Scalp, face and lacrimal

apparatus
Scalp
 Soft tissue covering the cranial vault
 It is the hair bearing area of the skull
 Extends from superciliary arches
anteriorly to external occipital
protuberance & superior nuchal line
posteriorly
 On each side to superior temporal line
SCALP
 S-Skin
 C-connective tissue
(superficial fascia)
 A-aponeurosis
(galea aponeurotica)
 L-loose areolar
tissue
 P-pericranium
Skin
 Thick and hairy
 Firmly attached to
the epicranial
aponeurosis through
dense fascia
 Abundant
sebaceous glands
 Sebaceous cysts
are common
Connective tissue
 Fibrous and dense containing blood vessels and nerves
 Binds skin to subjacent aponeurosis
 Wounds bleed profusely as walls of the blood vessels
are adherent to the fibrous network and are prevented
from retraction by fibrous tissue. Bleeding is stopped by
applying pressure against the bone
 Subcutaneous hemorrhages are not extensive since
fascia is dense.
 Inflammation causes little swelling but much pain.
Aponeurosis
 Formed by occipito-frontalis muscle and
corresponds to deep fascia.
 This layer is also called as epicranial apo.
or galea aponeurotica (helmet).
 The wounds of scalp do not gape unless
epicranial aponeurosis is cut transversely
becoz aponeuros is under tension in A-P
direction due to tone of occipito frontalis
muscle.
Occipito-frontalis muscle
 Frontal belly originates from skin of forehead,
root of the nose and mingle with orbicularis
oculi, corrugator supercilli and procerus
muscles. These bellies are inserted into
epicranial aponeurosis and are longer, wider
and partly connected in the midline.
 Occipital belly originates from lateral 2/3 of
superior nuchal line and is inserted in the apo.
Bellies are small and are separated by a gap.
Nerve supply and actions
 The occipital bellies are supplied by
posterior auricular br. of facial nerve
whereas frontal by temporal br of facial
nerve.
 Moves the scalp forwards and backwards
on the vault, raises the eyebrows in
surprise and produce transverse wrinkles
on the forehead.
Loose areolar tissue
 Extends anteriorly into the eyelids because frontalis has
no bony attachment
 Posteriorly to superior nuchal line
 On each side to superior temporal line
 Bleeding cause generalized swelling of scalp
 Called dangerous layer of scalp - emissary veins open
here and carry infections of the scalp to inside the
cranial cavity (venous sinuses).
 Bleeding leads to black eye
 Caput succedaneum in new born – subcutaneous
edema over the presenting part of the head at delivery
due to interference of venous return during the passage
of head thru the birth canal.
Pericranium

 Is the periosteum of skull

 Loosely attached to surface of bone but is
firmly adherent at the sutures
 Cephalhematoma – is a subperiosteal
collection of blood. The hematoma is
bound by suture lines and assumes the
shape of related bones. Commonly found
in the parietal region.
 Caput succedaneum  cephalhaematoma
Blood supply
 Arteries
 Supratrochlear
 Supraorbital
 Superficial temporal
 Posterior auricular artery
 Occipital artery
 Veins-follows the arteries
Nerve supply
 In front of auricle
 Supratrochlear n.
 Supraorbital n.
 Zygomaticotemporal n.
 Auriculotemporal n.
 Temporal branch of facial n.
(motor)
 Behind auricle
 Great auricular n
 Lesser occipital n.
 Greater occipital n.
 Third occipital n.
 Post. Auricular branch of facial
n.(motor)
Lymphatics

 Anterior part
 Preauricular (parotid) gr. of lymph nodes.
 Posterior part
 Posterior
auricular (mastoid) gr. of lymph
nodes &occipital gr. of lymph nodes.
Applied anatomy of scalp
 Scalp is a common site of sebaceous cysts.
 Wounds of scalp bleed profusely
 Scalp wounds heal quickly.
 Swelling of superficial fascia causes much pain
(bec of dense and fibrous connective tissue
layer).
 Dangerous area of the scalp (layer of loose
areolar tissue).
 Surgical layers of scalp – First three layers
are firmly adherent to each other and can’t
be separated from each other. These form
the surgical layers or the scalp proper.
 Black eye – Blood and fluid collecting in
the layer of the loose areolar tissue tracks
freely under the scalp producing
generalized swelling over the dome of the
skull but can not pass either in the
 temporal or occipital regions because of
the attachments of the occipito-frontalis. It
can however track forwards into the
eyelids becoz occipito frontalis has no
bony attachment anteriorly. This leads to a
brown discoloration around the eyes.
 Safety valve hematoma – In case of
fracture of cranial vault in children there
may be tearing of duramater and
 hemorrhage communicates with
subaponeurotic space of scalp thru
fracture lines thus signs of cerebral
compression do not develop.
 Cephalhematoma – It is the subperiosteal
collection of blood. The hematoma is
bounded by suture lines and takes the
shape of related bones.
 Caput succedaneum – Subcutaneus
edema over the presenting part of the
head at delivery. Occurs due to
interference of venous drainage. Generally
the edema subsides in few days, has no
well defined margins and crosses the
sutures.
Face

Boundaries
 Extends superiorly to the hair line,
inferiorly to the chin and base of mandible,
and on each side to auricle
 Forehead is common to both scalp and
face
Skin

 Thick, elastic and very vascular.

