Anatomy reimagined: The landfald classification as a transformative surgical and radiological guide to facial artery...

The facial artery (FA) is the main vascular supply to the anterior face, but it exhibits considerable anatomical variation that impacts surgical planning. We review FA anatomy and variants, examining clinical and radiological data since 2010, and introduce the updated Landfald Classification of FA variants. The common linguofacial trunk (LFT), in which the facial and lingual arteries arise as a single trunk, is the most prevalent variant (approximately 15 % of cases) (Herrera-Núñez et al., 2020; Triantafyllou et al., 2024). Rare variants include the thyrolinguofacial trunk (TLFT, <3 %) and true arterial duplication or early termination (on the order of a few percent) (Zaccheo et al., 2023; Yoon et al., 2024). These anomalies disrupt the usual FA territory and can increase the risk of tongue or facial ischemia during head and neck surgery, free flap failure, or inadvertent vascular occlusion in cosmetic injections. High-resolution angiographic imaging is essential: computed tomography angiography (CTA) and magnetic resonance angiography (MRA) reliably delineate FA course and branches, though CTA involves ionizing radiation (Furukawa et al., 2013). We present an enhanced Landfald Classification with five major types (I-V) and fourteen subtypes (Ia-Vb) that stratify FA anatomy by branching pattern, clinical implications, and imaging detectability. This framework supports tailored surgical approaches and risk mitigation. For example, classical ("Type I") FA patterns allow predictable flap design, whereas hypoplastic or aberrant ("Type IV-V") variants often necessitate alternative strategies. Surgeons and radiologists should apply detailed preoperative mapping - including CTA, MRA, Doppler ultrasonography, or augmented-reality simulations - to identify FA variants and plan safe dissections. In conclusion, recognizing the full spectrum of FA variation and using the Landfald classification can improve surgical precision and patient safety in reconstructive, oncologic, and aesthetic facial procedures.