Facial Nerve Anatomy

OVERVIEW The facial nerve, or cranial nerve (CN) VII, is the nerve of facial expression. The pathways of the facial nerve are variable, and knowledge of the key intratem poral and extratemporal landmarks is essential for accurate physical diagnosis a nd safe and effective surgical intervention in the head and neck. The facial nerve is composed of approximately 10,000 neurons, 7,000 of which are myelinated and innervate the nerves of facial expression. Three thousand of the nerve fibers are somatosensory and secretomotor and comprise the nervus interme dius. The course of the facial nerve and its central connections can be roughly divided into 6 segments, as shown in Table 1 below. Table 1. Segmental Description of the Facial Nerve and Central Connections Segment Location Length, mm Supranuclear Cerebral cortex NA Brain stem Motor nucleus of facial nerve, superior salivatory nucleus of tractus solitarius NA Meatal segment Brain stem to IAC 13-15 Labyrinthine segment Fundus of IAC to facial hiatus 3-4 Tympanic segment Geniculate ganglion to pyramidal eminence 8-11 Mastoid segment Pyramidal process to stylomastoid foramen 10-14 Extratemporal segment Stylomastoid foramen to pes anserinus 15-20 The objective of this article is to briefly review the anatomy of the facial ner ve in each of these segments and to follow the nerve from its most proximal orig in to its end organ, ie, the muscles of facial expression.

CENTRAL CONNECTIONS Crosby and DeJonge, along with Nelson, have provided two of the most complete de scriptions of the facial nerve's central connections. The reader is referred to these references for a more detailed description of the supranuclear and nuclear organization of the facial nerve. Cortex and internal capsule The voluntary responses of the facial muscles (eg, smiling when taking a photogr aph) arise from efferent discharge from the motor face area of the cerebral cort ex. The motor face area is situated on the precentral and postcentral gyri. The facial motor nerves are represented on the homunculus with the forehead uppermos t and the eyelids, midface, nose, and lips sequentially located more inferiorly (see Image 1). Discharges from the facial motor area are carried through fascicl es of the corticobulbar tract to the internal capsule, then through the upper mi dbrain to the lower brain stem where they synapse in the pontine facial nerve nu cleus. The pontine facial nerve nucleus is divided into an upper and a lower hal f, bilaterally. The corticobulbar tracts from the upper face cross and recross en route to the p ons; the tracts to the lower face cross only once. In 1987, Jenny and Saper perf

ormed an extensive study of the proximal facial nerve organizations in a primate model. They demonstrated that the descending corticofacial fibers innervated th e lower facial motor nuclear region bilaterally but with contralateral predomina nce. The upper facial motor nuclear regions received scant direct cortical inner vation on either side of the brain. Their results indicated that in monkeys, upp er facial movement is relatively preserved in upper motor neuron injury because these motor neurons receive relatively little direct cortical input. In contrast , the lower facial muscles are more severely affected because their motor neuron s depend on significant cortical innervation. The authors believe these observat ions also explain similar findings in humans. The deficits observed with unilateral ablation of the corticobulbar fibers refle ct the fact that upper facial motor neurons do not receive significant cortical innervations and that lower facial motor neurons contralateral to the lesion hav e functional loss because of their dependence on direct contralateral cortical i nnervation and because the remaining ipsilateral cortical projections are not su fficient to drive them. These findings may explain why a focal lesion in the fac ial area on one side of the motor cortex in humans spares eyelid closure and for ehead movement but results in paralysis of the lower face. Table 2. Summary of Innervation and Actions of Facial Mimetic Muscles Branch of CN VII Location of Lesion Actions Posterior auricular Posterior auricular Pulls ear backward Occipitofrontalis, occipital belly Moves scalp backward Temporal Anterior auricular Pulls ear forward Superior auricular Raises ear Occipitofrontalis, occipital belly Moves scalp forward Corrugator supercilii Pulls eyebrow medially and downward Procerus Pulls medial eyebrow downward Temporal and zygomatic Orbicularis oculi Closes eyelids and contracts skin aroun d eye Zygomatic and buccal Zygomaticus major Elevates corners of mouth Buccal Zygomaticus minor Elevates upper lip Levator labii superioris Elevates upper lip and midportion nasolabial fold Levator labii superioris alaeque nasi Elevates medial nasolabial fold and nasal ala Risorius Aids smile with lateral pull Buccinator Pulls corner of mouth backward and compresses cheek Levator anguli oris Pulls angles of mouth upward and toward midline Orbicularis Closes and compresses lips Nasalis, dilator naris Flares nostrils Nasalis, compressor naris Compresses nostrils Buccal and marginal mandibular Depressor anguli oris Pulls corner of mouth downw ard Depressor labii inferioris Pulls lower lip downward Marginal mandibular Mentalis Pulls skin of chin upward Cervical Platysma Pulls down corners of mouth Caution is advised in using preservation of forehead function to diagnose a cent ral lesion. Patients may have sparing of forehead function with lesions in the p ontine facial nerve nucleus, with selective lesions in the temporal bone, or wit h an injury to the nerve in its distribution in the face. An accurate neurologic diagnosis is best made by examining deficits in conjunction with "the company t hey keep." A cortical lesion that produces a lower facial deficit is usually ass ociated with a motor deficit of the tongue and weakness of the thumb, fingers, o r hand on the ipsilateral side (see Image 1). Nerve fibers influencing emotional facial expression are thought to arise in the

