SURGICAL ANATOMY

OF SCALP AND FACE

Seminar presented by-

HARSHINI
CONTENTS:
 INTRODUCTION
 SCALP
 STRUCTURE OF THE SCALP AND it’s APPLIED ANATOMY
 ARTERIAL SUPPLY OF THE SCALP
 VENOUS DRAINAGE OF THE SCALP
 LYMPHATIC DRAINAGE OF THE SCALP
 NERVOUS INNERVATION OF THE SCALP

 FACE
 DEVELOPMENT OF FACE AND BONES OF FACE
 SKIN AND SUPERFICIAL FASCIA
 MUSCLES OF THE FACE
 NERVOUS INNERVATION OF FACE – it’s APPLIED ANATOMY
 ARTERIAL SUPPLY OF FACE
 VENOUS DRAINAGE – it’s APPLIED ANATOMY
 LYMPHATIC DRAINAGE OF FACE
 SURGICAL APPROACHES TO FACIAL SKELETON

 CONCLUSION
 REFERENCES
SURGICAL ANATOMY OF SCALP AND FACE

INTRODUCTION :

• The scalp, temple and face are important areas of head; where injuries are
frequently inflicted, they range from superficial wounds to deep cuts.
• The face is the common site for plastic surgery for esthetics or to repair the
congenital defects or the ones due to trauma.
• - Inspection of face provides information about various underlying bodily
diseases.
Scalp:
The soft tissues covering the cranial vault is the scalp.

Extent of scalp:
Anteriorly- supra orbital margins
Posteriorly- external occipital protruberance
and superior nuchal lines
Laterally – superior temporal lines

Structure of scalp:
Scalp is made up of 5 layers
1. S – Skin
2. C – Connective tissue [Superficial Fascia]
3. A – Deep fascia in form of Epicranial
Aponeurosis
4. L – Loose areolar tissue
5. P – Pericranium
1. SKIN :
 Thick and contains hair follicles.
 Rich in sebaceous glands and sweat glands.
 Adherent to epicranial aponeurosis through dense superficial fascia.

2. CONNECTIVE TISSUE [SUBCUTANEOUS/SUPERFICIAL FASCIA] :

 Binds the skin to underlying aponeurosis and provides passage of blood
vessels and nerves to skin.
 Highly vascularised
 This fascia - fibrous and dense in the center

APPLIED ANATOMY :
• Abundance of sebaceous glands  skin of scalp is common site for sebaceous
cysts.
• Wounds of scalp bleed profusely because, vessel retraction is prevented by
fibrous fascia and also due to rich vasculature & free anastomoses b/w branches
of occipital and superficial temporal vessels.
3. EPICRANIAL APONEUROSIS: [ Galea aponeurotica ]

 Thin, tendinous sheet which is freely movable on

pericranium along with overlying adherent skin & fascia.
 Anteriorly - frontalis and
 Posteriorly - occipital bellies of occipitofrontalis muscle
 Attaches to external occipital protruberance and highest
nuchal lines in between occipital bellies.

Applied anatomy ;
- wounds gape open when it pierces till aponeurotic layer,
because of the pull of the bellies of occipitofrontalis muscle
4. LOOSE AREOLAR TISSUE:
 Thin mobile sub aponeurotic layer that loosely connects the
epicranial aponeurosis to pericranium
 Anteriorly - into eyelids, as frontalis muscle has no bony
attachment
 Posteriorly - highest & superior nuchal lines
 Laterally – superior temporal lines
 Contents: few small arteries and emissary veins

Clinical anatomy:
• This layer of loose areolar tissue is known as the dangerous
area of scalp, as emissary veins open here and transmit
infection from scalp to cranial venous sinuses.

extracranial veins of scalp  Emissary veins  diploic veins of skull bones

and intracranial venous sinuses.
• Collection of blood in this layer causes generalised
swelling of scalp.
- the blood may extend anteriorly into root of
nose and into eyelids (as frontalis muscle has no bony
attachment)  black eye

• Safety layer – as there is spread of blood in this layer

 no compression of brain.

