DOI: 10.7759/cureus.1505 Bilateral Absence of the Zygomatic Nerve
and Zygomaticofacial Nerve and Foramina Shehzad Khalid  , Joe Iwanaga  , Marios Loukas  , R. Shane Tubbs 
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4 Shehzad Khalid  , Joe Iwanaga  , Marios Loukas  , R. Shane Tubbs 
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4 1. Department of Anatomical Sciences, St. George's University School of Medicine 2. Seattle Science
Foundation 3. Department of Anatomical Sciences, St. George's University School of Medicine, Grenada,
West Indies 4. Neurosurgery, Seattle Science Foundation  Corresponding author: Shehzad Khalid, shezdk@gmail.com 
Disclosures can be found in Additional Information at the end of the article  Corresponding author: Shehzad Khalid, shezdk@gmail.com 
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d f h  Corresponding author: Shehzad Khalid, shezdk@gmail.com 
Disclosures can be found in Additional Information at the end of the article p
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Disclosures can be found in Additional Information at the end of the article Open Access Case
Report Open Access Case
Report Abstract The zygomaticofacial branch (ZFb) of the zygomatic nerve travels along the inferolateral angle
of the orbit, traverses the zygomaticofacial foramen (ZFF) in the zygomatic bone, and then
perforates the orbicularis oculi muscle to finally reach the skin of the malar area, which it
innervates. The bilateral absence of the ZFb and the ZFF was found in an 80-year-old Caucasian
cadaver. In addition, both zygomatic nerves were absent. A thin nerve arising from the lacrimal
nerve passed below it and gave rise to the lacrimal branch and a communicating branch to the
lacrimal nerve. This then entered the small bony canal, which opened at the medial aspect of
the lateral wall of the orbit on the right and left sides. The bilateral absence of the ZFb of the
zygomatic nerve and its foramen appears to be uncommon but should be realized during
surgery or invasive procedures over the cheek or infraorbital region. The additional absence of
both zygomatic nerves is exceptional. Categories: Neurology, Miscellaneous, Neurosurgery
Keywords: zygoma, foramen, nerve, anatomy, cadaver, variations Introduction The malar surface of the zygomatic bone is convex and perforated near its center with a small
aperture, the zygomaticofacial foramen (ZFF), where the zygomaticofacial branch (ZFb) and
vessels traverse to reach the face. The ZFb perforates the orbicularis oculi muscle to reach the
skin of the cheek. It joins with the zygomatic branches of the facial nerve and with the inferior
palpebral branches of the maxillary nerve (V2) [1]. The zygomatic nerve and its branches can be
easily injured during facial surgery in the periorbital region [2]. A postoperative hematoma may
occur by tearing the vessels arising from the ZFF if blind surgical dissections were to be done in
this area. Many cases have reported damage to the ZFb involving osteotomies in the malar area. It is vital that the zygomaticofacial vessels be identified and coagulated to prevent avulsion,
bleeding, and complications related to postoperative hematomas since these vessels can be
disrupted by elevating the periorbita from the lateral orbital wall [1]. The zygomatic bone shows
variations in the number of the foramina on its facial aspect. Occasionally, the nerve and the
foramen have been found to be absent [3]. We report a case of the bilateral absence of the ZFb
and ZFF and evaluate the intraorbital anatomy of the zygomatic nerve in this case. Received 06/28/2017 
Review began 07/13/2017 
Review ended 07/18/2017 
Published 07/23/2017 © Copyright 2017
Khalid et al. This is an open access
article distributed under the terms of
the Creative Commons Attribution
License CC-BY 3.0., which permits
unrestricted use, distribution, and
reproduction in any medium,
provided the original author and
source are credited. Received 06/28/2017 
Review began 07/13/2017 
Review ended 07/18/2017 
Published 07/23/2017
© Copyright 2017
Khalid et al. This is an open access
article distributed under the terms of
the Creative Commons Attribution
License CC-BY 3.0., which permits
unrestricted use, distribution, and
reproduction in any medium,
