Dr.Kathirvel Gopalakrishnan M.D.S (OMFS)

1. Vascular supply of face and neck
Dr. Kathirvel Gopalakrishnan
M.D.S (OMFS)

2. CONTENTS
• Arterial supply
 Common carotid artery
 External carotid artery
 Internal carotid artery
• Venous supply
 Venous drainage of face
 Venous drainage of neck
• Journal club discussion

3. COMMON CAROTID ARTERY
• Divided into right and left common
carotid artery
• It gives terminal branches as Internal
and External carotid artery
Right CCA Left CCA
Origin Bifurcation of
brachiocephalic
trunk
Arch of
aorta
Termination At the level of upper border of
thyroid cartilage

4. Carotid body:
• Small cluster of
chemoreceptors near the
bifurcation of common carotid
artery
• Detects changes in
composition of blood passing
through it, mainly Po2
• It is also sensitive to changes
in Ph and temperature

5. Carotid sinus
• Localized dilation at the origin of
internal carotid artery
• Contains numerous Baroreceptors for
maintaining blood pressure
• It is innervated by sinus nerve of
hering, which is a branch of
glossopharyngeal nerve

6. Applied anatomy:
• Common carotid artery is often used in measuring the carotid
pulse, in case of shock
• It can be felt between anterior border of sternocleidomastoid
muscle, above the hyoid bone and lateral to the thyroid cartilage.
• Both carotid artery should not be palpated at the same time, it
may limit the blood flow leading to fainting or brain ischemia

7. External Carotid artery
It is the terminal branch of CCA
Origin:
It begins at the level of the upper
border of thyroid cartilage
Course:
It passes upward and forward and
then inclines backward to the space
behind the neck of mandible, where it
divides into superficial temporal and
maxillary artery within the parotid gland

8. Branches of External Carotid Artery
Anterior
1. Superior thyroid
2. Lingual
3. Facial
Posterior
1. Posterior auricular
2. Occipital
Medial
1.Ascending pharyngeal
Terminal
1. Maxillary
2. Superficial temporal

9. SUPERIOR THYROID ARTERY
First branch
Origin:
• Arises just below the greater cornu of hyoid bone
Course and Relations:
• Descends forward in Carotid triangle along
thyrohyoid just superficial to external laryngeal nerve
• It passes deep to infrahyoid muscle to reach upper
pole of lateral lobe of thyroid gland
• Superficially – Skin, Superficial fascia, platysma,
deep cervical fascia
• Medially – Inferior constrictor, External
Laryngeal

10. Branches and supply:
Infrahyoid branch – inferior to hyoid
bone - Infrahyoid muscles
Sternocleidomastoid artery – deep parts
of sternocleidomastoid muscle
Superior laryngeal artery – within the
larynx it supplies muscles, glands and mucosa
Cricothyroid – cricothyroid muscle
Anterior thyroid – thyroid muscle

11. Applied anatomy:
• While performing thyroidectomy, this artery
must be ligated lateral to the superior pole of thyroid
gland (close to the gland) to avoid injury to external
laryngeal nerve
• If not ligated then, it bleeds profusely
• In order to gain control of bleeding surgeon may
need to extend the incision laterally to gain access of
its origin from external carotid artery
• Intra arterial infusion chemotherapy for
hypopharyngeal and laryngeal cancer

12. LINGUALARTERY
Origin:
Arises from external carotid artery between superior thyroid and facial artery
Arises opposite to the greater cornu of hyoid bone
Course and relationship:
First part lies in carotid triangle runs obliquely upwards and medialward to the greater
cornu of hyoid bone
Second part lies deep to hyoglossus muscle separating it from hypoglossal nerve
Third part runs upwards along the anterior margin of hyoglossus and anastomose with the
opposite side

13. Branches and supply:
Suprahyoid branch – muscles in its
vicinity
Dorsal Lingual – basal part of tongue
Deep lingual artery – body and apex of
tongue
Sublingual artery – medial to sublingual
gland - sublingual gland, mucous
membrane of floor of mouth,
mylohyoid muscle

14. Applied Anatomy:
During surgical removal of the
tongue, the first part of the artery is
ligated before it gives any branches to
tongue or tonsil
Injury to sublingual artery may
occur in molar and premolar region when
instrument slip and damage floor of the
mouth which may lead to sublingual
hematoma

