam S, Nam Y, Lee K. 2009. The marginal mandibular (Basel) 142:126–131.
branch of the facial nerve in Koreans. Clin Anat 22:207–214. Weerapant E, Bunaprasert T, Chokrungvaranont P, Chentanez V. 2010.
Lim YC, Lee JS, Choi EC. 2006. Perifacial lymph node metastasis in Anatomy of the facial nerve branching patterns, the marginal man-
the submandibular triangle of patients with oral and oropharyn- dibular branch and its extraparotid ramification in relation to the
geal squamous cell carcinoma with clinically node-positive neck. lateral palpebral line. Asian Biomed (Res Rev News) 4:603–608.
Laryngoscope 116:2187–2190. Woltmann M, Sgrott EA. 2006. Anatomosurgical study of the mar-
Makeieff M, Cartier C, Garrel R, Crampette L, Guerrier B. 2005. Con- ginal mandibular branch of the facial nerve for submandibular
tinuous facial nerve monitoring during pleomorphic adenoma surgical approach. Braz Dent J 17:71–74.
recurrence surgery. Laryngoscope 115:1310–1314. Yang H, Kim H, Park H, Sohn H, Ok H. 2016. Revisiting the topographic
Mitsukawa N, Moriyama H, Shiozawa K, Satoh K. 2013. Study on dis- anatomy of the marginal mandibular branch of facial nerve relating
tribution of terminal branches of the facial nerve in mimetic mus- to the surgical approach. Aesthet Surg J 36:977–982.
cles (orbicularis oculi muscle and orbicularis oris muscle). Ann Zani R, Fadul R Jr, Da Rocha MA, Santos RA, Alves MC, Ferreira LM.
Plast Surg 72:71–74. 2003. Facial nerve in Rhytidoplasty: anatomic study of its trajec-
Nason RW, Binahmed A, Torchia MG, Thliversis J. 2007. Clinical tory in the overlying skin and the most common sites of injury.
observations of the anatomy and function of the marginal man- Ann Plast Surg 51:236–242.
dibular nerve. Int J Oral Maxillofac Surg 36:712–715. Zhong W, Ashwell K. 2016. A cadaveric study of surgical landmarks
Potgieter W, Meiring J, Boon J, Pretorius E, Pretorius J, Becker P. for retrograde parotidectomy. Ann Med Surg 9:82–85.
2005. Mandibular landmarks as an aid in minimizing injury to the Ziarah HA, Haithem A, Atkinson ME. 1981. The surgical anatomy of
marginal mandibular branch: a metric and geometric anatomical the mandibular distribution of the facial nerve. Br J Oral Surg 19:
study. Clin Anat 18:171–178. 159–170.