Lec2

GENERAL ANATOMY | DGA 1 21

Scalp
Ture Dr. Raigel Kent Alcera
Second Semester – Prelims
Scalp of the skull bones and with the intracranial venous
sinuses.
 Pericranium. The pericranium is the periosteum
covering the outer surface of the skull bones. The
pericranium is continuous with the periosteum on
the inner surface of the skull bones (endosteum) at
the sutures between the individual skull bones

The scalp extends from the superciliary arches anteriorly to

the external occipital protuberance and superior nuchal
lines posteriorly and to the temporal lines laterally. It
consists of five layers. Conveniently, the first letters of each
layer together spell SCALP, making recall easier. The first
three layers are intimately bound together and move as a
unit.

Sensory Nerve Supply

 Skin. This is thick and hair bearing and contains
The main trunks of the sensory nerves lie in the dense
numerous sebaceous glands.
connective tissue layer (the “C” layer) of the scalp. The
 Connective tissue beneath the skin. This is a
nerves are arranged in two main groups: (1) branches of the
dense fibrofatty layer containing fibrous septa that
trigeminal nerve located anterior to the ear and (2) branches
unite the skin to the underlying epicranial
of cervical spinal nerves located posterior to the ear. Moving
aponeurosis. This layer contains numerous blood
laterally from the anterior midline, the following nerves are
vessels. The arteries are derived from both the
present.
external and internal carotid arteries, and free
anastomoses occur between them.
 Aponeurosis (epicranial). This is a thin, tendinous
sheet that unites the occipital and frontal bellies of
the occipitofrontalis muscle. The lateral margins of
the aponeurosis are attached to the temporal
fascia. The subaponeurotic space is the potential
space deep to the epicranial aponeurosis. It is
limited in front and behind by the origins of the
occipitofrontalis muscle, and it extends laterally as
far as the attachment of the aponeurosis to the
temporal fascia. Trigeminal branches:
 Loose areolar tissue. This occupies the  The supratrochlear nerve, a branch of the
subaponeurotic space and loosely connects the ophthalmic division of the trigeminal nerve, winds
epicranial aponeurosis to the periosteum of the around the superior orbital margin and supplies the
skull (the pericranium). This is the plane of scalp. It passes backward close to the median
movement of the scalp, that is, when the scalp plane and reaches nearly as far as the vertex of
moves, the first three layers (SCA) slide along this the skull.
layer relative to the underlying periosteum. The  The supraorbital nerve, a branch of the ophthalmic
areolar tissue contains a few small arteries, but it division of the trigeminal nerve, winds around the
also contains some important emissary veins. The superior orbital margin and ascends over the
emissary veins are valveless and connect the forehead. It supplies the scalp as far backward as
superficial veins of the scalp with the diploic veins the vertex.
Page 1|8
  The zygomaticotemporal nerve, a branch of the
maxillary division of the trigeminal nerve, supplies
the scalp over the temple.
 The auriculotemporal nerve, a branch of the
mandibular division of the trigeminal nerve,
ascends over the side of the head from in front of
the auricle. Its terminal branches supply the skin
over the temporal region.
Cervical spinal nerve branches:
 The lesser occipital nerve (C2), a branch of the
cervical plexus, ascends along the posterior edge of the
sternocleidomastoid muscle and supplies the scalp
over the lateral part of the occipital region and the
skin over the medial surface of the auricle.
 The greater occipital nerve, a branch of the posterior
ramus of the second cervical nerve, ascends over the
back of the scalp and supplies the skin as far forward
as the vertex of the skull.
Arterial Supply
The scalp has a rich blood supply to nourish the hair follicles,
and, for this reason, the smallest cut bleeds profusely. As
with the cutaneous nerves, the arteries run through the
dense connective tissue layer (the “C” layer) of the scalp,
typically follow the nerves, and form an extensive, freely
anastomosing network. Moving laterally from the anterior
midline, the following arteries are present.