thalamus and globus pallidus. Supranuclear pyramidal lesions spare movements of the face initiated as emotional responses and reflexes. With nuclear and infran uclear lesions, loss of both involuntary and voluntary facial movement occurs. The facial nerve nuclei also receive afferent input from other brainstem nuclei. Input from the trigeminal nerve and nucleus form the basis of the trigeminofaci al reflexes, eg, the corneal reflex. Input from the acoustic nuclei to the facia l nerve nucleus forms part of the stapedial reflex response to loud noises. Extrapyramidal system The extrapyramidal system consists of the basal ganglia and the descending motor projections other than the fibers of the pyramidal or corticospinal tracts. Thi s system is associated with spontaneous, emotional, mimetic facial motions. The interplay between the pyramidal and extrapyramidal systems accounts for resting tone and stabilizes the motor responses. The masked facies associated with parki nsonism are known to be the result of destruction of the extrapyramidal pathways . The facial dystonia seen in Meige syndrome is thought to be due to basal gangl ion disease. Lower midbrain A lesion in the lower midbrain above the level of the facial nucleus may cause c ontralateral paresis of the face and muscles of the extremities, ipsilateral abd ucens muscle paresis (due to effects on the abducens nerve), and ipsilateral int ernal strabismus (see Image 1). If the lesion extends far enough laterally to in clude the emerging facial nerve fibers, a peripheral type of ipsilateral facial paralysis might be apparent. Pons The facial motor nucleus is located in the lower third of the pons beneath the f ourth ventricle. The neurons leaving the nucleus pass around the abducens nucleu s as they emerge from the brain stem (see Image 1). Involvement of the facial ne rve nucleus and VI nerve nucleus are suggestive of a lesion near the fourth vent ricle. A lesion near the ventricle at the level of the superior salivatory nucle us may result in a dry eye in addition to a peripheral facial paralysis and abdu cens paresis. Many syndromes are known to result from pontine lesions, some of w hich are summarized in Table 3. Table 3. Syndromes Associated with Central Lesions Syndrome Location of Lesion Characteristic Feature Foville syndrome Lateral pons Ipsilateral facial paresis, ipsilateral facial ana lgesia, ipsilateral Homer syndrome, ipsilateral deafness Meige syndrome Basal ganglion Facial dystonia Millard-Gubler syndrome Pontine nucleus Unilateral sixth nerve palsy, ipsilateral seventh nerve palsy, contralateral hemiparesis Moebius syndrome Fundus of IAC to facial hiatus Ipsilateral facial paresis, ipsi lateral abducens (CN VI) palsy Parkinson disease Extrapyramidal pathways Masked facies Pseudobulbar palsy Pontine Bilateral facial paresis with other CN defects, hyper active gag reflex, hyperreflexia associated with hypertension, emotional labilit y Weber syndrome Upper midbrain Ipsilateral loss of direct and consensual pupillar y light reflexes, ipsilateral external strabismus, oculomotor paresis