5. PERICRANIUM :
 Periosteum covering the outer surface of the skull
bones.
 Loosely attached to surface of bones, but firmly
adherent to their sutures.
 The sutural ligaments binds it to the endocranium.
 Clinical Anatomy :
- As the pericranium is adherent to sutures,
collections of fluid deep to this layer
(cephalhematoma) take shape of bone concerned
when there is fracture of particular bone.

ARTERIAL SUPPLY OF SCALP AND SUPERFICIAL TEMPORAL REGION :

- High vascularised, these vessels anastomoses freely on the scalp.

- The arteries of scalp and superficial temporal region are derived from
external and internal carotid arteries, these 2 systems anastomoses over the
temple.
 ARTERIAL SUPPLY OF SCALP AND SUPERFICIAL TEMPORAL REGION

Branches Supra trochlear

of Internal Ophthalmic artery
carotid artery Supra orbital Supplies the scalp
artery artery in front of auricle
Superficial
temporal
Branches artery
of External
carotid Posterior
artery auricular artery
Supplies the scalp
behind the auricle
Occipital artery
 VENOUS DRAINAGE OF SCALP AND SUPERFICIAL TEMPORAL REGION
Supratrochlear Supra orbital Superficial
vein vein temporal vein Maxillary vein

Angular vein
Retro mandibular vein
Deep facial vein
Facial vein Anterior division Posterior division
Posterior
auricular vein
External Jugular vein
Common Facial vein

Subclavian vein
Internal jugular vein

Branchiocephalic vein Branchiocephalic

vein (opp side)
Superior Venacava
LYMPHATIC DRAINAGE OF SCALP:

- Lymphatic drainage of scalp generally follows the pattern of arterial distribution.

Area of the scalp Name of the lymph nodes which

they drain into

(1) Anterior to vertex Preauricular & parotid lymph nodes

(2) Posterior to vertex Posterior auricular (or) Mastoid lymph
nodes
(3) Occipital region occipital lymph nodes and upper
deep cervical lymph nodes.
 NERVE SUPPLY OF SCALP AND SUPERFICIAL TEMPORAL REGION

SENSORY INNERVATION :
MOTOR NERVES :

• Nerve in front of the ear is

temporal branch of the facial
nerve. It supplies frontal belly of
occipitofrontalis muscle.

• Nerve behind the ear is the

posterior auricular branch of the
facial nerve. It supplies occipital
belly of occipitofrontalis muscle.
FLAPS OF SCALP:

• BICORONAL FLAP

• HEMICORONAL FLAP

• ALKAYAT BRAMLEY APPROACH

 SURGICAL ANATOMY OF FACE

Development of face
- 5 processes of face; one fronto nasal, two maxillary processes and two
mandibular processes form the face .

( 1 ) Frontonasal process - forehead , Nasal septum , philtrum of upper lip

and premaxilla
( 2 ) Maxillary process - whole upper lip except philtrum & hard & soft palate
except premaxilla .
( 3) Mandibular process - whole lower lip .

Bones of face : → Facial skeleton is composed of 14 Bones ; ( 6 paired + 2

unpaired )
Paired Unpaired
1) Maxilla ( 2 ) 1) Mandible ( 1 )
2) Nasal ( 2 ) 2) Vomer ( 1 )
3) Zygomatic ( 2 )
4) Lacrimal ( 2 )
5) Palatine ( 2 )
6) Anterior Nasal concha ( 2 )
Boundaries of face :
Extends
- Superiorly to hair line ,
- Inferiorly to the chin and base of mandible &
- Laterally to auricle.
Forehead is common to both scalp and face .

• Face consists of skin and superficial fascia :

SKIN :
Highly vascular, making face blush and blanch ; wounds of face bleed profusely but heal
rapidly .
- Hence results of plastic surgery on face are excellent .
→ Rich in sebaceous & sweat glands ;
→ Laxity of skin,. causes rapid spread of edema ;
Renal oedema appears first in eyelids and face before other body parts.
→ Fixity of skin to underlying cartilage, boils in nose and ear are acutely painful .
→ Because of facial muscles insertion , facial skin  elastic and thick .
So wounds of face tend to gape
Cleavage Lines of Skin in the Face: ‘relaxed skin tension lines’
(Borges and Alexander)
• The direction of cleavage lines in the face varies regionally.
• These lines frequently (but not always) coincide with natural wrinkle lines
of the face.
• The natural wrinkle lines result from repeated folding of the skin
perpendicular to the long axis of the underlying contracting muscles of
facial expression.

