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THE FACE AND THE SCALP - The face extends from the hair margin to the chin, and from one auricle to the other. - The scalp covers the vault of the skull and extends between the left and right temporal lines laterally, the eyebrows anteriorly and the superior nuchal li...

THE FACE AND THE SCALP - The face extends from the hair margin to the chin, and from one auricle to the other. - The scalp covers the vault of the skull and extends between the left and right temporal lines laterally, the eyebrows anteriorly and the superior nuchal lines posteriorly, thus the forehead (which extends between the eyebrows and the hair margin) is common to the face and the scalp. - The facial region is subdivided into: 1- The forehead. 2- The temporal area (anterior to the ears). 3- The area of the eyes and eyelids. 4- The external nose. 5- The zygomatic area (the prominence of the cheek). 6- The mouth and lips. 7- The cheeks. 8- The chin. 9- The external ear.  Sensory nerves of the face - The facial cutaneous nerve supply is principally derived from the trigeminal nerve (cranial nerve no. 5). Within the skull, the trigeminal nerve is divided into 3 parts: 1) Ophthalmic N.: sensory nerve associated mainly with the orbit and its contents. 2) Maxillary N.: sensory nerve associated with the Nasomaxillary complex. 3) Mandibular N.: sensory and motor nerve associated with the lower jaw and the muscles of mastication. - Each division of trigeminal N. contributes sensory cutaneous branches of the face.    The ophthalmic nerve 1- It contributes several branches to the upper eyelid, the forehead scalp and the external nose. The supraorbital N.: Emerges from the roof of the orbit through the supraorbital foramen or notch, it supplies a portion of the frontal sinus, a large portion of the upper eyelid, and a large portion of the forehead and the scalp. 2- Supratrochlear N.: in the orbit, it passes over the pully or trochlea of the superior oblique M., it emerges from the medial aspect of the superior orbital margin to supply the medial portion of upper eyelid and adjacent forehead. 3- The infratrochlear N.: Passes under the trochlea in the orbit and emerges near the medial angle of the eye. It supplies the medial angel of the upper eyelid and the lacrimal sac. 4- Palpebral N.: It is a branch of the lacrimal N., which supplies the lacrimal gland. It is a small branch that emerges from the lateral aspect of the superior margin of the orbit to supply a small lateral portion of the upper eyelid. 5- The external nasal N.: it appears in the midline at the junction of the nasal bone and the nasal cartilage. It supplies the medial part of the external nose below the nasal bones.  The maxillary nerve 1- The infraorbital N.: It is the large terminal branch of the maxillary N.; it passes through a bony canal in the orbital floor to emerge into the face through the infraorbital foramen. On the face, it divides into three branches: a) Inferior palpebral branches: which convey sensation from the skin and conjunctiva of the lower lid. b) Lateral nasal branches: which convey sensation from the lateral aspect of the external nose.  c) Superior labial branches: which convey sensation from the skin and mucous membrane of the upper lip. 2- The zygomaticofacial N.: It is a small branch which emerges into the face through a bony opening of the same name, it supplies the skin of the zygomatic prominence. 3- The zygomaticotemporal N.: It passes through the zygomaticotemporal foramen & ascends to supply the skin of the anterior aspect of the temporal fossa & the scalp.  The mandibular nerve 1- Auriculotemporal N.: it passes between the temporomandibular joint and the tragus of the ear, it supplies the upper lateral portion of the external ear, the ear canal, the temporal region, and the lateral aspect of the scalp. 2- Buccal N.: It appears on the face under the cover of the ramus of the mandible. It spreads over the cheek and conveys sensation from the skin and mucous membrane of the cheek and the buccal gingiva. 3- Mental N.: it's the termination of the inferior alveolar N. that leaves the mandibular canal through the mental foramen and exits into the face lateral to the skin. It breaks up into three sets of branches: a) Mental branch  to the skin of chin. b) Inferior labial branch  to the skin and mucous membrane of the lower lip. c) Gingival branch  to the labial gingiva of the mandibular teeth.  Muscles of the face - The muscles of the face or muscles of the facial expressions are found within the superficial fascia around the facial orifices, the muscles of the scalp and the platysma muscle of the neck belong to the same muscle group. They perform two functions: 1- As dilators and sphincters, they control the openings of the orifices. 2- As movers of overlying skin, they reflect the various facial expressions. - Most of the facial muscles originate from the bones or from the fascia, and all insert into the skin of the face. - During the contraction of these muscles, they move the facial skin into various attitudes that reflect emotions.  