CEREBELLOPONTINE ANGLE AND THE INTERNAL AUDITORY CANAL The facial nerve emerges from the brain stem with the nerve of Wrisberg, ie, the nervus intermedius (see Image 2). The nervus intermedius gained its name from i ts position as it courses across the cerebellopontine angle (CPA) between the fa cial nerve and the vestibulocochlear nerves (ie, CN VII, CN VIII). The average d istance between the point where the nerves exit the brain stem and the place whe re they enter into the internal auditory canal (IAC) is approximately 15.8 mm. T he facial nerve and the nervus intermedius lie above and slightly anterior to CN VIII. The nervus intermedius conveys (1) afferent taste fibers from the chorda tympani nerve, which come from the anterior two thirds of the tongue; (2) taste fibers from the soft palate via the palatine and greater petrosal nerves; and (3) prega nglionic parasympathetic innervation to the submandibular, sublingual, and lacri mal glands. The fibers for taste originate in the nucleus of the tractus solitar ius (NTS), and the fibers to the lacrimal, nasal, palatal mucus, and submandibul ar glands originate in the superior salivatory nucleus. Fibers to the lacrimal g land are carried with the greater superficial petrosal nerve until it exits the skull, where they branch off as the Vidian nerve (see Image 3). The nervus intermedius also has a small cutaneous sensory component from afferen t fibers originating from the skin of the auricle and postauricular area. The close anatomic association between the facial nerve, the nervus intermedius, and the vestibulocochlear nerve at the level of the CPA and in the IAC may resu lt in disturbances in tearing, taste, salivary gland flow, hearing, balance, and facial function as the result of lesions at this level. Common examples are the symptoms of tinnitus, unilateral hearing loss, and balance disturbances often a ssociated with acoustic schwannomas. Large acoustic schwannomas may progress to involve the facial nerve and even CN V, CN IX, CN X, and CN XI. The facial nerve and the nervus intermedius enter the IAC with the vestibulococh lear nerve. The gross and microscopic anatomic relationships among the locations of CN VII, CN VIII, and the nervus intermedius are of surgical importance (see Image 4). The vestibulocochlear nerve enters the IAC inferiorly (caudad). The fa cial nerve runs superiorly (cephalad) along the roof of the IAC. A useful mnemon ic for remembering this relationship is "Seven-up over Coke." At the fundus of t he IAC, the falciform crest (crista falciformis) divides the IAC into superior a nd inferior compartments. The facial nerve passes along the superior part of the ledge, separated from the superior vestibular nerve by a vertical bony ridge na med the Bill bar (after the esteemed Dr William House).

INTRATEMPORAL COURSE OF THE FACIAL NERVES The facial nerve travels through the petrous temporal bone (see Image 5) in a bo ny canal called the fallopian canal (after Gabriel Fallopius). No other nerve in the body travels such a long distance through a bony canal. Because of this bon y shell around the nerve, inflammatory processes involving the CNS, facial nerve , and traumatic injuries to the temporal bone can produce unique complications. Proximal or labyrinthine segment

