HSB – Head • Wounds bleed profusely as blood vessels are

Mel Anthony Y. Cruz, MD prevented from retraction by fibrous tissue

RCCO 2021 • Subcutaneous hemorrhage are not extensive
since fascia is dense
SCALP • Inflammation cause little swelling but are much
• Soft tisse covering the cranial vault painful
• It is the hair bearing area of the skull
• Extends from supraorbital margin (anteriorly) to APONEUROSIS
external occipital protuberance and superior • Anteriorly, frontal belly and posteriorly, occipital
nuchal line (posteriorly) belly of occipitofrontalis muscle
• On each side to superior temporal line (laterally) • Frontal belly originate from skin of forehead and
migled with orbicularis oculi muscle
Anterior: • Occipital belly orginate from laterla 2/3 or superior
Supraorbital margin nuchal line
• It gaps if cut transversely and should be stitched
Posterior:
Superior nuchal line
LOOSE AREOLAR TISSUE
Lateral: • Extends anteriorly into the eyelids because
Superior temporal line frontalis has no bony attachment
• Posteriorly to superior nuchal line
• On each side to superior temporal line
• Bleeding cause generalized swelling of scalp
LAYERS OF THE SCALP • Called DANGEROUS LAYER of scalp because
EMISSARY VEINS open here and may carry any
S – Skin infections inside the brain through VENOUS
C – Connective Tissue (superficial fascia) SINUS
A – Aponeurosis (galea aponeurotica) • Bleeding leads to BLACK EYE
L – Loose areolar tissue
P – pericranium (periosteum) • CAPUT SUCCEDANEUM in newborns

!!! 1st three layers are FUSED together PERICRANIUM

• Periosteum of the skull
• Lossely attached to the surface of bone but is
firmly adherent to the sutures
• Firmly attached to the bone by fiber – SHARPEY’S
FIBERS
• Injury deep to it takes the shape of the bone as
seen in CEPHALHAEMATOMA

SKIN
• Thick and hairy
• Firmly attached to the epicranial aponeurosis
through dense fascia
• Abundant sebaceous glands
• Sebaceous cyst are common

CONNECTIVE TISSUE
• Fibrous and dense containing blood vessels and
nerves
• Binds skin to subjacent aponeurosis

Source: PPT from HSB department 1 of 19

 NERVE SUPPLY
• IN FRONT of auricle
o Supratrochlear n. Zygomatico-
o Supraorbital n. temporal n.
o Zygomaticotemporal n.
o Auriculotemporal n.
Auriculo-
o Temporal branch of facial n.
temporal n.
• BEHIND auricle
o Greater auricular n.
o Lesser occipital n.
o Greater occipital n. NERVES: BACK OF AURICLE
o Third occipital n. Motor:
o Post. Auricular branch of facial n. • Posterior auricular nerve
Supplies:
NERVES: FRONT OF AURICLE o Occipitalis muscle
Motor: o Superior & Posterior auricular muscles
• Temporal branch of Facial nerve
Supplies:
o Anterior & superior articularis
Posterior
o Frontalis muscle auricular n.
o Upper part of orbicularis oculi

Temporal branch
of facial nerve

Sensory:
• Greater occipital n.
o From posterior ramus of C2
• Lesser occipital n.
o From anterior ramus of C2 of spinal n.
Sensory:
• Supratrochlear nerve
o Branch of ophthalmic n. Greater
o Supplies upper eyelid & forehead occipital n.
• Supraorbital nerve
o Branch of ophthalmic n.
Lesser
o Supplies skin of head up to Lambdoid
occipital n.

Supratrochlear n.