There are many muscles, but the main are: a) Orbicularis oris muscle: - It is the sphincter of the oral aperture and lies within the upper and lower lips, encircling the mouth. Its fibers originate mainly from the contribution of other facial muscles that converge on the mouth. It closes the oral aperture, presses the lips against teeth and protrudes the lips. b) Buccinator muscle: It arises from three areas: 1- The pterygomandibular raphe: which is a thin fibrous band running from the  hamulus of the medial pterygoid plate down to the mandible just behind the last mandibular molar tooth. - The Buccinator muscle and the superior constrictor muscle of the pharynx are attached to this raphe. The Buccinator is directed to the wall of cheek from the anterior part of the raphe, while the superior constrictor muscle is directed to the wall of the pharynx from the posterior part of the raphe. 2- The maxillary alveolar process: the superior fibers of the buccinator muscle originate from the maxillary alveolar process in the molar region. 3- The mandibular alveolar process: the inferior fibers of the buccinator muscle originate from the mandibular alveolar process along the posterior half of the oblique line. The insertion: The muscle fibers sweep anteriorly through the cheek as a flattened sheet. On approaching the angle of the mouth, the upper fibers sweep inferiorly and the lower fibers sweep superiorly to blend with the orbicularis oris muscle. The function: it helps in mastication by pressing the cheek against the vestibular surface of the molar teeth. Sucking by decrease intraoral pressure, expelling air from oral cavity as in playing wind. c) Orbicularis oculi muscle: It is a sphincter muscle, which acts to the close the lids, and it originates as three components: 1- The orbital portion: Originates from the bone of the upper medial orbital margin, encircles the orbital margin, and inserts from below into the prominent medial palpebral ligament (the ligament anchored to the lacrimal crest of the maxilla). 2- The palpebral portion: Arises from the medial palpebral ligament and arches laterally within the upper and lower eyelids to form continuous layer with the orbital part. 3- The lacrimal portion: It is a small portion, originates from the lacrimal bone & the lacrimal fossa. Action: - The palpebral part  closes the eye lightly as in sleeping or blinking. - The orbital part  squeezes the lids to give more protection from bright light or the sun. - The lacrimal part  draws the eyelids medially to promote the flow of fluid (tears). Motor nerves of the face - The muscles of the face are supplied by the facial nerve (7 th cranial nerve). - The facial nerve exits from the skull through the stylomastoid foramen at the base of the skull. Enters the internal auditory (acoustic) meatus within the skull, it passes through the facial canal to the petrous temporal bone, then passes inferiorly and anteriorly for several millimeters, enters the substance of the parotid gland and here it breaks up into five main groups of branches, which radiate from the anterior margin of the gland and travel to various areas of the face. 1- Temporal branches: travel superiorly and anteriorly to supply facial muscles situated above the zygomatic arch, including the orbit and  forehead. 2- Zygomatic branches: travel Transversely across the face to supply facial muscles in the zygomatic, orbital, and infraorbital areas. 3- Buccal branches: supply the muscles of cheek. 4- Marginal mandibular branches: supply muscles of the chin and lower lip. 5- Cervical branches: descend to the neck to supply the platysma muscle. Bell’s palsy or facial palsy: 1- The patient cannot blink. 2- The patient cannot whistle. 3- Accumulation of food in the vestibule. 4- saliva and food (drooling) tend to escape from the corner of the mouth. 5- Slurred speech. 6- The corner of the mouth sag (drooping) on the affected side. 7- loss of facial expression on affected side. Nasolabial fold.  Sensory nerve communications: The motor branches of the facial N. communicate with the cutaneous branches of the trigeminal N. on the face and those communications represent sensory proprioceptive contributions, which distribute with the facial N. branches to the various facial muscles.  ARTERIES OF THE FACE - The face is richly supplied with blood from various arteries, and the terminal branches anastomose freely. - The entire blood supply is derived from either the internal or external carotid arteries. A) Facial branches of the ophthalmic artery: - Arise directly or indirectly from the ophthalmic artery of the orbit: 1. Supraorbital artery: It leaves the orbit (with the supraorbital N.) through the supraorbital notch or foramen, to supply the upper eyelid, forehead and scalp. 2. Supratrochlear artery: It emerges medial to the supraorbital artery and supplies the upper lid, forehead and scalp. 