 When the lesions of skin, viz. scars, pigmented patches, skin cancers are
excised.
 It is important to give incisions along the long axis of natural relaxed skin
tension lines and the lesion should be enclosed in an ellipse, so that the
scar will look like a natural skin crease.
Superficial fascia :
- It contains:
( i ) Facial muscles, which are inserted into the skin .
( ii) Vessels and Nerves to the muscles and skin .
( iii ) Variable amount of fat
( fat is absent in eyelids, but well developed in cheeks forming buccal pads)
• Deep fascia - absent in the face ,
but present over : Parotid gland - parotid fascia
Buccinator - Buccopharyngeal fascia

• Fascia of mid face is divided into superficial and deep fascia.

( 1 ) FACIAL MUSCLES : In the midface superficial fascia along with the muscles
→ Muscles of facial expression are sub cutaneous muscles
forms Superficial Musculo Aponeurotic system (SMAS).
They bring about different facial expressions . • In 1976 Mitz and Peyronie, described SMAS as a network of
→ Facial muscles represent best remnants of panniculus carnosus
dense fibrous and fatty tissues and septae that serves as the
( a continuous subcutaneous muscle sheet
cephalad seen inofsome
extension animalsmuscle
the platysma ) of the neck.
• SMAS
→ Embryologically , they develop from the mesoderm of 2ndends at the zygomatic
branchial arch , soarch,
theywhich is then called
are supplied by facial
Nerve temporoparietal fascia above it.
• The SMAS is maneuvered in a rhytidectomy (facelift)
Anatomic groups of facial muscles : .

→ The muscles of facial expression are also called mimetic muscles,

→ They commonly overlap each other, but 4 anatomic layers can be distinguished.
• 1st layer muscles - orbicularis oculi, Risorius, zygomaticus Minor, Depressor Anguli oris.
• 2nd layer muscles - Depressor labii Inferioris, zygomaticus major, Levator labii superioris Aleque
Nasi, Platysma.
• 3rd layer muscles - orbicularis oris, Levator labii superioris
• 4th layer muscles - Buccinator, Mentalis, hevator Anguli Oris.

Functional groups of facial muscles : .

Opening Sphincter Dilators

A. Palpebral fissure - Eyelids orbicularis oculi 1. Levator palpebrae superioris
2. frontalis part of occipitofrontalis
B. oral fissure Mouth orbicularis oris All the muscles around the mouth , except the
orbicularis oris , the mentalis
c . Nostrils compressor Naris 1. Dilator naris
2. Depressor septi
3. Medial slip of levator labie superioris alaeque nasi
ORAL GROUP
( Muscles around
the Lips )
ORBITAL GROUP
( Muscles of
eyelid/orbital
opening )
ORBITAL GROUP ( Muscles of eyelid/orbital opening )

• Crow’s feet: The contraction of

entire orbicularis oculi draws the skin
of forehead, temple, and cheek
towards the lateral angle of the eye,
producing radiating skin folds from
the lateral angle of the eye, which may
be a permanent feature in some old
people forming the so called crow’s
feet.

• Ectropion: The paralysis of

orbicularis oculi results in drooping of
the lower eyelid (ectropion) causing
spilling of tear on the cheek
(epiphora).
NASAL GROUP
( Muscles of
Nasal opening )
NASAL GROUP ( Muscles of Nasal opening )
MUSCLES OF THE SCALP :

MUSCLES OF THE NECK :

MUSCLES OF THE AURICLE : These are vestigial muscles
Modiolus :
The 8 muscles interlacing to form modiolus

1) Levator anguli oris

2) Orbicularis oris
[ LORD ]
3) Risorius
4) Depressor anguli oris
5 ) Buccinator
[ Bu Zy ]
6 ) zygomaticus major

7 ) Quadratus labii superioris

8)Quadratus labii interioris [ Q² ]

> Palpation :
Thumb on skin , index finger on oral mucosa oppose to thumb and compress gently to feel
hub of cart wheel shape
NERVE SUPPLY OF FACE:

MOTOR NERVE SUPPLY :

→ Facial Nerve (7th cranial nerve) is the Motor Nerve of face.