15. FACIALARTERY
Chief artery of face
Tortuosity of the artery prevents
its wall from being unduly stretched
during movements of mandible, lips and
cheek
Origin
Arises from ECA just above the
greater cornu of hyoid bone
Two parts 1. Cervical part
2. Facial part

16. Cervical part
Course and relationship:
Runs upwards on the superior constrictor of pharynx deep to the posterior belly of
digastric, within the stylohyoid and to the ramus of mandible
Grooves at posterior border of submandibular salivary gland
Next the artery makes an S-bend (2 loops) first winding down over the
submandibular gland and then up over the base of the mandible

17. Cervical Part:
Branch Distribution
Ascending
Palatine artery
Soft palate,
Palatine tonsil
Tonsilar artery Palatine tonsil
Glandular branch Submandibular
Salivary gland
Submental artery Sublingual
salivary gland,
Submental triangle

18. Facial part
Course and relationship:
Enters face by winding around the base of
the mandible and piercing the deep cervical fascia at
the anteroinferior angle of the masseter muscle
It runs upwards and forwards to a point 1.25
cm lateral to the angle of the mouth. Then it ascends
by the side of the nose up to the medial angle of the
eye
It terminates by supplying lacrimal sac,
anastomosing with the dorsal nasal branch of
ophthalmic artery

20. Branch Distribution
Superior
labial
Upper lip, antero inferior
part of nasal septum
Inferior
labial
Lower lip
Lateral
nasal
Ala, Dorsum of nose
Angular Lacrimal sac, orbicularis
oculi
Facial part:

21. Applied Anatomy:
At the antero inferior border of masseter,
It can be palpated – Anesthetists artery
While excising submandibular gland,
facial artery should be ligated in two point
before dividing, otherwise it may be retracted
with stylomandibular ligament causing serious
bleeding
In 3rd molar impaction, Care should be
taken not to injure the artery while extending
the vertical incision beyond the vestibule
Flaps based on facial artery are widely
used for facial reconstruction

22. OCCIPITAL ARTERY
Supplies the back of the scalp and
sternomastoid muscle
Origin
Posteriorly 2cm from the ECA origin
Course
Runs backwards and upwards deep to
lower border of posterior belly of digastric
Runs deep to mastoid process and the
muscle attached to it
Finally it pierces the trapezius 2.5cm
from the midline and comes to lie along greater
occipital nerve

23. Branches and supply
Sternocleidomastoid branch – Sternocleidomastoid muscle
Auricular branches - Skin of the posterior aspect of the auricle
Descending branch - Digastric, stylohyoid
Occipital branch – occipital belly of occipitofrontalis

24. POSTERIOR AURICULAR
ARTERY
Distributes partly to the ear and partly to the
scalp
Origin
Retromandibular fossa above stylohyoid muscle
Course and relationship:
Runs upwards and backwards deep to parotid
gland, follows upper border of stylohyoid muscle,
superficial to styloid process
Crosses base of mastoid process and ascends
behind the auricle

25. Branches and supply:
Stylomastoid – enters stylomastoid foramen
- supplies upper part of sternocleidomastoid
muscle, middle ear, mastoid antrum and air
cells, semicircular canals and facial nerve
Auricular – Back of auricle, skin over
mastoid process
Occipital – back of scalp

26. ASCENDING PHARYNGEAL
ARTERY
Smallest branch of external carotid artery
Origin:
Just superior to the bifurcation of common
carotid artery
Course:
Runs vertically upwards between side wall
of pharynx and tonsil, medial wall of middle ear
and auditory tube
Deeply seated in the neck among other
branches of ECA and under stylopharyngeus

27. Branches and supply:
• Pharyngeal branches – medial and
inferior muscles of pharynx and
stylopharyngeus
• Palatine branch – Soft palate and
tonsil
• Prevertebral branch – Sympathetic
trunk, Hypoglossal and vagus nerve,
lymph glands
• Inferior tympanic – medial wall of
tympanic cavity
• Meningeal branches – Dura mater

28. Applied anatomy
• Plays an important role in the healing process of Le Fort I
osteotomies, because it supplies the attached posterior palatal
soft-tissue pedicle
• Super selective infusion of the ascending pharyngeal artery is
necessary for successful embolization of cancer of the palate
• It is the primary source of supply to meningiomas and glomus
jugulare