 The supratrochlear and the supraorbital arteries,
branches of the ophthalmic artery (a branch of the
internal carotid artery), ascend over the forehead in
company with the supratrochlear and supraorbital
nerves.
 The superficial temporal artery, the smaller
terminal branch of the external carotid artery,
ascends in front of the auricle in company with the
auriculotemporal nerve. It divides into anterior and
posterior branches, which supply the skin over the
frontal and temporal regions.
 The posterior auricular artery, a branch of the
external carotid artery, ascends behind the auricle
to supply the scalp above and behind the auricle.
 The occipital artery, a branch of the external
carotid artery, ascends from the apex of the
posterior triangle in company with the greater
occipital nerve and pierces the trapezius muscle to
reach the scalp. It supplies the skin over the back
of the scalp and reaches as high as the vertex of the
skull.
Venous Drainage
 The supratrochlear and supraorbital veins unite
at the medial margin of the orbit to form the facial
vein.
 The superficial temporal vein unites with the
maxillary vein in the substance of the parotid gland
to form the retromandibular vein.
 The posterior auricular vein unites with the
posterior division of the retromandibular vein, just
below the parotid gland, to form the external jugular
vein.
 The occipital vein drains into the suboccipital
venous plexus, which lies beneath the floor of the
upper part of the posterior triangle, the plexus in
turn drains into the vertebral veins or the internal
jugular vein.
 The veins of the scalp freely anastomose with one
another and are connected to the diploic veins of
the skull bones and the intracranial venous sinuses
by valveless emissary veins.
Lymph Drainage
Lymph vessels in the anterior part of the scalp and forehead
drain into the submandibular lymph nodes. Drainage from
the lateral part of the scalp above the ear is into the
superficial parotid (preauricular) nodes. Lymph vessels in
the part of the scalp above and behind the ear drain into the
mastoid nodes. Vessels in the back of the scalp drain into
the occipital nodes.
Face
The face is the area from the superciliary arches superiorly
to the lower margin of the mandible inferiorly and to the
auricles laterally. It contains the orbits, nose, mouth, and
ears and therefore houses the interfaces for vision,
respiration, olfaction, taste, food processing, vocalization,
and hearing between the internal and external
environments. Further, the face is critical for individual
identity, and facial expression is a highly evolved means of
nonvocal communication
Facial Skeleton
The superior orbital margins
and the area above them are
formed by the frontal bone,
which contains the frontal
air sinuses. The lateral
orbital margin is formed by
the zygomatic bone, and the
inferior orbital margin is
formed by the zygomatic
bone and the maxilla. The
medial orbital margin is
formed above by the
maxillary process of the
frontal bone and below by the frontal process of the maxilla.
The root of the nose is formed by the nasal bones, which
articulate below with the maxilla and above with the frontal
Page 2|8
bones. Anteriorly, upper and lower plates of hyaline cartilage
and small cartilages of the ala nasi complete the nose.
The important central bone of the middle third of the face is
the maxilla, containing its teeth and the maxillary air sinus.
The bone of the lower third of the face is the mandible, with
its teeth.
Skin
The skin of the face possesses
numerous sweat and sebaceous
glands. It is connected to the
underlying bones by loose
connective tissue, in which are
embedded the muscles of facial
expression. There is no deep
fascia in the face. Wrinkle lines of
the face result from the repeated
folding of the skin perpendicular
to the long axis of the underlying
contracting muscles, coupled
with the loss of youthful skin
elasticity. Surgical scars of the
face are less conspicuous if they follow the wrinkle lines.
Sensory Nerves
The skin of the face is supplied by branches of the three
divisions of the trigeminal nerve, except for the small area
over the angle of the mandible and the parotid gland, which
is supplied by the great auricular nerve (C2 and 3). The
overlap of the three divisions of the trigeminal nerve is slight
compared with the considerable overlap of dermatomes of
the trunk and limbs. The ophthalmic nerve supplies the
region developed from the frontonasal process; the
maxillary nerve serves the region developed from the
maxillary process of the first pharyngeal arch; and the
mandibular nerve serves the region developed from the
mandibular process of the first pharyngeal arch. These
nerves not only supply the skin of the face but also supply
proprioceptive fibers to the underlying muscles of facial
expression. Additionally, they are the sensory nerve supply
to the mouth, teeth, nasal cavities, and paranasal air
sinuses.
