The Face

Skin of the Face

-possesses numerous sweat and sebaceous glands
- connected to the underlying bones by loose connective tissue in which muscles of expression are
embedded
- no deep fascia is present in the face
Sensory Nerves of the Face
- supplied by branches of the 3 divisions of the TRIGEMINAL NERVE (except for the small area oer the
angle of the mandible and the parotid gland spupplied by the great auricular nerve C2 and 3)
- 3 divisions of the trigeminal nerve

Opthalmic Nerve supplies the region developed from the frontonasal process
Maxillary Nerve serves the region developed from the maxillary process of the 1st pharyngeal arch
Mandibular Nerve serves the region developed from the mandibular process of the 1st pharyngeal
arch

-also supply proprioceptive fibers to the underlying muscles of facial expression

- sensory nerve supply to the mouth, teeth, nasal cavities and paranasal air sinuses
Ophalmic Nerve supplies the skin of the forehead, upper eyelid, conjunctiva and side of the nose down to
and including the tip.
-5 branches:
lacrimal nerve skin and conjunctiva of the lateral part of the upper eyelid
supraorbital nerve skin and conjunctiva of the central part of the upper eyelid, skin of the
forehead
supratrochlear nerve skin and conjunctiva on the medial part of the upper eyelid, skin over the
lower part of the forehead
infratrochlear nerve skin and conjunctiva on the medial part of the upper eyelid
external nasal nerve skin on the side of the nose down as far as the tip
Maxillary Nerve supplies the skin on the posterior part of the side of the nose, lower eyelid, cheek, upper
lip, and lateral side of the orbital opening
-3 branches:
infraorbital nerve skin of the lower eyelid and cheek, side of the nose, upper lip
zyygomaticofacial nerve skin over the prominence of the cheek
zygomaticotemporal nerve skin over the temple
Mandibular Nerve supplies the skin of the lower lip, lower part of the face, temporal region, part of the
auricle
-3 branches:
mental nerve skin of the lower lip, chin
buccal nerve skin over the small area of the cheek
auricotemporal nerve skin of the auricle, external auditory meatus, outer surface of the tympanic
membrane and skin of the scalp above the auricle

Clinical Notes:
Trigeminal Neuralgia
- Condition in which the patient experiences excruciating pain in the distribution of the mandibular or
maxillary division, with ophthalmic division usually escaping.
- Facial skin receives its supply from the 3 divisions of the trigeminal nerve.
-Great auricular nerve C2 and 3 supplies area of skin over the angle of the jaw
Arterial Supply of the Face
-2 main vessels:
facial artery
o arises from the external carotid artery
o arched upward and over the submandibular gland
o pulse can be easily felt
o covered by platysma and risorius muscles
o 7 branches:
submental artery skin of the chin and lower lip
inferior labial artery
superior labial artery
lateral nasal artery skin on the side and dorsum of the nose
superficial temporal artery smaller terminal branch of the external carotid artery
transverse facial artery branch of the superficial temporal artery
superaorbital and supratrochlear arteries branch of ophthalmic artery, supply the
skin of the forehead.
superficial temporal arteries
Clinical Notes:
Blood Supply of the Facial Skin
- blood supply of the skin is profuse
-rare in plastic surgery for skin flaps to necrose in this region
Facial Arteries and Taking the Patients Pulse
-superficial temporal artery common site for anesthetist to take the patients pulse
Venous Drainage of the Face
Facial vein
-union of the supraorbital and supratrochlear veins,
-connected to the superior ophthalmic vein directly through the supraorbital vein
-connected to cavernous sinus by superior ophthalmic vein provides a pathway for the spread of infection
from the face to the cavernous sinus
-crosses superficial to the submandibular gland
-joined by anterior division of the retromandibular vein
-drains to internal jugular vein

-tributaries:
o
o
o

pterygoid venous plexus by deep facial vein

cavernous sinus by superior ophthalmic vein
transverse facial vein

Lymph Drainage of the Face

o submandibular lymph nodes forehead and anterior part of the face
o buccal lymph nodes o parotid lymph nodes lateral part of the face, lateral parts of the eyelids
o submental lymph nodes central part of the lower lip, skin of the chin
Clinical Notes:
Facial Infections and Cavernous Sinus Thrombosis
- Nose, eye, upper lip dangerous zone to have infection
- boil in these region can cause thrombosis of the facial vein, spread of organisms through the inferior
ophthalmic vein to the cavernous sinus

Bones of the Face

The bones that forms the skull are shown below

Frontal bone forms the superior orbital margins and area above them.
- Contains the frontal air sinus.
Zygomatic bone forms the lateral orbital margin.
Zygomatic and maxilla forms the inferior orbital margin
Medial orbital margin is formed above the maxillary process of the frontal bone,
And below by the frontal process of the maxilla.
Nasal bones- forms the root of the nose
- Which articulates below with the maxilla and above with the frontal
bones.
- Anteriorly, the nose is completed by the upper and lower plates of
hyaline cartilage and small cartilages of the ala nasi.
Maxilla important central bone of the middle third of the face containing its
teeth and the maxillary air sinus.
Mandible bone of the lower third of the face.

