2nd year

The scalp
2022 The soft tissue envelope of the cranial vault is called the scalp.
The scalp extends from the external occipital protuberance and
superior nuchal lines to the supraorbital margins. Aesthetically, it
serves as an area where hair can grow and physically, as a barrier
L1 H. ANATOMY
that defends the body from foreign irritation. The scalp consists
DR. Natheer Ayed of 5 layers:
S: The skin on the head from which head hair grows. It contains
numerous sebaceous glands and hair follicles.
C: Connective tissue. A dense subcutaneous layer of fat and
fibrous tissue that lies beneath the skin, containing the nerves
and vessels of the scalp
A: The aponeurosis called epicranial aponeurosis is the next layer. It is a tough layer
of dense fibrous tissue which runs from the frontalis muscle anteriorly to
the occipitalis posterior fig.2
L: The loose areolar connective tissue layer provides an easy plane of separation
between the upper three layers and the pericranium and serves as a flexible plane.
In scalping the scalp is torn off through this layer. The areolar tissue contains a few
small arteries, but it also contains some important emissary veins which are valveless
and connect the superficial veins of the scalp with the diploic veins of the skull bones
and with the intracranial venous sinuses. fig.1
P: The pericranium is the periosteum of the skull bones and provides nutrition to the
bone and the capacity for repair. It tightly adheres to the calvarial bone of the skull. It
contains the vascular supply that is vital to supporting the underlying calvarium.fig.1

FIGURE 1: Coronal section of the upper part of the head showing the layers of the scalp.

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 Figure 2 occipitofrontalis muscle

Muscles
As previously mentioned, the galea aponeurotica is a continuation of the occipitofrontal
muscle. Note that when this muscle contracts, the first three layers of the scalp move
forward or backward, the loose areolar tissue of the fourth layer of the scalp allowing the
aponeurosis to move on the pericranium. The occipitofrontalis muscle is split into the
occipital and frontal bellies. Fig.2) The frontalis belly originates from the superior
orbicularis oculi at the level of the eyebrow (blunted in skin and superficial fascia) it
inserted into galea aponeurotica posteriorly. The occipitalis muscle origin is a posterior
attachment at the mastoid and superior nuchal lines and inserts on the galea
aponeurotica. These muscles are innervated by the superior zygomatic and posterior
auricular nerve, respectively (branches of facial nerve). They work in conjunction to pull
the scalp back and elevate the eyebrows. The contraction of the frontalis muscle
specifically creates wrinkles on the forehead. Of note, the loose connective tissue layer
extends deep to the muscles. Bleeding into this space can track down to the orbicularis
oculi causing a periorbital hematoma, more commonly known as a “black eye.”
Blood supply
The vascular supply to the scalp comes from the common carotid artery. These arteries
connect through an impressive network of anastomoses, with anastomoses in the
temporal region being the most numerous, The main blood supply of the scalp is via five
pairs of arteries, three from the external carotid and two from the internal carotid:

• internal carotid

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 o the supratrochlear artery to the midline forehead. The supratrochlear artery is a
branch of the ophthalmic branch of the internal carotid artery.
o the supraorbital artery to the lateral forehead and scalp as far up as the vertex. The
supraorbital artery is a branch of the ophthalmic branch of the internal carotid
artery.
• external carotid
o the superficial temporal artery gives off frontal and parietal branches to supply
much of the scalp
o the occipital artery which runs posteriorly to supply much of the posterior aspect of
the scalp
o the posterior auricular artery, a branch of the external carotid artery, ascends
behind the auricle to supply the scalp above and behind the auricle.

Because the walls of the blood vessels are firmly attached to the fibrous tissue of the
superficial fascial layer, cut ends of vessels here do not readily retract; so that even a
small scalp wound may bleed profusely fig.3

Fig.3 arteries and nerves of scalp

Venous Drainage of the Scalp

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 (Fig. 4).
The posterior auricular vein unites with the posterior division of the retromandibular
vein, just below the parotid gland, to form the external jugular vein (Fig. 4).
The occipital vein drains into the suboccipital venous plexus, which in turn drains into
the vertebral veins or the internal jugular vein.

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There are other veins, like the emissary vein and diploic vein The diploic veins are large,
thin-walled valveless veins that channel in the between the inner and outer layers of
the cortical bone in the skull. They develop fully by the age of two years. The diploic veins
drain this area into the dural venous sinuses. which also contribute to the venous
drainage. This vein, found in the loose areolar connective tissue layer, runs superiorly
along the lateral side of the head where it penetrates the cranium and communicates with
the superior sagittal sinus.

FIG.4 veins of face and scalp

Nerve supply
Innervation is the connection of nerves to the scalp: the sensory and motor nerves
innervating the scalp. (fig.3).The sensory nerve of scalp is innervated by the following:

• Supratrochlear nerve and the supraorbital nerve from the ophthalmic division of
the trigeminal nerve
• Greater occipital nerve (C2) posteriorly up to the vertex
• Lesser occipital nerve (C2) behind the ear
• Zygomaticotemporal nerve from the maxillary division of the trigeminal
nerve supplying the hairless temple
• Auriculotemporal nerve from the mandibular division of the trigeminal nerve
The innervation of scalp can be remembered using the mnemonic, "Z-GLASS"
for, Zygomaticotemporal nerve, Greater occipital nerve, Lesser occipital
nerve, Auriculotemporal nerve, Supratrochlear nerve and Supraorbital nerve.
Lymph Drainage of the Scalp
Lymph vessels in the anterior part of the scalp and forehead drain into the
submandibular lymph nodes (Fig. 5). Drainage from the lateral part of the scalp above
the ear is into the superficial parotid (preauricular) nodes; lymph vessels in the part
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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.

FIG.5 lymphatic drainage of scalp

Clinical Notes
The skin of the scalp possesses numerous sebaceous glands, the ducts of which are
prone to infection and damage by combs. For this reason, sebaceous cysts of the scalp
are common.
Even a small laceration of the scalp can cause severe blood loss. It is often difficult to
stop the bleeding of a scalp wound because the arterial walls are attached to fibrous
septa in the subcutaneous tissue and are unable to contract or retract to allow blood
clotting to take place. Local pressure applied to the scalp is the only satisfactory method
of stopping the bleeding.
Infections of the scalp tend to remain localized and are usually painful because of the
abundant fibrous tissue in the subcutaneous layer. Occasionally, an infection of the
scalp spreads by the emissary veins, which are valveless, to the skull bones, causing
osteomyelitis. Infected blood in the diploic veins may travel by the emissary veins
farther into the venous sinuses and produce venous sinus thrombosis. Furthermore,
blood or pus may collect in the potential space beneath the epicranial aponeurosis. It
tends to spread over the skull
Reference
1. Snell RS: Clinical anatomy by regions. Lippincott Williams & Wilkins, 2012.