The face pdf - Head and Neck

Basic Anatomy

579

posterior
auricular vein

vertebral vein

internal jugular
vein

external
jugular
vein

right
brachiocephalic
vein

anterior jugular vein

facial vein

maxillary
vein

superficial
temporal
vein

subclavian
vein

retromandibular
vein

FIGURE 11.39

Main veins of the head and neck.

retroauricular
(mastoid nodes)

occipital
nodes

superficial
cervical
nodes

deep cervical nodes

jugular trunk

tracheal nodes

laryngeal nodes

anterior cervical
nodes

submandibular
nodes

submental nodes

buccal
nodes

parotid nodes

FIGURE 11.40

Lymph drainage of the head and neck.

area over the angle of the mandible and the parotid gland

divisions of the trigeminal nerve, except for the small

The skin of the face is supplied by branches of the three

they follow the wrinkle lines.

elasticity. Surgical scars of the face are less conspicuous if

contracting muscles, coupled with the loss of youthful skin

of the skin perpendicular to the long axis of the underlying

Wrinkle lines of the face result from the repeated folding

No deep fascia is present in the face.

of facial expression.

loose connective tissue, in which are embedded the muscles

ceous glands. It is connected to the underlying bones by

The skin of the face possesses numerous sweat and seba

The Face

Skin of the Face

Sensory Nerves of the Face

(Fig. 11.41), which is supplied by the great auricular nerve

process; the maxillary nerve serves the region developed

nerve supplies the region developed from the frontonasal

of dermatomes of the trunk and limbs. The ophthalmic

inal nerve is slight compared with the considerable overlap

(C2 and 3). The overlap of the three divisions of the trigem-

supratrochlear nerve

infratrochlear nerve

supraorbital

nerve

lacrimal nerve

zygomaticotemporal

nerve

auriculotemporal

nerve

infraorbital nerve

external nasal nerve

buccal nerve

great auricular nerve

mental nerve

cervical branch

mandibular
branch

buccal
branch

zygomatic
branch

temporal
branch

supratrochlear artery

supraorbital artery

zygomaticotemporal

artery

superficial temporal artery

lacrimal artery

zygomaticofacial artery

infraorbital artery

transverse facial artery

external nasal artery

facial artery

mental artery

external carotid artery

internal jugular vein

mental vein

facial vein

transverse facial
vein

infraorbital vein

zygomaticofacial
vein

supraorbital vein

supratrochlear vein

zygomaticofacial

nerve

lacrimal vein

superficial temporal
vein

zygomaticotemporal
vein

FIGURE 11.41

Venous drainage of the face.

Arterial supply of the face.

expression.

Branches of the 7th cranial nerve to muscles of facial

Sensory nerve supply to the skin of the face. B.

580

CHAPTER 11

above the auricle (Fig. 11.41).

of the tympanic membrane, and the skin of the scalp

auricle, the external auditory meatus, the outer surface

poral vessels and the auricle. It supplies the skin of the

border of the parotid gland between the superficial tem

ascends from the upper

auriculotemporal nerve

The

a small area of the cheek (Fig. 11.41).

border of the masseter muscle and supplies the skin over

emerges from beneath the anterior

buccal nerve

The

chin (Fig. 11.41).

the mandible and supplies the skin of the lower lip and

emerges from the mental foramen of

mental nerve

The

branches of the nerve pass to the skin.

auricle. It then passes upward to the side of the scalp. Three

lower part of the face, the temporal region, and part of the

The mandibular nerve supplies the skin of the lower lip, the

Mandibular Nerve

temple (Fig. 11.41).

face of the zygomatic bone. It supplies the skin over the

ral fossa through a small foramen on the posterior sur

emerges in the tempo

zygomaticotemporal nerve

The

the cheek (Fig. 11.41).

matic bone. It supplies the skin over the prominence of

through a small foramen on the lateral side of the zygo

passes onto the face

zygomaticofacial nerve

The

(Fig. 11.41).