The labyrinthine segment of the facial nerve lies beneath the middle cranial fos sa and is the shortest segment in the fallopian canal (approximately 3.5-4 mm in length). In this segment, the nerve is directed obliquely forward, perpendicula r to the axis of the temporal bone (see Image 5). Both the facial nerve and the nervus intermedius remain distinct entities at this level. The term labyrinthine segment is derived from the location of this segment of the nerve immediately p osterior to the cochlea. The nerve is posterolateral to the ampullated ends of t he horizontal and superior semicircular canals and rests on the anterior part of the vestibule in this segment. The labyrinthine segment is the narrowest part of the facial nerve and is suscep tible to compression by means of edema. This is the only segment of the facial n erve that lacks anastomosing arterial cascades, making the area vulnerable to em bolic phenomena, low-flow states, or vascular compression. After traversing the labyrinthine segment, the facial nerve changes direction to form the first genu (ie, bend or knee), marking the location of the geniculate ganglion (see Image 5). The geniculate ganglion is formed by the juncture of the nervus intermedius and the facial nerve into a common trunk. Additional afferen t fibers from the anterior two thirds of the tongue are added to the geniculate ganglion from the chorda tympani. Three nerves branch from the geniculate gangli on: the greater superficial petrosal nerve, the lesser petrosal nerve, and the e xternal petrosal nerve. The greater petrosal nerve emerges from the upper portion of the ganglion and ca rries secretomotor fibers to the lacrimal gland. The greater petrosal nerve exit s the petrous temporal bone via the greater petrosal foramen to enter the middle cranial fossa. The nerve passes deep to the Gasserian ganglion (ie, trigeminal ganglion) to the foramen lacerum, through which it travels to the pterygoid cana l. In the pterygoid canal, the greater petrosal nerve joins the deep petrosal ne rve to become the nerve of the pterygoid canal. Axons from this nerve synapse in the pterygopalatine ganglion; postganglionic parasympathetic fibers, which are carried via branches of the maxillary (V2) divisions of the trigeminal nerve (CN V), innervate the lacrimal gland and mucus glands of the nasal and oral cavitie s. The external petrosal nerve is an inconstant branch that carries sympathetic fib ers to the middle meningeal artery; however, it is not as well known. The lesser petrosal nerve carries secretory fibers to the parotid gland. This nerve carrie s parasympathetic contributions from both the tympanic plexus (from CN IX) and t he nervus intermedius. Tympanic or horizontal segment The tympanic segment extends from the geniculate ganglion to the horizontal semi circular canal and is 8-11 mm in length. The nerve passes behind the cochlearifo rm process and the tensor tympani (see Image 5). The cochleariform process is a useful landmark for finding the facial nerve. The nerve lies against the medial wall of the cavum tympani, above and posterior to the oval window. The wall can be very thin or dehiscent in this area, and the middle ear mucosa may lay in dir ect contact with the facial nerve sheath. The fallopian canal has been reported to be dehiscent in the area of the oval window in 25-55% of postmortem specimens . Always anticipate finding a dehiscent or prolapsed facial nerve in its tympani c segment, especially in patients with congenital ear deformities. The distal portion of the facial nerve emerges from the middle ear between the p osterior wall of the external auditory canal and the horizontal semicircular can al. This is just distal to the pyramidal eminence, where the facial nerve makes a second turn marking the second genu. The most important landmarks for identify

ing the facial nerve in the mastoid are the horizontal semicircular canal, the f ossa incudis, and the digastric ridge. The second genu of the facial nerve runs inferolateral to the lateral semicircular canal. This is a relatively constant r elationship. In cases in which the lateral canal is difficult to identify (eg, cholesteatoma, tumor), the use of other landmarks, along with cautious exploration, is advised . The digastric ridge points to the lateral and inferior aspect of the vertical co urse of the facial nerve in the temporal bone. In poorly pneumatized temporal bo nes, the digastric ridge may be difficult to identify. The distal aspect of the tympanic segment can be surgically located via a facial recess approach. The cho rda tympani nerve and the fossa incudis can be used to identify the nerve when p erforming a facial recess approach (see Image 6). The long process of the incus points toward the facial recess. The chorda tympani nerve serves at the lateral margin of the triangular facial recess. The chorda tympani nerve can be exposed along its length and can be followed inferiorly and medially to its takeoff from the main trunk of the facial nerve. In practice, surgeons most likely employ cu es from all these landmarks in respecting the integrity of the facial nerve. Mastoid segment The second genu marks the beginning of the mastoid segment. The second genu is l ateral and posterior to the pyramidal process. The nerve continues vertically do wn the anterior wall of the mastoid process to the stylomastoid foramen. The mas toid segment is the longest part of the intratemporal course of the facial nerve , approximately 10-14 mm long. During middle ear surgery, the facial nerve is mo st commonly injured at the pyramidal turn. The 3 branches that exit from the mastoid segment of the facial nerve are (1) th e nerve to the stapedius muscle, (2) the chorda tympani nerve, and (3) the nerve from the auricular branch of the vagus. The auricular branch of the vagus nerve arises from the jugular foramen and joins the facial nerve just distal to the p oint at which the nerve to the stapedius muscle arises. Pain fibers to the poste rior auditory canal may be carried with this nerve. The chorda tympani is the terminal branch of the nervus intermedius. The chorda runs laterally in the middle ear, between the incus and the handle of the malleu s. The nerve crosses the middle ear cavity and exits through the petrotympanic f issure (ie, canal of Huguier) to join the lingual nerve. The chorda tympani nerv e carries preganglionic secretomotor fibers to the submaxillary and sublingual g lands. The chorda also carries special sensory afferent fibers (ie, taste fibers ) from the anterior two thirds of the tongue and fibers from the posterior wall of the external auditory canal responsible for pain, temperature, and touch sens ations. The facial nerve exits the fallopian canal via the stylomastoid foramen. The ner ve travels between the digastric and stylohyoid muscles and enters the parotid g land. A sensory branch exits the nerve just below the stylomastoid foramen and i nnervates the posterior wall of the external auditory canal and a portion of the tympanic membrane.

