Scalp and the face

SCALP :-

• Cover the calvaria .

• The scalp extends from the supraorbital margins
anteriorly to the highest nuchal lines posteriorly
of the skull and down to the ears and zygomatic
arches at the sides.
• Structures that form the Scalp can be
remembered from the word SCALP it self .

1. S → Skin
2. C → Connective tissue
3. A → Aponeurosis
4. L → Loose areolar tissue
5. P → Pericranium.

» 1. Skin :-

• is very hairy skin therefore it rich in sweat and

sebaceous glands .
• In the hospital many patein is presented
 with sebaceous cyst in the scalp because
it rich with it .

» 2. Connective Tissue :-

• Contain the blood vessels and the blood supply to

the scalp is come from this CT .
• The face and the scalp is very vascular
area in the body .
• This layer of CT is strongly attached to the
wall this vessels .

• ★ Why The bleeding from The scalp don't

stop easily?
• Because to stop blending initially we need
contraction of the blood vessel and this blood
vessel is firmly attach to The CT , this attachment
prevent the contraction of the blood vessels .

» 3. Aponeurosis with muscle at the front and back :-

• Aponeurosis with muscle called at the front

called frontalis muscle and attach to the eyebrows
and raise the eyebrows one of the muscle of
fascial expression and back called the occipitalis
 which attach to the superior nuchal line .
• Both muscle are inserted in the central
aponeurosis called Galea Aponeurotica .
• Both muscle together form occiptofrontalis
muscle.

Nerve supply of the muscle:

• By the facial nerve; temporal branches to
frontalis, posterior auricular branch to occipitalis.

Action of the muscle :

• While occipitalis can pull the scalp back in certain
individuals, frontalis elevates the eyebrows and
produces wrinkles in the skin of the forehead .

» 4. Loose C.T :-

• Fill the potential space below the aponeurosis .

This potential space can filled with blood and
cause hematoma called Subgaleal Hematoma.
• The attachment of this  potential space is same to
the attachment of occiptofrontalis muscle

• subgaleal‫وﻟﻮ رﺟﻌﺖ ورا ﺑﺘﺮﺟﻊ ﻋﺸﺎن ال‬eye‫ﻋﺸﺎن ﻛﺪا‬

‫اﻟﻌﻴﺎن ﻟﻮ ﺟﺎك اﻟﻤﺴﺘﺸﻔﻰ ﺑﻴﻘﻮل ﻟﻮ ﺣﺮﻛﺘﺎ رأﺳﻲ ﻗﺪام ﺑﺘﻤﺶ ﻟﻞ‬
hematoma is mobile.
» 5. pericrnium :-

• which is the periostium and it is strongly

attach to the bone and each bone has separate
periosteium .
• Subperiostial ‫ اﻛﺘﺮ ﺣﺎﺟﻪ ﺑﺘﻜﻮن ﻋﻨﺪ اﻷﻃﻔﺎل ف اﻟﻮﻻدة‬.
hematom or also called cephalohematom
• Rupture of the periosteal arteries resulting in a
cephalohematoma is defi ned as a collection of
blood underneath the periosteum. On the head, it
is located between the pericranium (periosteum
of the skull) and the calvaria (skull).

• ★ How to differentiate between the subperiostial

hematom and subgaleal hematoma ?
• Simply the the subgaleal hematom is mobile but
the The subperiostial hematom is plastered to the
bone and doesn't migrate .

» Arterial supply to the scalp :-

• The arteries of the scalp are derived from the

external carotid artery by the occipital, posterior
auricular and superficial temporal branches,
and from the internal carotid artery by the
supraorbital and supratrochlear branches.
• All these arteries anastomose very freely
with each other .

• occipital artery runs with the greater

occipital nerve supply the back of the scalp
up to the vertex
• posterior auricular artery runs with the lesser
occipital nerve to supply the scalp behind the ear.
• Superficial temporal run with the
auriculo-temporal nerve to supply the skin
in front of the ear
• The supraorbital and supratrochlear arteries run
with the corresponding nerves.

• The supraorbital is the larger and supplies the

front of the scalp up to the vertex. Its anastomo-
sis with the superficial temporal artery connects
the internal and external carotid systems.

» Venous drainage to the scalp :-

• The supraorbital and supratrochlear veins drain by

the angular vein into the facial vein .
• The superficial temporal veins run into the
retromandibular vein
• posterior auricular vein drains the scalp behind
 the ear to the external jugular vein; it
• occipital veins drains into the vertebral vein.