Ophthalmic Nerve
The ophthalmic nerve supplies the skin of the forehead, the
upper eyelid, the conjunctiva, and the side of the nose down
to and including the tip. Five branches of the nerve pass to
the skin
Main branches:
1. Nasociliary Nerve
• The infratrochlear nerve leaves the orbit
below the pulley of the superior oblique
muscle. It supplies the skin and conjunctiva on
the medial part of the upper eyelid and the
adjoining part of the side of the nose.
• The external nasal nerve leaves the nose by
emerging between the nasal bone and the
upper nasal cartilage. It supplies the skin on
the side of the nose down as far as the tip.
2. Frontal nerve
• The supraorbital nerve winds around the
upper margin of the orbit at the supraorbital
notch/supraorbital foramen. It divides into
branches that supply the skin and conjunctiva
on the central part of the upper eyelid; it also
supplies the skin of the forehead.
• The supratrochlear nerve winds around the
upper margin of the orbit medial to the
supraorbital nerve. It divides into branches that
supply the skin and conjunctiva on the medial
part of the upper eyelid and the skin over the
lower part of the forehead, close to the median
plane.
3. Lacrimal nerve supplies the skin and conjunctiva
of the lateral part of the upper eyelid.
Maxillary Nerve
The maxillary nerve supplies the skin on the posterior part of
the side of the nose, the lower eyelid, the cheek, the upper
lip, and the lateral side of the orbital opening. Three
branches of the nerve pass to the skin.
 The infraorbital nerve is a direct continuation of
the maxillary nerve. It enters the orbit and appears
on the face through the infraorbital foramen. It
immediately divides into numerous small
branches, which radiate out from the foramen and
supply the skin of the lower eyelid and cheek, the
side of the nose, and the upper lip.
 The zygomaticofacial nerve passes onto the face
through a small foramen on the lateral side of the
zygomatic bone. It supplies the skin over the
prominence of the cheek.
Page 3|8
  The zygomaticotemporal nerve emerges in the
temporal fossa through a small foramen on the
posterior surface of the zygomatic bone. It supplies
the skin over the temple
Mandibular Nerve
The mandibular nerve supplies the skin of the lower lip, the
lower part of the face, the temporal region, and part of the
auricle. It then passes upward to the side of the scalp. Three
branches of the nerve pass to the skin.
 The mental nerve emerges from the mental
foramen of the mandible and supplies the skin of
the lower lip and chin.
 The buccal nerve emerges from beneath the
anterior border of the masseter muscle and
supplies the skin over a small area of the cheek.
 The auriculotemporal nerve ascends from the
upper border of the parotid gland between the
superficial temporal vessels and the auricle. It
supplies the skin of the auricle, the external
auditory meatus, the outer surface of the tympanic
membrane, and the skin of the scalp above the
auricle.
Clinical Notes
Trigeminal Neuralgia
The facial skin receives its sensory nerve supply primarily
from the three divisions of the trigeminal nerve. Trigeminal
neuralgia (tic douloureux) is a relatively common (often
idiopathic) condition in which the patient experiences
sudden attacks of excruciating pain in the distribution of the
mandibular or maxillary division, with the ophthalmic
division usually escaping. A physician should be able to map
out accurately the distribution of each of the divisions of the
trigeminal nerve on a patient’s face.
