This slide includes notes on scalp and face anatomy ( the muscles, nerve supply and clinal anatomy)

1. Areeb Fatima
Student Doctor Of Physical Therapy
Government College University Faisalabad

3.  Soft tissue covering the cranial vault form
the scalp.
 Extent of Scalp:
 Anteriorly: Supraorbital margins
 Posteriorly: Occipital protuberance and
superior nuchal lines.
 Laterally: Superior temporal lines
 Conventionally, the superficial temporal
region is studied with the scalp.

4.  The scalp is made up of five layers:
 Skin
 Superficial fascia(Connective tissue)
 Deep fascia in the form of epicranial aponeurosis or
galia aponeurotica with the occipitofrontalis muscle.
 Loose areolar tissue
 Pericranium
 Skin:
 Thick and hairy
 Adherent to epicranial aponeurosis through the dense
superficial fascia.
 Has more number of sweat glands and sebaceous
glands.

5.  Subcutaneous or superficial fascia:
 More fibrous and dense in the centre than at the
periphery of head.
 May contain blood vessels.
 Binds the skin to the subjacent aponeurosis.
 Provides the proper medium for passage of vessels
and nerves to the skin.
 Occipitofrontalis muscle:
 Two bellies which are inserted into the epicranial
aponeurosis.
 Occipital bellies:
 Small and separate.
 Each arise from the lateral two third of superior nuchal
lines.
 Supplied by the posterior auricular branch of facial
nerve.

6. Figure: The occipitofrontalis muscle. Innervation of two bellies by
the posterior auricular and temporal branches of the facial nerve is
demonstrated

7.  Frontal bellies:
 Longer, wider and partly united in the median plane.
 Each arise from the skin of upper eyelid and forehead,
mingling with the orbicularis oculi and the corruggator
supercili.
 Supplied by temporal branch of facial nerve.
 Muscle raises the eyebrows and causes horizontal
wrinkles in the skin of forehead.
 Temporoparietalis muscle:
 Present on lateral side.
 Arises from temporal fascia and fuses with
epicranial aponeurosis.
 Supplied by the temporal branch of facial nerve.

8.  Epicranial aponeurosis / Galea aponeurotica:
 Freely moveable on the pericranium.
 Anteriorly: Receives the insertion of frontalis.
 Posteriorly: Receives the insertion of occipitalis and is
attached to external occipital protuberance and to
the highest nuchal lines in between the occipital
bellies.
 On each side: Attached to the superior temporal
lines, but sends down a thin expansion which passes
over the temporal fascia and is attached to the
zygomatic arch.
 First three layers of the scalp are called surgical
layers of scalp. These are also called as scalp
proper.

9.  Loose areolar tissue:
 Anteriorly: To the eyelids.
 Posteriorly: To the highest and superior nuchal
lines.
 On each side: superior temporal lines.
 Gives passage to the emissary veins.
 Pericranium:
 Loosely attached to the surface of bones.
 Firmly adherent to the their sutures.
 Sutural ligaments bind the pericranium to the
endocranium.

10. Figure: Layers of scalp, cranium and meninges.

11.  Superficial temporal region:
 It is the area between the superior temporal line
and the zygomatic arch.
 This area contains following six layers:
 Skin
 Superficial fascia
 Thin extension of epicranial aponeurosis which gives
origin to extrinsic muscles of auricle
 Temporal fascia
 Temporalis muscle
 Pericranium
 Greying of hair first starts here.

12. Figure: (a) Layers of scalp, (b) Layers of superficial
temporal region

13.  In front of the auricular: From before backwards
 Supratrochlear
 Supraorbital
 Superficial temporal
 Supratrochlear and supraorbital are branches of
ophthalmic artery which in turn is a branch of
internal carotid artery.
 Superficial temporal artery is a branch of external
carotid artery.
 Behind the auricle: From before backwards
 Posterior auricular
 Occipital arteries
 Poaterior auricular and occipital artery both are
branches of external carotid artery.

