Directional Terms and Body Planes

Introduction
Anatomical directional terms and body planes is a universally accepted language of anatomy,
allowing precise communication between anatomists and health professionals. The terms used to
describe anatomical positioning are described in relation to one standard position called the
anatomical position. This position is used to describe body parts and positions of patients
regardless if they are lying down, on their side or facing down. In the anatomical position, the
person is standing upright with arms to the side with the palms facing forward and thumbs
pointing away from the body, feet slightly apart and parallel to each other with the toes pointing
forward and the head facing forward and the eyes looking straight ahead.
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Locating structures in your body is one of the main components of anatomy. Learn all terms used
to describe location in the Human body.

Directional Terms
Directional terms allow description of one body part in relation to another.

Anterior and Posterior

Anterior indicates that the body part in question is in front of or front. Posterior indicates
that it is in behind of or behind.

Ventral and Dorsal

Ventral denotes towards the front of the body and dorsal means towards the back of the body.

Right and Left

Right indicates to the right side of and left indicates to the left side of.

Distal and Proximal

Distal indicates that it is away or farthest away from the trunk of the body or the point of
origin of the body part. Proximal means that it is closest or towards the trunk of the body or
point of origin.

Median

Median or midline is an imaginary line down the middle of the body that splits the body into
equal left and right parts.

Medial and Lateral

Medial is towards the median whereas lateral is away from the median and towards the side of
the body.

Superior and Inferior

Superior is upwards or towards the vertex/top of the head whereas inferior indicates the
opposite: below or towards the feet.

External and Internal

Sometimes known as superficial, external denotes towards the surface. Internal is also known
as deep and denotes that it is away from the body surface.

Frontal and Occipital

Frontal refers towards the front of the brain whereas occipital means towards the back of the
brain.

Body Planes
Body planes are imaginary planes or flat surfaces that cut through and section the body in its
anatomical position.

Coronal
The coronal plane is a vertical plane that divides the body into anterior (front) and posterior
(back) parts.

Sagittal
The sagittal plane is also a vertical plane that splits the body into left and right parts. A sagittal
plane that runs directly through the midline is also called the midsagittal plane or median plane.

Transverse
The transverse plane is a horizontal plane. It divides the body into superior (upper) and inferior
(lower) portions. In anatomy, they are also referred to as a cross section.

Regions of the Upper Limb

Introduction

The upper limb is essential for our daily functioning. It enables us to grip, write, lift and throw
among many other movements. The upper limb has been shaped by evolution, into a highly
mobile part of the human body. This contrasts with the lower limb, which has developed for
stability. In this article we will discuss the regions of the upper limb, as well as the individual
components and essential functions. This will be joint by joint, with other structures mentioned
throughout.
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Anatomy and definition of the acromioclavicular joint.
Regions
Scapular region

The scapula bone is otherwise known as the shoulder blade. Although the scapula is located on
the posterior side of the body, it is not a part of the human back. It is classified as a part of the
upper limb as it is so important for its functioning.
The scapula has a spine, as well as two fossae that lie above and below it. These form the origin
of the supraspinatus and infraspinatus respectively. Supraspinatus is a rotator cuff muscle that
increases the stability of the humeral head, as well as an abductor of the shoulder. The
infraspinatus is a lateral rotator of the shoulder.
The scapular muscles allow us to elevate our arm beyond 90 degrees of abduction. The wing-nut
like movement of the scapula allows us to elevate our upper limb above our heads. The rotation
of the scapula occurs through precise and coordinated contraction of several muscles including
the rhomboids (which are attached to its medial border) in addition to trapezius and levator
scapulae among others (both of which are attached to the superior border). The lateral border of
the scapula also gives rise to teres major and minor. These muscles are adductors of the
humerus. This region has a rich blood supply via the anastomosis of several arteries including the
transverse cervical, dorsal scapular and subscapular. The nerve supply is from the
suprascapular nerve as well as the upper and lower subscapular nerves.
The Scapulothoracic joint

This is a physiological joint, as the scapula has no bony attachments posteriorly, and is held in
place purely by muscles. These include the rhomboids and trapezius among others. The rotation
and elevation of the scapula is essential for the abduction of the upper limb.

Shoulder region

The shoulder region must be seen as a complex of several joints, rather than an individual joint.
Classically the glenohumeral joint is what anatomists mean when referring to the shoulder joint.
Glenohumeral joint

This is clearly a joint designed for mobility rather than stability. The glenoid fossa is a shallow
dish like surface, deepened by the labrum that is attached at its periphery. The labrum is said to
provide a suction effect to the head of the humerus as well as deepening the joint socket and
therefore increasing stability. The joint is supplied by the medial and lateral circumflex arteries,
which branch from the brachial arteries.
Acromioclavicular joint

This joint is formed between the thin surface of the clavicle laterally and the acromion process of
the scapula. It is a gliding synovial joint, which ensures functional continuity between the
scapula region and the thoracic wall.
Learning point

The rounded side of the clavicle is it medial surface, and its thin side is the lateral surface. The
underside is marked laterally by the conoid tubercle and trapezoid line which give rise to their
respective ligaments.
Sternoclavicular joint

The manubrium is the superior part of the sternum and is attached to the clavicle laterally. It is a
highly mobile synovial joint that allows for both anterior posterior and medial lateral movement.
This enables the upper limb to reach a large area.
All these joints are best seen as a continuous functional unit rather than a series of isolated joints.
They influence each other and work in coordination to mobilize the upper limb effectively.
Arm (brachium)

In a colloquial sense, the term arm refers to the whole upper limb. In an anatomical sense, it
refers to the upper arm only i.e. above the elbow. The brachial artery, a direct continuation of
the axillary, supplies the region. It becomes the brachial at the lower border of teres major.
The elbow joint refers to articulation of the humerus and the two forearm bones. The ulna
articulates with the medial condyle of the humerus known as the trochlear. The ulna has the
pronounced olecranon process on its posterior surface, which fits into the olecranon fossa of the
humerus posteriorly to limit extension. The triceps is the three-headed muscle that extends the
elbow.

The head of the radius articulates with the capitulum of the humerus. The neck of the radius also
forms part of the proximal radioulnar joint, which is where supination and pronation of the
hand occurs. The radius acts as a wheel, and the annular ligament that encircles the radial neck
and attaches it to the ulna holds it in place when both movements occur. There are named
muscles that perform these movements i.e. pronator teres, supinator and pronator quadratus.
Anconeus is a small muscle at the back of the elbow that abducts the ulna in pronation.
Forearm

The forearm is the region between the elbow and wrist joint. It comprises two bones, the radius
and the ulna. The brachial artery divides into the radial and ulnar, which run down the forearm
on their respective sides. The ulnar artery also gives rise to the anterior and posterior
interosseus arteries that supply the deep muscles of the flexor and extensor compartment. The
nerve supply is from the ulnar and median nerves (mainly median).
The proximal part of the radius is the head, and the distal part is the base, and vice versa for the
ulna. A tough interosseus membrane connects the two bones and distributes the load. The fibers
of this membrane are very tough as well as flexible, and are orientated in an obliquely downward
direction. There is also a fibrous structure called the oblique cord, which is thought by some to
be vestigial, but does offer some structural advantage in connecting the bones.
Wrist

The wrist joint can be divided into three main parts. There is the radiocarpal joint, the ulnocarpal
joint, and the midcarpal joints. The joints derive their arterial supply from the dorsal and palmar
carpal arches. The radius articulates with the scaphoid laterally and the lunate medially. The
ulna articulates with a triangular pad of fibrocartilage, which is interposed between it and the
triquetrum bone. When extended the wrist joint creates torque for the long flexors to perform
their movements with higher strength. The mid carpal joint is between the proximal and distal
row of carpals. It is active in early flexion and extension as well as radial and ulnar deviation. In
late flexion and extension, the scaphoid bridges the proximal and distal carpal rows, which
consequently move in unison.
Hand

The hand is an exquisite example of engineering. The complexity of its movements as well as its
functional use make it perfect for working with tools. The blood supply is derived from the
superficial and deep palmar arches from the ulnar and radial arteries respectively. The nerve
supply is from the ulnar and median nerves (mainly ulnar).
The carpometacarpal joints are simple synovial joints. But the first carpometacarpal joint is
more unique. It is a saddle joint that allows the thumb to oppose with the other fingers. It also

enables the thumb to move with a great deal of freedom. Our thumb is much longer when
compared to other primates, which signifies the move our ancestors made from the trees to the
planes of the African savannah. Climbing was no longer as useful, and throwing, hammering and
gripping generally were of more use to our species. The elongated, powerful and highly mobile
thumb reflects this.
The other joints to consider are the metacarpophalangeal (MCP) and interphalangeal (IP) joint.
The MCP joints allow for flexion, extension, abduction and adduction. The IP joints however
only allow for flexion and extension. The proximal and distal interphalangeal joints are
connected by a collateral ligament, which means that extending or flexing your DIP causes your
PIP to move in the same way.
Clinical points
Winged Scapula

The long thoracic nerve (nerve roots C5, C6, C7) innervates serratus anterior. This muscle
protracts the scapula, i.e. it moves the scapula forwards. This muscle is well developed in boxers
who need to maximize the reach of their punches and therefore extend their arms and protract
their scapulas. When the long thoracic nerve is damaged, the scapula comes away from the
thorax, causing a winged appearance.
Clavicular fracture

The clavicle has a narrowing in its middle third. This is where the bone is most commonly
fractured. The bone is close to the surface and therefore quite vulnerable. If the fractured
segment is left loose, it could shear the subclavian vein (which lies anterior to the scalenus
anterior) and result in fatal exsanguination. The subclavian artery lies behind the muscle, and
therefore is not as vulnerable.
Radial nerve palsy/Saturday night palsy

The radial nerve supplies the extensor compartment of the arm and forearm. If an individual
undergoes axillary compression e.g. while resting their arm on a chair in a drunken state, the
nerve may also be compressed. This results in wrist drop, as the wrist extensors are not
functioning. Gravity is able to extend the elbow.
Carpal tunnel syndrome

The median nerve supplies the thenar eminence and the first two (radial side) lumbricals in the
hand. It runs in the carpal tunnel beneath the flexor retinaculum. If it becomes compressed here,
the patient suffers thenar muscle wasting, as well as a burning and tingling sensation in the
radial 3 and a half fingers.