3. Dorsal nasal artery: This is the companion artery to the infratrochlear nerve. It emerges from the medial angle of the orbit to supply the medial upper lid, the lacrimal sac, and the upper part of the nose. 4. Lacrimal artery: This is the small terminal portion of the ophthalmic artery, which emerges at the lateral aspect of the supraorbital margin to supply the lateral aspect of the upper lid. 5. External nasal artery: It is the terminal branches of the anterior ethmoidal artery, which arises from the ophthalmic artery, it passes at the junction of the nasal bone and the lateral nasal cartilage. 6. Zygomatic artery: It is a branch from the lacrimal artery, passes through the zygomatic canal in the lateral wall of the orbit and divides into two terminal branches, which emerge on the face: a. The zygomaticofacial artery: emerges through the zygomaticofacial foramen to supply the skin of the prominence of cheek. b. The zygomaticotemporal artery: emerges through the zygomaticotemporal foramen to supply the skin of the anterior temporal region. B) Facial branches of the maxillary artery: 1. Infraorbital artery: It passes through the infraorbital foramen below the orbit and immediately breaks up into: a. Inferior palpebral branches to the lower eyelid. b. Nasal branches to the lacrimal aspect of the nose. c. Superior labial branches to the upper lip. 2. Buccal artery: It appears from under the cover of the ramus and masseter muscle. It is divided in the cheek, supplying the skin and mucous membrane of the cheek and vestibular gingiva of mandibular molar area. 3. The mental artery: The mental artery branches from the inferior alveolar artery within the mandibular canal of the mandible. It exits through the mental foremen along with the mental nerve to supply the chin, lower lip and the vestibular gingiva of the mandibular anterior teeth. C) The branches of the facial artery: - The facial artery is a branch from the external carotid artery, it leaves the submandibular region of the neck and ascends on the inferior border of the mandible. - As it ascends obliquely on the face, it follows a tortuous route toward the medial angle of the eye. - It passes between the more superficial and deep muscles of the facial expressions. It supplies several branches to the face that anastomose freely with the terminal branches of the maxillary and ophthalmic arteries. 1. Labial branches: As the facial A. travels tortuously toward the medial angle of the mouth, it gives of the: a. Inferior labial artery to the lower lip. b. Superior labial artery to the upper lip. 2. Nasal branches: They are given to the side of the nose and they anastomose with the nasal branches of infraorbital artery and the external nasal artery. 3. Angular artery: The facial artery ends in the medial angle of the eye as the angular artery. It provides branches to the nose and medial aspect of the lids. D) Facial branches of the superficial temporal artery: - The Superficial Temporal Artery is a terminal branch of the external carotid artery. - It emerges into the face between the jaw joint and the ear to ascend on the scalp. Just below the ear, it sends a branch forward as Transverse facial artery immediately below the zygomatic arch.  VEINS OF THE FACE - The veins of the face follow somewhat the same pattern of distribution as the arterial supply, veins in several show more variability in their distribution than the arteries. - For each of the named arteries described previously as facial branches of the ophthalmic artery or maxillary, there are corresponding veins of the same name that flow in the opposite direction. - The veins of the forehead, scalp, and upper lid flow to the superior ophthalmic vein in the orbit, the vein of the upper lip, lateral nose and lower lid flow through the infraorbital vein to the pterygoid plexus of veins in the infraorbital region.  The facial vein: - The facial vein is nearly parallel to the course of the facial artery. It is however more posterior, takes a straighter and less tortuous course, and travels in the opposite direction. The facial vein originates and gathers tributaries in the following manner: 1. The angular vein: Forms at the medial angle of the eye by the union of the supraorbital and the supratrochlear veins. The angular vein divides, one division passes into the orbit to drain to the superior ophthalmic vein, and the other division remains superficial and passes inferior as facial vein. 2. Facial vein: passes posteriorly toward the angle of the jaw, and as it descends, it takes several tributaries. 3. Nasal vein: drains the side of the nose and communicates with tributaries of the infraorbital vein. 4. Deep facial vein: communicates with the pterygoid plexus of veins deep within the infratemporal region. 5. Labial vein: drains the upper and lower lips. The superior labial vein communicates with the infraorbital vein, the inferior labial vein communicates with the mental vein. - Then the facial vein descends over the inferior border of the mandible to enter  the submandibular region of the neck. Unlike the facial artery, the vain takes a superficial course through the submandibular region.  