→ It gives out 5 branches which emerges from the parotid

gland and diverge to supply the facial muscles .

1 ) Temporal - frontalis , auricular muscles , corrugator

supercilia, orbicularis oculi , Procerus

2 ) Zygomatic - orbicularis oculi ( lower eyelid ) , Procerus,

levator muscles, zygomaticus muscles

3 ) Buccal - muscles of cheek and upper lip ( Buccinator,

Risorius , Depressor septi , Nasalis

4 ) Marginal mandibular → muscles of lower lip (Depressor

Anguli oris, depressor labii inferioris , Mentalis )

5 ) cervical → platysma
Applied Anatomy

1) Examination of facial Nerve :

→ Facial nerve examined by testing following facial muscles :
a ) Frontalis : Pt looks upward without moving head -->
Horizontal wrinkles on forehead should be seen,
b ) Dilators of mouth : ask patient to show teeth .
c ) orbicularis oculi : Tight closure of eyes .
d) Buccinator : Puffing mouth and blowing forcibly ( whistling )

2 ) Infra nuclear lesion / Lower motor nerve lesion of

Facial Nerve ( LMN lesion of VII.CN )
→ lesion at stylomastoid foramen
→ Bell's palsy - LMN lesion
→ Upper & Lower quarters of face on the same side get paralysed .
3) Upper motor neuron lesion :
• In UMN type paralysis of facial muscles due to
involvement  pyramidal tract.
• Upper part of the face - not affected  (bilateral cortical
innervation)
• Only lower quarter of opp side of the face is paralysed.

4) FREY’S Syndrome :
• Sweating while eating (gustatory sweating) and facial
flushing.
• Injury to auriculotemporal nerve, typically after surgical
trauma to the parotid gland.
• This nerve, when it heals, reattaches to sweat glands instead
of the original salivary gland (which had been removed
during surgery).
SENSORY NERVE SUPPLY :
Source Cutaneous Nerve Area of Distribution
A)
C) Ophthalmic
Mandibular 1) supratrochlear
1) .N
Auriculo temporal. → upper head
→Upper eyelid
2/3rds of &
division
divisionofofCN. V N forehead
lateral side of auricle,
(trigeminal
CN.V
Nerve)
2) supra orbital . N →temporal région.
upper eyelid, frontal air
sinus, scalp.
3) Lacrimal. N → Median part of both
2) Buccal. N →skin of lower part of
eyelids.
cheek.
4) Infra trochlear .N → Lower part of dorsum &
tip of Nose.
5) External nasal. N → Later part of upper
3) Mental. N →Anterior part of
eyelid
temporal region.

D) Cervical 1) Anterior division of → skin over angle of

plexus
B) Maxillary greater
1) auricular
Infraorbital. N Nerve thelower
→ jow and overside of
eyelid,
division of CN. (C₂, C3) parotid
Nose gland..lip.
& upper
V 2) Zygomatico facial. N → Upper part of cheek
2) zygomatico
3) Upper division of →Lower margin
→Anterior part ofof
transverseNcutaneous
temporal. lower jaw.region.
temporal
nerve of Neck (C₂, C3)
Applied Anatomy Treatment
Medical management :
Carbamazepine 100 mg BD ,increase dose
• Trigeminal neuralgia (tic douloureux): of 100 mg every 48 hrs, Slowly withdraw at a
 Characterized by sudden paroxysmal attacks of rate of 100 mg every 48 hrs
lancinating pain lasting from few hours to several Baclofen ,Clonazepam ,Valproic
acids ,Oxcarbazepine
days, confined to distribution of one or more Surgical management :
divisions of trigeminal nerve. • Microvascular decompression surgery
 It commonly starts in the maxillary territory and • Percutaneous Rhizotomy
• Percutaneous gycerol injection
more frequently on the right side. • Percutaneous balloon compression
rhizotomy
• Radiofrequency rhizotomy
• Herpes zoster ophthalmicus:
• Microsurgical rhizotomy
 Viral infection involving  ophthalmic nerve. • Gamma knife radiosurgery
 Severe pain and edema in the ophthalmic territory • Peripheral trigeminal nerve blocks
and appearance of vesicles along the course of
cutaneous branches of the ophthalmic nerve.
ARTERIAL SUPPLY OF FACE:
The face is the highly vascular region and is supplied by the
following arteries :