Scaphoid fracture

The fracture usually occurs from a fall on an outstretched hand. This bone gets its blood supply
from a nutrient branch of the radial artery given off in the anatomical snuffbox. The artery
enters its distal pole and feeds proximally. This means a fracture in its middle third (the
narrowest and therefore most vulnerable section) results in avascular necrosis of the proximal
segment. Symptoms include tenderness in the anatomical snuffbox.
Dupuytrens Contracture

When the palmar fascia is thickened, it causes a claw appearance of the medial two fingers and
sometimes more. It has an unknown aetiology and is associated with Peyronies disease.

Eccentric muscle contraction

Introduction

Contraction is a process of becoming smaller and tighter under the influence of force. Muscles
generally function by contracting to exert a pulling force, but they never push. Muscle actions
can conventionally be defined as the movement that takes place when the muscle contracts, but
this is, however, an operational definition that equates contraction with shortening, and
relaxation with lengthening. In the context of whole muscles and real movements, this
conventional definition does not solely apply. Movements that involve shortening of a muscle are
referred to as concentric, and examples include the contraction of biceps brachii and the
brachialis. Those in which the active muscle is lengthened are called eccentric, while a muscle
that contracts without change in muscle length is termed isometric.
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Description of eccentric contraction

Several types of muscle

contractions have been identified. They include: reflexive contraction which is generally
automatic (i.e., crossed extensor reflex); tonic contraction characterized by muscle tone (tonus)

and does not produce movement or active resistance; and phasic (active) contraction. Of phasic
contractions there are three types: isometric or static, dynamic concentric and dynamic eccentric
contractions. Isometric contractions are generated tension without a change in joint/limb position
(e.g., holding a dumbbell at 90 degrees), or more specifically without shortening sarcomere
length (e.g., as cardiac tissue develops tension prior to ejection phase). Dynamic contractions
have previously been known as isotonic, whereby the muscle generates the same tension across a
range of movement. Concentric contractions occur as a result of the muscle actively shortening
(e.g., the biceps when lifting a dumbbell), whereas eccentric contractions occur as a result of
active lengthening (e.g., the biceps when controlling the drop of a dumbbell). Eccentric
movements produce the greatest force, even in situations like the raising and lowering of the
same dumbbell, and are typically observed functionally in deceleration of movements. Dynamic
contractions are not only present in skeletal muscle but also in cardiac and smooth muscle, and
indeed in cardiac tissue isometric and isotonic contractions are intimately related to changes in
the concentric contraction.
The relationship between the load and the direction of contraction is best explained by the forcevelocity curve. The force of a contraction directly relates to the direction of the contractile
movement and the velocity at which the muscle contracts. As described by the force-velocity
relationship, the tension developed by concentric contractions reduces as the shortening velocity
(in response to reducing load) increases; whereas, tension developed by eccentric contractions
increases with increasing load and lengthening velocity. Once the load becomes too great for the
muscle to develop eccentric tension, a sudden reduction in tension occurs. The reason eccentric
contractions develop greater tension is due largely to changes in the crossbridge cycling,
whereby more myosin filaments maintain a strong-binding state. As myosin filaments remain
bound there is more time for force to develop through neuromodulatory pathways, such as
recruitment of additional motor units and increased frequency of the motor units involved. If the
force becomes too great the myosin filaments can be torn from the active binding site on the
actin filament. The force required to tear the crossbridges from their binding sites is greater than
that produced during normal crossbridge cycling, but also poses a great risk for muscle damage.
This greater force production during eccentric contractions was first observed by Adolf Fick
(1882). Despite the greater force production observed in eccentric contractions, the muscle
activation, energy consumption, and oxygen consumption are lower than during concentric
contractions at any given force.
In life, movements are comprised of concentric, isometric and eccentric contractions, both in
isolation and as stabiliser or antagonistic functions. As illustrated above with the biceps brachii
example, many movements consist of an eccentric lengthening phase following a concentric
contraction. Similarly, more complex movements such as the gait cycle contain eccentric
components when the foot experiences heel strike the knee is seen to briefly change from
extension to flexion and back, as the loading on the quadriceps muscle group forces a period of
eccentric contraction. This is exacerbated during running and furthermore during downhill

running. Thus eccentric contractions are as important as concentric contractions and help in
coordinated movements such as running, walking, and sitting down. Furthermore, eccentric
contractions are arguably as common in daily life as concentric contractions, as although
concentric contractions and eccentric contractions can occur in isolated situations, as the
aforementioned examples suggest, they also occur in relation to one another in order to slow, and
control movements.
Clinical perspective

Breakage of crossbridge binding sites during resistance training is known to produce the greatest
amount of muscle tissue damage, and it is not unheard of for eccentric contractions to tear
muscle from bone (some best examples come from the deceleration of baseball pitches whereby
the biceps tendon is torn from the radial tuberosity). However, eccentric loading - and the muscle
damage associated - commonly leads to Delayed Onset Muscle Soreness (DOMS), which is
usually experienced 1-2 days following the exercise bout and can continue for a few days.
Incorrect technique has been repeatedly demonstrated to further exacerbate the risk of
deceleration injuries, especially in repetitive throwing exercises. In baseball a pitch count limit
has been imposed in little league to limit the number of deceleration and repetitive strain injuries.
Deceleration has contributed to throwing injuries such as shoulder dislocation, elbow dislocation,
tendon tears, tendonitis/tendonosis (such as tennis elbow).

Rectus abdominis muscle

Introduction

The rectus abdominius muscle is one of four muscles of the anterior abdominal wall. It acts as
a flexor of the spine and an accessory muscle of respiration. In those with low body fat, is clearly
visible beneath the skin. In this article we will discuss the gross and functional anatomy of the
rectus abdominis muscle. We will also discuss the clinical relevance of the structure, and provide
a summary of key points at the end of the article. We will finally conclude with some review
questions to test the readers understanding of the article content.
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Origin, insertion, innervation and function of the rectus abdominis muscle.
Anatomy

The rectus abdominis muscle is paired muscle that runs vertically, either side of the linea alba,
on the anterior surface of the abdominal wall. The linea alba is a band of connective tissue that
divides the two halves of the muscle vertically. The linea semilunaris is the tendinous
intersection that separates the lateral edge of the muscle from the external oblique and internal
oblique muscles that lie on the lateral surface of the anterior abdominal wall, it usually extends
from tip of the ninth costal cartilage to pubic tubercle. The rectus abdominis muscle is attached
superiorly to the xiphoid process and costal margins of 5th, 6th and 7th ribs (principally the
fibers of the 5th rib), inferiorly it is attached by two tendons, the larger is attached to the pubic
crest, pubic tubercle to the pectineal line and small medial tendon is attached to the pubic
symphysis. There are three tendinous intersections in the rectus abdominis muscle. One of these
horizontal intersections is present at the level of umbilicus, another at the level of xiphoid
process and third mid way between them. These fibrous bands divide the muscle into segments,
resulting in a grid iron six pack shape in those with low body fat. The intersections are believed
as representation of myosepta which delineate the muscle forming myotomes.
The rectus sheath

The rectus abdominis muscle itself lies within the rectus sheath, which is formed by the
merging of the aponeurosis of transversus abdominis, external and internal oblique abdominal
muscles. External oblique is the most superficial muscle of the anterior abdominal wall. The
transversus abdominis is the deepest of the three muscles and its fibers run in a horizontal
direction. The internal oblique aponeurosis divides into two. The anterior part of the internal
oblique aponeurosis passes in front of the rectus abdominis muscle with the external oblique
aponeurosis. The posterior division of the internal oblique aponeurosis passes behind the rectus
abdominis muscle with the transversus abdominis aponeurosis. However, below the arcuate line

(which lies one third of the way from the umbilicus to the pubic crest), all three of the muscular
aponeuroses pass anterior to the rectus abdominis, and the posterior surface of the muscle is
covered only by transversalis fascia, and parietal peritoneum.
The muscle itself is a flexor of the spine, and also acts as an accessory muscle of respiration. It
compressed the abdomen, which raises the diaphragm further due to superior displacement of the
abdominal contents, which allows for more air to be released during exhalation.
The blood supply to the rectus abdominius muscle arises from a number of vessels. The inferior
epigastric artery and vein arise from the external iliac artery and vein respectively. They run
along the posterior surface of the muscle, and enter the rectus sheath at the level of the arcuate
line. The superior epigastric is another vessel that supplies the rectus abdominius muscle, and is a
branch of the internal thoracic (internal mammary) artery. The internal thoracic is a branch of the
subclavian artery near its origin. In addition small terminal branches of the lower three posterior
intercostal arteries, subcostal and deep circumflex artery also provide some contribution.
The rectus abdominius muscle is innervated by the thoracoabdominal nerves, which enter the
rectus sheath by piercing its anterior surface. They pass between the transversus abdominis and
internal oblique muscle layers, and pierce the sheath of the rectus abdominis muscle. The nerves
are simply the anterior divisions of the 7th to 11th lower intercostal nerves, that continue to
supply the abdominal wall after the intercostal spaces they supplied end medially.
Clinical Points

Myocutaneous Flap- The transverse rectus abdominius muscle flap is a free flap used for breast
reconstruction surgery. A segment of the muscle is incised and raised along with the perforating
inferior epigastric artery and anastomosed with branches of the internal mammary/internal
thoracic artery. Nowadays, the deep inferior epigastric artery perforator flap (skin, fascia and fat
only i.e. no muscle) has replaced the TRAM flap as it requires less recovery time.
Abdominal Hernias- A hernia is an abnormal protrusion of an organ beyond its usual cavity.
The anterior abdominal wall and inguinal region are common sites for hernias. A hernia can be
irreducible (cannot be returned to the abdominal cavity by pressure), obstructed (the intestine
becomes blocked, resulting in frank constipation and abdominal pain), incarcerated (stuck in its
cavity) or strangulated (loss of blood supply due to compression of the vessels).
Spigelian Hernia- This occurs when the fascia or musculature of the linea semilunaris is weak,
allowing bowel to herniate through. The linea semilunaris separated the lateral margin of the
rectus abdominius from the lateral abdominal muscles.
Umbilical Hernia- This is when the posterior surface of the umbilicus is weak or becomes
weakened, and it causes an outpouching of bowel. It occurs in children (most commonly African