eyelid and cheek, the side of the nose, and the upper lip

out from the foramen and supply the skin of the lower

divides into numerous small branches, which radiate

face through the infraorbital foramen. It immediately

maxillary nerve. It enters the orbit and appears on the

is a direct continuation of the

infraorbital nerve

The

branches of the nerve pass to the skin.

upper lip, and the lateral side of the orbital opening. Three

part of the side of the nose, the lower eyelid, the cheek, the

The maxillary nerve supplies the skin on the posterior

Maxillary Nerve

the tip (Fig. 11.41).

supplies the skin on the side of the nose down as far as

between the nasal bone and the upper nasal cartilage. It

leaves the nose by emerging

external nasal nerve

The

and the adjoining part of the side of the nose (Fig. 11.41).

and conjunctiva on the medial part of the upper eyelid

ley of the superior oblique muscle. It supplies the skin

leaves the orbit below the pul

infratrochlear nerve

The

the median plane.

and the skin over the lower part of the forehead, close to

and conjunctiva on the medial part of the upper eyelid

(Fig. 11.41). It divides into branches that supply the skin

margin of the orbit medial to the supraorbital nerve

winds around the upper

supratrochlear nerve

The

supplies the skin of the forehead.

junctiva on the central part of the upper eyelid; it also

It divides into branches that supply the skin and con

gin of the orbit at the supraorbital notch (Fig. 11.41).

winds around the upper mar

supraorbital nerve

The

the lateral part of the upper eyelid (Fig. 11.41).

supplies the skin and conjunctiva of

lacrimal nerve

The

pass to the skin.

down to and including the tip. Five branches of the nerve

the upper eyelid, the conjunctiva, and the side of the nose

The ophthalmic nerve supplies the skin of the forehead,

Ophthalmic Nerve

sinuses.

supply to the mouth, teeth, nasal cavities, and paranasal air

of facial expression. They are, in addition, the sensory nerve

also supply proprioceptive fibers to the underlying muscles

These nerves not only supply the skin of the face, but

mandibular process of the first pharyngeal arch.

the mandibular nerve serves the region developed from the

from the maxillary process of the first pharyngeal arch; and

The Head and Neck

■

-
-

■

is a relatively

Trigeminal neuralgia

auricular nerve (C2 and 3).

area of skin over the angle of the jaw is supplied by the great

The facial skin receives its sensory nerve supply from the

Sensory Innervation and Trigeminal Neuralgia

three divisions of the trigeminal nerve. Remember that a small

common condition in which the patient experiences excru-

ciating pain in the distribution of the mandibular or maxillary

division, with the ophthalmic division usually escaping. A phy-

sician should be able to map out accurately on a patient’s face

the distribution of each of the divisions of the trigeminal nerve.

C L I N I C A L N O T E S

Arterial Supply of the Face

branches to the septum and ala of the nose.

the mouth. It runs medially in the upper lip and gives

arises near the angle of

superior labial artery

The

ses with its fellow of the opposite side.

mouth. It runs medially in the lower lip and anastomo

arises near the angle of the

inferior labial artery

The

skin of the chin and lower lip.

lower border of the body of the mandible. It supplies the

arises from the facial artery at the

submental artery

The

Branches

of the ophthalmic artery (Fig. 11.41).

of the eye, where it anastomoses with the terminal branches

cle and runs along the side of the nose to the medial angle

zygomaticus muscles and the levator labii superioris mus

sma and the risorius muscles. It then ascends deep to the

toward the angle of the mouth and is covered by the platy

(Fig. 11.132). It runs upward in a tortuous course

ily felt

It is here that the pulse can be eas

of the masseter muscle.

margin of the body of the mandible at the anterior border

submandibular salivary gland, it curves around the inferior

(Figs. 11.55 and 11.59). Having arched upward and over the

arises from the external carotid artery

facial artery

The

sensory nerves of the face.