Arterial Supply
The face receives a rich blood supply from two main vessels,
the facial and superficial temporal arteries, which are
supplemented by several small arteries that accompany the
sensory nerves of the face. The facial artery arises from the
external carotid artery in the upper neck. It arches upward
and over the submandibular salivary gland and curves
around the inferior margin of the body of the mandible at the
anterior border of the masseter muscle. Its pulse can be
easily felt here. It next runs upward in a tortuous course
toward the angle of the mouth and is covered by the
platysma and the risorius muscles. It then ascends deep to
the zygomaticus muscles and the Levator labii superioris
muscle and runs along the side of the nose to the medial
angle of the eye, where it anastomoses with the terminal
branches of the ophthalmic artery
Branches
 The submental artery arises from the facial artery
at the lower border of the body of the mandible. It
supplies the skin of the chin and lower lip.
 The inferior labial artery arises near the angle of
the mouth. It runs medially in the lower lip and
anastomoses with its fellow of the opposite side.
 The superior labial artery arises near the angle of
the mouth. It runs medially in the upper lip and
gives branches to the septum and ala of the nose.
 The lateral nasal artery arises from the facial
artery alongside the nose. It supplies the skin on the
side and dorsum of the nose.
 The angular artery is the terminal part of the facial
artery. It runs in the narrow gap between the side of
the nose and the medial canthus of the eye.
The superficial temporal artery, the smaller terminal
branch of the external carotid artery, commences in the
parotid gland. It ascends in front of the auricle to supply the
scalp.
Branches
 The transverse facial artery arises within the
parotid gland. It runs forward across the cheek just
above the parotid duct and below the zygomatic
arch.
 The anterior (frontal) and posterior (temporal)
branches are the terminal branches of the
superficial temporal artery. They distribute across
the temporal fossa
 The supraorbital, supratrochlear, infraorbital,
and mental arteries are small vessels that
accompany the like-named cutaneous nerves of
the face.
Venous Drainage
 The facial vein is formed at the medial angle of the
eye by the union of the supraorbital and
supratrochlear veins. It connects to the superior
ophthalmic vein directly through the supraorbital
vein. The facial vein connects to the cavernous
sinus by way of the superior ophthalmic vein. This
anastomosis is of great clinical importance
Page 4|8
 because it provides a pathway for the spread of
infection from the face to the cavernous sinus. The
facial vein descends behind the facial artery to the
lower margin of the body of the mandible. It crosses
superficial to the submandibular gland and is joined
by the anterior division of the retromandibular
vein. The facial vein ends by draining into the
internal jugular vein.
 The facial vein receives tributaries that correspond
to the branches of the facial artery. It joins the
pterygoid venous plexus by the deep facial vein
and the cavernous sinus by the superior
ophthalmic vein. The transverse facial vein joins
the superficial temporal vein within the parotid
gland
 The facial muscles are subject to great individual
variability in size, shape, thickness, strength, and
general degree of development. Therefore, their
actions are individually variable and diverse,
especially in their subtler uses. All the facial
muscles develop from the second pharyngeal
arch and are supplied by the facial nerve.
 The eyelids, nostrils, lips, and auricles guard the
facial orifices. The auricular muscles that operate
the external ear are essentially a group of vestigial
muscles in humans.
Eyelid Muscles
 The orbicularis oculi is the sphincter muscle of the
eyelids, whereas the occipitofrontalis is a dilator
muscle. The corrugator and procerus also act on
the orbit. The levator palpebrae superioris also
elevates the upper eyelid but is generally
considered an extraocular muscle and is described
with the orbit.

Lymph Drainage Nostril Muscles

 Lymph from the forehead and the anterior part of  The nasalis (compressor naris) and depressor septi
the face drains into the submandibular lymph are the sphincter muscles, and the dilator naris and
nodes. A few buccal lymph nodes may be present levator labii superioris alaeque nasi are the dilator
along the course of these lymph vessels. Lymph muscles.
vessels that end in the parotid lymph nodes drain
the lateral part of the face, including the lateral
parts of the eyelids. The central part of the lower lip
and the skin of the chin drain into the submental
lymph nodes.
Facial Muscles (Muscles of Facial Expression;
Mimetic Muscles)
 The facial muscles are the skeletal muscles that
are embedded in the superficial fascia of the face.