Caribbean children), where it usually disappears itself. It also occurs in conditions where the
intra-abdominal pressure is raised e.g. ascites from liver disease, or pregnancy.
Paraumbilical hernia- This occurs when the fascia or musculature around the umbilicus is
weak, allowing bowel to herniate through.
Epigastric hernia- This occurs when the fascia or musculature of the epigastric region is weak,
allowing bowel to herniate through the linea alba.
Incisional hernia- This occurs when the fascia or musculature after a surgical incision is weak,
allowing bowel to herniate through.
Omphalocele/Exomphalos- This is a rare defect of the anterior abdominal wall, when the
muscular layers fail to close, resulting in the abdominal content being held outside the abdominal
cavity in a sac. It is associated with chromosomal abnormalities such as Edwards syndrome
(trisomy 18) and Patau syndrome (trisomy 13).
Gastroschisis- If the anterior abdominal wall fails to close during foetal development, the
contents of the abdominal cavity may herniate out. This is similar to Omphalocele, but it usually
does not involve the umbilical cord, and is to the right of the umbilical site. Some parts of organs
may be suspended in amniotic fluid. The disorder is less associated with other defects
than omphalocele. Surgical treatment is difficult as the abdominal cavity shrinks and the
abdominal organs swell as they develop.
Direct Inguinal hernias- It is an acquired hernia, the bowel herniates through a region known as
Hasselbachs triangle, which is bordered by the lateral margin of the rectus abdominis muscle
medially, the inferior epigastric artery and vein laterally, and the inguinal ligament inferiorly.
Hernia exits through the superficial inguinal ring.
Indirect inguinal hernias- This occurs is there is a patent processus vaginalis, or a congenital
weakened area around the region of the processus. This allows bowel to herniate through. The
bowel herniates medially to the inferior epigastric artery and vein, and hence enters the deep
inguinal ring. Over time, or acutely, this may traverse the length of the inguinal canal, and pass
through the superficial inguinal ring (at the superolateral aspect of the scrotum), and may enter
the scrotum. This is termed an inguinoscrotal hernia.

Facial Artery
Introduction

The facial artery supplies the muscles and skin of the face. It has a crucial function in
maintaining these areas, and provides them with oxygen and nutrients. The facial artery is one of
the eight branches of the external carotid artery. In this article we will explore the anatomy,
function and clinical relevance of the vessel. We will also conclude with some review questions
to test the readers understanding of the article content.
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Maxillary artery and its branches.
Course and Relations

The common carotid artery is the first branch of brachiocephalic trunk on the right side, and the
first branch of the arch of the aorta on the left side. It travels superiorly, and divides into the
external and internal carotid arteries at the superior border of the thyroid cartilage. The internal
carotid continues to pass upwards, and passes into the skull via the carotid canal. The artery then
passes forwards to enter the cavernous sinus, and makes a 180 degrees turn back on itself and
emerges lateral to the optic chiasm. The internal carotid artery then trifurcates into the middle
cerebral, anterior cerebral and posterior communicating arteries, which supply various regions of
the brain.
The external carotid passes upwards and superficially and gives off a number of branches to the
face, and scalp. These are the superior thyroid artery (supplies the thyroid gland in the neck), the
lingual artery (supplies the tongue), ascending pharyngeal artery (supplies the pharynx), facial
artery (supplies the facial muscles, skin and part of the scalp), occipital artery (supplies the
posterior scalp), posterior auricular artery (the scalp behind the ear as well as the ear itself),
maxillary artery (the deep structures of the face) and finally the superficial temporal artery (the
scalp in the temporal region). The facial artery also known as the external maxillary artery arises
from the anterior surface of external carotid, and has a tortuous route along the nasolabial fold
towards the medial canthus of the eye. It moves beneath the digastric and stylohyoid muscles and
it will pass through the submandibular gland.
The artery will then curve over the body of the mandible (deep to platysma), as the anteroinferior
angle of the masseter, will ascend forwards and upwards across the cheek, to the angle of the
mouth and along the side of the nose. It terminates near the medial aspect of the eye. In the
region of the head, the facial artery runs roughly parallel to the facial vein, although not adjacent
to it.

Cervical Branches

Ascending Palatine Artery- This artery passed superiorly between the styloglossus and
stylopharyngeus. It divides close to the levator veli palatini muscle into two branches. One
branch pierces the superior pharyngeal constrictor, in order the reach the auditory tube and the
palatine tonsil. It will then anastomose with the ascending pharyngeal artery as well as the
tonsillar branch of the facial artery. The other branch runs with the levator veli palatini and
passes over the superior pharyngeal constrictor in order to supply the soft palate, finally
anastomosing with the maxillary artery (the descending palatine branch).
Tonsillar Branch- This branch ascends between styloglossus and the medial pterygoid muscle,
before piercing the superior pharyngeal constrictor to reach the palatine tonsil.
Submental artery- This branch runs on the inferior aspect of the chin. This is the largest of the
cervical branches of the facial artery. The branch is given off just as the facial artery passes
through the submandibular gland. The vessel passes anteriorly on top of the mylohyoid muscle,
beneath the digastric muscle and just inferior to the body of the mandible. The artery supplies the
muscle surrounding this region, and anastomoses with the sublingual artery as well as the
inferior alveolar artery (the mylohyoid branch). The submental vessels supply the skin over the
submental area. The submental artery also divides into the superficial and deep branch. The
superficial branch anastomoses with the inferior labial artery. The deep branch also anastomoses
with the inferior labial artery as well as the mental branch of the inferior alveolar artery.
Glandular Branches- These are 3-4 large branches that supply the submandibular salivary
gland, as well as some structures that are found nearby i.e. the lymph nodes and integument.
Facial Branches

Inferior Labial artery- This branch of the facial artery arises close to the corner (angle) of the
mouth. It then passes superiorly and forwards in order to run beneath the triangularis (depressor
anguli oris) muscle and pierces the orbicularis oris muscle. It supplies the mucous membrane and
muscles of the lower lip and also supplies the labial glands. The vessel anastomoses with the
artery of the opposite side and inferior alveolar artery (the mental branch).
Superior Labial artery- This a significantly larger and more tortuous branch of the facial artery
when compared to the inferior labial artery. It supplies the upper lip and also gives a few
branches that ascend to supply and nasal septum and ala of the nose.
Lateral nasal branch - This branch of the facial artery ascends along the lateral aspect of the
nose. It supplies numerous structures, including the dorsum of the nose, the ala, and anastomoses
with its contralateral fellow, the infraorbital branch of the internal maxillary artery as well as the
dorsal nasal branch of the ophthalmic artery.

Angular artery (the terminal branch)- This is the final and terminal branch of the facial artery.
On the cheek the artery supplies the lacrimal sac and orbicularis oculi and ultimately
anastomoses with the ophthalmic artery (the dorsal nasal branch). It also ascends toward the
medial angle of the orbit, and lies within the fibers of the quadratus labii superioris (a broad sheet
of muscle that arises from the lateral aspect of the nose to the zygomatic bone). The terminal
portion ultimately finishes at the medial canthus of the eye. It is accompanied by the greater
occipital nerve, that innervates the scalp and provides sensation.
Clinical Points

Palpation- Anaesthetists palpate the facial artery against the anteroinferior angle of the masseter
muscle against the bony surface of the mandible.
Carotid Artery Vascular disease- Atherosclerosis (vascular disease) of the common carotid
artery (commonly at its bifurcation) increases the risk of emboli shooting off and hence strokes
occurring. Transient ischaemic attacks (a stroke where the symptoms resolve in less than 24
hours) are also more likely to occur. Treatment includes carotid endarterectomy, or endovascular
treatment of the disease.

Cephalic vein
Introduction

The cephalic vein is a superficial vein of the upper limb. Its name derives from cephalic
meaning head, as the vein runs up to the shoulder. The superficial venous network is the source
of blood for most blood tests, and is the easiest place to access venous blood. In this article we
will discuss the anatomy and clinical relevance of the cephalic vein.
Recommended video: Axillary artery
Anatomy of the axillary artery and its branches.
Anatomy

The cephalic vein is a superficial vein of the hand, forearm and arm. Between the superficial
and deep networks of veins, are valves that reduce the likelihood of backflow from the deep
venous system.
Course

The cephalic vein drains the dorsal venous network of the hand that crosses the anatomical
snuffbox, runs superficial to the radial styloid process and then ascends in the superficial fascia
of the forearm. The cephalic vein then communicates with the basilic vein at the cubital fossa,
via the median cubital vein. At this point the vein lies superficially in the lateral part of the elbow
joint crease.
The cephalic vein now runs along the groove between the brachioradialis (elbow flexor and
forearm supinator) and biceps brachii (forearm supinator and elbow flexor) muscles. The vein
continues to ascend in the superficial fascia anterolateral to biceps brachii and superficial to the
lateral cutaneous nerve of the forearm, which is a sensory branch of the musculocutaneous nerve
(ventral rami of C5-7) that innervates the muscles of the anterior compartment of the arm. The

cephalic vein continues to ascend in a groove between the pectoralis major and deltoid
muscles. The deltoid branch of the thoracoacromial trunk accompanies the cephalic vein in this
region.
Drainage

It crosses the clavipectoral fascia and axillary artery to drain into the axillary vein below the
clavicle. The axillary vein is renamed the subclavian vein once it passes the lateral border of the
first rib, and the subclavian vein unites with the internal jugular vein to form the
brachiocephalic vein.
The thoracic duct drains lymph from the lower limbs, pelvis, abdomen, left thorax, left upper
limb and left side of the head and neck and drains into the angle between the left jugular vein and
the subclavian vein on the left hand side. The lymphatic drainage of the right upper limb, right
thorax and right side of the head and neck empties into the junction between the right subclavian
vein and internal jugular vein, which merge to form the right brachiocephalic vein. The two
brachiocephalic veins unite to form the superior vena cava that drains into the right atrium of
the heart.
Clinical Points
Cephalic vein cutdown

When a patients peripheral veins are too small or incompetent, central venous access may be
required. This is traditionally in the form of a central line into the subclavian vein. However the
cephalic vein has presented an alternative where venous access is faster, easier and does not risk
the complications of central venous access, i.e. pneumothorax. Other purposes of a cephalic vein
cutdown include the percutaneous placement of pacemaker leads into the heart, and the
placement of a long-term venous catheter.
The Housemans friend

The junior doctor is usually the one in charge of getting the blood for blood tests. The superficial
veins of the upper limb are therefore the easiest place to access this blood, and are therefore
termed the Housemans friend. The median cubital vein in the cubital fossa is the most
frequently accessed vein.
Varicose Veins

Varicose veins are engorged tortuous superficial veins that result from incompetence of the
valves that separate the deep and superficial venous systems, resulting in a buildup of venous
blood in the superficial venous system. Varicose veins of the upper limb are very rare, with the
vast majority of patients presenting with lower limb varicose veins.

