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Atlas of the Facial Nerve and Related Structures

Nobutaka Yoshioka, MD, PhD


Director
Department of Craniofacial Surgery and Plastic Surgery
Tominaga Hospital
Osaka, Japan
Albert L. Rhoton, Jr., MD
R.D. Keene Family Professor and Chairman Emeritus
Department of Neurosurgery
College of Medicine
University of Florida
Gainesville, Florida

With 97 Illustrations

Thieme
New York Stuttgart Delhi Rio de Janeiro

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Thieme Medical Publishers, Inc.


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Library of Congress Cataloging-in-Publication Data
Yoshioka, Nobutaka, author.
Atlas of the facial nerve and related structures / Nobutaka
Yoshioka, Albert L. Rhoton, Jr.
p. ; cm.
Includes index.
ISBN 978-1-62623-171-9 (alk. paper)
I. Rhoton, Albert L., 1932 , author. II. Title.
[DNLM: 1. Facial Nerveanatomy & histologyAtlases.
2. Headanatomy & histologyAtlases. 3. Neckanatomy &
histologyAtlases. WL 17]
QP327
612.92078dc23
2014044551

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Contents
Preface by Nobutaka Yoshioka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface by Albert L. Rhoton, Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

Section I

Intracranial Region and Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1
2
3

Intracranial Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Skull: External and Internal Views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Orbit and Facial Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Section II

Upper Facial and Midfacial Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4
5
6
7
8
9
10

Upper Facial and Midfacial Region Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


Forehead and Orbital Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Temporal Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Superficial Structures in the Midfacial Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Maxillary Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Masseteric Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Deep Structures in the Midfacial Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Section III Lower Facial and Posterolateral Neck Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79


11
12
13
14

Lower Facial Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81


Oral Floor and Upper Neck Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Posterior Neck and Occipital Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Lateral Neck Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Note: Every figure shows the left side whenever the unilateral side is shown.

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Preface
It has been more than ten years since I finished my fellowship
at the Microneuroanatomy Laboratory at the University of
Florida. I first met Dr. Albert Rhoton at the seventh meeting
of the Japanese Society for Skull Base Surgery, held in Hakata,
Japan, in 1995. I will never forget how deeply impressed I was
by the anatomical illustrations he showed at that meeting. As
every neurosurgeon now knows, his images detail delicate
brain anatomy in a unique way, and it was something that I
had never seen before. Then, from Septembr 2003 to August
2004, I had an opportunity to study head anatomy at his laboratory. At that time, I was a board-certified plastic surgeon
and a board-certified neurosurgeon in Japan. Although I had
been working exclusively as a plastic surgeon rather than as
a neurosurgeon, Dr. Rhoton generously allowed me to study
the anatomy of the extracranial region at his laboratory. This
had been my major interest as a plastic surgeon, and I found
in my research that the qualities of anatomical specimens
varied greatly. For example, the quality of silicon injection of
the extracranial region diered from the intracranial region,
and this concerned me. Fortunately, at Dr. Rhotons laboratory
I was finally able to obtain some good specimens in which the
silicon was almost perfectly injected into the extracranial
region.

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Facial reanimation surgery has been my lifes work for


more than 10 years, and with this book, Dr. Rhoton and
I had as our goal the creation of an atlas of anatomy of the
facial nerve illustrated with precisely dissected specimens,
similar to the beautifully illustrated Pernkopf Anatomy. I
believe that an atlas of anatomy consisting of specimens is
more understandable than one with illustrations, even if they
are delicately drawn. Our appreciation of basic human
anatomy is not always complete, and a thorough reevaluation
of the literature supplemented by detailed cadaver dissections can lead to new insights that may alter our surgical
technique.
Finally, I want to express my appreciation for the patience
of my children, Aya, Satoshi, Akira, and Jun, while I have been
immersed in this project and clinical work. I think this book
should be dedicated to the donors of the specimens shown
because only their devotion made this work possible.
Nobutaka Yoshioka, MD, PhD