provided the original author and
source are credited. Case Presentation Case Presentation During our routine dissection of the face of a fresh cadaver, a bilateral absence of the ZFb and
ZFF was found in a Caucasian female whose age at death was 80 (Figure 1). How to cite this article
Khalid S, Iwanaga J, Loukas M, et al. (July 23, 2017) Bilateral Absence of the Zygomatic Nerve and
Zygomaticofacial Nerve and Foramina. Cureus 9(7): e1505. DOI 10.7759/cureus.1505 Received 06/28/2017 
Review began 07/13/2017 
Review ended 07/18/2017 
Published 07/23/2017 How to cite this article
Khalid S, Iwanaga J, Loukas M, et al. (July 23, 2017) Bilateral Absence of the Zygomatic Nerve and
Zygomaticofacial Nerve and Foramina. Cureus 9(7): e1505. DOI 10.7759/cureus.1505 2017 Khalid et al. Cureus 9(7): e1505. DOI 10.7759/cureus.1505 FIGURE 2: Zygomaticotemporal branch of the lacrimal nerve
The zygomaticotemporal branch (white arrowheads) arising from the lacrimal nerve (black
arrowheads) and entering a bony canal (arrow). LG: Lacrimal gland; N: Nose; ZB: Zygomatic bone
Dissection was performed under a surgical microscope (OPMI CS NC31, Carl Zeiss,
Oberkochen, Germany), and measurement was made with a microcaliper (Mitsutoyo,
Kanagawa, Japan). The study was conducted in accordance with the requirements of the
Declaration of Helsinki (64th WMA General Assembly, Fortaleza, Brazil, October 2013). FIGURE 2: Zygomaticotemporal branch of the lacrimal nerve FIGURE 2: Zygomaticotemporal branch of the lacrimal nerve
The zygomaticotemporal branch (white arrowheads) arising from the lacrimal nerve (black
arrowheads) and entering a bony canal (arrow). The zygomaticotemporal branch (white arrowheads) arising from the lacrimal nerve (black
arrowheads) and entering a bony canal (arrow). LG: Lacrimal gland; N: Nose; ZB: Zygomatic bone Dissection was performed under a surgical microscope (OPMI CS NC31, Carl Zeiss,
Oberkochen, Germany), and measurement was made with a microcaliper (Mitsutoyo,
Kanagawa, Japan). The study was conducted in accordance with the requirements of the
Declaration of Helsinki (64th WMA General Assembly, Fortaleza, Brazil, October 2013). Dissection was performed under a surgical microscope (OPMI CS NC31, Carl Zeiss,
Oberkochen, Germany), and measurement was made with a microcaliper (Mitsutoyo,
Kanagawa, Japan). The study was conducted in accordance with the requirements of the
Declaration of Helsinki (64th WMA General Assembly, Fortaleza, Brazil, October 2013). FIGURE 1: Surface of the zygomatic bone
Note that no zygomaticofacial foramen is present. N: Nose; ZB: Zygomatic bone
Inside the orbit, neither the zygomatic nerve nor the ZFb was seen. A thin nerve arose from the
lacrimal nerve, passed below it, and gave rise to the lacrimal branch and a communicating
branch with the lacrimal nerve. This nerve then entered a small bony canal, which opened into
the medial aspect of the lateral wall of the orbit on both the right and left sides (Figure 2). The
diameter of this nerve was 0.67 mm on the right and 0.62 mm on the left side, respectively. This nerve was considered the ZFb of the lacrimal nerve. FIGURE 1 S
f
f th
ti
b    FIGURE 1: Surface of the zygomatic bone
Note that no zygomaticofacial foramen is present. N: Nose; ZB: Zygomatic bone
Inside the orbit, neither the zygomatic nerve nor the ZFb was seen. A thin nerve arose from the
lacrimal nerve, passed below it, and gave rise to the lacrimal branch and a communicating
branch with the lacrimal nerve. This nerve then entered a small bony canal, which opened into
the medial aspect of the lateral wall of the orbit on both the right and left sides (Figure 2). The
diameter of this nerve was 0.67 mm on the right and 0.62 mm on the left side, respectively. This nerve was considered the ZFb of the lacrimal nerve. FIGURE 1: Surface of the zygomatic bone
Note that no zygomaticofacial foramen is present. FIGURE 1: Surface of the zygomatic bone
Note that no zygomaticofacial foramen is present. FIGURE 1: Surface of the zygomatic bone Note that no zygomaticofacial foramen is present. N: Nose; ZB: Zygomatic bone Inside the orbit, neither the zygomatic nerve nor the ZFb was seen. A thin nerve arose from the
lacrimal nerve, passed below it, and gave rise to the lacrimal branch and a communicating
