Applied Surgical Anatomy of Head and Neck

Scalp
Upper Facial Skeleton:

Frontal Bone
Sphenoid Bone

Mid Facial Skeleton:

Maxilla
Zygoma

Different Approaches:
Nasal Bone
Ethmoid Bone
Vomer
Palatine Bone
Inferior Nasal Concha
Frontal Bone
Sphenoid Bone

Lower Facial Skeleton:

Mandible
TMJ
Mandibular Fracture Location
Anatomic Fractures in displacement

Different Approaches:

Neck:
Surgical Anatomy of Scalp Temporal and Face

Scalp:
Scalp is made of five layers, three of which are closely bound together.
These are the:
1. Skin
2. Dense connective tissue
3. Galea Aponeurotica
Deep into this layer is loose connective tissue and the periosteum or
pericranial layer.
Scalp bleeds freely because the vessels are bound firmly in the dense
connective tissue layer. This firm union and extensive blood supply
frequently make bleeding excessive and often difficult to control with
hemostats.
Pressure usually controls the open bleeders and the rapid application of
Raney’s clips controls full thickness laceration or elective incisions.
Dissection of the scalp is rather easy because of nature of loose connective
tissue layers, however effusion of fluid spreads rapidly in this plane leading
to Bog like edema.
The innervation of the scalp comes from the trigeminal nerve anteriorly and
laterally, and from the cervical nerves C2, C3 posteriorly. If dissection done
within the loose connective tissue layer, these nerves are avoided.
In supra orbital region, the superior orbital branch of trigeminal nerve passes
through either a notch or a foramen to innervate area of scalp. The supra
trochlear nerve is located slightly medially and innervates the upper lid and
the medial area of the forehead. Care should be taken when one elevates
flaps and manages laceration in this area.
Scalp is supplied in front of auricle by
1. Supra trochlear.
2. Supra Orbital.
Branches of Ophthalmic artery which in turn is a branch of Internal
Carotid Artery and Superficial Temporal artery branch of External Carotid
Artery.
Behind the auricle scalp is supplied from backward by
1. Posterior Auricle.
2. Occipital Arteries.
Both are branch of External Carotid Artery.
Frontal Bone:

Frontal Bone is a cranial bone that is unpaired and forms the anterior portion
of the calvaria. The importance of this bone in facial trauma is its
relationship.
Frontal bone articulates anteriorly to mid facial skeleton and paranasal
sinus, laterally with zygoma, medially with the maxilla and nasal bones.
Inferiorly and deep in the middle of the face it articulates with the
ethmoid and lacrimal bones. Posterio inferiorly articulates with the wings of
the sphenoid bone. Posterio laterally with parietal bones.
The frontal sinus lies in the frontal bone in an area superior to the
articulation with the nasal bones. About 4% of the population do not have a
frontal sinus. The sinus is divided into left and right by a intra sinus septum.
A well formed duct drains it into the anterior middle meatus of the nose,
where it empties. The frontal sinuses are protected some what from injury
by supra orbital ridges highly resistant.
Surgical Note:- Multiple incisions and techniques of management for the frontal sinus
exist. The major anatomic point of concern is the inner table, which when fractured
demands a neuro surgical evaluation.
Other areas of concern are the supra orbital nerves which can be carefully saved with
careful dissection and removal from supra orbital foramen by use of small Osteotome.
The neuro vascular bundle can then be retracted with orbital contents.

Sphenoid Bone:-

The Sphenoid Bone is a single midline bone situated at the base of the skull, that
oreates antero inferior extent of the cranial base and posterior transition from facial bones
to cranial bones.
The Sphenoid Bone articulates with the temporal and occipital bones to form the cranial
base and anteriorly and superiorly it joins the parietal and frontal bones to complete the
cranial complex.
It meets the vomer and ethmoid bone in the midline anteriorly and meets the zygoma,
palatine bones and sometimes tuberosity of the maxilla to complete the articulation with
facial skeleton.
The body of Sphenoid bone is hollow and forms two cavities separated by thin bony
septum. The hollow cavities are the sphenoid sinuses and they drain into sphenoethmoid
recess above and behind the superior nasal concha.
Although, air fluid levels are frequently be noted on radiographs, surgical management in
the trauma patient is rarely necessary.