They should not be confused with the masticatory
muscles (e.g., masseter and temporalis, which are
located in the face) or with the smooth arrector pili
muscles that attach onto hair follicles. The facial Lip and Cheek Muscles
muscles are integumentary muscles. Most arise
from the bones of the skull and all insert into the
skin or other facial muscles.
 The primary biological role of the facial muscles is
to regulate (constrict or dilate) the facial orifices
(i.e., the orbits, nostrils, mouth, and ears). Because
of these actions, the facial muscles must be
considered as accessory muscles of vision,
olfaction, respiration, feeding, speech, and
hearing. Facial expression is a secondary by-
product of the fine control of the facial orifices, and
facial expressions are essentially orifice displays
The orbicularis oris is the primary sphincter muscle of the
(think about what you are doing when you smile,
lips and has a complex structure. Some of the fibers arise
frown, wink, glare, etc.).
near the midline from the maxilla above and the mandible

Page 5|8
below. Other fibers arise from the deep surface of the skin
and pass obliquely to the mucous membrane lining the inner
surface of the lips. Many of the fibers are derived from the
buccinator muscle. A series of small muscles that radiate
out from the lips make up the dilator muscles. Their action is
to separate the lips; this movement is usually accompanied
by opening of the jaws. The muscles arise from the bones
and fascia around the oral aperture and converge to be
inserted into the substance of the lips. Traced from the side
of the nose to the angle of the mouth and then below the oral
aperture, the muscles are named as follows:
 Levator labii superioris alaeque nasi (this also
dilates the nostril)
 Levator labii superioris
 Zygomaticus minor (an inconstant muscle that
often is part of the orbicularis oculi)
 Zygomaticus major
 Levator anguli oris (deep to the zygomatic muscles)
 Risorius
 Buccinator
 Depressor anguli oris
 Depressor labii inferioris
 Mentalis
The buccinator muscle originates from the outer surface of
the alveolar margins of the maxilla and mandible opposite
the molar teeth and from the pterygomandibular ligament.
The muscle fibers pass forward, forming the muscle layer of
the cheek, and the parotid duct pierces the muscle. At the
angle of the mouth, the central fibers decussate, those from
below entering the upper lip and those from above entering
the lower lip; the highest and lowest fibers continue into the
upper and lower lips, respectively, without intersecting. The
buccinator muscle thus blends with and forms part of the
orbicularis oris muscle. The decussation of the buccinator
fibers causes a small indentation in the cheek of some
individuals when the buccinator contracts. This appears as
a “dimple” and is highly variable in form. The buccinator is a
significant muscle in food processing in that it compresses
the cheeks and lips against the teeth, thus positioning food
for efficient chewing. The compression action also is
important in producing sucking and so is critical in suckling
in neonates. Cheek compression is also important in
producing blowing actions, such as in blowing a horn.
Clinical Notes
Facial Muscle Paralysis
The facial muscles are innervated by the facial nerve.
Damage to the facial nerve in the internal acoustic meatus
(by a tumor), in the middle ear (by infection or surgery), in the
facial nerve canal (perineuritis, Bell’s palsy), or in the parotid
gland (by a tumor) or caused by lacerations of the face
causes distortion of the face. Inability to close the eyelids,
drooping of the lower eyelid, and sagging of the angle of the
mouth on the affected side are characteristic sequelae. The
patient has an expressionless, masklike side of the face and
commonly dribbles from the corner of the mouth when
attempting to eat or drink. This is essentially a lower motor
neuron lesion. An upper motor neuron lesion (involvement
of the pyramidal tracts) will leave the upper part of the face
normal because the neurons supplying this part of the face
receive corticobulbar fibers from both cerebral cortices.
Facial Nerve
The facial nerve divides into its five terminal branches as it
runs forward within the substance of the parotid salivary
gland
 The temporal branch emerges from the upper
border of the gland and supplies the anterior and
superior auricular muscles, the frontal belly of the
occipitofrontalis, the orbicularis oculi, and the
corrugator supercilii.
 The zygomatic branch emerges from the anterior
border of the gland and supplies the orbicularis
oculi.