Small Saphenous Vein

Introduction

The small (short) saphenous vein is a superficial vein of the leg. It drains the lateral surface of
the leg, and runs up the posterior surface of the leg to drain into the popliteal vein. In this article
we will discuss the anatomy and clinical relevance of the small saphenous vein.
Recommended video: Neurovasculature of the lower leg and knee
Arteries, veins and nerves of the lower leg and knee.
Anatomy
Drainage

The dorsal venous arch of the foot connects the great saphenous vein, that drains the medial
surface of the leg and thigh into the femoral vein at the saphenofemoral junction, to the small
saphenous vein, which is a superficial vein.
Course

The small saphenous vein extends from the lateral marginal of the foot posterior to the lateral
malleolus. It then ascends

along the posterior

surface of the leg and passes between the two heads of gastrocnemius. In many individuals,
the small saphenous vein drains into the popliteal vein at the saphenopopliteal junction, whose

location is variable but proximal to the tibial plateau in most cases. The small saphenous vein
usually gives off a branch, the vein of Giacomini, which extends up the thigh and runs between
the biceps femoris and semimembranosus muscles.
The small saphenous vein is accompanied by the sural nerve along its course in the posterior
aspect of the leg. The sural nerve is a sensory cutaneous nerve that is formed by branches from
the common fibular (ventral rami of L4-S2) and tibial (ventral rami of L4-S3) branches of the
sciatic nerve (ventral rami of L4-S3).
Clinical Points

Varicose veins: The small saphenous vein is a superficial vein. The deep veins (posterior tibial,
anterior tibial, fibular, popliteal, femoral) are separated from the superficial veins by a series of
valves. These valves ensure blood flows from the superficial system to the deep system
and prevent backflow. Incompetence of these valves results in tortuous veins, called varicose
veins. Signs associated with such veins include:

tenderness

pain, if chronic

brown discoloration of the distal leg, resulting in champagne bottle shaped

legs

Varicose vein removal: If the presence of varicose veins is causing problems, endovenous
thermal ablation of the veins can be performed. This procedure is sometimes associated with
complications due to the proximity of adjacent structures such as the sural nerve. Possible
indications include:

pain

venous ulcers

skin changes

cosmetic reasons

Popliteal vein
Introduction

The popliteal vein is a deep vein of the leg. It drains blood away from the leg into the femoral
vein, which drains blood to the inferior vena cava to return to the right atrium of the heart.

The deep
veins contain valves just like the superficial veins of the body. They also rely on muscular

contractions to assist in returning the venous blood to the right atrium of the heart. In this article
we will discuss the anatomy and clinical relevance of the popliteal vein.
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Arteries, veins and nerves of the lower leg and knee.
Anatomy
Popliteal fossa

The popliteal vein is a deep vein that drains the leg. The sciatic nerve runs down the posterior
surface of the leg, and its largest branch, the tibial nerve is the most superficial structure of the
popliteal fossa, which is a diamond-shaped fossa that lies at the posterior surface of the knee.
The biceps femoris defines the popliteal fossa proximolaterally, and the semimembranosus and
semitendinosus muscles define its proximomedial border. The two heads of the gastrocnemius
muscle form the inferior borders, medially and laterally.
Tributaries

The popliteal vein is formed by the confluence of the deep veins of the leg, i.e. the posterior
tibial, anterior tibial and common fibular veins. It also receives venous blood from the
superficial vein of the lateral leg, i.e. the short saphenous vein. The short saphenous vein
pierces the deep fascia of the leg, and enters the popliteal fossa by passing through the two heads
of the gastrocnemius.
Course

The popliteal vein then ascends and passes through the adductor hiatus (an opening formed
between the two insertions of the adductor magnus muscle) to become the femoral vein, which
passes superiorly and runs in the femoral triangle medial to the femoral artery, which is itself
medial to the femoral nerve. The femoral nerve runs underneath the inguinal ligament, and
provides motor innervation to the anterior compartment of the thigh.
Clinical Points

Popliteal vein aneurysm: Popliteal vein aneurysms are rare, and do not commonly present
clinically. Surgical repair is indicated if it is causing symptoms, such as:

deep vein thrombosis

pulmonary embolisms

Deep vein thrombosis: The deep veins of the lower limb are the most vulnerable to this
condition, which rarely presents in the upper limb. Any patient that has prothrombotic risk
factors is at risk of deep vein thrombosis. Some of these factors include:

smoking

lack of mobility

use of oestrogen contraceptive pills

recent surgery

Iliac vein
Introduction

The common iliac vein is formed by the unification of the internal and external iliac veins The
external iliac vein drains the lower limb, and the internal iliac vein drains the gluteal region and
pelvic viscera. The unification of the two common iliac vein forms the inferior vena cava. In this
article we will discuss the basic venous anatomy of the lower limb in order to frame the common
iliac vein in a larger anatomical context. We will also discuss the regional anatomical relations of
the left and right common iliac veins, and also the clinical relevance of the common iliac vein as
well as its tributaries. We will also conclude with a summary and some review questions to test
the readers understanding of the article content.
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Anatomy and function of the inferior vena cava.
Anatomy

The popliteal vein is the middle structure of the popliteal fossa (deep to sciatic nerve, superficial
to popliteal artery), and drains the short saphenous vein (drains the superficial lateral leg
compartment), the anterior tibial (drains the anterior leg compartment), posterior tibial (drains
the posterior leg compartment) and fibular veins (drains the lateral leg compartment). The
popliteal vein becomes the femoral vein when it passes through the adductor hiatus/hunters
canal along with the artery and the saphenous nerve (a branch of the femoral nerve). Once the
femoral vein passes the inguinal ligament, it is renamed the external iliac vein. The external iliac
vein drains the inferior epigastric vein, deep circumflex iliac vein and also the pubic vein. The
common iliac vein is formed by the unification of the internal (drains the pelvic organs) and
external iliac veins just in front of the sacroiliac joint. The internal iliac vein drains all of the
veins of the pelvic cavity and some of the gluteal region. The extra pelvic veins include the
superior and inferior gluteal veins, the obturator (drains the lateral pelvis wall) and internal
pudendal veins (drains the pelvis). The pelvis veins include the lateral sacral, median sacral,
uterine, vaginal and vesical veins. The latter four veins drain both the presacral venous plexus
and the visceral venous plexuses i.e. the prostatic, uterine, rectal and vaginal plexuses.
The common iliac veins unite with the common iliac vein of the contralateral side slightly at the
right side of vertebral level L5. They form the inferior vena cava. Both the internal and common
iliac veins are valveless. The external iliac vein may have a single valve. The right common
iliac vein begins medial to the right common iliac artery but as it ascends it runs posterior to the
artery, this vein is more shorter and vertical. Right obturator nerve is in its posterior relation. The
left common iliac vein runs medial to the left common iliac artery then also becomes posterior.

Left common iliac is longer and more oblique. This vein has attachment of sigmoid mesocolon
and superior rectal vessel in its anterior relations.
Both of the veins drain iliolumbar and lateral sacral vein (sometimes). The left common iliac
vein also receive median sacral vein. The inferior vena cava then ascends to the right of the
vertebral column and passes through the diaphragm at vertebral level T8-T9. After approximately
2.5cm of length in the thoracic cavity, the inferior vena cava then drains into the the
inferoposterior part of right atrium.
Clinical Points

May-Thurner Syndrome- This condition is caused by compression of the left common iliac
vein against the lumbar vertebrae under the proximal section of the aneurysmal or tortous left
common iliac artery, which may occur with or without a deep vein thrombosis. The pulsations of
the artery may damage the endothelium of the left common iliac vein and result in spur
formation. This predisposes to deep vein thrombosis formation. Diagnosis is made by CT scan,
and treatment involves stenting and thrombolysis. There are other variants of May-Thurner,
sometimes left common iliac vein passes between iliopsoas muscle and spine which may cause
venous compression. The left common iliac vein may be compressed by left common iliac artery
due to high bifurcation of aorta or left sided inferior vena cava.
Transposition of the Inferior vena cava- In some patients the inferior vena cava may lie to the
left side of the abdominal aorta instead of the right. This is an important variation to be aware of
in diagnostic procedures involving the vessel e.g. abdominal aortic aneurysm repair, inferior
vena cava placement filter, nephrectomy and portosystemic shunt placement.
Inferior vena cava filter- If someone had recurrent deep vein thrombosis and is at risk of
recurrent pulmonary embolism (or is non compliant with anticoagulant medication) a small filter
can be passed through the femoral vein, through the common iliac vein and into the infrarenal
inferior vena cava through an image guided procedure. This means that any ascending emboli
from the legs will not reach the heart, and go onto the lungs. This is a lifesaving procedure and
the filter is usually left in place for a few weeks or months.
Summary

The common iliac vein is formed by the unification of the external and
internal iliac vein

The two common iliac veins unite to form the inferior vena cava, anterior to
the sacroiliac joints at vertebral level L5

The femoral vein is renamed the external iliac vein once it passes the inguinal
ligament

