Superficial Structures of the Face and Scalp
The subcutaneous tissue of the face
and scalp is highly vascular and is traversed by several nerves. Most of the
nerves are sensory to skin and
include branches of the trigeminal (V) and upper cervical spinal nerves. In
addition, there are branches that are motor from the facial (VII) nerve to a
group of muscles in the subcutaneous tissues of the face, scalp and front of
the neck, known as the muscles of facial expression.
Muscles
of facial expression
In
general, these muscles are arranged as sphincters or dilators around the
orifices of the face (Fig. 7.18). Most
are anchored to bone at one end and attached to skin at the other.
Palpebral
fissure
The
sphincter of the palpebral fissure (the gap between the eyelids) is orbicularis
oculi, which is divided into inner palpebral and outer orbital parts. The
palpebral part lies within the eyelids and is attached to the medial and
lateral palpebral ligaments. The orbital portion is attached only to the medial
palpebral ligament, and its fibres lie around the orbital margin. Both parts close
the palpebral fissure, the palpebral part gently and the orbital part
forcefully as when ‘screwing up the eyes’. The palpebral part also helps sweep
tears medially across the cornea from lacrimal gland to lacrimal canaliculi.
The dilator components are provided by levator palpebrae superioris within the
orbit (p. 380), and by occipitofrontalis in the scalp. The latter muscle has
two bellies, occipital and frontal, linked by an extensive intermediate tendon,
the epicranial aponeurosis, which forms a mobile layer over the vault of the
skull. From its posterior extremity the occipital belly (occipitalis) descends
to its attachment on the highest nuchal line of the occipital bone (Fig. 7.19); from its anterior end the frontal belly
(frontalis) descends in the forehead and its fibres interdigitate with those of
orbicularis oculi and attach to skin near the eyebrow. Occipitalis fixes the epicranial aponeurosis
allowing frontalis to raise the eyebrows.
Around
each nostril is nasalis with two feeble parts, alar and transverse, which
dilate and compress the nostrils, respectively.
Orbicularis
oris, the sphincter of the mouth, is embedded in the lips and attaches near the
midline to the mandible and maxilla.
In
addition, there are dilators around the mouth whose fibres continue into
orbicularis oris. The most medial dilator of the upper lip is levator labii
superioris alaeque nasi. This muscle attaches near the medial margin of the
orbit and runs to the alar cartilage of the nose and to the upper lip. Levator
labii superioris is attached to bone beneath the orbital margin, whereas
levator anguli oris lies slightly deeper and its fibres incline towards the
angle of the mouth. Two of the dilator muscles take attachment from the zygoma:
zygomaticus major and minor. Attached to the mandible are three muscles,
called, from lateral to medial, depressor anguli oris, depressor labii infe-
rioris and mentalis.
The
buccinator muscle (Figs 7.18 & 7.20) lies deep to the other dilator muscles
in the wall of the cheek. Anteriorly, it blends with the deep surface of
orbicularis oris. Posteriorly, it gains attachment to the outer surface of
the mandible from the level of the first to the third molar teeth. Passing
behind the third molar tooth, buccinator is attached to the pterygomandibular
raphe and the pterygoid hamulus. The muscle attachment continues forwards along
the outer surface of the maxilla as far as the first upper molar tooth.
Buccinator controls the size of the vestibule of the mouth (that part of the
buccal cavity lying between the cheek and the teeth).
The
platysma (Fig. 7.21), the most extensive muscle of
facial expression, descends in the subcutaneous tissue of the neck from the
inferior border of the mandible and fades out on the anterior surface of the
thorax. A few fibres may run horizontally from the angle of the mouth as
risorius. Platysma is most easily seen in action during respiratory distress
when the skin of the neck is pulled taut.
Ear
In
the human, the auricular muscles are almost vestigial.
Facial
nerve
All
the muscles of facial expression derive their motor nerve supply from the
facial (VII) nerve. Occipitalis and some of the auricular muscles are innervated
by the posterior auricular branch of the nerve (p. 340); the remaining muscles
are supplied by the five sets of branches (Fig. 7.22) that
emerge from the anterior border of the parotid gland (p. 339). The temporal
branch of the facial nerve ascends to supply the remaining auricular muscles
and frontalis. The zygomatic branch is directed towards the eye and supplies
muscles above and below the palpebral fissure. The third branch, the buccal,
runs horizontally forwards to innervate buccinator and the muscles of the upper
lip. The mandibular branch supplies the muscles of the lower lip, dipping below
the mandible in its course. The cervical branch descends to supply platysma.
Blood
supply of face
Most
of the superficial structures of the face obtain their blood supply from the
facial artery (Fig. 7.22), a
branch of the external carotid artery. The facial artery enters the face by
hooking under the inferior border of the mandible, where it is easily palpated. The vessel then pursues a tortuous course across the face towards the
inner angle of the orbit. The area of the face in front of the ear is supplied
by the transverse facial artery, an anterior branch of the superficial temporal
artery. Emerging from the orbit to supply the forehead are the supraorbital and
supratrochlear branches of the ophthalmic artery.
Blood
from the face drains into the facial vein (Fig. 7.22), which
accompanies the facial artery. The vein also receives the supratrochlear and
supraorbital veins and thus communicates with ophthalmic veins in the orbit.
Blood from the lateral part of the face drains into the superficial temporal
vein.
Sensory
supply
The
sensory nerve supply of the face is conveyed in branches of the three divisions
of the trigeminal (V) nerve (Fig. 7.23).
Scalp
The
scalp (Fig. 7.24) extends from the superior nuchal line posteriorly to the
superior orbital margin anteriorly, and to the external acoustic meatus and
zygomatic arch laterally. It comprises two functional layers applied to the
outer surface of the vault of the skull. Close to the bones lies the
pericranium, which forms the periosteum of the skull. This is loosely attached
over each constituent bone but is firmly bound to the sutures so that
subperiosteal bleeding is limited to the area of the bones involved.
Superficial to the pericranium, but separated from it by a layer of loose
connective tissue, lie the epicranial aponeurosis (intermediate tendon of
occipitofrontalis) and the skin of the scalp, firmly bound to each other so
that they move as one over the underlying pericranium and skull.
The
arteries and nerves that supply the scalp enter at its circumference and
because they accompany each other, they will be described together, starting
anteriorly. Near the midline are the supratrochlear and supraorbital nerves,
arteries and veins. The nerves are derived from the ophthal- mic division of
the trigeminal (V) nerve. The vessels communicate with their ophthalmic
counterparts within the orbit.
Lateral
to the orbit the zygomatico-temporal nerve from the maxillary division of the
trigeminal nerve, accompanied by its vessels, ascends a short distance into the
scalp. Just in front of the ear, the auriculotemporal nerve from the mandibular
division of the fifth cranial nerve passes into the scalp. The superficial
temporal artery and vein follow a similar course.
The
area of the scalp behind the ear is supplied by the lesser occipital nerve (C2
anterior ramus) accompanied by the posterior auricular artery and vein.
Posteriorly near the midline the scalp receives the greater occipital nerve (C2
posterior ramus) and the occipital artery and vein.
In
addition, venous blood may drain via the diploic veins of the skull into the
intracranial venous sinuses. Scalp wounds bleed profusely, making suturing
difficult. To diminish bleeding, circumferential pressure may be temporarily
applied with an elastic bandage.