supplemented by several small arteries that accompany the

sels: the facial and superficial temporal arteries, which are

The face receives a rich blood supply from two main ves-

■

Basic Anatomy

(Fig. 11.41).

of the ophthalmic artery, supply the skin of the forehead

branches

supratrochlear arteries,

supraorbital

The

(Fig. 11.41).

forward across the cheek just above the parotid duct

temporal artery, arises within the parotid gland. It runs

a branch of the superficial

transverse facial artery,

The

auricle to supply the scalp (see page 578).

mences in the parotid gland. It ascends in front of the

terminal branch of the external carotid artery, com

(Fig. 11.41), the smaller

superficial temporal artery

The

dorsum of the nose.

alongside the nose. It supplies the skin on the side and

arises from the facial artery

lateral nasal artery

The

581

■

and

of the masseter, are commonly used by the anesthetist to take

Blood Supply of the Facial Skin

The blood supply to the skin of the face is profuse so that it is

rare in plastic surgery for skin flaps to necrose in this region.

Facial Arteries and Taking the Patient’s Pulse

The superficial temporal artery, as it crosses the zygomatic

arch in front of the ear, and the facial artery, as it winds around

the lower margin of the mandible level with the anterior border

the patient’s pulse.

C L I N I C A L N O T E S

Venous Drainage of the Face

drains into the submandibular lymph nodes (Fig. 11.42).

Lymph from the forehead and the anterior part of the face

Lymph Drainage of the Face

vein within the parotid gland.

joins the superficial temporal

transverse facial vein

The

sinus by the superior ophthalmic vein.

and to the cavernous

deep facial vein

venous plexus by the

branches of the facial artery. It is joined to the pterygoid

The facial vein receives tributaries that correspond to the

Tributaries

ing into the internal jugular vein.

of the retromandibular vein. The facial vein ends by drain

submandibular gland and is joined by the anterior division

of the body of the mandible. It crosses superficial to the

vein descends behind the facial artery to the lower margin

of infection from the face to the cavernous sinus. The facial

cal importance because it provides a pathway for the spread

cavernous sinus (Fig. 11.9); this connection is of great clini

superior ophthalmic vein, the facial vein is connected to the

directly through the supraorbital vein. By means of the

(Fig. 11.41). It is connected to the superior ophthalmic vein

by the union of the supraorbital and supratrochlear veins

is formed at the medial angle of the eye

facial vein

The

Facial Infections and Cavernous Sinus Thrombosis

sinus thrombosis may be fatal unless adequately treated with

The area of facial skin bounded by the nose, the eye, and the

upper lip is a potentially dangerous zone to have an infection.

For example, a boil in this region can cause thrombosis of the

facial vein, with spread of organisms through the inferior oph-

thalmic veins to the cavernous sinus. The resulting cavernous

antibiotics.

C L I N I C A L N O T E S

A few buccal lymph nodes may be present along the course

maxilla.

of the

process of the frontal bone and below by the frontal process

The medial orbital margin is formed above the maxillary

maxilla.

zygomatic bone

margin is formed by the

and the inferior orbital

zygomatic bone

is formed by the

The lateral orbital margin

frontal air sinuses.

which con

frontal bone,

above them are formed by the

Figure 11.42. The superior orbital margins and the area

The bones that form the front of the skull are shown in

submental lymph nodes.

of the lower lip and the skin of the chin are drained into the

sels that end in the parotid lymph nodes. The central part

ing the lateral parts of the eyelids, is drained by lymph ves

of these lymph vessels. The lateral part of the face, includ-

Bones of the Face

tains the

and the

frontal

ethmoid

parietal

lesser wing of

sphenoid

greater wing of

sphenoid

squamous temporal

lacrimal

zygomatic

mastoid process

nasal

maxilla

mandible

submental
nodes

deep cervical
nodes

submandibular
nodes

buccal
node

parotid
nodes

FIGURE 11.42

drainage of the face.