The internal iliac vein drains the pelvic viscera and gluteal region

The common iliac veins have a few tributaries (right lumbar vein on the right,
and left lumbar vein and median sacral veins on the left)

The inferior vena cava passes through the diaphragm at vertebral level T8,
and empties into the right atrium at vertebral level T9

Portosystemic anastomosis
Introduction

Porto-systemic anastomosis also known as portocaval anastomosis is the collateral

communication between the portal and the systemic venous system.
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Liver in situ seen from an anterior view of the abdomen with liver retracted.
Portal venous system

The portal venous system transmits deoxygenated blood from most of the gastrointestinal tract
and gastrointestinal organs to the liver. Substance absorbed in the GIT are processed in the liver,
hepatocytes receives oxygenated blood via hepatic artery. This mixture filter through the
sinusoids and collects in a central vein and finally to the heart through the inferior vena cava by
hepatic veins.
The portal vein is the most important vein in the portal venous system; it starts its formation
close to the level of the second lumbar vertebrae (L2) and it is located in front (anterior) of the
inferior vena cava and at the back (posterior) of the neck of the pancreas. It is about 8cm long.
The portal vein is formed by joining of the superior mesenteric vein and the splenic vein. It
runs upwards and lies behind the bile duct and hepatic artery it also lies anterior to the inferior
vena cava. It penetrates in the right border of the lesser omentum and continues upwards in front
(anterior) of the epiploic foramen to reach the porta hepatis (transverse fissure on the liver). After
it reaches the porta hepatis, it bifurcates into a right and left branch which penetrates the liver.
Various veins drains into the portal vein and these veins are the superior mesenteric vein which
drains blood mainly from small intestine, splenic vein which receives blood from short gastric,
left gastroepiploic, inferior mesenteric, and pancreatic veins right and left gastric veins drains
blood from the stomach and oesophagus, the superior pancreaticoduodenal veins drains blood
from the pancreas and duodenum, cystic veins drains blood from the gallbladder and the
paraumbilical vein.
From the portal vein, the blood is drained into the left and right branches of the portal vein into
the left and right side of the liver. Inside the liver it passes through tiny capillary beds called
venous sinusoids of the liver and finally into the hepatic vein which transmits the blood into the
inferior vena cava (carries deoxygenated blood to the heart).
The importance of portosystemic anastomosis is to provide alternative routes of circulation
when there is blockage in the liver or portal vein. This routes ensure that venous blood from the

gastrointestinal tract still reaches the heart through the inferior vena cava without going through
the liver.
The various anastomosis and the sites in which they occur are described below:
1. The anastomosis between the left gastric which are portal veins and the
lower branches of oesophageal veins that drains into the azygos and
hemiazygos veins which are systemic veins. The site of this anastomosis is
the lower oesophagus.
2. The anastomosis between the superior rectal veins which are portal veins
and the inferior and middle rectal veins which are systemic veins. The site
of this anastomosis is the upper part of the anal canal.
3. The anastomosis between the paraumbilical veins which runs in the
ligamentum teres as portal veins and small epigastric veins which are
systemic vein. The site of this anastomosis is the umbilicus.
4. The anastomosis between the intraparenchymal branches of the right division
of the portal vein and retroperitoneal veins which are systemic veins and
drain into the azygos, hemiazygos and lumbar veins (systemic veins). The
site of this anastomosis is the bare area of the liver.
5. The anastomosis between omental and colonic veins (portal veins) with the
retroperitoneal veins (systemic veins) in the region of hepatic and
splenic flexure.

6. Another anastomosis is between the ductus venosus which is a portal vein and the
inferior vena cava which is a systemic vein. This is very rare and at the site of patent
ductus venosus.
Clinical anatomy

Portal hypertension: This is increase in blood pressure in the veins of the portal system. It is
caused by blockage in the veins of the liver due to pathological conditions such as liver cirrhosis
and the inability of the blood to flow through. Signs and symptoms are varicose veins on the
abdominal wall called caput medusae, oesophageal varices, enlargement of the spleen,
accumulation of fluid in the peritoneal cavity and bleeding in the gastrointestinal tract.
Portosystemic shunts: This is an abnormal connection between the veins of the portal and
systemic system. In portosystemic shunts, blood is shunted directly to the systemic circulation
from the portal vein without reaching the liver. Porto systemic shunts occur naturally in the
developing fetus because blood from the placenta flows through the ductus venosus into the
system without going through the liver; the ductus venosus is meant to close on the first week
after birth but persistence leads to a pathological condition called congenital portosystemic

shunts. There is an extrahepatic congenital portosystemic shunt as well which is the

developmental abnormality of the vitelline vein connecting the portal vein to the caudal vena
cava. Signs and symptoms are tremors, epileptic seizures, weight loss, bladder stones and
vomiting. Portosystemic shunts are also performed in the clinical setting to reduce the effects of
portal hypertension and this can be done surgically by creating a link between the portal vein and
the inferior vena cava or by creating a link between the splenic vein and left renal vein.

Saphenous nerve
Introduction

The saphenous nerve is a sensory branch of the femoral nerve, and supplies sensation to the
anteromedial, medial and posteromedial surface of the leg. The nerve passes through the
adductor canal, and gives off an infrapatellar branch. It continues to become subcutaneous to
supply prepatellar skin and also supplies the medial side of the ankle and foot. In this article we
will discuss the anatomy and clinical relevance of the saphenous nerve.

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Anatomy and supply of the musculocutaneous nerve.
Course
Thigh

The saphenous nerve (L3-4) is the largest terminal

cutaneous branch of the femoral nerve (dorsal divisions of the ventral rami of L2-L4) that arises
within the femoral triangle. The nerve branches from the femoral nerve, and passes lateral to

the femoral artery. It then runs deep to the Sartorius muscle, and behind the aponeurotic
covering of the adductor canal. At this point the saphenous nerve gives a branch to join the
subsartorial plexus. The nerve then descends behind the Sartorius muscle and pierces the
fascia lata (it passes between the Sartorius and gracilis muscle), and becomes subcutaneous to
supply the skin over the anterior surface of the patella.
Leg

The nerve continues to descend down the medial/tibial side of the leg, and runs with the greater
saphenous vein. The vein divides into two branches when it reaches the lower third of the leg. A
branch of the vein continues to descend down the anterior surface of the tibia, and terminates at
the ankle. The other branch passes anterior to the medial malleolus, and drains blood from the
medial surface of the foot as far distally as the base of the hallux. The nerve communicates with
the medial branch of the superficial branch of the common fibular nerve. Both of these nerves
then supply sensation to the anterior surface of the leg.
The medial crural cutaneous branches of the saphenous nerve supply sensation to the anterior
and medial surface of the leg, as well as communicate with the cutaneous branches of the
obturator and femoral nerve.
Clinical Points

Saphenous vein cutdown: A saphenous vein cutdown is a procedure used to gain access to the
patients venous system. A potential complication of saphenous vein cutdown is damage to the
saphenous nerve. Symptoms will include loss of sensation over the medial surface of the leg.
Saphenous nerve block: Indications for blocking the nerve include:

trauma to the anteromedial aspect of the knee or leg, as far down as the
medial malleolus

pain after a partial meniscectomy of the knee

manipulation of an ankle fracture, in conjunction with blockage of other

nerves which supply sensation to the ankle region

Saphenous nerve entrapment neuropathy: The adductor canal is a space deep to the sartorius
from the apex of the femoral triangle to the adductor hiatus. The saphenous nerve passes through
the Adductor (Hunter's) canal along with the femoral artery and vein. The nerve can become
entrapped, causing the following symptoms:

deep thigh ache

knee pain

loss of sensation over the medial aspect of the leg

The Parasympathetic Nervous System

Introduction

The autonomic nervous system contains three subsystems: the sympathetic nervous system and
the parasympathetic nervous system, which are usually in opposition, and the enteric nervous
system.
The parasympathetic nervous system, also known as the craniosacral division, is a branch of
the autonomic nervous system (ANS). Its presynaptic neuron cell bodies located in two regions
within the central nervous system (CNS), and their fibres exciting by two routes. The two
regions where their neuron cell bodies are located are the medulla (a brainstem part) which
constitutes the cranial half of the system, as well as the sacral segment of the spinal cord (sacral
half of the system).
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Anatomy and function of the circulatory system.
Cranial part

In the gray matter of the medulla, the fibres exit the CNS within the following cranial nerves
(CN):

CN III (oculomotor nerve)

CN VII (facial nerve)

CN IX (glossopharyngeal nerve)

CN X (vagus nerve)

The associated cranial nerves form the cranial preganglionic parasympathetic fibres or what is
known as the cranial parasympathetic outflow; 75% of all parasympathetic fibres are in the
vagus nerve.
The preganglionic fibres from the medulla and spinal cord project to ganglia very close, or
attached, to the target organ and makes a synapse.

Sacral part

The presynaptic parasympathetic neuron cell bodies of the sacral half of the system lie within
the gray matter of the sacral segments (S2 S4) of the spinal cord. These fibres leave the spinal
cord through the anterior roots of the sacral spinal nerves S2 S4 and the pelvic splanchnic
nerves that arise from their anterior branches. They join together, after exiting the spinal cord,
to form the pelvic nerves and mainly innervate the viscera of the pelvic cavity. These fibres
constitute the sacral parasympathetic outflow (or sacral part of the preganglionic
parasympathetic fibres). Parasympathetic synapses use the neurotransmitter acetylcholine, and
are called cholinergic pathways.