» Lymph drainage :

• There are no lymph nodes within the scalp

• lymphatic from the posterior half of the scalp
drain to occipital and mastoid nodes, and from the
anterior half to preauricular (parotid) nodes.
• The lymph eventually reaches the nodes of the
deep cervical chain

» Nerve supply :
• The main sensory nerves run with the arteries

•--------------------------------------------------•

Muscles Of Facial Expression :-

• In the face we have 3 important orifices: The

eyes ,The nose or nostrils and The mouth .
• Facial muscles are the muscle fibers around
the above three orifices , their function is to
close and opening these orifices and as result
get facial expression .
• These muscles are superficial and just below the
skin and the superficial fascia So face is one of
the difficult areas to be dissceted.
• Face is rich in blood supply and this is very good
because the healing will be very rapid .
• There is no deep fascia on the face .
• Motor innervation to these muscle is by the
Facial nerve , abd proprioceptive sensation
by Trigeminal nerve

• Important muscles of facial expression:

1. Orbicularis occuli:
• that form circle concentric fibers around the eye
Contraction of this muscle close the eye
It has three parts:
• Orbital part : cause strong closure of the eye that
we disappear eyelashes
• Palpebral part : cause gently closure in which we
can see the eyelashes
• Lacrimal part : attach to the lacrimal apparatus
(lacrimal sac and lacrimal gland) it's function is to
help in spreading of the tears through the eye.

2. Frontalis :
• it's fibers descend from the scalp attach to
 the upper eyelid, it's action is to open the eye
more causing wrinkles in the forehead and this
is facial expression,
• it's innervated by facial Nerve
Note :
• Opening of the eye is not a facial expressions ,
because the eye is normally open
• Here The facial nerve give motor innervation
only , and you don't want to controlle you eye
because if your eye will open all the time using a
muscle there will be muscle fatigue
• Levator palpebrae superioris : come from the
inner orbit and attach to the upper eyelid
and it's action is to open the eye by elevating
the upper eyelid
• it's innervated by occulomotor nerve CN 3. So as
it's not innervated by facial nerve and it's not one
of the facial expression muscles .
• Muscle that open the eye : levator papberae
superioris and frontalis .
• Muscle that close the eye Orbicularis Occuli only .

3. Nasalis :
• is general muscle of the nose .
• Composed of two parts :
1. Compresser nasi ( transverse part ) : attach to
 the nostrils and compress the nose .
2. Dilator nasi ( alar part ) : attach to the nasal
spine, it's action is to open the nose and
it's more developed in animals because it
use it in smelling .

4. Buccinator :
• upper fibers originate from maxilla and the lower
fibers originate from the mandible
• The uppermost fibers go toward the upper lip
and the lowermost fibers go toward the lower lip
forming orbicularis oris .
• the middle fibers of buccinator will decussate;
the upper fibers go downward and the lower
fibers go upward.
• it's has deep origin interdigitate with
superior pharyngeal constrictor in line called
ptrygomandibular raphe .
• The muscle is pierced by the parotid duct
opposite the third upper molar tooth

5. Orbicularis oris :
• has concentric fibers around the mouth , most of
these come from the buccinator.
• it's action is to close the mouth ;to make it
 smaller (important in for whistling action) .

6 . Levator labii superioris:

• come from infraorbital margin above the
infraorbital formen (which transport infraorbital
nerve,artery and vein) to be attached to the upper
lip,it's action is to elevate the upper lip upward .
7. Levator labii superioris alaeque nasi:
• Attach to the nose as well as the upper
lip ,alaeque because it attach to ala of nose, it's
action is to elevate the nose and the upper lip
at the same time, it's more developed in animals
(‫)ﺑﺴﺘﺨﺪﻣﻮﻫﺎ ﻓﻲ اﻟﺘﻜﺸﻴﺮ‬

8 . Levator anguli oris:

• come from below the orbit below the infraorbital
foramen so the infraorbital nerve is sandwiched
between levator labii superioris and Levator
anguli oris, attach to the angle of the mouth, it's
action is to elevate the upper lip.

9. Zygomaticus major and minor :

• major come from zygomatic bone and minor
come from zygomaticomaxillary suture and they
inserted in the angle of the mouth , they are
 important muscles for smiling

10. Risorius :
• superficial muscle ‫ ﺑﺘﻌﻤﻞ اﻟﻮﺟﻨﺎت‬sometime is
doubled and sometime it spilted and appears
ad congenital defect .