Supraorbital n. • Third occipital n.

o Dorsal ramus of C3
• Greater auricular n.
o From anterior ramus of C2 & C3

• Zygomatico-temporal nerve
Third
o Arises from zygomatic branch of maxillary
Occipital n.
division of trigeminal n.
• Auriculo-temporal nerve Greater
o Branch of mandubular division of auricular n.
trigeminal n.
o Supplies the auricle, external auditory
meatus and skin at the lateral of the head

Source: PPT from HSB department 2 of 19

 BLOOD SUPPLY CALVARIA
ARTERIES: FRONT OF AURICLE • SUTURES – immobile joints
• Supratrochlear artery o Coronal
• Supraorbital artery o Sagittal
o 1 & 2 arises from the Ophthalmic artery o Lambdoid
• Superficial temporal artery • SUTURAL LIGAMENT
o External carotid artery • BONES OF THE SKULL:
o Cranium
o Facial
• Compositions:
Supratrochlear a.
o Compact bone
Supraorbital a. o External & Internal tables
o Spongy bone (diploe)
• Grooves:
Superficial o Superior Sagittal Sinus
temporal a.
o Middle Meningeal Vessels
• Other landmarks:
o Frontal crest
ARTERIES: BACK OF AURICLE o Granular pits/ Granular foveolae
• Occipital artery
o External carotid artery
• Posterior auricular artery
o External carotid artery

Occipital a.

Posterior
auricular a. PAROTID, TEMPORAL & INFRATEMPORAL REGION
TEMPORAL FOSSA

VEINS
• Follows the artery

LYMPH DRAINAGE
• Submandibular LN
o Anterior scalp & forehead
• Superficial Parotid (Preauricular) LN
o Lateral Scalp (above ear)
• Mastoid LN
o Scalp above & behind ear
• Occipital LN
o Posterior scalp

Source: PPT from HSB department 3 of 19

 MAXILLARY ARTERY

INFRATEMPORAL FOSSA

Source: PPT from HSB department 4 of 19

 MUSCLES OF MASTICATION
PTERYGOID VENOUS PLEXUS

TEMPORO-MANDIBULAR JOINT

PAROTID REGION
• The region on the
lateral surface of the
face that comprises
the parotid gland & the
structures immediately
related to it
• Between mastoid process & ramus of mandible
• Parotid gland – capsule – from investing layer –
attached to zygomatic arch & temporal bone
(Tympanic part)
• PAROTID DUCT – enters mouth, pierces
buccinator opposite 2nd mandibular molar tooth;

Source: PPT from HSB department 5 of 19

 makes a 90 turn – act as passive valve, lets you between the medial pterygoid
blow up ballons muscle & the ramus of mandible
▪ Carotid process – lies posterior to
the external carotid artery

• CAPSULES
o The parotid gland is enclosed in two
capsules:
▪ An inner connective tissue
capsule
▪ An outer dense fibrous capsule
derived from the investing layer of
the deep cervical fascia
PAROTID GLAND o The deep cervical fascia extends upward,
• Largest of the salivary glands reaches the inferior border of parotid
• Located subcutaneously, below and in front of the gland, splits into the superficial & the
external auditory meatus deep layer, to enclose the gland
• Occupies the deep hollow behind the ramus of the o Above the gland, the:
mandible ▪ Superficial layers gets attached
• Wedge-shaped when viewed externally, with the to the zygomatic arch
base above & the apex behind the angle of the ▪ Deep layer gets attached to the
mandible tympanic plate of temporal bone
• Wedge-shaped in horizontal section with the base
in the lateral position and apex against the
pharyngeal wall
• It exhibits 3 surfaces:
o Lateal
o Anteromedial
o Posteromedial

• LOBES
o The facial nerves courses horizontally
through the gland and divides into the
▪ Superficial lobes Deep lobe • RELATIONS
▪ Deep lobe o Superficial (lateral):
• PROCESSES ▪ Skin & superficial fascia
o The gland is an ▪ Great auricular nerve
irregular lobulated ▪ Parotid lymph nerves
mass, sends o Superior:
‘processes’ in ▪ External auditory meatus
various directions ▪ Temporomandobular joint
▪ Its glenoid process is related to
o These include: Superficial lobe Facial nerve the auriculo-temporal nerve
▪ Glenoid process – extends
upward behind the temporo-
mandibular joint, in front of
external auditory meatus
▪ Facial process – extends
anteriorly onto the masseter
muscle
▪ Accessory process (part) – small
part of facial process lying along
the parotid duct
▪ Pterygoid process – extends
forward from the deeper part, lies

Source: PPT from HSB department 6 of 19

 ANTEROMEDIAL: o Buccinator muscle
o Buccal mucosa
Stylomandibular ligament •
• Opens into the vestibule of mouth on a small
Medial pterygoi papilla, opposite the second upper molar tooth

Post. Border of ramus of mandible

Massater

Terminal branches of the facial n.