Functions

The ANS controls and regulates the internal viscera without any conscious recognition or effort
by the individual, and is thus referred to as involuntary. It plays a crucial role in the
maintenance of homeostasis through the opposing functions of its two anatomically and
functionally distinct divisions, the parasympathetic and sympathetic nervous systems. Both
systems provide some degree of nervous input to a given tissue at all times and either
increase/enhances or decrease/inhibits the activity of the innervated structure. Parasympathetic
fibres are sent to various viscera to ensure different involuntary functions, such as:

constriction of the pupil (protecting the pupil from excessive bright light)

contraction of the ciliary muscle, (allowing the lens to thicken for near
vision e.g., accommodation)

promotion of the secretion of the lacrimal glands

promotion of abundant watery secretions of salivary glands, decreasing the

rate and strength of contraction (conserving energy)

constriction of coronary vessels in relation to reduced demand

constriction of the bronchi (conserving energy)

promotion of bronchi mucus secretion of the lungs

sending impulses to induce peristalsis and secretion of digestive juices

contraction of the rectum during defecation

inhibition of the internal anal sphincter to cause defecation

promoting the building/conservation of glycogen

increases secretion of bile

inhibition of the contraction of internal sphincter of urinary bladder

contraction of the detrusor muscle of the urinary bladder wall causing

urination

stimulation of engorgement (erection) of erectile tissues of the external

genitals

However, to ensure homeostasis in the activities of these organs, the sympathetic nervous system
also innervates those structures in an antagonistic way. Furthermore, it can clearly be seen that
the cranial outflow provides parasympathetic innervation of the head, and the sacral outflow
provides the parasympathetic innervations of the pelvic viscera. However, in terms of nerve
contribution to the thoracic and abdominal viscera, the cranial outflow, through the vagus nerve
is dominant.
Distinctive characteristics

Apart from the opposing actions of the sympathetic and parasympathetic nervous system, a
striking anatomical difference between both systems relates to the axons. Those of the
preganglionic neurons of the parasympathetic nervous system are longer than those of the
sympathetic system. They also synapse with postganglionic neurons within terminal ganglia
which are close to or embedded within the effector tissues.
However, the axons of the parasympathetic postganglionic neurons are very short, and usually
unmyelinated, compared with the sympathetics. This is due to their proximity to the cells of
the effector tissue. In addition, the parasympathetic fibres are more restricted than the
sympathetic. They do not reach the body walls or the limbs.
Clinical Correlation

Diabetic cardiac autonomic neuropathy is a serious and common complication of diabetes

mellitus that is often under-diagnosed but can lead to severe morbidity and mortality, due to the
associated cardiovascular burden. In the early periods of this condition, there is degeneration of
the sympathetic control of the heart, which is followed in later stages by the degeneration of the
parasympathetic stimulation of the heart. Also, its effects on the parasympathetic nervous system
cause several cardiovascular disturbances, including resting tachycardia, exercise intolerance and
postural hypotension.

Glands
Introduction

Epithelia are a group of tissues derived from all three embryonic germ layers, which are involved
in absorption, secretion, selective diffusion and physical protection. Epithelia primarily involved
in secretion are arranged into structures known as glands. Glands are invaginations of epithelial
tissue and can be divided into two main types:

Exocrine glands

Endocrine glands

This article will discuss the structure and function of exocrine and endocrine glands as well as
examples of these glands. This will be followed by any relevant clinical pathology.
Exocrine Glands

Exocrine glands release their secretions onto an epithelial surface via a duct. Exocrine glands
consist of two main parts, a secretory unit and a duct. The secretory unit consists of a group of
epithelial cells which release their secretions into a lumen whereas a duct is lined with
epithelium and is involved in transport of the secretions from the secretory unit to an epithelium
lined surface.
Exocrine glands can be classified into a variety of categories in terms of their structure. They can
be categorised according to the shape of their secretory unit. Secretory units shaped as a tube are
referred to as tubular, whereas spherical units are referred to as alveolar or acinar, when the
pancreas is involved. Exocrine glands can also be comprised of both tubular and alveolar
secretory units and are in this case referred to as tubuloalveolar. They can also be categorised
according to whether their duct is branched or not. An unbranched duct is referred to as a simple
gland, whereas a branched duct is known as a compound gland. An example of a simple gland
is a sweat gland whereas the pancreas is an example of a compound gland.
Exocrine glands can also be classified into a variety of categories in terms of their function. They
can be categorised into 3 subtypes according to their type of secretory product:

Serous glands

Mucous glands

Mixed glands

Serous glands produce serous fluid, a watery substance containing enzymes, whereas mucous
glands are involved in the production of mucus, a viscid (sticky) glycoprotein. Mixed glands are
comprised of both serous and mucous glands and secrete a mixed substance containing both
serous fluid and mucus.
Exocrine glands can also be categorised into another 3 subtypes according to their secretion
mechanism:

Merocine glands

Apocrine glands

Holocrine glands

Merocrine glands are the most common and release their secretory products via exocytosis. The
major secretory products of these glands are usually proteins. Apocrine glands release their
secretory products contained within membrane-bound vesicles. This type of secretion is rare and
these glands are found in the breast and constitute some sweat glands. Holocrine glands release
whole secretory cells, which later disintegrate to release the secretory products. This type of
secretion is seen in sebaceous glands associated with hair follicles.
The release of secretory products from the secretory unit is aided by some contractile cells,
known as myoepithelial cells. These cells comprise characteristics of both muscle and epithelial
cells and lie between the secretory unit and basement membrane. The cytoplasmic processes of
these cells envelop the secretory unit so that contraction of these cells results in release of the
secretory products from the secretory units and into the ducts. Release of secretory products
occurs in response to stimulation by hormones or autonomic nerve impulses.
Endocrine Glands

Endocrine glands release their secretory products directly into the bloodstream, rather than via a
duct. These glands are surrounded by a strong connective tissue capsule which has fibrous
extensions known as trabeculae. These trabeculae provide internal support and give the gland a
lobular appearance. Endocrine glands release secretions known as hormones, which travel via
the bloodstream to reach their target cells, where they elicit functional changes. The hormones
are commonly stored intracellularly within secretory vesicles and are released intermittently via
exocytosis. An exception to this is the thyroid gland, which stores its hormone extracellularly as
an inactive precursor molecule. Secretion of hormones is usually regulated by negative
feedback, where a rise in the level of hormone in the blood decreases its secretion.
Examples of Glands

Sebaceous glands are simple, branched, acinar, exocrine glands located within the skin. They
secrete a fatty substance sebum, into the follicular duct, which surrounds the hair shaft. Sebum
helps keep the skin flexible and prevents water loss. These are known as holocrine glands, as
sebum is released when the secretory cells degenerate.
The pituitary gland is a small endocrine gland within the brain involved in hormone synthesis
and regulation. It consists of two parts, the anterior pituitary or adenohypophysis, and the
posterior pituitary, or neurohypophysis. The anterior pituitary secretes growth hormone (GH),
prolactin, adenocorticotrophic hormone (ACTH), follicle-stimulating hormone (FSH), luteinising
hormone (LH) and thyroid-stimulating hormone (TSH). ACTH and TSH travel to their target
organs, the adrenal gland and the thyroid gland, respectively in order to stimulate the release of
further hormones. The posterior pituitary secretes antidiuretic hormone (ADH), otherwise known
as vasopressin, and oxytocin.
The pancreas is an organ comprised of both exocrine and endocrine glands. The majority of the
pancreas has an exocrine function and secretes an enzyme-rich alkaline fluid into the pancreatic
duct, which joins the common bile duct before emptying into the duodenum. The exocrine glands
secrete the proteolytic enzymes trypsinogen and chymotrypsinogen, which are activated to
trypsin and chymotrypsin in the duodenum and aid in digestion. The exocrine pancreas also
secretes bicarbonate ions, which neutralise the acidic chyme as it reaches the duodenum. There
are also clusters of endocrine glands located within the exocrine tissue and these are referred to
as islets of Langerhans. The two main hormones released from the endocrine glands of the
pancreas are insulin and glucagon. The pancreas also secretes somatostatin, vasoactive
intestinal peptide (VIP), pancreatic polypeptide (PP), motilin, serotonin and substance P in
smaller quantities.
Other examples of glands include sweat glands, salivary glands, the thyroid gland, the
parathyroid gland, the pineal gland and the adrenal gland.
Clinical Notes

Adenocarcinomas are malignant tumours that arise from glandular epithelium and are common
in the gastrointestinal system, uterus, lungs breast and prostate. They consist of abnormal glands
and can secrete mucus. They are usually diagnosed by a biopsy, a CT scan or by an MRI scan.
Treatment can involve solely surgery, chemotherapy or radiotherapy or a combination of these.
Adenomas are the benign counterparts of adenocarcinomas and are commonly found in the
pituitary gland. Pituitary adenomas do not invade the surrounding tissues but they can have
serious consequences due to compression on surrounding structures such as the optic chiasm,
which can lead to visual problems. They can also secrete hormones such as ACTH, which can
lead to Cushings disease, or GH, which can lead to gigantism in children and acromegaly in
adults.

Hyperfunctioning of an endocrine gland such as the thyroid gland, pituitary gland or adrenal
gland can lead to increased secretion of hormones. An example of this is Graves disease, which
is due to an overproduction of thyroid hormones and can cause symptoms such as irritability,
weight loss, tremor and a rapid heartbeat. Treatment can involve pharmacotherapy such as
carbimazole or propylthiouracil, surgery or radioiodine therapy.
A hypofunctioning endocrine gland can also occur resulting in a reduced production of
hormones. An example of this is hypopituitarism, where production of one or more of the
hormones of the pituitary gland, is reduced. Symptoms are related to the hormones involved and
can include short stature (GH deficiency), polyuria (ADH deficiency) and weakness (ACTH
deficiency). Treatment can involve hormone replacement, surgery or radiation therapy.
Another example of a disease due to hypofunction is type I diabetes mellitus, where
autoimmune destruction of the beta cells of the pancreas leads to reduced insulin in the
bloodstream. This can lead to polyuria (increased urination) and polydipsia (Increased thirst) due
to a reduction in glucose storage. Treatment involves daily insulin injections and blood glucose
monitoring to try and prevent complications such as diabetic nephropathy (kidney damage) and
diabetic neuropathy (damage to the nerves).