29. Maxillary artery
Larger of two terminal
branches
Supplies deep structures of
face
Origin
Arises behind the neck of
the mandible and first embedded
behind the substance of parotid

30. Course
The maxillary artery continues as one of the terminal divisions of the external carotid
artery at the level of the neck of the mandible and passes forwards between the neck of the
mandible and the sphenomandibular ligament.
It continues its path by running deeply to the lower head of lateral pterygoid and passes
forward between the two heads of the lateral pterygoid muscle to break into its terminal
branches at the pterygopalatine fossa

31. Divisions:
Divided into 3 parts
• First part – Mandibular
• Second part – Pterygoid
• Third part – Pterygopalatine

32. Clinical Anatomy of the Maxillary Artery
Ippei Otake Et Al – February 2011

33. Mandibular part (First part)
Passes between neck of condyle and sphenomandibular ligament, below
auriculotemporal nerve
Branches Foramen Distribution
1.Deep auricular artery Foramen in floor of
external auditory
meatus
External acoustic
meatus, Outer surface
of tympanic
membrane
2.Anterior tympanic
artery
Petrotympanic fissure Inner surface of
tympanic membrane
3.Middle meningeal
artery
Foramen spinosum 5th and 7th nerve,
middle ear, tensor
tympani
4.Accessory meningeal
artery
Foramen ovale Meninges, Structures
in infratemporal fossa
5.Inferior alveolar
artery
Mandibular foramen Lower teeth,
Mylohyoid muscle
5
34
2
1

34. Pterygoid part (Second part)
Ascends obliquely forwards medial to temporalis and superficial to
lower head of lateral pterygoid
Branches Distribution
1.Deep temporal branch Temporalis muscle
2.Pterygoid branch Lateral Pterygoid,
Medial Pterygoid
3.Masseteric artery Masseter muscle
4.Buccal artery Buccinator muscle
11
234

35. Pterygopalatine part (Third part)
Passes between heads of pterygoid and through pterygomaxillary fissure
and passes into pterygopalatine fossa
Branches Foramen Distribution
1.Posterior
superior alveolar
Alveolar canal
in body of
maxilla
Upper molar and premolar
teeth, maxillary sinus
2.Infra orbital Infra orbital
fissure
Lower orbital muscle,
lacrimal sac
3.Greater
palatine
Greater palatine
canal
Soft palate, tonsil, palatine
glands
4.Pharyngeal Pharyngeal
canal
Root of nose, pharynx,
sphenoid sinus
5.Artery of
Pterygoid canal
Pterygoid canal Auditory tube, upper
pharynx, middle ear
6.Sphenopalatine
(Terminal part)
Sphenopalatine
foramen
Lateral and medial wall of
nose and air sinuses
1
3
5
6
2
4

36. The Clinical Anatomy of the Maxillary Artery in the Pterygopalatine Fossa
Jinho Choi Et Al - J Oral Maxillofac Surg 61:72-78, 2003

37. Applied anatomy:
In surgeries involving condyle,
avoid damage to maxillary artery as it
lies medially to condyle
Ankylotic mass may encircle the
artery. So it is advised to remove the
ankylotic mass in pieces than in toto

38. During Lefort 1 osteotomy
procedure, Pterygopalatine portion of
maxillary artery may be injured
during fracturing the pterygoid plates
if the tessiers osteotome is directed
backwards
It should be directed medial
and downwards

39. SUPERFICIAL TEMPORAL
ARTERY
Smaller of the two terminal branch
Origin:
Begins in parotid gland behind mandible
neck
Course:
Runs vertically upwards, crossing the root
of the zygoma or preauricular point.
About 5 cms above of zygoma, It divides
into anterior and posterior branches. Anterior
branch anastomoses with the supraorbital,
supratrochlear branches of ophthalmic artery

40. Branches & supply
Transverse facial artery
Zygomatico orbital branches –
superficial branch – orbicularis oculi
Middle temporal branch – rises above
zygomatic arch - periosteum of temporal
bone
Frontal branch – Frontal regions
Parietal branch – Lateral areas of scalp