11. Depressor labii inferioris:

• arise from the mandible and attach to the
lower lip ,it's action is to depress the lower
lip downward
12. Depressor Anguli Oris

13. Mentalis

Note:
• angle of the mouth is site of insertions of many
muscles ,this called modiolus, contain fibers of:
1. Buccinator
2. levator anguli oris and Depressor anguli iris
3. Zygomaticus major and minor .
4. Risorius

# Nerve Supply Of Muscle Of Facial Expressions :-

1) Motor by the Facial nerve :-

• It emerge through stylomastoid foramen ,

as it emerge it supply auricularis posterior
muscle which move or rotate the ear (more
important in animals)
• Then it give nerve to posterior belly of digastric
and stylohyoid .

★ mention the motor branches of the facial nerve

befor it enter. the parotid gland ?
1. Nerve to auricularis posterior and occipital belly
of occipitofrontalis .
2. Nerve to posterior belly of digastric muscle .
3. Nerve to stylohyoid muscle .

• Then the facial nerve enter the parotid gland and

devide into two trunks :
1. Temporofacial
2. Cervicofacial
• then these trunks will meet again and give
terminal branches:
1. Temporal branches
2. Zygomatic branches
3. Buccal branches
4. marginal mandibular branch
5. Cervical branch.

Note :

• Temporal and zygomatic branches cross the

zygomatic arch in addition to the auriclotemporal
nerve and superficial temporal artery .

Temporal branches supply:

1. Auricularis anterior
2. Frontalis .

Zygomatic branches : mainly supply the orbicularis

occuli which is only muscle that close the eye and it's
important for protection of the eye .

Buccal branches : supply

1. Buccinator
2. Nasal muscles
3. Zygomaticus muscles
4. Levator labii superioris
5. Levator labii superioris alaeque nasi
6. Levator anguli oris
7. Risorius
Mandibular branches: supply
1. The orbicularis oris and
2. Mentalis
3. Depressor labii inferioris
4. Depressor anguli Oris

Cervical branch : supply platysma muscle and it's

dose not has a major role in humans .

• The facial nerve has important anatomical

relation to the submandibular gland so you
have to be careful during surgery and make
the incision away .

• The most Injury of the facial nerve occur during

the parotid surgery .
• The facial nerve devide the gland into superficial
and deep parts .
• Tumors of the parotid gland has two types:
1. Benign : commonly affect the superficial part .
( ‫ﻋﺸﺎن ﻛﺪه ﻓﻲ اﻟﺤﺎﻟﺔ دي اﻧﺖ اﻟﻤﻔﺮوض ﺗﺨﺶ ﺗﺸﻴﻞ اﻟﻮرم‬
‫) ﺑﺪون ﻣﺎ ﺗﻀﺮب اﻟﻌﺼﺐ‬
2. Malignant : affect the superficial part ,but has
no margin , either the tumer filtrate and affect
the nerve and the deep part (So the patient
come with clear facial palsy) or you cut the
 nerve with the tumor to make sure that you
clear the tumor facial
• To avoid these consequences surgeons use a
nerve graft using the sural nerve (sometime it
give a good results)

Facial nerve test :

• Test for temporal branches : you say to the

patient elevate your eyebrows , if you see
wrinkles in one side and the other side is flat, this
mean tempotal branches .
• Test for zygomatic branches : The patient
can't close his eyes, one eye will be closed and
the other it's open .
• Test for buccal branches : the patient can't bloats
• Test for mandibular branches : you say to the
patient smile or show your teeth , the mouth will
deviate to one side ( the intact side)
other side
• Mouth deviation also associate with stroke
because the nerve is damaged at the
supraneuclear innervation .

The problem associated with facial nerve injury :

1. If the buccal branches damage, the patient can't
move the food inside his mouth on that side
 damaged ,because the movement of the food
inside the mouth need buccinator
2. The patient can't close his eye when he wants to
sleep , so the eye will be open all the time .
3. The facial nerve supply the lacrimal gland, so
there will no production of tears so the eye
will be dried and once it dried the cornea will
ulcreate and BLINDNESS will occur.
• So if you asked the most dangerous problem
associate with facial nerve damage it's Blindness .
• Dcotors can avoid this blindness by give the
patient protected glass and artificial tears untill
the nerve is recovered.

2) Sensory innervation via trigeminal nerve :-

The Three divisions of the trigeminal nerve are :-
1. Ophthalmic
2. Maxillary
3. Mandibular

• Those division are important because :-

1. Represent the dermatome of the face .
2. Certain types of infection can infect this
dermatom like viral infection and herpes
zoster (‫)اﻟﺤﺰام اﻟﻨﺎري‬
3. Syndrome ..........
#1. Ophthalmic nerve :
• has the following branches :
1. Supraorbital nerve : arise laterally and
follow it artery.
2. Supra trochlear nerve arise medially and
follow it artery.
3. Infratrochlear nerve arise medially and inferiorly .
4. Lacrimal nerve : arise laterally and inferiorly
supply the lacrimal gland and overlying skin
5. External nasal nerve : supply the nose to the
tip of the nose .