Integumentary system
Introduction

The integumentary system is the body system which surrounds you, both literally and
metaphorically speaking. If you look in the mirror you see it, if you look anywhere on your body
you see and if you look around you in the outside world, you see it. It is the system that can
instantly tell us whether someone is young or old, someones ethnicity or race or if he/she has
been on holidays recently. It also protects us a great deal from harm and allows us to sense our
surrounding environment. This article will discuss the components of the integumentary system
together with some basic knowledge about each of them.
Components

The integumentary system is composed of the following parts:

1. Skin
2. Skin appendages
o

Hairs

Nails

Sweat glands

Sebaceous glands

3. Subcutaneous tissue and deep fascia

4. Mucocutaneous junctions
5. Breasts
Skin

The skin is the largest component of this system. It is an extensive sensory organ, which forms
an outer, protective coat around the entire external surface of the body. In fact, it is the largest
organ of the human body, covering an area of 2 square meters. It has a thickness between 1.5 and
5 mm, depending on location.

Functions

The skin has a significant capacity for renewal and crucial roles for the normal functioning of
the human body. It is an effective barrier against potential pathogens and protects against
mechanical, chemical, osmotic, thermal and ultraviolet radiation damage (through melanin). The
skin also takes part in a variety of biochemical synthetic processes, such as vitamin D
production under the influence of ultraviolet radiation, but also the production of cytokines and
growth factors. Skin also has a major role in controlling body temperature by increasing or
decreasing the blood flow through the cutaneous circulation, which in turn affects the magnitude
of heat loss. Sweating also assists this process. The skin is also a major sensory organ,

containing a large number of nerve terminals for touch, temperature, pain and other stimuli. The
skin greatly assists in locomotion and manipulation due to its good frictional properties given
by its texture and elasticity.
Layers

The skin is anatomically organized as follows, from superficial to deeper layers:

Epidermis
o

Stratum corneum

Stratum lucidum

Stratum granulosum

Stratum spinosum

Stratum basale

Dermis
o

Papillary dermis

Reticular dermis

If you want to find out more about the anatomy of the skin, have a look at this article.
Skin appendages
Hairs

Hairs are filamentous cornified structures which grow out of the skin and cover most of the
body surface. Several areas of the body like the palms, soles, flexor surface of the digits and
specific parts of the reproductive organs are devoid of hairs. Hairs are important in sensing,
thermoregulation and protection against injury and solar radiation.
There are two major types of hairs: vellus and terminal. Vellus hairs do not project beyond their
follicles in some of the areas, however, they are short and narrow and cover most of the surface
of the body. This hair type is most easily observed on children and adult women and is
colloquially known as peach fuzz. Terminal hairs are longer, thicker and more heavily
pigmented. They are mostly observed on males but also in the axillary and pubic regions of both
sexes.

Hair follicle

The hair follicle is the sac containing the hair, out of which it grows. It is actually a
downgrowth of the dermis and contiguous with the epithelium. The hair follicles go through a
cyclic activity of hair growth and loss.
Hair bulb

The hair bulb is the lowest expanded extremity of the hair follicle that fits like a cap over the
dermal hair papilla, enclosing it. The dermal hair papilla is a cluster of mesenchymal cells
giving rise to several capillaries, which form a capillary loop. The hair bulb generates the hair
and its inner root sheath.
The bulb consists of two parts: germinal matrix and the upper bulb. The germinal matrix
consists of pluripotent keratinocytes, which gives rise to the upper bulb. As the cells from the
matrix migrate apically and differentiate further, they form several structures and layers. From
the interior to the exterior, these include:

Hair shaft
o

Medulla

Cortex

Cuticle

Inner root sheath

o

Cuticle

Huxleys layer

Henles layer

Outer root sheath

Glassy membrane (basement membrane of hair follicle)

You can image these layers as tree rings in a cross-section of the hair follicle since they are
concentric cylinders. Each layer completely encloses the previous one situated more internally.

Hair cycle and growth

The growth, rest and shedding of hair follicles occurs in cyclical stages of variable duration.
During the growing (anagen) phase, the follicles produce an entire hair shaft from the dividing
cells of the hair bulb.
During the shedding (catagen) phase, the epithelial cells in the hair bulb and the and outer root
sheath die in a regulated fashion (apoptosis). Differentiation of the hair shaft also stops, and the
bottom of it becomes sealed into a structure called the club.
During the resting (telogen) phase, the hair follicles lie dormant. No differentiation or apoptosis
happens. Shedding or loss of club hair happens when the cycle is re-initiated and the newly
growing hair follicle pushes the old one out. The average rate of hair growth is between 0.2 and
0.44 mm in 24 hours.
Nails

Nails are homologous to the stratum corneum of the epidermis and contain a variety of
minerals, such as calcium. They consist of compacted and layered keratin-filled squames
(scales). The arrangement and cohesion of the squames are responsible for the hardness of nails.
A nail consists of: the nail plate, nail folds, nail matrix, nail bed and hyponychium.
Nail plate

The nail plate is a rectangular and convex structure embedded within the nail folds. It originates
from the nail matrices, found at the base of the nails. The nail plate is completely free distally to
the onychodermal band (distal margin of the nail bed).
Nail folds

The nail folds are the borders of the nail plate, located laterally and proximally, which are
continuous around the nail plate. The cuticle (eponychium) is an extension of the proximal nail
fold located on the dorsal aspect of the nail plate, overlying the root of the nail.
Nail matrix

The nail matrix is the structure out of which the nail plate grows. Cornified cells from the
matrix are gradually extruded distally to form the nail plate.
Nail bed

The nail bed extends between the lunula (crescent shaped, white area of the nail bed) and the
hyponychium (area under the free edge of the nail plate). The distal margin of the nail bed is
called the onychodermal band. There is a perfect match between the nail bed and plate, forming
a seal, which prevents microbial invasion and debris collection. The nail bed consists of two
layers: the epidermis and dermis. The dermis is directly attached to the periosteum of the distal

phalanx and it is richly vascularized. It also contains numerous sensory nerve endings, such as
Merkel endings and Meissners corpuscles.
Sweat glands

Sweat glands are small, tubular structures located in the skin. They are exocrine glands, hence
they secrete substances on the epithelial surface via ducts. The glands produce sweat, which is
important for thermoregulation. There are two types of sweat glands, eccrine and apocrine and
each one produces a different type of sweat.

Eccrine sweat glands

The majority of sweat glands are eccrine. They are long, unbranched, tubular structures with a
highly coiled secretory portion situated deep in the dermis. A narrower duct emerges from the
gland and it opens via a pore on the skin surface.
Apocrine sweat glands

These are large glands specifically located in the axillae, perianal region, nipples, periumbilical
region, prepuce, scrotum, mons pubis, labia minora, nail bed, penis and clitoris.
Similar to eccrine glands, apocrine glands also consist of a secretory coil. However, the duct
emerging from the gland opens inside the pilary canal above the duct of the sebaceous gland or
directly on the surface of the skin.
Sebaceous glands

Sebaceous glands are small saccular structures located in the dermis, which cover most of the
body. They consist of a cluster of secretory acini, which is continued by a duct which opens into
the dermal pilary canal of the hair follicle. The ducts can also open directly on the surface of the
skin, as seen on the lips and buccal mucosa. Sebaceous glands secrete sebum, which is an oily
and fatty secretion. Sebum is crucial in the epidermal barrier and the skins immune system.

Subcutaneous tissue

The subcutaneous tissue, also called the hypodermis, is a layer of adipose tissue attached to the
deep aspect of the dermis. It increases the mobility of the skin, it thermally insulates the body,
acts as a shock absorber and is a source of energy. The hypodermis is filled with subcutaneous
nerves, vessels and lymphatics. It specifically contains the platysma muscle in the head and neck.

Mucocutaneous junctions

These are regions of the body where there is a transition from mucosa to skin. At such regions,
epithelium transitions to epidermis, lamina propria changes to dermis and smooth muscle
becomes skeletal muscle. They occur at orifices in areas like the lips, nostrils, conjunctivae,
urethra, vagina, foreskin and anus.
Breasts

The breasts, also known as the mammary glands, are prominent, superficial structures on the
anterior thoracic wall, seen especially in women. They also occur in men but are functionless.
They are located in the subcutaneous tissue overlying the pectoralis major and minor muscles.
If you want to find out more about the anatomy of the breast, have a look at this article.
Blood supply

The integumentary system is supplied by the cutaneous circulation, which is crucial for
thermoregulation. It consists of three types: direct cutaneous, musculocutaneous and
fasciocutaneous systems. The direct cutaneous are derived directly from the main arterial trunks
and drain into the main venous vessels. Musculocutaneous vessels arise from intramuscular
vasculature after piercing muscles and spreading out in the subcutaneous tissue.
Fasciocutaneous blood vessels consist of perforating branches from vessels located deep to the
deep fascia. The cutaneous circulation consists of many capillary and arterio-venous
anastomoses, particularly in the extremities to facilitate thermoregulation.
Innervation

The largest part of the innervation of the integumentary system is for the skin to facilitate its
great sensorial capabilities. These include Pacinian corpuscles, Meissners corpuscles and a
large variety of other receptors for a range of stimuli. The components of the integumentary
system receive their innervation, mostly autonomic, via spinal and cranial nerves. The nerve
endings branch out and form reticular plexuses in the dermis, innervating the respective
components.
Clinical considerations
Alopecia areata

Alopecia areata is a non scarring, autoimmune condition which results in hair loss on the scalp
and/or the body. The hair loss can affect the entire scalp (Alopecia totalis) or the entire epidermis
(Alopecia universalis). Apart from understanding the involvement of the immune system, the
exact pathogenesis is unknown yet. It is histopathologically characterized by telogenic (dormant)
hair follicles and infiltrating inflammatory lymphocytes.
Onychomycoses

Onychomycoses are fungal infections and the most common pathologies affecting the nails. They
include distal subungual, proximal subungual, white superficial and candidal. The fungi usually
reside on the scales of the skin of the palms and soles and send hyphae that penetrate the
hyponychium to invade the nail. The commonly affected parts are the nail bed (distal subungual)
and nail plate (proximal subungual, white superficial, candidal).

Bromhidrosis

Bromhidrosis is a condition characterized by an unpleasant body odour. It is due to the

biotransformation of odourless natural secretions, such as sweat, into volatile odorous molecules.
This condition is closely linked to excessive sweating (hyperhidrosis). The pathology also
involves abnormal changes of the apocrine glands.