Muscles of the Face (muscles of facial expression)

Embedded in the superficial fascia
Most arise from the bones of the skull and are inserted into the skin
Orifices : guard
- Orbit: eyelids
- Nose: nostrils
- Mouth: lips
Function: serve as sphincters or dilators
Secondary fxn: modify the expression of the face
All muscles of the face are developed from second pharyngeal arch
Supplied by the facial nerve
Muscles of the eyelids
Orbicularis oculi sphincter m. of the eyelids
Dilator muscles:
1. Levator palpebrae superioris

2. Occipitofrontalis forms the scalp

The origin, insertion and nerve supply and action are described in table 11.4
presented on the last page of this summary.
Muscles of the nostrils
CompresSor naris Sphincter muscle
Dilator naris dilator muscle
The origin, insertion and nerve supply and action are described in table 11.4
presented on the last page of this summary.
Muscles of the lips and cheeks
Orbicularis oris sphincter muscles of the lips.
Origin and insertion: the fibers encircle the oral oris within the substance of
the lips. Some of the fibers arise near the midline from the maxilla above and
mandible below. Other fibers arise from the deep surface of the skin and pass
obliquely to the mucous membrane lining the inner surface of the lips.
Many fibers are derived from the buccinators muscle
Nerve supply: buccal and mandibular branches of the facial nerve
Action: compresses the lip together
Dilator muscle of the Lips
Radiate out from the lips
Action: separate from the lips; this movement is usually accompanied by
the separation of the jaws.
The muscles arise from the bones and fascia around the oral aperture and
converge to be inserted into the substance of the lips.
Traced from the side of the nose to the angle of the mouth and then below
the oral aperture, the muscles are named as follows:
1. Levator labii superioris alaeque nasi
2. Levator labii superioris
3. Zygomaticus minor
4. Zygomaticus major
5. Levator anguli oris
6. Risorius
7. Depressor anguli oris
8. Depressor labii inferioris
9. Mentalis
Nerve supply : buccal and mandibular branches of the facial nerve

Muscles of the cheek

Buccinator
Origin from the outer surface of the alveolar margins of the maxilla and
mandible opposite the molar teeth and from the pterygomandibular ligament.
Insertion: the muscle fibers pass forward, forming the muscle layer of the
cheek.
- Pierced by the parotid duct
- The the angle of the mouth the central fibers decussate, those from
below the entering the upper and lower lip
- The highest and lowest continue into the upper and lower lips
respectively, without intersecting.
- The buccinators thus blends and forms part of the orbicularis oris
muscle.
Nerve supply buccal branch of the facial nerve

Action : compresses the cheeks and lips against the teeth.

The origin, insertion and nerve supply and action of the lips and cheeks are
described in table 11.4 presented on the last page of this summary.

Clinical notes :
Facial muscle paralysis
The facial muscle are innervated by the FACIAL NERVE. Damage to the nerve
- in the internal acoustic meatus (by a tumor),
-in the middle of the ear by infection or operaton,
-in the facial nerve canal (perineuritis, bells palsy)
- in the parotid gland by a tumor
- or by lacerations of the face will cause distortion of the face, with drooping of
the lower eyelid and the angle of the mouth will sag on the affected side. This is
essentially the lower motor neuron lesion.
- upper motor neuron lesion (involvement of the pyramidal tracts) will
leave the upper part of the face normal because the neurons supplying this part
of the face receive corticobulbar fibers from both cerebral
Facial nerve
As the facial nerve runs forward within the substance of the parotid gland, it
divides into 5 terminal branches.
1. Temporal branch emrges from the upper border of the gland and supplies :
- the anterior and superior auricular muscles
- the frontal belly of the occipitalis frontsalis
- orbicularis oris
- corrugator supercilii
2. Zygomatic branch emerges from the upper border of the gland , supplies:
orbicularis oculi
3. Buccal merges from the anterior border of the parotid duct and supplies: the
buccinator muscle, and muscles of the upper lip and nostril
4. Mandibular - merges from the anterior border of the gland
Supplies: muscles of lower lip
5. Cervical emerges from the lower border of the gland , passes forward in the
neck below the mandible.
supplies: the platysma muscle
facial nerve and second pharyngeal arch : supplies all the muscles of facial
expression, does not supply the skin
-

Its branches communicate with the branches of the trigeminal

nerve.
It is believed that the proprioceptive nerve fibers of the facial
muscles leave the CNS via trigeminal nerve.