#2. Maxillary nerve :-

• has the following branches :
1. Zygomaticotemporal nerve : laterally
2. Zygomaticofacial nerve : medially.
3. Infra orbital nerve : terminal continuation of the
maxillary nerve and supply the lower eyelids,
nose and upper libs.

#3 . Mandibular nerve :-
.
• has the following branches :
1. Auriculotemporal : supply the ear above the
acoustic meatus and the the temporal skin.
2. Buccal nerve { not nerves} : supply the buccal
skin and mucous membrane and give prioceptive
branch to the buccinator muscle.
3. mental nerve
Note :
• we have Buccal nerves branch of the facial nerve
and they are motor but this Buccal nerve are
single and sensory and branch of the trigeminal so
be smart and not confuse between them.

• To examine the trigeminal nerve clinically you

examine the sensation of the face ( all of the face
is supplied by the trigeminal except
1. Angle of the mandible
2. Skin of the parotid area
3. Lower part of the auricle
• which is supplied by the great auricular nerve }

# Blood supply of the face :-

1) Facial artery :-
• main source of the blood supply as it name
imply . When it pass deep to the submandibular it
give the following branches:
1. Branches to the tongue .
2. Tonsillar branch to the tonsils.
3. Ascending palatine branches (participate in
blood supply of the palate.)
• Then the facial artery pass in the border of
masseter muscle { site of the pulse} and give the
following branches :
1. Submental artery .
2. Inferior labial artery supply the lower lib .
3. Superior labial artery supply the upper lib and
give nasal branches to enter the nose { septal
branch to the nasal septum }.
• during it is course it tortuous .

Note :
• Tortuous arteries are
1. Facial artery
2. Splenic artery
3. Posterior inferior cerebellar artery.
2) Superficial Temporal Artery :
• Supply the side of the face { temporal area}and
anastmose with superficial temporal of the other
side in scalp there fore it also supply the scalp .

3) Supraorbital (lateral) .and supratrochlear

(medial). arteries
• are branch of the ophthalmic artery which is the
first branch of the internal carotid artery.
• Both arteries supply the forehead and anterior
part of the scalp and make anastmose with the
superficial temporal artery (connection between
the internal and external carotid systems).

4) The transverse facial artery :

• a branch of the superficial temporal artery, runs
across the cheek just above the parotid duct

5) The dorsal nasal artery :-

• a small terminal branch of the ophthalmic artery,
supplies skin at the root of the nose.

# Lymph drainage of the face :-

• The face drains into three superficial

groups of nodes
1. Submental nodes
2. Submandibular nodes
3. Preauricular (parotid) nodes
• Eventually all lymph from the face reaches
deep cervical nodes.

• •--------------------------------------------------•

PAROTID GLAND :-

• one of the major salivary gland and purely serous.

• Usually has relations to the ear .
• The gland is wedge shaped with superficial ,
anteromedial and posteriomedial border.
• The investing layer of deep cervical fascia sp.lits
to envelope the gland
• the inner leaf passes up to the base of the
skull . The outer leaf extends superiorly as the
parotidomasseteric fascia. and reaches up to
the zygomatic arch.

# RELATIONS :-

• Anteriorly :
1. Mandibular ramus
2. Masseter muscle
3. Medial pterygoid muscle deep to the
masseter muscle .

• Posterioly :
1. mastoid process
2. Styloid process
3. SCM muscle
4. Posterior bony belly of the digasstric .

• Superiorly :
1. The ear
2. Zygomatic arch .

• The lateral surface (superficial) :

1. skin
2. Subcutaneous tissue
3. Platysma
4. Investing layer of deep cervical fascia which
form the Parotid fascia.

• All of the above relation is to the superficial part .

• Buccinator muscle is not related to the gland
• The gland is always below the zygomatic arch .
• ‫ﻟﻮ ﺟﺎك ﻋﻴﺎن ﺑﻲ ورم ﻓﻮق اﻵرش ﻣﻌﻨﺎﻫﺎ ﻣﺎ ﻋﻨﺪو‬
gland ‫ﻋﻼﻗﺔ ﺑﺎل‬

» The parotid duct :-

• about 5 cm long, passes forwards across the
masseter and pierce the buccinator

# CONTENTS OF THE PAROTID GLAND :-

• from deep to superficial :-

1) External carotid artery enter the gland in
the posteromedial surface  and divid into 2
terminal branches
1. Superficial temporal artery : in front of the ear .
2. Maxillary artery : enter the infra temporal fossa
which are emerge in the antermedial surface .