Lymph

Bones of the front of the skull. B.

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CHAPTER 11

Buccal branch of the facial nerve

Nerve supply:

thus blends and forms part of the orbicularis oris muscle.

respectively, without intersecting. The buccinator muscle

and lowest fibers continue into the upper and lower lips,

and those from above entering the lower lip; the highest

ers decussate, those from below entering the upper lip

parotid duct. At the angle of the mouth the central fib

muscle layer of the cheek. The muscle is pierced by the

The muscle fibers pass forward, forming the

Insertion:

and from the pterygomandibular ligament (Fig. 11.38).

of the maxilla and mandible opposite the molar teeth

From the outer surface of the alveolar margins

Origin:

nerve

Buccal and mandibular branches of the facial

Nerve Supply

Mentalis

Depressor labii inferioris

Depressor anguli oris

Risorius

Levator anguli oris (deep to the zygomatic muscles)

Zygomaticus major

Zygomaticus minor

Levator labii superioris

Levator labii superioris alaeque nasi

are named as follows:

the mouth and then below the oral aperture, the muscles

of the lips. Traced from the side of the nose to the angle of

oral aperture and converge to be inserted into the substance

The muscles arise from the bones and fascia around the

usually accompanied by separation of the jaws.

and their action is to separate the lips; this movement is

The dilator muscles (Fig. 11.38) radiate out from the lips,

Compresses the lips together

Action:

facial nerve

Buccal and mandibular branches of the

Nerve supply:

muscle.

Many of the fibers are derived from the buccinator

mucous membrane lining the inner surface of the lips.

the deep surface of the skin and pass obliquely to the

above and the mandible below. Other fibers arise from

of the fibers arise near the midline from the maxilla

fice within the substance of the lips (Fig. 11.38). Some

The fibers encircle the oral ori

Origin and insertion:

from the lips.

muscles consist of a series of small muscles that radiate out

The sphincter muscle is the orbicularis oris. The dilator

shown in Table 11.4.

compressor naris, the dilator naris, and the procerus are

The origin, insertion, nerve supply, and action of the

tor muscle is the dilator naris (Fig. 11.38).

The sphincter muscle is the compressor naris and the dila

Muscles of the Nostrils

in Table 11.4.

orbicularis oculi and the corrugator supercilii are described

The origin, insertion, nerve supply, and action of the

page 575.

itofrontalis forms part of the scalp and is described on

palpebrae superioris is described on page 550. The occip

rioris and the occipitofrontalis (Fig. 11.38). The levator

and the dilator muscles are the levator palpebrae supe

The sphincter muscle of the eyelids is the orbicularis oculi,

Muscles of the Eyelids

supplied by the facial nerve.

face are developed from the second pharyngeal arch and are

modify the expression of the face. All the muscles of the

structures. A secondary function of the facial muscles is to

the facial muscles to serve as sphincters or dilators of these

eyelids, nostrils, and lips, respectively. It is the function of

namely, the orbit, nose, and mouth, are guarded by the

inserted into the skin (Fig. 11.38). The orifices of the face,

fascia, and most arise from the bones of the skull and are

The muscles of the face are embedded in the superficial

page 530).

bones of the face is given in the discussion of the skull (see

mandible, with its teeth. A more detailed account of the

air sinus. The bone of the lower third of the face is the

face is the maxilla, containing its teeth and the maxillary

The important central bone of the middle third of the

and lower plates of hyaline cartilage and small cartilages of

frontal bones. Anteriorly, the nose is completed by upper

which articulate below with the maxilla and above with the

nasal bones,

The root of the nose is formed by the

The Head and Neck

the ala nasi.

Muscles of the Face (Muscles of Facial

Expression)

Muscles of the Lips and Cheeks

Sphincter Muscle of the Lips: Orbicularis Oris

■

Dilator Muscles of the Lips

■

Muscle of the Cheek

Buccinator

■

cles of the lips and cheeks are shown in Table 11.4.