 Due to rich vascularity face blush and blanch.
 Wounds of face bleed profusely but heal rapidly.
 Results of plastic surgery are excellent on face.
 Facial skin is rich in sebaceous glands and
sweat glands.
 Sebaceous glands keep the skin oily but also
cause acne in adult.
 Sweat glands regulate body temperature.
Superficial fascia
 Contains muscles of facial expressions
and variable amount of fat.
 Fat is absent in eyelids but well developed
in cheeks.
 Buccal fat more prominent in children and
is called suctorial pad of fat.
Deep fascia
 Absent in the region of face except over
parotid gland and masseter muscle.
Facial muscles

 Called muscles of facial expressions and lie in

superficial fascia
 Embryologically they develop from mesoderm of
2nd branchial arch, therefore supplied by facial
nerve
Facial muscles
 Muscles of scalp : Occipitofrontalis
 Muscles of auricle : Auricularis anterior
Auricularis posterior
Auricularis superior
 Muscles of eyelids : Orbicularis oculi
Corrugator supercilli
Levator palpebrae
superioris
 Muscles of nose: Procerus
Compressor naris
Dilator naris
Depressor septi
 Muscles of neck: Platysma
 Muscles around the mouth: Orbicularis oris, Levator labii
superioris alaequae nasi, Zygomaticus major,
zygomaticus minor, Levator labii superioris, Levator
anguli oris, Depressor labii inferioris, Depressor anguli
oris, Mentalis, Buccinator and Risorius.
Common facial expressions and
muscles producing them
Surprise – Frontalis
Frowning – Corrugator supercilli and
procerus
Anger – Dilator naris and depressor septi
Laughing – Zygomaticus major
Sadness – Lev lab sup, Lev & Dep Ang oris
Grinning – Risorius
Doubt - Mentalis
Occipitofrontalis muscle
 Origin : Occipital bellies arise from lateral part
of superior nuchal line
Frontal bellies arise from the skin of the
forehead merging with procerus, corrugator
supercilli and orbicularis oculi.
 Insertion : Epicranial aponeurosis.
 Nerve supply : Occipital bellies by the posterior
auricular branch of facial nerve.
: Frontal bellies by the temporal
branch of facial nerve.
Orbicularis oculi
 3 parts-
 Orbital part
 Originate from medial part of medial palpebral ligament and form
concentric rings, return to point of origin
Action –closes the lids tightly
 Palpebral part
 Originate from lateral part of medial palpebral ligament
 Insert into lateral palpebral raphe
Action-closes the lids gently
 Lacrimal part
 Originate from lacrimal fascia& lacrimal bone
 Insert into upper &lower tarsi
Action-dilates lacrimal sac
Applied anatomy
 Crow’s feet – The contraction of orbicularis
oculi draws the skin of the forehead,
temple and cheek towards the lateral
angle of the eye and is permanent feature
in some old people.
 Ectropion – paralysis of orbicularis oculi
results in drooping of lower eyelid and
epiphora.
Orbicularis oris
 Originate from maxilla (superior incisivus) and
mandible (inferior incisivus).It also arises from
the buccinator and from elevators and
depressors of the lips.
 Insert into skin of lip and angle of the mouth.
Action – closes and purses the mouth.
 Applied anatomy – Paralysis of one half of
orbicularis oris prevents proper closure of lips on
that side. Speech is slurred and there is
dribbling of saliva.
Buccinator (Trumpeter’s
muscle)
Upper fibers
 Origin- from maxilla opposite
molar teeth
 Insertion-upper lip
 Lower fibers
 Origin-from mandible opposite
molar teeth
 Insertion-lower lip
 Middle fibers
 Origin –from
pterigomandibular raphe
 Insertion-decussate before
passing to lips
 Action- prevent accumulation of
food in vestibule of mouth and
helps in blowing the cheek.
Modiolus
 Dense, compact, mobile fibromuscular
mass situated about 1.25 cm lateral to the
angle of the mouth formed due to
interlacing of fibers of muscles converging
towards the angle of mouth.
 Facial artery can be palpated lateral to the
modiolus.
 Damage leads to facial asymmetry.
Platysma
 Origin– upper part of pectoral
and deltoid fascia
 Insertion– base of mandible,
skin of lower face and lip
 Action– releases pressure of
skin on the subjacent veins,
depress mandible, pulls angle
of mouth downwards
Nerve supply of face