2) retromandibular vein is formed by joining of the

Maxillary vein and Superficial temporal vein in the
gland and emerge from the lower border of the gland
and then divid into :-
1. Anterior division which join the fascial vein and
the lingual vein to form the common facsial vein
which drain to the internal jugular vein.
2. Posterior division join the postertior auricular
vein to form the external jugular vein which drain
to the Subclavian vein

• 3) Facial nerve

• 4) the partotid lymph node or the preauricular

lymph node perforate the parotid fascia and must
examine them in pateint.

1. The parotid duct

2. Branches of the facial nerve
3. The terminal branches of the external carotid
artery (superficial temporal and maxillary)
• emerge from the anteromedial surface and run
forwards deep to the anterior border ( so the
penetrate the parotidomasseteric fascia )

• styloid process and its attached muscles (stylo-

hoid, stylopharyngeus and styloglossus) separate
the gland from the carotid sheath and its contents

# Blood Supply :-
• External carotid artery .
# venous drainage :-
• Retromandibular vein .

# NERVE SUPPLY :-

1/ Sensory innervation by the great auricular nerve .

2/ Secretomotor innervation  { parasympthetic }

is by :-

• the glossopharyngeal nerve is (CN 9) has nucleus

in the brain called inferior salvitory, this nucleus
has only one function to stimulate the salvation
in the parotid gland .

• The function of the glossopharyngeal nerve

 is to supply posterior one third of the tongue
and the pharynx .
• After emmarge from the Brain it gives typanic
branch . This tympanic branch form plexus with
the vagus nerve and from this plexus come the
lesser petrosal nerve to relay in Otic Ganglia in
the infra temporal fossa .
• From the otic ganglia the message of salivation is
taken by auriculotemporal nerve

‫ ﻟﻮ ﺟﺎك ﺳﺆال ف‬secretomotor ‫ اﻻﺟﺎﺑﻪ ﻣﻤﻜﻦ ﺗﻜﻮن‬:-

 ‫اﻻﻣﺘﺤﺎن ﻋﻦ اﻟﺤﺎﺟﺎت اﻟﺒﻴﺘﻌﻤﻞ‬
1. Inferior salvitory nucleus
2. glossopharyngeal nerve
3. Tympanic branch
4. Lesser petrosal nerve
5. Otic ganglia .
6. Auriculotemporal nerve

Important Notes :-
• occulomotor, the facial , glossopharyngeal and
vagus {1973 } are stongest cranial  nerves why ?
• Because the have Motor innervation , Sensory
innervatoin, prioceptive innervation and
secretomotor innervation. While The other cranial
nerves has only sensory and motor innervation .
• Superior salvitory nucleus for stimulation of the
salviation in the submandibular gland and minor
salivary and lacrimal gland and the impulse is
taken by the fascial nerve .
• Secretion is always parasympthtic except in the
sweat gland is sympathetic.
• Facial nerve enter the gland and don't innervat it .

• The aurculotemporal has close relation to the

Superficial temporal artery and both crosses the
zygomatic arch ( ‫) ﻣﻬﻤﺔ ﻓﻲ ﺣﺎﻟﺔ اﻟﻜﺴﻮر وﻛﺪه‬
• The aurculotemporal give sensory innervation to
the upper part of the auricle of the ear and the
temporal skin as it name imply .

» CLINICAL NOTES REGARDING THE

PAROTID GLAND :

Freys Syndrome :
• If you have tumer in the parotid gland and and
during the removal of the tumer you make little
injury to both the aurculotemporal and great
auricular nerve . And during healing there was a
mixing between the two above nerves .
• The patein will said when I am eat the salivation is
stimulated normally but also he has sweating .
• The explanation :
• Due to the mixing between the two Nerves , the
impulse that cone from the inferior salvitory
nucleus will go to both aurculotemporal and
great auricular nerves .
• Aurculotemporal which is responsible for the se-
cretomotor impulse to the gland salivation . But
the great auricular nerve carrys swearing impulse .
• Salivation and sweating with eating is diagnosed
as FREYS SYNDROME.
• The most dangerous structure to be injury in
partid surgery is facial nerve. Because the venous
drainge dies not depends on the Retromandibular
veins only , and the there is two external carotid
artery abd there is anastamose between them ,so
you can cut ine of them without causing a
serious problem .
Last modified: Sep 10, 2018