41. Applied anatomy:
Pulsation of superficial temporal
artery:
Infront of the auricle, above the
root of zygomatic arch pulsations can
be felt
Anesthetist mostly depend on
pulsation of superficial temporal artery

42. Super microsurgical reconstruction of nasal tip defects using the preauricular reversed superficial temporal artery flap
Jiao Weia Et Al - August 26, 2019 - Journal of Plastic, Reconstructive & Aesthetic Surgery

43. INTERNAL CAROTID
ARTERY
Terminal branch of common carotid
artery
Origin:
It arises between C3 and C5
vertebral level where the common
carotid artery bifurcates
It passes straight up in the
carotid sheath to the carotid canal in the
base of the skull

44. Segments of ICA:
According to Bouthilliers classification (1996)
C1 - Cervical
C2 - Petrous (Horizontal)
C3 - Lacerum
C4 - Cavernous
C5 - Clinoid
C6 - Ophthalmic (supraclinoid)
C7 - Communicating (Terminal)
Segments of the internal carotid artery : A new classification
Alain Bouthillier, M.D., Harry R. Van Loveren, M.D., Jeffrey T Keller, Ph.D

45. Segments of the internal carotid artery : A new classification
Alain Bouthillier, M.D., Harry R. Van Loveren, M.D., Jeffrey T Keller, Ph.D
SEGMENT EXTENT
1.Cervical From Origin of ICA and
ends at Carotid canal of
Petrous bone
2.Petrous From carotid canal and
ends at foramen lacerum
3.Lacerum From vertical canal of
lacerum and ends at
petrolingual ligament

46. Segments of the internal carotid artery : A new classification
Alain Bouthillier, M.D., Harry R. Van Loveren, M.D., Jeffrey T Keller, Ph.D
SEGMENT EXTENT
4.Cavernous Begins at petrolingual
ligament and ends at
proximal dural ring
5.Clinoid Begins at proximal dural
ring and ends at distal
dural ring
6.Ophthalmic Begins at Distal dural
ring and ends at posterior
communicating artery
7.Communicating Begins at posterior
communicating artery

47. Branches:
1.Cervical ( no branch )
2.Petrous Caroticotympanic artery
Vidian artery
3.Lacerum (no branch)
4.Cavernous Meningohypophyseal
Inferolateral
5.Clinoid (no branch)
6.Ophthalmic Ophthalmic artery
Superior hypophyseal artery
7.Communicating
Posterior communicating
Anterior choroidal
Anterior cerebral
Middle cerebral
Segments of the internal carotid artery : A new classification
Alain Bouthillier, M.D., Harry R. Van Loveren, M.D., Jeffrey T Keller, Ph.D

48. Ophthalmic artery
Origin:
Arises from ICA medially in the
anterior clinoid process
Course:
Runs anteriorly passing through
optic canal and inferolateral to the optic
nerve

49. Branch Supply
1.Central retinal artery Retina of eye
2.Lacrimal artery Lacrimal gland, portion
of eyelid and anterior
eyeball.
Gives anterior ciliary
branch to eyeball
3.Posterior ciliary artery Pierces sclera and
supply structures inside
eye ball
4.Supra orbital artery Supply forehead and
scalp
5.Supra trochlear artery Supplies antero medial
part of forehead
(1)
(3)
(3)
(2)
(5)
(4)

50. Branch Supply
6.Post ethmoidal
artery
Nasal cavity,
Ethmoidal cells
7.Anterior
ethmoidal artery
Nasal septum,
lateral wall of nose
end as dorsal nasal
artery
8.Dorsal nasal
artery
Root of nose
9.Muscular artery Ocular muscles
10.Median
palpebral
Medial part of upper
and lower eyelids
(7)
(8) (10)
(6)
(9)

51. Applied anatomy:
Keiselbach’s plexus

52. VENOUS SUPPLY

53. Veins of Face
• Supra trochlear
• Supra orbital
• Facial
• Superficial temporal
• Pterygoid venous plexus
• Maxillary
• Retromandibular
• Posterior auricular
• Occipital

54. Supra trochlear vein
Origin:
Begins on forehead which communicates with
frontal branches of superficial temporal vein
Course:
Joins supraorbital vein at median angle of orbit
to form angular vein
Supra orbital vein
Origin
Begins on forehead above orbit which
communicates with frontal branches of
superficial temporal vein
Course:
Joins supratrochlear vein at the medial angle of
orbit to form the angular vein