 Motor supply
 Facial nerve
 Bell’s palsy – facial
nerve is compressed
in the facial canal near
the stylomastoid
foramen leading to
LMN paralysis of facial
muscles.
Features of bell’s palsy
 Facial asymmetry.
 Loss of horizontal wrinkleson forehead
 Inability to close the eye
 Epiphora
 Loss of nasolabial furrow
 Accumulation of food into the vestibule
 Dribbling of saliva
Sensory supply
 Ophthalmic division
 Supratrochlear

 Supraorbital

 Lacrimal

 Infratrochlear

 External nasal

 Maxillary nerve
 Infraorbital

 Zygomaticofacial and
zygomaticotemporal
 Mandibular nerve
 Auriculotemporal

 Buccal nerve

 Mental

 Skin over the mandibular angle is

supplied by ant. Div. of great
Applied anatomy
 Trigeminal neuralgia ( tic douloureux) –
Clinical condition characterized by sudden
attack of severe pain confined to
distribution of one or more divisions of
trigeminal nerve.
 Herpes zoster ophthalmicus – viral
infection involving the ophthalmic nerve.
Severe pain and edema in the ophthalmic
territory and vescicles along its cutaneous
Blood supply of face
 Arterial supply-
 Facial artery
 Transverse facial
artery
 Arteries that
accompany the
cutaneous nerves.
Facial artery
 Main arterial supply of the face.
 Arises from the ECA in the neck at the
level of greater cornu of hyoid bone and
after a looped course in the submandibular
region enters the face at the anteroinferior
angle of the masseter by piercing the
investing layer of deep cervical fascia.
 In the face it passes upwards and
forwards to a point 1.25 cm lateral to the
angle of the mouth and then along the side
of the nose to the medial angle of the eye
where it ends by anastomosing with the
dorsal nasal br of ophtalmic artery.
 Branches in the face – Superior labial,
inferior labial and lateral nasal.
Applied anatomy
 The tortuosity of the artery prevents its
walls from being unduly stretched during
movements of the mouth.
 Facial artery takes part in numerous
anastomoses, so that if cut blood spurts
from both cut ends.
 Medial angle of the eye is a site of
anastomosis between the ECA and ICA.
Venous drainage
 Veins follow the arteries and
drain into facial vein and
retromandibular vein
 Facial vein is the main vein of
the face.It begins as the
angular vein at the medial
angle of the eye. Once formed
the facial vein runs downwards
and backwards behind the
facial artery.
 At the anteroinferior angle of
masseter it joins the anterior
division of retromandibular
vein to form the common facial
vein
 Common facial vein in turn
Deep connections of facial vein

 Facial vein communicates with superior

ophthalmic vein at its commencement. SOV
passes backwards within the orbit and drains
into cavernous sinus.
 In the cheek facial vein is joined to the pterygoid
venous plexus via deep facial vein. The
pterygoid venous plexus in turn communicates
with the cavernous sinus thru emissary vein.
Dangerous area of the face
 Facial vein and its communications are
devoid of valves. Facial vein directly rests
on the muscles of facial expressions and
the movement of these muscles may
facilitate the spread of septic emboli from
lower part of nose, upper lip and adjoining
cheek in retrograde direction thru deep
facial v, pterygoid plexus and emissary
veins into the CS leading to meningitis and
CST.
Lymphatic drainage
 3 territories-
 Upper territories- greater part
of forehead, lateral ½ of eye
lid, conjunctiva, lateral part of
cheek and parotid area–
preauricular lymph node
(parotid)
 Middle territories- median part
of forehead, external nose,
upper lip, lateral part of lower
lip, medial ½ of eye lid, medial
part of cheek, greater part of
lower jaw– submandibular
lymph node
 Lower territories- central part
of lower lip, chin– sub mental
lymph node
Applied

 Trigeminal neuralgia
 Maxillary and mandibular nerve are commonly involved
 Excruciating pain in the region of distribution of these nerve
 In infranuclear lesions of facial nerve (eg, bell’s palsy)-
whole face of the same side is paralyzed
 c/f
 Affected side is motionless
 Loss of wrinkles
 Eye cannot be closed
 In smiling the mouth is drawn to normal side
 During mastication food accumulates in vestibule of mouth
 In supranuclear lesions of facial nerve only the lower
part of face of the opposite side is paralyzed. The upper
part (frontalis &part of orbicularis oculi) escapes due to
its bilateral innervation by corticonuclear fibers.