 The buccal branch emerges from the anterior
border of the gland below the parotid duct and
supplies the buccinator muscle and the muscles of
the upper lip and nostril.
 The mandibular branch emerges from the anterior
border of the gland and supplies the muscles of the
lower lip.
 The cervical branch emerges from the lower border
of the gland and passes forward in the neck below
the mandible to supply the platysma muscle; it
may cross the lower margin of the body of the
mandible to supply the depressor anguli oris
muscle
The facial nerve is the nerve of the second pharyngeal arch
and supplies all the muscles of facial expression. It does not
supply the skin, but its branches communicate with
branches of the trigeminal nerve. It is believed that the
proprioceptive nerve fibers of the facial muscles leave the
facial nerve in these communicating branches and pass to
the central nervous system via the trigeminal nerve.
Embryology Notes
The Pharyngeal Arches
 The development of the head and neck begins in
the 4th and 5th week. Growth of mesenchymal
tissue (connective tissue) in the cranial region of
the embryo results in the formation of arches,
separated by clefts. These are
the pharyngeal arches and pharyngeal clefts.
 Simultaneously, a number of outpocketings appear
on the lateral wall of the pharynx –
the pharyngeal pouches. The pouches separate
Page 6|8
 the arches on the internal (endodermal) surface
whilst the clefts separate the arches on the
external (ectodermal) surface.
 In this article, we will explore these structures from
outside to inside and discuss the structures that
arise from the pharyngeal apparatus.
Pharyngeal Clefts
 There are initially four pharyngeal clefts. However,
only the 1st cleft gives rise to a permanent structure
in the adult – the external auditory meatus.
 The 2nd, 3rd and 4th clefts only form temporary
cervical sinuses – which are then obliterated by the
rapidly proliferating 2nd pharyngeal arch.
 Pharyngeal Arches
 There are six pharyngeal arches – however, the
5th regresses soon after forming.
 Each arch is innervated by an arch-
associated cranial nerve, and has a muscular
component, a skeletal and cartilaginous
supporting element. as well as
a vascular component.
 In the adult, each pharyngeal arch is associated
with specific structures within the head and neck.
First Arch
The first pharyngeal arch is comprised of two parts:
 Maxillary prominence (dorsal portion) – becomes
the future maxilla, zygomatic bone and part of the
temporal bone.
o Is associated with the maxillary
cartilage, which gives rise to the incus.
 Mandibular prominence (ventral portion) –
becomes the future mandible.
o Is associated with Meckel’s cartilage,
which gives rise to the malleus and the
sphenomandibular ligament.
 The artery of the first pharyngeal arch becomes the
terminal portion of the maxillary artery, which is a
branch of the external carotid.
 Its associated nerve is the trigeminal nerve (CN
V). The first arch gives rise to the muscles of
mastication and the mylohyoid, anterior belly of
digastric, tensor veli palatani and tensor tympani –
all of which are innervated by the branches of the
trigeminal nerve.
 Its sensory field is that of the trigeminal nerve too,
namely the skin of the face, the lining of the mouth
and nose, and general sensation to the anterior
2/3 of the tongue.
Second Arch
There are two arteries associated with the second
pharyngeal arch:
 Stapedial artery – connects the embryonic
precursors of the internal carotid, internal maxillary
and middle meningeal arteries. It regresses before
birth.
 Hyoid artery – gives rise to the corticotympanic
artery in the adult.
Reichart’s cartilage is the name given to the cartilage
component of the second arch. It is the precursor to the
stapes, the styloid process, the stylohyoid ligament and the
upper body and lesser horn of the hyoid bone.
The nerve associated with the second pharyngeal arch is
the facial nerve (CN VII). It innervates all the muscular
derivatives of the 2nd arch – the muscles of facial
expression, stapedius, stylohyoid, platysma and the
posterior belly of digastric.
The sensory field of the second arch is that of the facial
nerve, namely taste sensation to the anterior 2/3rds of the
tongue (via the chorda tympani).