THE SCALP
STRUCTURE (fig 11.37, 11.38)
has 5 layers
1st 3 are bound together and move as a unit
SCALP:
Skin
Thick, with hair and sebaceous glands
Connective tissue
Beneath skin
Fibrofatty, fibrous septa unites skin to underlying aponeurosis of
occipitofrontalis muscle
Numerous arteries and veins
Arteries: branches of ext. and int. carotid arteries and free anastomosis
between them
Aponeurosis (epicranial)
Thin, tendinous sheet
Unites occipital and frontal bellies of occipitofrontalis muscle
Lateral margins of aponeurosis attached to temporal fascia extends
laterally as far as the attachment of the aponeurosis to temporal fascia
SUBAPONEUROTIC space= potential space beneath epicranial aponeurosis


Loose

Limited in front and behind by ORIGINS of OCCIPITOFRONTALIS m.

areolar tissue
Occupies subaponeurotic space
Loosely connects Epicranial aponeurosis to Periosteum of the skull
(pericranium)
Contains few small arteries, but contains some emissiary veins
Emissiary veins = valveless, connect superficial veins of scalp with Diploic
veins of skull bones and with intracranial venous sinuses
Pericranium
Periosteum that covers the skull bones outer surface
@ SUTURES between individual skull bones = periosteum on the Outer surface
becomes continuous with periosteum on the Inner surface of skull bones

MUSCLES OF THE SCALP

OCCIPITOFRONTALIS M.

when it contracts = 1st 3 layers of the scalp move Forward or Backward, the
loose areolar tissue of the 4th layer of the scalp allowing aponeurosis to move
on the pericranium
frontal bellies= can raise eyebrows in expression of surprise or horror

SENSORY NERVE SUPPLY OF THE SCALP (fig 11.37)

main trunks of Sensory nerves lie in superficial fascia
moving laterally from the midline anteriorly, ff nerves as present:
Supratrochlear Nerve
- branch of ophthalmic division of Trigeminal N.
- winds around the Superior orbital margin
and supplies the Scalp
- passes backward to Median plane and reaches as far as the Vertex of the skull
Supraorbital Nerve
- brach of ophthalmic div. of Trigeminal N.
- winds around the superior orbital margin and Ascends over the forehead
- supplies the Scalp as far backward as the Vertex
Zygomaticotemporal Nerve
- branch of Maxillary div. of Trigeminal N.
- supplies Scalp over the temple
Auriculotemporal Nerve
- branch of Mandibular div. of Trigeminal N.
- Ascends over the side of the head from In front of the auricle
- Its terminal branches supply skin over temporal region
Lesser Occipital Nerve
- branch of Cervical plexus (C2)
- supplies Scalp over lateral part of the occipital region and skin over medial
surface of auricle
Greater Occipital Nerve
- branch of Posterior ramus of C2
- Ascend over the back of the scalp
- supplies Skin as far forward as the vertex
ARTERIAL SUPPLY OF THE SCALP (fig 11.37)
- scalp has rich supply of blood to nourish hair follicles
- smallest cuts may bleed profusely

arteries lie in superficial fascia

moving laterally from midline anteriorly the ff arteries are present:

Supratrochlear and Supraorbital arteries

- braches of Ophthalmic a.
- ascend over the forehead in company with the supratrochlear and supraorbital
nerves
Superficial Temporal Artery
- smaller terminal branch of Ext. carotid artery
- ascends in front of the auricle, in company with the auriculotemporal nerve
- divides into Anterior and Posterior branches, which supply the skin over the
Frontal and Temporal regions
Posterior Auricular Artery
- branch of Ext. carotid artery
- ascends behind the auricle to supply the Scalp above and behind the auricle
Occipital Artery
- branch of Ext. carotid artery
- ascend from apex of the posterior triangle, in company with the great occipital
nerve
- supplies skin over the back of the scalp and reaches as high as the vertex
VENOUS DRAINAGE OF THE SCALP (fig 11.37, 11.39)
Supratrochlear and Supraorbital Veins
- unite at medial margin of the orbit to form the facial vein
Superficial Temporal Vein
- unites with the maxillary vein in the parotid gland to form the
Retromandibular Vein
Posterior Auricular Vein
unites with the posterior div. of the retromandibular vein, just below the
parotid glands, to form the External jugular vein
Occipital Vein
- Drains into suboccipital venous plexus
- Lies beneath the floor of the upper part of the posterior triangle
- Plexus drains into the vertebral veins or the internal jugular veins
veins of the scalp freely anastomose with one another, and are connected to diploic
veins of the skull bones and the intracranial venous sinuses by the valveless
EMISSIARY VEINS

LYMPH DRAINAGE OF THE SCALP (fig 11.40)

- Lymph vessels in the anterior part of the scalp and forehead drain into the
Submandibular lymph nodes
- Drainage from the lateral part of the scalp and above the ear is into
Superficial parotid (preauricular) nodes
- Part of the scalp above and behind the ear drain into the Mastoid nodes
- Back of the scalp drain into Occipital nodes