POSTEROMEDIAL:

Carotid sheath w/ its contents

Styloid process & attached muscles

Facial nerve
Posterior belly of digastric muscle
ARTERIAL SUPPLY
Mastoid process
• External carotid artery & its terminal branches
Sternocleidomastoid
Superficial temporal artery
STRUCTURES COURSING W/N THE PAROTID GLAND

Auriculotemporal n.
DEEP
External carotid a.
Maxillary artery
Retromandibular v.
External carotid artery
Facial n.

VENOUS DRAINAGE
SUPERFICIAL
• Into the retro-mandibular vein

A few lymph nodes are scattered in the substance of the

gland

PAROTID (STENSEN’S DUCT)

• About 2 inches long
• Emerges from the facial process of the gland
Retromandibular vein
• Passes forward over the lateral surface of the
masseter muscles LYMPH DRAINAGE
o About a fngerbreadth below the • Into the parotid & then into the deep cervical
zygomatic arch lymph nodes
o Accompanied by the:
▪ Transverse facial vessels & upper
zygomatic branches of facial
nerve above
▪ Lower zygomatic branches of
facial nerve below
• Turns around the anterior border of masseter Parotid LN
muscle
• Pierces the:
o Buccal fat pad
o Buccopharyngeal fascia
Deep cervical LN
Source: PPT from HSB department 7 of 19
NERVE SUPPLY • Receives motor innervation from CN VII (Facial n.)
• Sensory: • Usually built around holes in the skull such as the
o Auriculotemporal n. orbits, nose and mouth
• Autonomic:
o Sympathetic through plexus around the
arteries
o Parasympathetic through otic ganglion

MUSCLES OF FOREHEAD

FACE
• Tripartite Composite
1. Skin
2. Soft tissue (Fat, muscle and connective
tissue)
3. Hard tissue Foundation

1. Frontalis
• O – epicranial aponeurosis
• I – skin of eyebrow
• A – elevates eyebrows; produce
HORIZONTAL wrinkles in the forehead
2. Corrugator supercili
• Horizontally oriented muscle at the root of
the nose; produces VERTICAL frown lines
• Boundaries at the forehead
o Forehead to the chin
o From one ear to another ear MUSCLES OF MOUTH, LIP & CHEEKS
o Muscles → subcutaneous

MUSCLES
The actions of the Facial Musculature can be divided as:
1. Muscles of Facial Expression
2. Muscles of Mastication
They can be grouped as those located around the:
1. Forehead
2. Eyes
3. Nose
4. Mouth

MUSCLES OF FACIAL EXPRESSION

• Attached to bone or fascia and to the skin

Source: PPT from HSB department 8 of 19

 • Orbicularis oris o 3 parts:
o Sphincter of the mouth ▪ Lacrimal
o For oral competence ▪ Palpebral
o Speech and social expression ▪ Orbital
• Levator labii superioris Alaque nasi
o Elevates the upper lip and wings of the MUSCLES AROUND THE NOSE
nose
• Levator labii superioris
o Helps zygomaticus minor to deepen the
nasolabial sulcus
o SADNESS
• Levator anguli oris
o Raises the angle of the mouth
• Zygomaticus minor
o Raises the lips
o CONTEMPT OR SADNESS
• Zygomaticus major
o Pulls the angle of mouth supero-laterally
o SMILING OR LAUGHING
• Nasalis
• Risorius
o Compresses or dilates the nostrils
o Draws corner of the mouth laterally when
o 2 parts:
grinning
▪ Compressor nares
o SARDONIC SMILE
▪ Dilator nares (alar)
• Depressor anguli oris
• Procerus
o Triangularis
o Contraction causes HORIZONTAL
o Depresses the angle of the mouth
creases at the root of the nose
o FROWNING
• Depressor septi
• Depressor labii inferioris
o Pulls down the nasal septum
o Quadrangularis
o Overcontraction may cause GUMMY
o Pulls lips inferiorly
SMILE
o IMPATIENCE
SQUINT MUSCLES
• Mentalis
o Raises the skin of the chin
o EXPRESSION OF DOUBT
• Buccinator
o Aids in mastication by pressing the
cheeks against the molar teeth
o For whistling and sucking or blowing
o TRUMPETER MUSCLE