16. In front of auricle Behind the auricle
Sensory nerves Sensory nerves
• Supratrochlear nerve • Great auricular nerve
• Supra orbital nerve • Lesser occipital nerve
• Zygomatico temporal nerve • Greater occipital nerve
• Auriculotemporal nerve • Third occipital nerve
Motor nerve Motor nerve
• Temporal branch of facial
nerve
• Posterior auricular nerve

18.  Scalp wounds:
The epicranial aponeurosis is clinically
important. Because of the strength of this
aponeurosis, superficial scalp wounds do not
gape, and the margins of the wound are held
together. Furthermore, deep sutures are not
necessary when suturing superficial wounds
because the epicranial aponeurosis does not
allow wide separation of the skin. Deep scalp
wounds gape widely when the epicranial
aponeurosis is lacerated in the coronal plane
because of the pull of the frontal and occipital
bellies of the occipitofrontalis muscle in
opposite directions (anteriorly and posteriorly).

19. Sebaceous cyst:
The ducts of sebaceous
glands associated with
hair follicles in the scalp
may become obstructed,
resulting in the retention
of secretions and the
formation of sebaceous
cysts (pilar cysts).
Because they are in the
skin, sebaceous cysts
move with the scalp.

20. Wounds of the scalp bleed profusely
because the vesels are prevented from
retracting by the fibrous fascia.
Bleeding can be arrested by applying
pressure at the site of injury by tight
cotton bandage against the bone.
Because of the density of fascia,
subcutaneous haemorrhages are never
extensive, and the inflammations in
this layer cause little swelling but
much pain.

21.  Cephalohematoma:
 Because the pericranium is adherent
to sutures, collections of fluid deep to
the pericranium known as
cephalohematoma take the shape of
the bone concerned when there is
fracture of particular bone.
 Sometimes after a difficult birth,
bleeding occurs between the baby’s
pericranium and calvaria, usually over
one parietal bone. Blood becomes
trapped in this area, forming a
cephalohematoma. This benign
condition frequently seen in neonates
results from birth trauma that
ruptures multiple, minute periosteal
arteries that nourish the bones of the
calvaria.

22.  Dangerous area of scalp:
 The layer of loose areolar tissue is
known as the dangerous area of scalp
because the emissary veins, which
course here may transmit infection
from the scalp to the cranial venous
sinuses.
 Collection of the blood in the loose
connective tissue causes generalized
swelling of the scalp.
 The blood may extend anteriorly into
the root of the nose and into the
eyelids(as frontalis muscle has no bony
origin) causing resulting in black eye.
 Poaterior limit of such haemorrhage is
not seen. If bleeding is due to local
injury, the posterior limit of
haemorrhage is seen.

23. Safety layer:
 Because of the spread of blood,
compression of brain is not seen and so this
layer is also called the safety layer.
Since the blood supply of the scalp and
the superficial temporal region is very
rich; avulsed portions need not be cut
away, they can be replaced in position
and stitched; they usually take up and
heal.

24.  The face extends superiorly from the adolescent
position of hairline, inferiorly to the chin and the
base of the mandible and on each side to the
auricle.
 Forehead is common to both the scalp and face.
 Skin:
 Facial skin is very vascular.
 Wounds of face bleed profusely but heal rapidly.
 Facial skin is rich in sebaceous and sweat glands.
 Facial skin is very elastic and thick because the facial
muscles are inserted into it.
 Wounds of the face tend to gape.

25.  Superficial fascia:
 It contains:
 Facial muscles
 Vessels and nerves
 Fat
 Absent from the eyelids.
 Well developed in cheeks, forming the buccal pads.
 Deep fascia
 Absent in face, except
 Over the parotid gland where it forms the parotid
fascia.
 Over the buccinator where it forms the
buccopharyngeal fascia.

26.  Subcutaneous muscles.
 Bring out different facial expressions.
 Have small motor units.
 Embryologically, develop from mesoderm of
second branchial arch.

28.  Functional groups of facial muscles:
Opening Sphincter Dilators
Palpebral fissure Orbicularis occuli Levator palpebrae superioris
Frontalis part of
occiptofrontalis
Oral fissure Orbicularis oris All the muscles around the
mouth, except orbicularis
oris, the sphincter, and the
mentalis which do not
mingle with orbicularis oris
Nostrils Compressor neris Dilator neris.
Depressor septi
Medial slip of levator labii
superioris alaeque nasi.