1. Facial artery : chief artery of the face

2. Transverse facial artery :

• Branch of superficial temporal artery.
• After emerging from parotid gland, it runs forwards over
masseter b/w parotid duct and zygomatic arch along with
buccal branch of facial nerve.
• Supplies: Parotid gland n ducts, Masseter and overlying skin.

3. Arteries that accompany the cutaneous nerves.

These are small branches of
a) Ophthalmic artery (supra trochlear, supra orbital,
lacrimal, external nasal, dorsal nasal )
b) Maxillary artery (Infra orbital, buccal and mental )
c) Superficial temporal artery
Facial Artery
Arises from external carotid artery in the neck (at
the level of greater cornu of the hyoid bone)

After a looped course in the submandibular region, it

enters the face by winding around the lower border
of mandible (at anteroinferior angle of the masseter
by piercing the investing layer of deep cervical
fascia.)

In the face, the artery passes tortuously, first

upwards and forwards to a point 1.25 cm
lateral to the angle of the mouth

Inferior labial –lower lip

Then ascends along the side of the nose to Superior labial – upper
the medial angle of the eye where it ends by lip,anteroinferior part of nasal
anastomosing with the dorsal nasal branch of septum
ophthalmic artery.
Lateral nasal – ala and dorsum
of the nose
The terminal part of facial artery is called
angular artery. Medial angle of orbit
Anastomoses:
• Large anterior branches  with similar branches of opp side and with mental
artery
• Small post branches  tansverse facial and infra orbital arteries
• At medial angle of eye  angular artery branches of opthalmic artery

VENOUS DRAINAGE OF FACE :

Facial Vein

Deep Facial vein

Pterygoid venous plexus

Emissary vein
Hence called Dangerous
Cavernous sinus area of Face

Causing cavernous sinus

thrombosis, when pustules
in upper lip/side of nose/
even cheek are squeezed
LYMPHATIC DRAINAGE OF THE FACE :

The face has 3 lymphatic territories:

1. Upper territory  Preauricular parotid nodes.

• greater part of the forehead,
• lateral halves of eyelids
• Conjunctiva
• Lateral part of the cheek and parotid area

2. Middle territory  submandibular nodes.

• a strip over the median part of the forehead
• external nose
• upper lip & lateral part of the lower lip
• medial halves of eyelids & medial part of cheek
• greater part of lower jaw

3. Lower territory  submental nodes

• the central part of the lower lip and the chin.
Approaches to facial skeleton:

1. Approaches to mandible:
• Submandibular approach
• Retro mandibular approach
• Pre auricular approach
• Intra oral approach

2. Approaches to mandible and TMJ :

• Pre auricular approach
- ALKAYAT Bramley approach, Dingman’s,
Blair’s, Thoma’s, popowitch’s
• Post auricular approach
• Endaural approach
• Retro mandibular approach – Hind’s
• Sub mandibular approach – Risdon

3. Approaches to Maxilla
• Weber fergusson approach
Conclusion:

• Proper knowledge of anatomy of Scalp and Face and various surgical

approaches to the facial skeleton and scalp is important as injuries in
these regions of head are more common & face is the commonest site
for plastic surgery.
• The scalp and face are have complex anatomy with high vasculature ,
nervous innervation and also associated with sinuses , hence proper
understanding of all the associated structures is essential to avoid
complications during the procedures.
REFERENCES :

 The anatomical basis of clinical practice – Gray’s

anatomy (41st edition).
 Anatomy of Head and Neck by B D Chaurasia , 6th
edition.
 Netter’s Head and Neck Anatomy for Dentistry , 2nd
edition.
 Textbook of Anatomy (Vol 3- head, neck and brain)
by Vishram singh , 2nd edition.
 Surgical Approaches to the Facial Skeleton by
Edward Ellis III, 3rd edition.