Anatomy of the Skin

Introduction

The skin is the largest organ and covers the external surface of the human body. It protects us
from ultraviolet radiation, from variations in temperature, pathogens and other toxins. Our skin is
also our connection with the outside world and contains sensory receptors and nerves that enable
us to experience tactile sensation and temperature variations. It can also give us our sense of
racial identity and ethnicity. This article will look at the anatomy of the skin including its layers
and components. We will also discuss function and clinical relevance.
Overview

The skin is also referred to as the integument, and consists of the epidermis and dermis, two
closely associated layers. Beneath the skin we have the subcutaneous layer, which contains fat,
vessels and other structures. Skin is constantly shedding and being replaced by epithelial cells
which divide frequently.
Embryology

The skin starts developing in the fourth week of foetal life. It begins initially as a single cell
thick layer of ectoderm, below which the cells of the mesoderm proliferate and divide.
Fingernails and toenails are keratinous structures, and arise from the ectoderm alone. Specialised
structures such as sweat glands (apocrine and eccrine), hair follicles and sebaceous glands
develop from the epidermis, and grow downwards as invaginations into the dermis. Males have
thicker skin all over the body than females, with the skin of the soles and palms the thickest, and
eyelid and post auricular skin being the thinnest. Variations in thickness are dependent on dermal
thickness, as epidermal thickness remains relatively consistent throughout the body.
Epidermis

This layer arises from the surface ectoderm and is colonized by melanocytes, Langerhans cells
(dendritic cells), as well as Merkel cells (pressure sensing receptors). It is devoid of blood
vessels and relies on the dermis underneath for blood, nutrients and waste disposal.

Stratum corneum

The stratum corneum is composed of corneocytes (mature keratinocytes), each of which is

surrounded by a protein envelope. They are arranged in around 20 cell thick layers (number of
cells in this layer varies by location), which remains together due to corneodesmosomes and
surrounding lipids. The barrier functions of the skin are largely dependent on this layer, and
include fighting infection, chemical effects, daily wear and tear as well as dehydration. When
corneocytes are shed from this layer due to corneodesmosome degradation, the process is
referred to as desquamation. It takes cells two weeks to migrate from the stratum basale to the

stratum corneum. Cells that sit in this layer have no nuclei, and are the largest and most abundant
in the whole epidermis.
Stratum lucidum

The name stratum lucidum comes from Latin for clear, which is lucid. This layer only exists on
the palms and soles, where the thickest skin of the body can be found. This layer is
approximately 4 keratinocytes thick.
Stratum granulosum

The stratum granulosum is the granular layer where the mature anucleated keratinocytes reside
with their cytoplasmic granules. Lipids, which are initially polar, are located within the
cytoplasm of these cells, and are extruded to form a barrier on the cell surface, where they
become non-polar.
Stratum spinosum

Less developed keratinocytes sit in the stratum spinosum, and are connected through
desmosomes. The spinous appearance of this layer is due to the shrinking of the cells (artefact of
fixation for histology slides), which results in desmosomes resembling spines. Langerhans
cells are also located in this layer. They arise from the bone marrow, and are dendritic cells
(antigen presenting cells) that fight infection. They are found in multiple layers of the skin
(basale, spinosum and granulosum) but are most abundant in the stratum spinosum.
Stratum basale

The stratum basale is where the keratinocytes are dividing and growing, and therefore where the
keratinocyte stem cells can be found. They are attached to the basement membrane underneath
by hemidesmosomes. As keratinocytes arise from the stratum basale, they gradually ascend to
the stratum corneum in a process that takes 14 days. This layer also contains melanocytes, which
arise from neural crest cells, and produce melanin (the pigment which gives skin its colour).
Melanin is also found in the retina, uveal tract and hair follicles. The melanin produced here also
accumulates within organelles (melanosomes), which then anchor the pigment to the
surrounding keratinocytes. They end up within the keratinocytes themselves and sit within the
cytoplasm as granules. Melanomas (type of skin cancer) arises from these cells. ACTH, MSH
and oestrogens promote the production of melanin. Ethnic differences in skin colour arise from
the size of the melanosomes rather than the cell number. Melanosomes decline in number with
age.
Receptors

Pressure receptors (Merkel cells) are also found in this layer, together with sensory nerves for
tactile discrimination/acuity.
Meissners corpuscles detect light touch and low frequency vibrations and are found mainly in
the fingertips. The Pacinian corpuscles lie within the deep dermis and detect pressure and high
frequency vibrations. Cutaneous nerves detect sensation, and Krause bulbs and Ruffini
corpuscles detect temperature (cold and heat respectively). Each spinal nerve supplies a given
dermatome, or strip/area of skin. They can be tested clinically to look for lesions in the nerves or
the nerve roots.
Basement membrane

The thin and undulating basement membrane is composed of two layers, that lies between the
stratum basale and the dermis. It is formed by the lamina lucida (it is thin and lies right below
the stratum basale) and the lamina densa (it is deeper and lies adjacent to the dermis). It
regulates the movement of molecules and ions at the dermal-epidermal junction and anchors the
epidermis to the dermis. Proteins from this layer have been found to speed up the process of
epithelial cell division. The layer can also act as a barrier to slow the spread of cancers arising
in the epidermis to the dermis and beyond.
Dermis

This layer of skin arises from the mesoderm, and contains blood vessels, sensory receptors,
fibroblasts and collagen. Its primary function is to support and sustain the epidermis.

Papillary dermis

This is the more superficial of the two dermal layers, and is composed of loose connective
tissue that is filled with capillaries, collagen and elastic fibers. There are a number of dermal
papillae that arise from this surface and form an irregular layer. They act to increase the surface
area between the dermis and epidermis for the transfer of oxygen and nutrients up to the
epidermis.
Reticular dermis

The deeper reticular dermis is thicker and is composed of thicker connective tissue. This matrix
is bathed in a fluid containing a number of molecules including mucopolysaccharides and
glycoproteins. The deepest border of the reticular dermis is irregular and is superficial to the
subcutaneous layer, which acts as a cushion beneath the skin.
Within the dermis, the major cell type is the fibroblast. It gains its name from its ability to form
procollagen (which is transformed into collagen by cleavage and cross linkage) and numerous
elastic fibers. In terms of weight, collagen provides 70% of the weight of the dermis. Type 1
collagen makes up 85% of this, with type 3 collagen forming the remainder. Collagen provides
high strength as well as resistance to shearing and mechanical forces. Elastic fibers enable the
skin to return to its original shape after deformation, and also has resistance to deformation of the
skin.
Appendages

These are additional structures that lie within the dermis, and are lined with epithelial cells that
enable them to divide and replicate swiftly. In cases of epithelial damage, these appendages act
as a source of additional epithelial cells.
Pilosebaceous units

These are also known as holocrine glands. They produce sebum (which is composed of lipids
such as triglycerides, wax esters, squalene and free fatty acids among other substances). It
lubricates the skin, maintains moisture and protects against friction. Sebaceous glands are found
all over the body (highest concentration in the face and scalp), except for the palms and feet (sole
and dorsum).
Eccrine sweat glands

They are found all over the body (aside from the lip border, the external ear and parts of the
external genitalia i.e. glans penis and labia majora). This gland produces sweat that cools the
body when it evaporates. A coiled duct that connects to the epidermis forms the gland and the
temperature center in the hypothalamus regulates sweat formation.
Apocrine glands

These are found in the axilla and anogenital area and begin working during puberty. The sweat
secreted by apocrine glands only produces odour when in contact with the bacterial skin flora.
The mammary gland is essentially a highly modified apocrine gland. Modified versions are also
found in the ear (ceruminous glands) and the eyelid (Molls glands).
Vasculature and lymphatics

The major arteries of the body form complex vascular networks that perfuse the skin. They also
aid with thermoregulation and supply the skin with oxygen and nutrients.
There are lymphatic vessels that arise from the interstitial spaces of the dermal papillae. They
drain to the deeper plexi (dermal and subdermal), which join to form larger channels and
ultimately enter the subclavian vein to reach the venous circulation.
Clinical Points
Skin cancer

There are many types of skin cancer (non-melanoma and melanoma skin cancers), depending on
the type of cell and the nature of the cancer. Basal cell carcinomas are known a rodent ulcers
(due to their dark gnawing appearance) and arise from the stratum basale. Squamous cell
carcinomas arise from the squamous cells found in the stratum spinosum. Melanoma is a
malignant cancer that arises from the melanocytes. Treatment usually involves surgical excision.
Naevi (moles)

These result from the benign proliferation of melanocytes. They may be congenital or acquired.
Fairer people tend to have more moles.
Surgical skin flaps

Plastic surgeons utilise the skin in all their operations. Skin grafts can be used to cover defects at
other sites (nearby or distant), and are transplanted onto vascular bed of the defect. Split
thickness skin grafts (epidermis and a layer of dermis) can be taken and spread into a net like
formation for use on a distant site. The donor site recovers a few weeks later.
Skin flaps are of varying thickness and can be harvested and transferred to the defect. Pedicled
flaps are attached to their artery which is not excised. Free flaps are harvested along with their
artery and transferred to a distant site. The skin can be excised and rearranged (not harvested or
removed) with different surgical flaps e.g. z plasty, VY advancement etc. that are used to cover
defects and provide cosmetically improved outcomes.
Ehlers-Danlos syndrome

This is a collagen disease that usually causes symptoms including stretchy skin, hypermobile
joints, or fragile skin. The symptoms and type of disease depend on the type of collagen affected.
Psoriasis

This is an autoimmune condition resulting in pink scaly plaques across the body. There is a
strong genetic component, and treatment includes phototherapy, immunosuppressants, topical
agents and alternative therapies.
Eczema

This is also known as atopic dermatitis, and is essentially dry inflammation of the skin. The skin
develops patchy areas of dryness. The condition is linked to other hypersensitivity conditions e.g.
asthma and hayfever. Treatment includes emollients and steroid creams.
Burns

Burns are of varying severity depending on location, depth and surface area. Treatment includes
fluid replacement (the Parkland formula for fluid amount depends on burn surface area), skin
grafts, antibiotics to reduce the risk of wound infection as well as keeping the patient warm.
Burns patients lose fluid fast due to their exposed deep tissue.