29.  Muscles of the
auricle:
 Auricularis anterior.
 Auricularis superior.
 Auricularis posterior.
 These are vestigeal
muscles
 Actions: In man,
these muscles possess
very little action: the
Auricularis anterior
draws the auricula
forward and upward;
the Auricularis
superior slightly
raises it; and the
Auricularis posterior
draws it backward.

30.  Muscles of the eyelids or orbital openings:
Name Action
Corrugator
supercilii
Vertical lines in forehead as in frowing.
Orbicularis occuli:
a) Orbital part
b) Palpebral part
c) Lacrimal part
a) Protects eye from bright light , wind and rain.
Causes forceful closure if eyelids.
b) Closes lids gently as in blinking and sleeping.
c) Dilates lacrimal sac for sucking of lacrimal
fluid into the sac, directs lacrimal puncta into
lacus lacrimalis; supports the lower lid.
Levator palpebrae
superioris
(extraocular muscle
supplied by
aympathetic fibres
and third cranial
nerve)
Responsivbe for superior eyelid moveent

31.  Muscles of the eyelids or orbital openings:
Figure: Orbicularis occuli and corrugator supercilii

32.  Muscles of the eyelids or orbital openings:
Figure: Levator palpebrae superioris

33.  Muscles of the nose:
Name Action
Procerus Causes transverse wrinkles
Compressor
neris
Nasal aperture compressed
Dilator neris Nasal aperture dilated
Depressor septi Nose pulled inferiorly

34.  Muscles of the nose:

35.  Muscles around the mouth:
Name Action
Orbicularis oris
a) Intrinsic part, deep
stratum very thin sheet.
b) Extrinsic part, two
strata formed by
converging muscles
Closes lips and protrudes lips, numerous extrinsic
muscles make it most versatile for various types of
grimaces.
Buccinator, the muscle of
cheek
Flatten cheek against gums and teeth; prevent
accumulation of food in the vestibule. This is the
whistling muscle
Levator labii superioris
alaeque nasi
Lifts upper lip and dilates the nostrils
Zygomaticus major Pulls the angle upward and laterally as in smiling
Levator labii superiorioris Elevates the upper lip, forms nasolabial groove
Levator angulii oris Elevates the angle of mouth, forms nasolabial
groove

36.  Muscles around the mouth:
Name Action
Zygomaticus minor Elevates the upper lip
Depressor anguli oris Draws angle of mouth downwards and laterally
Depressor labii
inferioris
Draws lower lip downwards
Mentalis Elevates and protrudes lower lip as it swrinkles
on chin
Risorius Retracts angle of mouth

37. Figure: Muscle around the mouth
(underlined muscles names)

38.  Muscles of the neck:
Name Action
Platysma Releases pressure of skin on the
subjacent veins; depresses mandible;
pulls the angle of the mouth
downwards at in horror or fright

39.  A few of common facial expressions and the muscles
producing them are given below:
Expression Muscle involved
Smiling and laughing Zygomaticus major
Sadness Levator labii superioris and levator anguli
oris
Anger Dilator neris and depressor sapti
Grief Depressor anguli oris
Dislike Corrugator supercilii and procerus
Horror, terror and fright Platysma
Surprise Frontalis
Doubt Mentalis
Grinning Risorius
Contempt Zygomaticus minor
Closing the mouth Orbicularis oris
Whistling Buccinator, orbicularis oris

42.  Motor nerve supply:
 Facial nerve is the motor nerve of he face.
 Five terminal branches emerge from the
parotid gland.
Branch of
facial nerve
Muscles supplied by branch
Temporal Frontalis, auricular muscles, orbicularis
occuli
Zygomatic Orbicularis occuli (lower eyelid part)
Buccal Muscles of cheek and upper lip
Marginal
mandibular
Muscles of lower lip
Cervical Platysma