The origin, insertion, nerve supply, and action of the mus

Compresses the cheeks and lips against the teeth

Action:

■

essentially a lower motor neuron lesion. An upper motor neu

(by a tumor) or caused by lacerations of the face will cause

), or in the parotid gland

Bell’s palsy

nerve canal (perineuritis,

Facial Muscle Paralysis

The facial muscles are innervated by the facial nerve. Damage

to the facial nerve in the internal acoustic meatus (by a tumor),

in the middle ear (by infection or operation), in the facial

distortion of the face, with drooping of the lower eyelid, and

the angle of the mouth will sag on the affected side. This is

ron lesion (involvement of the pyramidal tracts) will leave the

upper part of the face normal because the neurons supply-

ing this part of the face receive corticobulbar fibers from both

cerebral cortices.

C L I N I C A L N O T E S

Basic Anatomy

emerges from the anterior

mandibular branch

The

nostril.

buccinator muscle and the muscles of the upper lip and

of the gland below the parotid duct and supplies the

emerges from the anterior border

buccal branch

The

oculi.

border of the gland and supplies the orbicularis

emerges from the anterior

zygomatic branch

The

supercilii.

frontalis, the orbicularis oculi, and the corrugator

auricular muscles, the frontal belly of the occipito

of the gland and supplies the anterior and superior

emerges from the upper border

temporal branch

The

terminal branches (Fig. 11.41).

parotid salivary gland (see page 630), it divides into its five

As the facial nerve runs forward within the substance of the

583

Facial Nerve

■

border of the gland and supplies the muscles of the

shown in Figure 11.67.

mary of the origin and distribution of the facial nerve is

the central nervous system via the trigeminal nerve. A sum

facial nerve in these communicating branches and pass to

proprioceptive nerve fibers of the facial muscles leave the

branches of the trigeminal nerve. It is believed that the

but its branches communicate with

not supply the skin,

It does

and supplies all the muscles of facial expression.

The facial nerve is the nerve of the second pharyngeal arch

the depressor anguli oris muscle.

the lower margin of the body of the mandible to supply

mandible to supply the platysma muscle; it may cross

of the gland and passes forward in the neck below the

emerges from the lower border

cervical branch

The

lower lip.

■

Development of the Face

ous processes that ultimately form the face unite during the

finally bury the premaxilla and fuse in the midline. The vari

extend medially, forming the upper jaw and the cheek, and

The maxillary processes

development, the maxillary processes grow medially and fuse

With further

medial

appear as depressions in the lower edge

oping brain, and this grows toward the stomodeum. Meanwhile,

together and fusion of several important processes, namely, the

area is a depression in the ectoderm known as the

Early in development, the face of the embryo is represented by

an area bounded cranially by the neural plate, caudally by the

pericardium, and laterally by the mandibular process of the first

pharyngeal arch on each side (Fig. 11.43). In the center of this

stomodeum.

In the floor of the depression is the buccopharyngeal membrane.

By the fourth week, the buccopharyngeal membrane breaks

down so that the stomodeum communicates with the foregut.

The further development of the face depends on the coming

frontonasal process, the maxillary processes, and the mandibu-
lar processes (Fig. 11.43). The frontonasal process begins as a

proliferation of mesenchyme on the ventral surface of the devel-

the maxillary process grows out from the upper end of each first

arch and passes medially, forming the lower border of the devel-

oping orbit. The mandibular processes of the first arches now

approach one another in the midline below the stomodeum and

fuse to form the lower jaw and lower lip (Fig. 11.43).

The olfactory pits

of the advancing frontonasal process, dividing it into a
nasal process and two lateral nasal processes.

with the lateral nasal processes and with the medial nasal pro-

cess (Fig. 11.43). The medial nasal process forms the philtrum

of the upper lip and the premaxilla.

second month.