55. Facial vein
Largest vein of face
Origin
Begins as angular vein at median
angle of orbit
Course:
Downwards and backwards behind
facial artery, but with a straight
course
Drainage:
Anterior division of retromandibular
vein

56. Tributaries:
• Supratrochlear vein
• Supraorbital vein
• Superior ophthalmic vein
• Vein from Ala of nose
• Masseter
• Superior Labial vein
• Inferior Labial vein
• Deep facial vein
• Tonsillar vein
• Submandibular vein

57. Applied anatomy
Dangerous area of face - Connected to cavernous sinus

58. Superficial temporal veins
Origin
From a venous plexus on the side
and vertex of the skull
Course
Descends in front of tragus, enters
parotid gland and joins maxillary
vein to form retromandibular vein
Tributaries
• Parotid veins
• Articular veins from TMJ
• Anterior auricular veins
• Transverse facial vein

59. Pterygoid venous plexus
Location: Partly between the temporalis and lateral pterygoid
Course : Corresponding with the branches of the maxillary artery

60. Tributaries:
• Sphenopalatine
• Middle meningeal
• Deep temporal
• Pterygoid
• Masseteric
• Buccinator
• Alveolar
• Palatine veins
• Infraorbital vein

61. Applied anatomy:
During PSA nerve block, chance for damaging Pterygoid
plexus and may lead to hematoma formation
Needle track communication may lead to infection to
pterygoid plexus which communicates with cavernous sinus
May also spread infection to eye

62. Maxillary vein :
The maxillary veins consist of a short
trunk which accompanies the first part
of the maxillary artery.
Origin:
Formed by a confluence of the veins
of the pterygoid plexus
Course:
Passes backward between the
sphenomandibular ligament and the
neck of the mandible and unites with
the superficial temporal vein to form
the retromandibular vein.

63. Retromandibular vein
Origin:
Formed by the union of the superficial
temporal and maxillary vein
Course:
Descends in the substance of the parotid
gland, superficial to the external carotid
artery but beneath the facial nerve,
between the ramus of the mandible and the
sternocleidomastoid muscle.

64. Branches:

66. Applied anatomy:
In normal anatomy, risk of damage to retromandibular vein is less during
parotid surgery
In cases of abnormal anatomic variation where retromandibular vein
passes lateral to the facial nerve and its branches, risk of injury to the vein is
higher
In surgeries, facial nerve can be identified with superficial temporal vein
and retromandibular vein as guide

67. Occipital Vein:
Origin:
As a plexus at the posterior aspect of
the scalp from the external occipital
protuberance and superior nuchal line
to the back part of the vertex of the
skull
Course:
It joins the posterior auricular vein and
through it opens into the external
jugular.
Occasionally, it follows the occipital
artery and ends in internal jugular vein

68. Posterior auricular vein :
Origin:
Upon the side of the head, in a
plexus which communicates with
the tributaries of the occipital vein
and superficial temporal veins.
Course:
It descends behind the auricle, and
joins the retromandibular vein to
form the external jugular.

69. Veins of neck:
• External jugular vein
• Posterior external jugular vein
• Anterior jugular vein
• Internal jugular vein
• Lingual vein
• Superior thyroid vein
• Inferior thyroid vein
• Middle thyroid vein
• Vertebral vein
• Deep cervical vein

70. Posterior external jugular
vein :
Origin:
In the occipital region and returns
the blood from the skin and
superficial muscles in the upper and
back part of the neck, lying between
the Splenius and Trapezius.
Course:
Runs down the back part of the
neck, and opens into the external
jugular vein just below the middle of
its course.

71. External jugular vein :
Receives the greater part of the blood
from the exterior of the cranium and
the deep parts of the face.
Origin:
Near the mandibular angle, just below
or within the substance of the parotid
gland
Formed by the junction of the
posterior division of the
retromandibular vein with the
posterior auricular vein

72. Course: It runs inferiorly in the
anterolateral neck, deep to platysma but
superficial to sternocleidomastoid, before
piercing the deep cervical fascia
posterior to the clavicular head of the
sternocleidomastoid.
Tributaries:
•Anterior jugular vein
•Posterior external jugular vein
•Suprascapular vein
•Transverse cervical vein
Drainage: Directly into the subclavian
vein.