branch with the lacrimal nerve. This nerve then entered a small bony canal, which opened into
the medial aspect of the lateral wall of the orbit on both the right and left sides (Figure 2). The
diameter of this nerve was 0.67 mm on the right and 0.62 mm on the left side, respectively. This nerve was considered the ZFb of the lacrimal nerve. 2 of 4 2017 Khalid et al. Cureus 9(7): e1505. DOI 10.7759/cureus.1505 Conclusions The absence of both the ZFF and its ZFb appears to be uncommon. The additional bilateral
absence of zygomatic nerves is exceptional. Procedures in adjacent areas of the infraorbital
region should keep this in mind so as not to deinnervate the skin over the cheek by injuring a
branch of the infraorbital nerve that would be present there. Disclosures Conflicts of interest: The authors have declared that no conflicts of interest exist. sides, respectively. The ZFF has often been reported as doubled [1] or absent [5]. Occasionally,
the ZFb, which travels through the ZFF does not exist [1], and in these cases, the inferior
palpebral branches of the infraorbital nerve supply the area normally covered by the ZFb. A
recent study by Iwanaga et al. [6] also found an additional inferior palpebral branch of the
infraorbital nerve arising from the superior surface of the infraorbital canal, which has not been
previously described. This could also explain why sensory innervation is still intact after
surgical dissection with damage to this nerve [7]. Both the ZFb of the zygomatic nerve and the zygomatic nerve were absent in our case. The
zygomaticotemporal branch (ZTb) usually arises from the zygomatic nerve, traverses a canal in
the zygomatic bone, and emerges into the anterior part of the temporal fossa [1]. It occasionally
has a communicating branch with the lacrimal nerve. In this case, the ZTb arose from the
lacrimal nerve and had a communicating branch with the lacrimal nerve. The zygomatic bone may have one to three ossification centers. These appear in the eighth
week of fetal life and fuse in the twenty-second week [2]. The embryological origin of the
variations of the ZFF may be due to the variations of its ossification centers. As the ossification
of the bone and related foramina are induced following the formation of the enclosed nerve [8],
an absence of the nerve could result in the absence of the foramen. Discussion The prevalence of the ZFF has been reported by Aksu et al., where 80 adult dry skulls (160 sides)
of West Anatolian people were studied [4]. They measured the distance from the ZFF to the
midpoint of the frontozygomatic suture (ZFF-FZ), to the lowest point of the
zygomaticomaxillary suture (ZFF-ZMS), and to the closest point of the orbital rim (ZFF-OK). When more than one foramen was found, the largest one was taken as the point of reference
and the measurements described earlier were performed [4]. The mean ZFF-FZ was 26.2 ± 3.2
mm, the mean ZF-ZMS was 18.6 ± 3.1 mm, and the mean ZFF-OK was 5.9 ± 1.4 mm for both
sides. There was no statistically significant difference between the right and left sides. The
number of ZFFs on each side was as follows: one on 71 sides (44.4 percent), two on 45 sides
(28.1 percent), three on 10 sides (6.3 percent), four on 7 sides (4.4 percent), and five on 2 sides
(1.3 percent) [4]. There were no foramina on 25 sides (15.6 percent) [4]. Meanwhile, in a study
by Mangal et al. (2004), there was no ZFF on 11.5 percent and 10.3 percent on the right and left The prevalence of the ZFF has been reported by Aksu et al., where 80 adult dry skulls (160 sides)
of West Anatolian people were studied [4]. They measured the distance from the ZFF to the
midpoint of the frontozygomatic suture (ZFF-FZ), to the lowest point of the 2017 Khalid et al. Cureus 9(7): e1505. DOI 10.7759/cureus.1505 3 of 4 2017 Khalid et al. Cureus 9(7): e1505. DOI 10.7759/cureus.1505 References 1. Standring S: Gray's anatomy: the anatomical basis of clinical practice . Am J Neuroradiol. 2005,
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infraorbital canal: application to surgery of the eyelid and treatment of orbital floor fractures. Clin Anat. 2017, 10.1002/ca.22940 7. Martins C, Li X, Rhoton AL Jr: Role of the zygomaticofacial foramen in the orbitozygomatic
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