The upper lip is formed by the growth medially of the maxillary

processes of the first pharyngeal arch on each side. Ultimately,

the maxillary processes meet in the midline and fuse with each

other and with the medial nasal process (Fig. 11.43). Thus, the

lateral parts of the upper lip are formed from the maxillary

processes, and the medial part, or philtrum, from the medial

remains and tethers each lip to the gum, thus forming the

the gums. In the midline, a short area of the labiogingival lamina

later degenerates. A deep groove thus forms between the lips and

which grows down into the underlying mesenchyme and

labiogingival

Each lip separates from its respective gum as the result of the

nasal process, with contributions from the maxillary processes.

The lower lip is formed from the mandibular process of the

first pharyngeal arch on each side (Fig. 11.43). These processes

grow medially below the stomodeum and fuse in the midline to

form the entire lower lip.

appearance of a linear thickening of ectoderm, the
lamina,

frenulum.

At first, the mouth has a broad opening, but later this dimin-

ishes in extent because of fusion of the lips at the lateral angles.

Sensory Nerve Supply to the Skin of the Developing Face
The area of skin overlying the frontonasal process and its deriva-

tives receives its sensory nerve supply from the ophthalmic divi-

sion of the trigeminal nerve, whereas the maxillary division of the

trigeminal nerve supplies the area of skin overlying the maxillary

process. The area of skin overlying the mandibular process is

supplied by the mandibular division of the trigeminal nerve.

Muscles of the Developing Face (Muscles of Facial
Expression)
The muscles of the face are derived from the mesenchyme of the

second pharyngeal arch. The nerve supply of these muscles is

the nerve of the second pharyngeal arch—namely, the seventh

cranial nerve.

Cleft Upper Lip

Cleft upper lip may be confined to the lip or may be associated

with a cleft palate. The anomaly is usually unilateral cleft lip and

is caused by a failure of the maxillary process to fuse with the

medial nasal process (Figs. 11.44 and 11.45). Bilateral cleft lip

is caused by a failure of both maxillary processes to fuse with

E M B R Y O L O G I C N O T E S

(continued)

584

CHAPTER 11

The Head and Neck

the medial nasal process, which then remains as a central flap

gery no later than 2 months after birth, provided the baby’s condi

Cleft lower lip is a rare condition. The cleft is exactly central and is

of tissue (Figs. 11.46 and 11.48). Median cleft upper lip is very

rare and is caused by the failure of the rounded swellings of the

medial nasal process to fuse in the midline.

Oblique Facial Cleft

Oblique facial cleft is a rare condition in which the cleft lip on

one side extends to the medial margin of the orbit (Figs. 11.44 and

11.47). This is caused by the failure of the maxillary process to

fuse with the lateral and medial nasal processes.

Cleft Lower Lip

caused by incomplete fusion of the mandibular processes (Fig. 11.44).

Treatment of Isolated Cleft Lip
The condition of isolated cleft lip usually is treated by plastic sur-

tion permits. The surgeon strives to approximate the vermilion

border and to form a normal-looking lip (Fig. 11.48A–C).

Macrostomia and Microstomia

The normal size of the mouth shows considerable individual vari-

ation. Rarely, there is incomplete fusion of the maxillary with the

mandibular processes, producing an excessively large mouth or

macrostomia. Very rarely, there is excessive fusion of these pro-

cesses, producing a small mouth or microstomia. These condi-

tions can easily be corrected surgically.

olfactory pit

frontonasal process

mandibular process

maxillary process

lateral

nasal process

lateral

nasal process

medial

nasal process

medial nasal process

mandibular process

buccopharyngeal membrane

forming floor of

stomodeum

second pharyngeal

arch

mandible

nostril

future

external ear

future

external ear

philtrum

maxilla

8 weeks

6.5 weeks

5.5 weeks

5 weeks

FIGURE 11.43

Different stages in development of the face.