MUSCLES AROUND THE ORBITAL OPENING

MUSCLES OF MOUTH AND LIPS

• Orbicularis oculi
o Closes the eyes

Source: PPT from HSB department 9 of 19

UPPER LIP AND NASAL MUSCLES NERVES
NERVES OF THE FACE
• Facial Nerve (CN VII)
o Motor nerve for muscle of facial
expression
• Trigeminal Nerve (CN V)
o Sensory nerve for the face
o 3 Major divisions/nuclei
▪ Ophthalmic n. (CN V1)
▪ Maxillary n. (CN V2)
▪ Mandibular n. (CN V3)
ORBICULARIS AND NASAL MUSCLES
FACIAL NERVE (CN VII)

SMILE MUSCLES

MOTOR ROOT:
• Facial expression muscle
• Platysma
• Auricular muscles
• Scalp muscles
SENSORY ROOT:
LOWER LIP PROTRUSION • Has no sensory fibers in the face
TRACT:
• Pons → Internal Auditory Meatus → Stylomastoid
foramen → Parotid gland
BRANCHES:
• Chorda tympani
• Nerve for stapedius
• Nerve for stylohyoid muscle
• Nerve for posterior belly of digastric muscle
• Posterior auricular nerve
• Temporal
• Zygomatic
• Buccal
• Mandibular
• Cervical
Mnemonic: Ten Zillion
Bucks Mean Cash

Source: PPT from HSB department 10 of 19

 Mnemonic: 3 holes lying in a vertical line passing thru the pupils
at midline gaze

TRIGEMINAL NERVE (CN V)

OPHTHALMIC NERVE (CN V1)
• Passes trigeminal ganglion and leaves the skull
thru SUPERIOR ORBITAL FISSURE

Branches:
From the trigeminal ganglion, nerves leaves the skull thru: 1. Nasociliary nerve
• V1: Superior orbital fissure • Anterior ethmoidal nerve
• V2: Foramen rotundum ▪
• V3: Foramen ovale ▪ External nasal nerve
Mnemonic: Standing Room Only ▪ Skin tip of the nose
• Posterior ethmoidal nerve
▪ None on the face
• Infratrochlear nerve
▪ Root of the nose
2. Frontal nerve
• Supratrochlear nerve
▪ Skin middle of forehead to the
hair line
• Supraorbital nerve
▪ Mucous membrane of frontal
sinus
▪ Upper eyelid and palpebral
conjunctiva
▪ Skin of forehead to the vertex
3. Lacrimal nerve
• Smallest ophthalmic branch
• Innervates the skin lateral upper eyelid

Sensory branches of trigeminal nerve innervate the face

after passing thru:
• V1: Superorbital notch
• V2: Infraorbital notch
• V3: Mental foramen

Source: PPT from HSB department 11 of 19

 MAXILLARY NERVE (CN V2) MOTOR
• Passes trigeminal ganglion and leaves the skull • Innervates muscles of mastication
thru FORAMEN ROTUNDUM at base of greater • Masseter, medial and lateral pterygoids,
wing of sphenoid temporalis
SENSORY
1. Auriculotemporal nerve
• Innervates:
▪ Auricle
▪ External acoustic meatus
▪ External surface of tympanic
membrane
▪ Skin above the auricle
Branches 2. Buccal nerve
1. Infraorbital nerve • Innervates
• Innervates: ▪ Small skin near the angle of the
▪ Skin of upper cheek mouth
▪ Mucosa of maxillary sinus 3. Mental nerve
▪ Upper alveolar and gingiva • Innvervates
▪ Conjunctiva of inferior eyelid ▪ Skin of chin
▪ Skin & mucosa of upper lip ▪ Mucous membrane and skin of
2. Zygomatic nerve lower lip
• Zygomaticotemporal nerve ▪ Inferior labial gingiva
▪ Innervates the anterior part of
temple
• Zygomaticofacial nerve
▪ Innvervates skin over zygomatic
prominence
3. Palatine branches
• None on the face surface
4. Nasal branches
• None on the face surface