The retromandibular vein: It is formed by two sources: 1. Superficial temporal vein: which drains the scalp and the side of the head. It descends anterior to the ear into the substance of the parotid gland, here it unites with the maxillary vein. 2. Maxillary vein: it is formed from the pterygoid plexus of veins. The plexus organizes posteriorly as maxillary vein. The maxillary vein travels posteriorly deep into the neck of the condyle, and joins the superficial temporal vein within the parotid gland to form the retromandibular vein. - Retromandibular vein: continues inferiorly and leaves the gland at its inferior bound. - At the angle of the mandible, it divides into anterior and posterior divisions in the neck. a. The posterior division of the retromandibular vein units with the posterior auricular vein behind the ear to form the external jugular vein. b. The anterior division of the retromandibular vein joins the facial vein in the neck to form the common facial vein. - The common facial vein drains deep to the internal jugular vein.  THE SCALP - The scalp extends from the supraorbital margins back to the superior nuchal line posteriorly. - Laterally, the scalp extends down into the temporal fossae.  Layers of the scalp: 1- Skin: a layer of thin skin containing numerous hair follicles, sweat glands and sebaceous glands, it covers the scalp. 2- Connective tissue: a thick dense subcutaneous connective tissue is anchored firmly to the skin above and the membranous layer below. 3- Aponeurosis: The membranous aponeurosis (galea aponeurotica) is an intermediate tendon for the two fleshy bellies of the occipitofrontalis (Epicranius) muscle. - The occipital. portion originates just above the superior nuchal line and inserts into the aponeurosis. It pulls the scalp backwards. - The frontalis portion originates from the aponeurosis and inserts into skin above the eyebrows. It pulls the scalp forwards and produces transverse wrinkling of the brow. 4- Loose connective tissue: It is formed by loose c. t., which allows freedom of movement of the superficial three layers over the top of the skull. 5- Periosteum: It is firmly anchored to the underlying bone. 6-  Blood supply - The blood supply to the scalp arises from various sources but mainly from branches of the ophthalmic and external carotid arteries. The arteries are: 1) Supra trochlear A. 2) Supraorbital A. 3) Zygomaticotemporal A. 4) Superficial temporal A. 5) Posterior auricular A. 6) Occipital A.  Sensory nerve supply The cutaneous nerve supply arises from three divisions of the trigeminal nerve anterior to the ear and spinal cutaneous nerves from the neck posterior to the ear. - The nerves anterior to the ear are: 1- Supratrochlear N. 2- Supraorbital N. 3- Zygomaticotemporal N. 4- Auriculotemporal N. - The nerves posterior to the ear are: 1- Lesser occipital N. (C2+C3) 2- Greater occipital N. (C2) 3- Third occipital N. (C3)  The motor nerve supply The facial Nerve supplies the occipitofrontalis muscle: 1- Temporal branches: which supply the facial muscles above, the zygomatic arch including the frontal belly. 2- Posterior auricular nerve: Leaves the facial nerve as it emerges from the stylomastoid foramen and runs above the superior nuchal line to supply the occipital belly of the occipitofrontalis muscle. Boundaries FACE Temporal region face auricle Sensory Nerve supply of the face Zygomaticofacial  Muscles of the face (muscles of facial expression) They found within the superficial fascia Most of muscles originate from bones or fascia and all inserted into the skin of the face. 1- as a dilator and sphincters by control the opining of the orifices. 2- when they contract: reflected the various facial expressions Orbicularis Oculi Lacrimal part Lacrimal part  Orbital part Palpebral part Lacrimal part Buccinator muscle  Max.Alv.Pro. Pty.Man.raphe Mand.Alv.Pro. Pterygomandibular raphe Pt.M.R. OrbicularisOris Motor nerve supply of the muscles of the face 1- Temporal 2- zygomatic 1 3- Buccal 2 3 4- Marginal mandibular 3 5- Cervical 5 4 Bell s palsy or facial palsy 1- The patient can not blinking 2- The patient can not whistle 3- Accumulation of food in the vestibule. 4- saliva and food (drooling) tend to escape from the corner of the mouth. 5- Slurred speech. 6- The corner of the mouth sag(drooping) on the affected side 7- lose of facial expression on affected side. Nasolabial fold Blood Supply of the Face Dorsal nasal Buccal artery Buccal artery Facial artery Veins of the face Danger triangle of the face  The danger triangle of the face consists of the area from the corners of the mouth to the bridge of the nose, including the nose and maxilla it is possible, infection from the nasal area to spread to the brain, causing cavernous sinus thrombosis, meningitis or brain abscess. Retromandibular vein Scalp Blood supply of scalp Blood supply of scalp Motor supply