73. Clinical significance:
• EJV has relatively superficial course on neck, thus
air may enter into vein when it get severed
• Thus it may cause air embolism and may stop the
blood flow to right atrium. This should be managed by
stopping the bleeding and entry of air
• Most commonly used venous pedicle in facial
transplant for both as donor/ recipient site

74. Anterior jugular vein :
Origin:
Begins near the hyoid bone by the
confluence of several superficial veins
from the submaxillary region.
Course:
Just above the sternum the two
anterior jugular veins communicate by
a transverse trunk, the venous jugular
arch, which receive tributaries from
the inferior thyroid veins, each
communicates with the internal
jugular.
There are no valves in this vein.

75. Lingual vein :
Origin:
Begin on the dorsum, sides, and under surface of the tongue
Course:
Passing backward along the course of the lingual artery ends in the internal
jugular vein.
Tributaries
• Sublingual vein
• Deep lingual vein
• Dorsal lingual vein
• Suprahyoid vein
Drainage:
Internal Jugular vein

76. Applied Anatomy:
They are capable of rapid absorption of drugs
For this reason, Sublingual route of administration such as nitroglycerin is
given under the tongue to patients suspected of having angina pectoris.
Deep lingual veins may get injured during frenectomy, which may lead to
hematoma formation

77. Superior thyroid vein
Origin:
Begins in the substance and on the
surface of upper part of thyroid
gland
Course:
Tributaries corresponding with the
branches of the superior thyroid
artery
Drainage:
Upper part of the internal jugular
vein

78. Middle thyroid vein:
Origin:
Lower part of the thyroid gland and
joined by some veins from the larynx
and trachea
Drainage: Lower part of the internal
jugular vein.
Inferior thyroid vein:
Frequently three or four in number
Origin:
Arise in the venous plexus on the
thyroid gland
Communicating with the middle and
superior thyroid veins.

79. Internal jugular vein :
Collect the blood from the brain, the superficial parts of
the face and the neck.
Origin:
Originates within the posterior part of
the jugular foramen
Inferior petrosal sinus and the sigmoid sinus join to
form the internal jugular vein.
Course:
The right internal jugular vein is at a little distance from
the common carotid artery, and crosses the first part of
the subclavian artery, while the left internal jugular vein
usually overlaps the common carotid artery.
Left vein is generally smaller than the right

80. Tributaries:
Pharyngeal veins
Common facial veins
Lingual veins
Occipital veins
(occasionally)
Superior thyroid veins
Middle thyroid veins
Drainage:
Subclavian vein

81. Clinical significance:
Acts as a guide for surgeons to remove neck nodes
The jugular veins are relatively superficial and not protected by tissues
such as bone or cartilage. This makes them susceptible to damage.
It should also be noted that cuts or abrasions in the skin near the jugular
vein will bleed longer and more profusely
It takes on an average of about 30 minutes to fully stop a shaving abrasion
on the face.

82. JVP
• As there is one pair of valves between the right atrium of the heart and the internal
jugular, blood can flow back into the internal jugular when the pressure in the atrium is
sufficiently high.
• This can be seen from the outside, and allows one to estimate the pressure in the atrium.
The pulsation seen is called the jugular venous pressure
• This is normally viewed with the patient at 45 degrees turning his/her head slightly away
from the observer

83. Deep cervical vein :
Origin: It begins in the suboccipital region
Course: Accompanies its artery between
Semispinales capitis and colli
Tributaries:
• Communicating branches from the
occipital vein
• Small veins from the deep muscles at the
back of the neck.
• From the plexuses around the spinous
processes of the cervical vertebra
Terminates in the lower part of the vertebral
vein.

84. Vertebral vein :
• Origin: Formed in the suboccipital
triangle at the level of the sixth
cervical vertebra
• Course: Runs inferiorly crossing the
lateral sides of the cervical vertebrae,
initially lying over the anterior aspect
of the vertebral artery and then
crossing over its anterolateral side
• Tributaries: Occipital vein, anterior
vertebral vein, accessory vertebral
vein, suboccipital venous plexus
• Drainage : Subclavian vein

85. THANK YOU !