THE HEAD

Head separated from neck by line, passes from (protuberantia mentalis) along the lower edge of mandible, the
posterior edge of the ascendant part of the mandible, the lower edge of the acoustic pore, (linia nuchae superior)
to the external occipital protuberance.
There are the cerebral cranium and visceral cranium. In cerebral cranium are vault (calvaria) and base of the
skull (basis cranii).
Cerebral cranium is separated from the visceral cranium by the supraorbital margin and zygomatic arch that
runs up to the external acoustic pore.
There are external surface of the base of skull (basis cranii externa) and the internal one (basis cranii interna).

CEREBRAL CRANIUM
There are the following of the skull fornix: frontoparietooccipital and temporal regions. The mastoid
region is described in this section becaus. Anatomically, the area belongs to the base of the skull.

Frontoparietooccipital Region
Borders: frontal one - supraorbital margin; lateral one - upper temporal line.
posterior one – superior nuchal line;
The skin is thick and mostly covered with hair. contains a lot of fat and sudoriferous gland –sweat-.
Skin is movable and connected with the galea aponeurotica by numerous fibrous bundles. Becouse cells
filled by fat. Hematoma is local.
Blood vessels and nerves are located in the subcutaneous cellular tissue.
Supratrochlear and supraorbital arteries are located in the frontal region; they pass with veins and
nerves of the same name. These blood vessels and nerves leave the orbital cavity through the openings of the
same names. Both arteries are branches of the ophthalmic artery from the inner carotid artery system.
The basic trunk of the superficial temporal artery and the auriculotemporal nerve are projected
vertically forward from the tragus. Posterior auricular blood vessels and the posterior auricular nerve run behind
the ear fixation point. Occipital artery is located in the middle between the mastoid process and the external
occipital protuberance. The greater occipital nerve (n. occipitalis major) and lesser occipital nerve (n.
occipitalis minor) is the sensitive branch of cervical plexus.
 The veins make anastomoses forming a dense net in the subcutaneous tissue
 frontal region = upper ophthalmic vein and cavernous sinus.
 Occipital and parietal regions = facial and external jugular veins.
 There are anastomoses between diploic veins of skull and the sinuses of dura mater.
 . Absence of venous valves is one of reason for spreading of infections and development of
diseases like trombosinusitis, meningitis and brain abscess.
 Lymph flows in direct to three groups of lymphatic nodes.
Galea aponeurotica is located below the subcutaneous cellular tissue. Galea aponeurotica is meddle
(tendon) part of epicranius muscle. It is tightly connected with skin and subcutaneous tissue. In case of trauma
of this region muscular bellies of m. epicranius are contracted and soft tissues move aside from the skull bone.
Wounds of this type are called scalped. Subaponeurotic space, filled with cellular tissue, locates under it.
 Periosteum of the region is a thin layer separated from skull bones by a layer of subperiosteal cellular
tissue. Periosteum is fixed to bones along sutures, thus subperiostal haematomes are localized in limits of the
one bone.
Skull bones consist of compact substance - internal and external laminae - and spongious or diploe
between them. The latter contains a dense venous net (diploetic veins) that collects venous blood from skull
fornix and make anastomoses greatly with venous sinuses of dura mater and superficial head veins by
emissaries.
Temporal Region
Borders: superior and posterior = the upper temporal line; the anterior border is the zygomatic process
of frontal bone and the frontal process of zygomatic bone; the lower limit is the zygomatic arch.
The skin of the region is like one of frontoparietooccipital region. Subcutaneous cellular tissue is poorly
developed. The superficial temporal gives branches in this layer. It is accompanied by the vein of the same
name and by the auriculotemporal nerve from third branch of trigeminal nerve. Motor branches of the
facial nerve locate here. Anterior and superior auricular muscles, with the branches of facial nerve are located
in subcutaneous cellular tissue.
Superficial fascia is the continuation of galea aponeurotica and passes to the subcutaneous cellular tissue
of lateral region of the face. Proper fascia consists of two sheets - superficial and deep. Both sheets begin from
the superior temporal line. The superficial sheet is fixed to the external surface of zygomatic arch and deep
sheet is fixed to the inner surface. Thus a space is formed between aponeurotic sheets and the zygomatic arch. It
is filled with interaponeurotic fat cellular tissue. Middle temporal artery is located there. It is accompanied by
a vein of the same name. Just below the profound sheet of temporal aponeurosis the third layer of cellular
tissue- subaponeurotic layer- is located. Temporal muscle is deeply.
The periosteum is separated from bone by subperiosteal fatty layer, but in lower region it is tightly
connected with bone. The spongious layer of temporal bone is poorly developed, thus the bone is thin and easily
damaged.
Middle meningeal artery from a. maxillaris runs along the inner surface of temporal bones.