EXTRATEMPORAL FACIAL NERVE A number of useful landmarks are used to locate the facial nerve. Topographic la ndmarks can serve as guides for locating the course of the facial nerve and its

branches (see Image 7). For example, a line drawn between the mastoid tip and th e angle of the mandible can serve as a useful landmark for the superior limits o f a neck dissection. Removal of parotid tissue inferior to this line can be perf ormed relatively safely. The topographic trajectory of the frontal and/or margin al branches should be identified during a rhytidoplasty, submandibular gland exc ision, and/or neck dissection. The frontal branch can be roughly located along a line extending from the attachment of the lobule (approximately 5 mm below the tragus), anterior and superiorly to a point 1.5 cm above the lateral aspect of t he ipsilateral eyebrow, as described by Pitanguy, Peterson, and Larrabee and Mak ieldki. Surgical landmarks to the facial nerve include the tympanomastoid suture line, t he tragal pointer, and the posterior belly of the digastric muscle. The tympanom astoid suture line lies between the mastoid and tympanic segments of the tempora l bone. The tympanomastoid suture line lies approximately 6-8 mm lateral to the stylomastoid foramen. The main trunk of the nerve can also be found midway betwe en (10 mm posteroinferior) the cartilaginous tragal pointer of the external audi tory canal and the posterior belly of the digastric muscle. The nerve is usually located inferior and medial to the pointer. During surgical dissection, the sur geon may encounter a branch from the occipital artery that lies lateral to the n erve. Brisk bleeding at this time may be a sign that the nerve is in close proxi mity; hemostasis should be obtained using bipolar electrocautery, and further di ssection should proceed cautiously. The styloid process is deep to the main trun k of the nerve. In the infant and young child, these landmarks are not applicable because of dif ferences in the rate of anatomic development of the parotid gland and mastoid. T he modified Blair incision most commonly used in adults is often avoided in chil dren because the facial nerve is located more superficially, and the risk of inj ury is increased with elevation of the skin flaps. Many textbooks on pediatric o tolaryngology provide detailed descriptions of the safe placement of surgical in cisions for exposing the facial nerve and its branches in children. Once it has exited the fallopian canal at the stylomastoid foramen, the facial n erve gives off several rami before it divides into its main branches. Below the stylomastoid foramen, the posterior auricular nerve leaves the facial nerve and innervates the postauricular muscles. Two small branches innervate the stylohyoi d muscle and posterior belly of the digastric muscle. The facial nerve crosses lateral to the styloid process and penetrates the parot id gland. The nerve lies in a fibrous plane that separates the deep and superfic ial lobes of the parotid gland. In the parotid gland, the nerve divides at the p es anserinus into 2 major divisions, the superiorly directed temporal-facial and the inferiorly directed cervicofacial branches (see Image 7). After the main point of division, 5 major branches of the facial nerve exist: te mporal (ie, frontal), zygomatic, buccal, marginal mandibular, and cervical. The facial nerve innervates 14 of the 17 paired muscle groups of the face on their d eep side. The 3 muscles innervated from other sources are the buccinator, levato r anguli oris, and mentalis muscles. Frequent connections between the buccal and zygomatic branches exist. The temporal and marginal mandibular branches are at highest risk during surgical procedures and are usually terminal connections wit hout anastomotic connections. Superficial musculoaponeurotic system The superficial musculoaponeurotic system (SMAS) is a superficial fascial layer that extends throughout the cervical facial region. In the lower face, the SMAS invests the facial muscles and is continuous with the platysma muscle. Superiorl y, the SMAS ends at the level of the zygoma because of attachments of the fascia

