Outline Scalp and Face Can tell a lot of things about a patient by observing their faceDr. Bennett-Clarke Scalp (Does not have clear margins) - The scalp consists of five layers. The word scalp can help you remember these five layers. Usually considered the superior part of the forehead

S- Skin most exterior layerUsually covered with hair and has sweat & sebaceous glands

C- Connective tissue Dense Irregular connective tissueWhere majority of blood vessels & nerves resideHolds of the blood vessels open = causes profuse bleedingNot where scalp infection occur

A- Aponeurosis – Galea (Helmet-like) AponeuroticaBetween frontal and occipital belly of fronto-occipitalis

L- Loose areolar tissue Danger area Spread of infection can occur hereP- Pericranium Periosteum of the skull bones

S,C, & A = tightly adhered to each otherAllows for scalping to happen Clinically it can suture back together and heal wellWounds of the scalp almost always require stitches

1. Innervation to the scalp Cranial nerves

1. Supratrochlear nerve (CN V1)2. Supraorbital nerve (CN V1) = supplies scalp at vertex & slightly beyond 3. Zygomaticotemporal Nerve (CN V2)4. Auriculotemporal Nerve (CN V3)

Ventral primary ramus 1. Lesser Occipital Nerve (C2) – from cervical plexus

Dorsal primary ramus 1. Greater Occipital Nerve (C2)2. Third Occipital Nerve (C3)

2. Blood supply to the scalp Internal carotid

1. Supratrochlear & Supraorbital Artery From ophthalmic arteryExternal carotid

1. Posterior Auricular Artery2. Superficial Temporal Artery3. Occipital Artery

Venous Drainage = follows named arteries but drains in to External & Internal JugularsEmissary Veins = run from scalp, through bone, & into dural sinuses (Not Primary Pathway)

Conduit from scalp to meninges and vice versa = can aid spread of infection

Face- The skin of the face contains numerous sweat and sebaceous glands. It is connect to the underlying bones by loose connective tissue. There is no deep fascia present in the face. 1. Bones of the face- These are the bones seen on the anterior view of the skull. A. Nasal Bones (2)B. Maxilla (2)C. Mandible (1)D. Zygomatic Bones (2)E. Lacrimal Bones (2 of them in orbit)F. Vomer (1 & part of nasal septum)G. Palatine (2)H. inferior Nasal Conchae (2)I. Ethmoid (1 & in nasal cavity & part of nasal septum)

** Make sure you review the bones of the face.

Skin of the faceVery vascular = heals wellVery flexible/pliable – Diminishes with ageTightly fixed at chin & bridge of nose – everywhere else it can sag/droopNo deep fascia on the face = nothing to limit/contain injury/infection to compartmentsNo fascia connected to underlying bonesHighly innervated

1. Sensory innervation of the skin of the face-The three braches of the trigeminal nerve provide the majority of the sensory innervation to the skin of the face.

1. Ophthalmic nerve 1. Supraorbital Nerve = uses Supraorbital foramen2. Supratrochlear Nerve3. Lacrimal nerve4. Infratrochlear Nerve5. External Nasal nerve

2. Maxillary nerve 1. Infraorbital Nerve = uses Infraorbital foramen2. Zygomaticofacial nerve3. Zygomaticotemporal Nerve

3. Mandibular nerve1. Mental nerve = uses Mental foramen2. Buccal nerve3. Auriculotemporal Nerve

2. Blood supply to the face- The main artery to the face is the facial artery, a branch of the external carotid artery. There are other smaller arteries which also help to provide blood to the face.

1. Facial artery A. Submandibular ArteryB. Inferior Labial ArteryC. Superior Labial ArteryD. Angular Artery (Medial corner of eye)

2. Superficial temporal artery 3. Transverse facial artery (Runs with Parotid Duct)4. Supraorbital5. Supratrochlear arteries6. Angular Vein 7. Facial Vein (Not torturous like the artery & Gets its tributaries)

1. At medial corner of eye it is continuous with Inferior Ophthalmic VeinContinuous with Cavernous Sinus (Dural Sinus)

2. Drains into Deep Facial vein to Pterygoid Plexus Continuous with Cavernous Sinus

***No valves in this area & is an abnormal pathway for venous drainage

Muscles of the face- The Muscles of facial expression are embedded in the superficial fascia of the face insert on the skin. They are all innervated by the facial nerve (CN VII). Refer to the attached diagram for the specific location of several of these muscles.***Origin & Insertion = not important BUT Actions = IMPORTANTMost Origen = Subcutaneous fascia & Some = Facial BonesAttached to skin of face (Act as Dilators of SphinctersAll innervated by CN VIIAll developed from pharyngeal arch II

1. Frontal belly of Fronto-occipital muscle3. Orbicularis Oculi close eye tightly10. Orbicularis Oris Close Lips – Fish Lips13. Depressor Anguli Oris Depresses corner of mouth14. Depressor Labii InferiorisDepress Lower lip = shower lower teeth7. Zygomaticus major Draw up corners of mouth = smile11. Levator Labii Superioris Elevate upper lip = show upper teeth12. Levator Anguli Oris Help draw up corner of mouth = show upper teeth & smile9. Levator Labii Superioris Alaque Nasi Works with upper lip to flair the nostrals

PlatysmaTighten skin of neckSome depression of jawInnervation = cervical branch of facial nerve

Fronto-occiptal MuscleFrontal & Occipital BelliesRaise Eyebrows = Frontal bellies

Facial nerve (CN VII)- This nerve supplies all of the muscles of facial expression but does not supply the skin overlying them. The facial nerve exits the skull via the stylomastoid foramen to supply the muscles of facial expression.Innervation for Muscles of Facial Expression (Skeletal Muscles) = CN VII = Facial NerveMultipolar motor neurons = originate in brainstem

It courses through the substance of the parotid gland to be distributed in 5 main branches on the face.

Temporal branch TwoZygomatic Branch ZebrasBuccal Branch BitMarginal Branch MyCervical branch Cookie

Any trauma, inflammation, damage of the facial nerve results in loss of function to the muscles of facial expression (Bell’s palsy). Loss of facial competence, drooling, etcPatient CANNOT close eye (get dry eyes and can get corneal ulceration from chronic dryness)Usually not permanentUsually from inflammation of the nerve (more frequently from middle ear infection)Frequent with Lyme’s disease 7 higher incidences with pregnancyMost likely treatment = steroids

The Parotid Gland/ Parotid Bed - These are the largest salivary glands in the body. The parotid duct passes over the surface of the masseter muscle, pierces the buccinator muscle and opens on the mouth adjacent to the second upper molar. Structures which traverse or lie deep to the parotid gland include: 1. Facial nerve (CN VII) & Branches2. Superficial temporal artery 3. Retromandibular vein 4. Auriculotemporal nerve

***Anything that can impart/injure the parotid can impact these structures