Third Arch
 The artery of the third pharyngeal arch becomes
the common carotid artery and the proximal
portion of the internal carotid artery.
 Its cartilaginous component is less complex than
the first two arches and gives rise to only the lower
body and greater horn of the hyoid.
 Its associated cranial nerve is
the glossopharyngeal nerve (CN IX).
 The third arch gives rise to stylopharyngeus, and
its sensory function is to provide taste and general
sensation to the posterior 1/3rd of the tongue.
Face Development
 Early in development, the face of the embryo is
represented by an area bounded cranially by the
neural plate, caudally by the pericardium, and
laterally by the mandibular process of the first
pharyngeal arch on each side. In the center of this
area is a depression in the ectoderm known as the
stomodeum. In the floor of the depression is the
buccopharyngeal membrane. By the 4th week, the
buccopharyngeal membrane breaks down so that
the stomodeum communicates with the foregut.
 The further development of the face depends on
the coming together and fusion of several
important processes, namely, the frontonasal
process, the maxillary processes, and the
mandibular processes. The frontonasal process
begins as a proliferation of mesenchyme on the
ventral surface of the developing brain, and this
grows toward the stomodeum. Meanwhile, the
maxillary process grows out from the upper end of
each first arch and passes medially, forming the
lower border of the developing orbit. The
mandibular processes of the first arches now
approach one another in the midline below the
stomodeum and fuse to form the lower jaw and
lower lip.
 The olfactory pits appear as depressions in the
lower edge of the advancing frontonasal process,
dividing it into paired medial and lateral nasal
processes. With further development, the
maxillary processes grow medially and fuse with
the lateral nasal processes and with the medial
nasal process. The medial nasal process forms the
philtrum of the upper lip and the premaxilla. The
Page 7|8
 maxillary processes extend medially, forming the Macrostomia and Microstomia
upper jaw and the cheek, and finally bury the The normal size of the mouth shows considerable individual
premaxilla and fuse in the midline. The various variation. Rarely, there is incomplete fusion of the maxillary
processes that ultimately form the face unite with the mandibular processes, producing an excessively
during the second month. large mouth or macrostomia. Very rarely, there is excessive
 The upper lip is formed by the medial growth of the fusion of these processes, producing a small mouth or
maxillary processes of the first pharyngeal arch on microstomia. These conditions can be corrected surgically.
each side. Ultimately, the maxillary processes
meet in the midline and fuse with each other and
with the medial nasal process. Thus, the lateral
parts of the upper lip are formed from the maxillary
processes and the medial part, or philtrum, from
the medial nasal process, with contributions from
the maxillary processes.
 The lower lip is formed from the mandibular
process of the first pharyngeal arch on each side.
These processes grow medially below the
stomodeum and fuse in the midline to form the
entire lower lip. Each lip separates from its
respective gum as the result of the appearance of a
linear thickening of ectoderm, the labiogingival
lamina, which grows down into the underlying
mesenchyme and later degenerates. A deep
groove thus forms between the lips and the gums.
In the midline, a short area of the labiogingival
lamina remains and tethers each lip to the gum,
thus forming the frenulum. At first, the mouth has
a broad opening, but later, this diminishes in extent
because of fusion of the lips at the lateral angles.
Muscles of the Developing Face (Muscles of Facial
Expression)
 The muscles of the face are derived from the
mesenchyme of the second pharyngeal arch. The
nerve supply of these muscles is the nerve of the
second pharyngeal arch—namely, the seventh
cranial nerve.

Cleft Upper Lip

Cleft upper lip may be confined to the lip or may be
associated with a cleft palate. The anomaly is usually
unilateral cleft lip and is caused by a failure of the maxillary
process to fuse with the medial nasal process. Bilateral
cleft lip is caused by a failure of both maxillary processes to
fuse with the medial nasal process, which then remains as
a central flap of tissue. Median cleft upper lip is very rare
and is caused by the failure of the rounded swellings of the
medial nasal process to fuse in the midline

Page 8|8