l layers to the zygomatic arch. The temporoparietal fascia is not continuous with the SMAS, but the two are most likely embryologic equivalents. The temporoparietal fascia extends from the zyg omatic arch as an extension of the deep temporal fascia. In the temporal region, the frontal branch of the facial nerve crosses the zygomatic arch and courses w ithin the superficial layer of the deep temporal fascia (temporoparietal fascia) . In the scalp, the equivalent of the SMAS is the galea aponeurotica, which spli ts to ensheathe the frontalis, occipitalis, procerus, and some of the postauricu lar muscles. In the upper face, the neurovascular structures exit their bony for amina and penetrate the SMAS to run within its superficial aspects or on its sur face. The SMAS encloses all of the facial muscles and comprises their only attachment to the overlying dermis, thus transmitting contractions of the facial muscles to the overlying skin. A conceptual understanding of the anatomy of the SMAS is im portant to the surgeon. In the lower face, the facial nerve always runs deep to the platysma and SMAS and innervates the muscles on their undersurfaces (except for the buccinator, levator anguli oris, and mentalis muscles). The SMAS also he lps the surgeon identify the location of the facial nerve during dissection towa rd the midline of the face, where the nerve can be found running on top of the m asseter muscle just below the SMAS. Temporal branches The relationships of the temporal branch are complex and only briefly described in this article. Refer to Larrabee and Makielski for a more complete anatomic de scription. The temporal branch of the facial nerve exits the parotid gland and r uns within the SMAS over the zygomatic arch into the temple region. The frontal branch enters the undersurface of the frontalis muscle and lies superficial to t he deep temporalis fascia. To avoid injury to the frontal branch during elevatio n of facial flaps, the surgeon should elevate either in a subcutaneous plane or deep to the SMAS. Marginal branches The mandibular (or marginal) division lies along the body of the mandible (80%) or within 1-2 cm below (20%). This is a critical landmark in head and neck surge ry. The marginal branch lies deep to the platysma throughout much of its course. It becomes more superficial approximately 2 cm lateral to the corner of the mou th and ends on the undersurface of the muscles. Injury to the marginal branch re sults in paralysis of the muscles that depress the corner of the mouth.

FACIAL NERVE PARALYSIS The spectrum of facial motor dysfunction is wide, and characterizing the degree of paralysis can be difficult. Several systems have been proposed, but, since th e mid 1980s, the House-Brackmann system has been widely used. In this scale, gra de I is assigned to normal function, and grade VI is complete paralysis. Interme diate grades vary according to function at rest and with effort. These are summa rized in Table 4. Table 4. House-Brackmann Facial Nerve Grading System Grade Description Characteristics I Normal Normal facial function in all areas II Mild dysfunction Slight weakness noticeable on close inspection; may have ver y slight synkinesis

III Moderate dysfunction Obvious, but not disfiguring, difference between 2 side s; noticeable, but not severe, synkinesis, contracture, or hemifacial spasm; com plete eye closure with effort IV Moderately severe dysfunction Obvious weakness or disfiguring asymmetry; norm al symmetry and tone at rest; incomplete eye closure V Severe dysfunction Only barely perceptible motion; asymmetry at rest VI Total paralysis No movement

VASCULAR SUPPLY OF THE FACIAL NERVE The cortical motor area of the face is supplied by the Rolandic branch of the mi ddle cerebral artery. Within the pons, the facial nucleus receives its blood sup ply primarily from the anterior inferior cerebellar artery (AICA). The AICA, a b ranch of the basilar artery, enters the internal auditory canal with the facial nerve. The AICA branches into the labyrinthine and cochlear arteries. The superf icial petrosal branch of the middle meningeal artery is the second of 3 sources of arterial blood supply to the extramedullary (ie, intrapetrosal) facial nerve. The posterior auricular artery supplies the facial nerve at and distal to the s tylomastoid foramen. Venous drainage parallels the arterial blood supply.

EMBRYOLOGY OF THE FACIAL NERVE By the third week of gestation, the fascioacoustic primordium gives rise to cran ial nerves VII and VIII. During the fourth week, the chorda tympani can be disce rned from the main branch. The former courses ventrally into the first branchial arch and terminates near a branch of the trigeminal nerve that eventually becom es the lingual nerve. The main trunk courses into the mesenchyme, approaching th e epibranchial placode. The geniculate ganglion, nervus intermedius, and the gre ater superficial petrosal nerve are visible by the fifth week. The second branch ial arch gives rise to the muscles of facial expression in the seventh and eight h week. To innervate these muscles, the facial nerve courses across the region t hat eventually becomes the middle ear. By the eleventh week, the facial nerve ha s arborized extensively. In the newborn, the facial nerve anatomy approximates t hat of an adult, except for its location in the mastoid, which is more superfici al.