MUSCLES OF MASTICATION

MANDIBULAR NERVE (CN V3)

• Inferior and largest division of CN V
• Formed by union of sensory and motor root of CN
V in the FORAMEN OVALE

Branches:

Source: PPT from HSB department 12 of 19

 VESSELS AND LYMPHATICS LYMPHATIC DRAINAGE OF THE FACE
• Lymph from lateral part of face & eyelids drain to
o PAROTID LN
• Lymph from deep parotid nodes drain into
o DEEP CERVICAL LN
• Lymph from upper lip and lateral part of the lower
lip drains to
o SUBMANDIBULAR LN
• Lymph from the chin and central part of the lower
lip drain into
o SUBMENTAL LN

ARTERIES OF THE FACE

1. External carotid artery
• Facial artery
• Superficial temporal artery
• Transverse facial artery
2. Internal carotid artery
• Superior orbital artery
• Superior trochlear artery

Points to remember:
✓ Facial skin is:
o Thin
o Vascular
o Movable
VEINS OF THE FACE o Muscles arising from the bone insert
• Supratrochlear vein directly to the skin
• Supraorbital vein ✓ Dangerous area
• Angular vein o Triangular area from the root of the nose
• Facial vein and angles of the mouth
• Superficial temporal vein o Angular vein → Superior ophthalmic vein
• Retromandibular vein → Cavernous sinus
o SIGNIFICANCE: Infection may travel to
CAVERNOUS SINUS
✓ Main artery of the face
o Facial artery (external maxillary) – a
branch of the external carotid artery
✓ Nerves:
o Facial nerve supplies muscles of
mastication
o Trigeminal nerve supplies the integument
and muscles of mastication
o Trigeminal nerve innervates entire skin of
the face EXCEPT that over the lower half
of the ramus of the mandible (great
auricular nerve)

Source: PPT from HSB department 13 of 19

 o Facial nerve gives motor branches to the • Chronic
muscles of expression, stapedius, o Relatively slow process that leads to
stylohyoid and posterior belly of digastric, tissue damage
scalp muscles, auricle, face (buccinator & o Includes pressure, venous and diabetic
platysma) ulcers
o Insufficiency in the circulation or other
CORRELATIVE ANATOMY FOR HEAD AND FACE systemic support of the tissue causes soft
TRAUMATIC INJURY tissue to fail and disintegrate
WOUNDS BY ETIOLOGY (OPEN)
• Incisions WOUND BY TYPE
o cause by clean, sharp-edged object such • Clean
as a knife, razor or a glass splinter o Elective, not emergency, non-traumatic,
• Lacerations primarily closed
o Irregular tear-like wounds caused by o No acute inflammation
some blunt trauma o No break in technique
• Abrasions (grazes) • Contaminated
o Superficial wounds in which the epidermis o Non-purulent inflammation
is scraped off o Gross spillage from GIT
• Puncture wounds o Penetrating trauma of <4 hours old
o Caused by an object puncturing the skin, o Chronic open wounds to be grafter or
such as nail or needle covered
• Penetration wounds • Dirty
o Caused by an object such as a knife o Purulent inflammation (eg. Abscess)
entering and coming out from the skin o Colonized: <1x105 organisms per gram of
• Gunshot wounds tissue
o Caused by a bullter or similar projectile o Infected: 1x105 organisms per gram of
driving into or through the body tissue
• Avulsion
o Tearing away
o Amputation where the extremity is pulled
off rather than cut off
o Removal of all the layer of skin

WOUNDS BY ETIOLOGY (CLOSE)

• Contusions
o Bruises
o Caused by a blunt force trauma that
damages tissue under the skin
• Hematomas
o Blood tumor
o Caused by a damage to a blood vessel
that causes blood to collect under the
skin
• Crush injury
o Caused by a great or extreme amount of
force applied over a long period of time
• Pneumatic injury
o Separation of the skin and subcutaneous
tissue from the underlying fascia

WOUNDS BY TEMPORALITY
• Acute
o Traumatic wounds as a result of injuries
that disrupt the tissue