Maxilla:-

The Maxilla is paired bone of the upper jaw, fused to form one bone and is the
Central focus of the middle third of the face.
Each hemi maxilla contains a large pyramid shaped body, the maxillary sinus
(antrum of highmore) and four prominent processes , the frontal, alveolar, zygomatic and
palatine processes.
The anterior wall of the sinus is the facial surface of the maxilla, and is usually
thin, the medial wall is the lateral nasal wall. The sinus opens superiorly and medially
into nasal cavity at the semilunar hiatus in the middle meatus. The superior wall or roof
of the sinus is the orbital floor and the floor of the sinus is the palatine and alveolar
processes of the maxilla.
The frontal process arises from the anteromedial corner of the body and
articulates with the frontal bone to form the medial orbital rim. The medial portion of the
frontal process fuses with the nasal bone and may therefore termed the nasofrontal
process. Posteriorly the process articulates with the lacrimal bone to form the anterior
portion of the medial orbital wall. This area of articulation with frontal bone, nasal bone
and lacrimal bone is prominent in the facial skeleton and is frequently fractured by blunt
trauma.
The inferiorly extending portion of the maxilla is the alveolar process which
contains the maxillary teeth. The teeth are key to the accurate management of many mid
facial fractures. The alveolar process may be fractured by direct trauma and therefore
may be functionally separate from other portion of the maxilla.
The horizontal process arising from the lower edge of the medial surface of the
body is the palatine process. It joins the process of the other side and forms the major
portion of the hard palate.
The surgical anatomy of the facial skeleton and adjacent structures is extremely
important in understanding the pattern of fracture. The displacement of fractured bone
fragments and the factors necessary for uncomplicated healing.
Traditional division of facial skeleton into upper third, middle third and lower
third is useful when considering detailed treatment of particular fractures and their
interconnections because they tend to increase support to each other.
The upper facial skeleton, the frontal bone, the body and greater and lesser wings
of sphenoid are not usually fractured. In fact they are protected to a considerable extent
by the cushioning effect achieved as the fracturing force crushes the comparatively weak
bones comprising the middle third of the facial skeleton. When fracture of the cranial
component of the facial skeleton do occur there are important consequences.
The brain may have sustained direct injury.
The brain may be at risk from indirect injury, secondary to bleeding at fracture site.
A fracture may involve the posterior wall of the frontal sinus, the orbital roof or
cribriform plate, which in turn associated with a breach of the duramater and leakage of
cerebrospinal fluid.
Displacement particularly in caudal direction will interfere with reduction of facial bones
as a whole.

The Mid Facial Skeleton:

This area of facial skeleton is made of maxilla, zygoma, lacrimal, nasal, palatine,
inferior nasal concha and vomer bones and also sphenoid frontal and ethmoid bones are
also considered since they are frequently traumatized in mid facial fracture.
The zygomatic process of the maxilla arises from the anterolateral corner of the
maxilla and articulates laterally with the zygoma. Together they form the inferior orbital
rim and the greatest portion of the orbital floor. The infraorbital foramen is on the is on
the anterior surface of the zygomatic process of the maxilla.

Surgical Note:-

The classic Lefort I fractures passes through the anterior wall of the maxilla, extending
posteriorly to the Pterygoid plates.
Eventhough maxilla is fused at midline, it behaves like two separate bones. It
may often be separated along the midpalatal suture in the more extreme facial fractures.

Zygoma:-
The Zygoma (Zygomatic bone, malar bone) is paired bone that makes up the
essence of the cheek prominence. This thick strong diamond shaped bone forms the
lateral and anterior projections to the midface and it composed of four process.
The frontal process forms the lateral orbital wall and articulates with the frontal bone at
Fronto zygomatic suture. It is this articulation that is either separated or rotated in
isolated zygomatic fractures.
The temporal process forms the zygomatic arch articulates with the temporal bone.
The maxillary process articulates with the maxilla to form the infra orbital rim and part of
the floor of the orbit.
The fourth process forms the maxilla on the lateral wall and forms the zygomatic
eminence. This is an area of thickened bone that is usually available for fixation in the
treatment of zygomaticomaxillary complex. (ZMC) fractures.

Along the crest of the zygoma on the inferior aspect is the insertion of the masseter
muscle. The direction of force for this muscle is downward and backward and its
contraction contributes to displacement of the complex fracture of the zygoma and
precipitate redisplacement in the improperly fixated fracture.