43.  Motor nerve supply:

44.  Motor nerve supply:
Figure: terminal branches of facial nerve can be understood by putting your
right wrist on the right ear and spreading five digits; the thumb over the
temporal region, the index fingeron the zygomatic bone, middle finger on
the upper lip, the ring finger on the lower lip and the little finfer on the neck

45.  Sensory nerve supply:
Source Cutaneous nerve Area of distribution
Ophthalmic
division of
trigeminal
nerve.
1. Supratrochlear
nerve
2. Supraorbital nerve
3. Lacrimal nerve
4. Infratrochlear
nerve
5. External nasal
nerve
1. Upper eyelid and forehead
2. Upper eyelid, frontal air
sinus, scalp
3. Lateral part of eyelid
4. Medial parts of both eyelid
5. Lower part of dorsum and
tip of nose
Maxillary
division of
trigeminal
nerve
1. Infraorbital nerve
2. Zygomaticofacial
nerve
3. Zygomaticoteporal
nerve
1. Lower eyelid, side of
nose, upper lip
2. Upper part of cheek
3. Anterior part of temporal
region

46.  Sensory nerve supply:
Source Cutaneous nerve Area of distribution
Mandibular
branch of
trigeminal
nerve
1. Auriculotemporal
nerve
2. Buccal nerve
3. Mental nerve
1. Upper two thirds of lateral
side of auricle, temporal
region
2. Skin off lower part of
cheek
3. Skin over cheek
Cervical plexus 1. Anterior division of
great auricle nerve
(C2, C3)
2. Upper division of
transverse
(anterior)
cutaneous nerve of
neck (C2, C3)
1. Skin over angle of the jaw
and over the parotid gland
2. Lower margin of the lower
jaw.

47.  Sensory nerve supply:

48. Examination of facial nerve:
 Examined by testing the following facial
muscles:
Muscle Test
Frontalis Ask the patient to look upward without
moving the head, and look for normal
horizontal wrinkles on the forehead
Dilators of
mouth
Showing the teeth
Orbicularis
occuli
Tight closure of eyes
Buccinator Puffing the mouth and then blowing
forcibly as in whistling

49. Examination of facial nerve:
Figure: (a) Test for frontalis, (b) Test for dilators of mouth, (c) Test
for orbicularis occuli, (d) Test for buccinator

50.  Bell’s palsy:
 Infranuclear leison of the facial nerve at the
stylomastoid process is known as bell’s palsy.
 Upper and lower quarters of the face on the same side
get paralyzed.
 Face becomes asymmetrical and is drawn up to the
normal side.
 The affected side is motionless.
 Eye cannot be closed.
 Any attempt to smile draws the mouth to the normal
side.
 During mastication, food accumulates between the teeth
and cheek.
 Articulation of labias is impaired.

51. Bell’s palsy:

52.  Facial palsy:
 Supranuclear lesions of facial nerve; usually a
part of hemiplegia, with injury of
corticonucldear fibres
 Only the lower quarter of opposite dide of face
is paralyzed.
 Upper quarter with the frontalis and
orbicularis occuli escapes due to its bilateral
representation in the cerbral cortex.
 Only voluntary movements are affected and
emotional expressions remain normal as there
are separate pathways for voluntary and
emotional movements.

53. Facial palsy:

54.  Trigeminal neuralgia/ tic douloureux:
 Sensory disorder of sensory root of CN V that occurs
most often in middle aged and elderly persons.
 CN V2 is most frequently involved, then CN V3 and
least frequently CN V1.
 It causes attacks of very severe burning and
scalding pain along the distribution of the affected
nerve.
 Pain is relieved by:
 By injecting 90% alcohol into the affected division of the
trigeminal ganglion.
 By sectioning the affected nerve, the major sensory root,
or the spinal tract of the trigeminal nerve which is
situated superficially in the medulla. The procedure is
called medulllary tractotomy.

55. Trigeminal neuralgia/ tic douloureux:

56. Headache:
 Sensory distribution of trigeminal nerve
explains why headache is a uniformly
common symptom in involvements of
nose (common cold, boils), para nasal
air sinuses (sinusitis), infections and
inflammation of teeth and gums,
refractive errors of eye, and infection of
meninges as in meningitis.