Source: PPT from HSB department 14 of 19

LE FORT FRACTURES
• Le Fort I
o
o Horizontal goes through the maxilla at
about the level of the piriform rim
• Le Fort II
o Involves the nasofrontal junction, the
nasal processes of the maxilla, and the
medial aspect of the inferior orbital rim
• Le Fort III
o A craniofacial dysjunction
o The maxilla is intact in a pure le fort III
fracture

Source: PPT from HSB department 15 of 19

 CONGENITAL ANOMALIES
• Hemangioma
o The most common benign tumor of the
skin
o May be present at birth (faint red mark) or
may appear in the 1st months after birth
o 83% occur in the head or neck area
o Occur five times more often in females
than males (5:1 F:M)

• Vascular Malformation
o Congenital growth, made up of arteries,
veins, capillaries, or lympahatic vessels
o Named according to which type of blood
vessel is predominantly affected
o Also known as lymphangioma,
arteriovenous malformations and vascular
gigantism

HEMANGIOMA VM
Not usually present at birth Present at birth
(very faint red marks)
Grows rapidly – often Enlarges proportionately
faster than child’s growth with child’s growth
Involutes Does not involute (may be What is the cause of a CLEFT LIP AND CLEFT PALATE?
more apparent as child • Before the 1st trimester of pregnancy, the five
grows) facial elements – frontonasal, two lateral maxillary,
• Hamartoma and two mandibular segments – fuse by
o Tumor-like growth that is benign mesenchymal migration to create the face and
o Occurs when an abnormal amount of jaws
normal cells collect on healthy tissue. The • When these fusions are interrupted, cleft/s result/s
cells that compromise the hamartoma • Causes:
maintain their function, unlike cells that o But genetics, viral infection, lack of certain
create malignant tumors vitamins, and other factors during the 1st
o They have limitied growth potential trimester of pregnancy
o Hemangioma is a type of hamartoma • RULE OF 10s in CLEFT LIP REPAIR
o 10 weeks
o 10 pounds
o Hemoglobin of 10

Source: PPT from HSB department 16 of 19

 SKIN MALIGNANCIES
Skin cancers
• Are the most common of all cancers
• Approximately 77% of all skin cancers are basal
cell carcinomas (BCCs), 20% are squamous cell
carcinomas (SCCs) and 3% are melanomas
• Attributed to sun exposure habits and the aging
population

BASAL CELL CARCINOMA

• Usually occur on the face
• Locally invasive and can potentially cause
significant loss of function and scarring
• They can be infiltrative, but they rarely metastasize

• CLEFT PALATE
o Failure of the two halves of the roof of the
mouth, or palatal shelves, to join in the
midline and fuse
o The cleft may involve the soft palate or
both soft and hard palates
SQUAMOUS CELL CARCINOMA
• From the keratinizing or malpighian cell layer of
the epithelium
• It is seen primarily in older patients, mostly men.
• Etiologic factor is solar radiation
• Chemicals, chronic ulcer, cytotoxic drugs,
immunosuppresant drugs, chronic lesions, discoid
lupus erythematosus, and hydradenitis
suppurative play a role

Source: PPT from HSB department 17 of 19

MELANOMA AMELOBLASTOMA
• A large proportion of melanomas can ascribed to • Benign tumor of odontogenic epithelium much
a single factor – SUN EXPOSURE more commonly appearing in the mandible than
• Diagnosis of melanoma at an early stage is almost the maxilla
always curable • Rarely malignant or metastasize progress slowly,
• No effective treatment for advanced melanoma is the resulting lesions can cause severe
available abnormalities of the face and jaw
• Wide surgical excision is required to treat this
disorder

HYPERTROPHIC SCARS KELOIDS

Remain w/n confines of Invades adjacent normal
original wound skin
Arise after several weeks, Arise much later after
present for many months, wounding and may
then regress enlarge definitely

WHAT HAPPENS IF YOU JUST EXCISE A KELOID?

• Simple excision of a keloid stimulates a quick
recurrence of up to 100% of the time

Source: PPT from HSB department 18 of 19

Source: PPT from HSB department 19 of 19