Mastoid Region
It lies behind ear and it borders correspond to the location of the mastoid process.
Skin of the region is thin, hairless, and unmovable especially in posterior part.
Subcutaneous cellular tissue is loose. Posterior auricular muscle locates in it together with parotid and
mastoid lymphatic nodes.
Periosteum is tightly connected with external surface of mastoid process, except the flat triangular area
- Shipot triangle, where periosteum can be removed easily.
The limits of this triangle are as follows: anterior - posterior side of external acoustic pore, posterior -
crista mastoidea, superior – continuation of zygomatic arch posteriorly.
Mastoid process contains bone cells (cellulae mastoideae); the largest of them is called antrum. It is
connected with tympanic cavity.Sigmoid sinus may be close to the posterior wall of antrum especially in case of
poor development of mastoid process. It is projected on crista mastoidea.

OPERATIONS ON THE HEAD

DEBRIDE OF THE SHORT WOUNDS OF THE CRANIAL VAULT

Wounds of skull may be non-penetrating (dura mater undamaged) and penetrating (dura mater damaged).

The operative field is prepared: hair should be shaved in 3.0-4.0 cm from the wound limits; skin of the area is
painted with jodonatum and alcohol; local anesthesia will be performed after that.

Wound edges should be widened by a wound-retractor. Foreign particles, blood clots and hair must be
removed from the wound by forceps. Then wound is washed by hydroxiperoxide solution. Wound edges are
dissected till the bone approximately 0.3-0.5 cm externally from wound. Thus wound has an oval shape and
smooth edges.

Hemorrhage should be stopped by tissue pressure performed by fingers, then with applying hemostatic forceps,
ligating or coagulation of vessels. Bone fragments that lie freely are removed. Large fragments, which are
connected with periosteum are preserved.

 If the area is needed to wide, bone edges may be removed by Luer's forceps.
 If dura mater is undamaged and pulsates, the wound should be sutured with silk threads.
 If dura mater is damaged, its edges are removed with scissors in an economic way.
 If the brain tissue was damaged, the wound is washed up by a stream of warm physiologic solution.
Then the wound should be bandaged with long- term Mikoulich’s bandage.

TREPANATION OF THE SCULL

There are two types of the trepanation – osteoplastic and decompressive.

Osteoplastic trepanation of skull

operation are temporary access to cranial cavity for operations on brain tissue, sub- and extradural hematoma.

After the preparation of the operating field, make the horseshoe-like cut of soft tissue up to periosteum. The
dermo-aponeurotic flap is thus formed. It is wrapped off and covered with napkin, which is soaked with 3.0 %
hydroxiperoxide solution.

Then the osteoperiostal flap is formed. At first we make incision of periosteum on 1.0 cm internally then cat of
the skin. Using Farabef's raspator, periosteum is moved aside on both sides from the edges of the incision. The
diameter of clean area should respond the size of bone cutter. Make 4-5 holes by a drilling, two of holes should
be located by the base of skin flap.

Be especially careful in time of drilling of region of temporal bone because sharp bone cutter forceps may easily
perforate the bone and damage the brain. The spaces between the drilled openings are connected by Jigle's wire
saw. If you are unable to conduct the saw with Polenov’s conductors, cut the bones is performed with
Dhalgrene’s forceps.

Then osteo-periosteal flap is elevated by an elevator. Bone is broken along its base and the flap is turned
downward. Dura mater and the branches of a. meningea media become visible. If hematoma was present in
extradural space, it is removed by physiologic solution stream. If the operation concerns removal of subdural
haematoma or brain operating, then dura mater is cut (in the area with no blood vessels if possible). Operation is
finished by placing of both flaps in their proper position and suturing of wounds edges.

Decompressive trepanation

That is a palliative operation in cases of resistant increase in intracranial pressure and nonoperable tumor of the
brain. According to P.Kushing the operation begins by forming of a horseshoe-like dermoaponeurotic flap in
right temporal area. The flap is turned down; temporal muscle should be cut down along its fibers in the meddle
part. Muscle is moved aside from bone by raspator; free area should be not less than 6.0 cm. The clean area is
drilled; the limits of opening are widened by Luer’s forceps. The size of the opening is larger, the higher the
intracranial pressure. Dura is cut in radial or longitudinal direction and remains without suturing at the end of
operation. Temporal muscle is sutured; dermo-aponeurotic flap is placed back and sutured by silk threads.

Mastoid Process trepanation (antrotomy)

The main reason for operation is purulent inflammation of cellulae mastoidea- purulent mastoiditis.

After the preparation of operation area, a semicircular cut of soft tissues is made behind the ear on 1.0 cm from
its fixing line. The cut goes from the upper side of ear to the apex of mastoid process. After the dissection of
soft tissues periosteum is moved aside. Limits of Shipot’s triangle are determined. Upper limit is the
continuation of zygomatic arch, anterior limit is a posterior edge of the external auditory meatus, posterior limit
is the crista mastoidea.

External wall of the process is perforated by Voyachek’s chisel. Walls of cellulae mastoidea, puss, necrotic
tissue should be removed by Faulkman's or Brownse’s spoon. Antrum must be opened and washed. All
manipulations are performed with care to avoid damage of middle cranial fossa lying upward, wall of sigmoid
venous sinus lying backwards, facial nerve canal lying forwards. Drainage is put into the wound; skin is
sutured.