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Preface
One of the joys of my professional career has been to work
with Nobutaka Yoshioka, MD, PhD, an outstanding plastic
surgeon, on this atlas. My applause and congratulations go to
him for this outstanding book. Michelangelo and da Vinci and
many great artists pursued cadaveric dissection as a way of
achieving perfection in their art; this beautiful anatomical
volume highlights Dr. Yoshiokas own passion for perfection.
Dr. Yoshioka worked in our microsurgery laboratory, where
he created precise and accurate dissections of the facial nerve
as a guide to improving the lives of our patients. We are fortunate to have had Dr. Yoshioka in our laboratory, where he
worked night and day to achieve the excellence reflected in
the photographs in this book.
In sections, which begin with the skull and intracranial
structures, followed by the upper, mid, and lower
face and the posterolateral neck, this atlas captures the

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full course of the facial nerve. Each section is filled with


stunning color images of his magnificent dissections, and
every figure is supplemented with a concise, well-focused
description that provides a wealth of information. Surgeons,
particularly neurosurgeons and plastic surgeons, as well as
ENT and head and neck specialists around the world will
benefit from this work. Students and trainees will also benefit
from studying this book cover to cover, while readers with
advanced knowledge and experience will find it a useful
reference.
My work with Dr. Yoshioka and other young surgeons from
across the globe has been one of the most rewarding aspects
of my career and a source of many treasured friendships. This
book is a reflection of this friendship and cooperation.
Albert L. Rhoton, Jr., MD

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Intracranial Region and Skull

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Intracranial Region

Motor root of V
Cerebellum

Sensory root of V

Vestibulocochlear n.
Facial n. (cisternal segment)
Trigeminal ganglion
Anterior semicircular canal
Greater (superficial)
petrosal n. (GSPN)
Lesser petrosal n.
Superior tympanic a.

V3

Middle meningeal a.
Tympanic cavity
Malleus

Posterior semicircular canal


Lateral semicircular canal
Stapes
Incus
Facial n.
Chorda tympani

Fig. 1.1. Middle fossa from above. The tegmen tympani and the roof of the internal acoustic meatus have been opened.

The facial nerve contains motor fibers, which are responsible


for facial expression, as well as other nerve fibers involved in
sensation (auricular concha; see Fig. 13.3b), taste (anterior
two-thirds of the tongue; see Fig. 1.3), and secretory function
(lacrimal gland, submandibular gland, and sublingual gland;
see Fig. 5.9a and Fig. 12.1).
The facial nerve emerges from the brainstem at the junction of the pons and medulla. The course of the facial nerve
may be divided into intracranial, intratemporal, and extratemporal segments. The intracranial segment, known as the
pontine or cisternal segment, spans roughly 25 mm and connects the facial nerve from its origin to the entrance of the
internal acoustic meatus. The intratemporal segment can be
divided into four segments: meatal, labyrinthine, horizontal,
and vertical. The facial nerve, accompanied by the vestibulocochlear nerve, enters the temporal bone through the internal
acoustic meatus. Initially, there are two separate components,
which are the motor root supplying the muscle of the face
and the nervus intermedius that contains sensory fibers concerned with the perception of taste and parasympathetic
(secretomotor) fibers to the lacrimal, submandibular, and

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sublingual glands. The two components merge within the


meatus.
The greater (superficial) petrosal nerve (GSPN) is a branch
of the facial nerve and carries parasympathetic fibers to the
pterygopalatine fossa. It emerges within the facial canal of the
temporal bone, close to the geniculate ganglion of the facial
nerve. It then passes through the bone to appear on the floor
of the middle cranial fossa and runs medially in a shallow
groove to the foramen lacerum. Passing within the foramen
lacerum, the greater petrosal nerve enters the pterygoid canal
that lies at the base of the pterygoid process. On leaving the
pterygoid canal, the nerve emerges into the pterygopalatine
fossa and joins the pterygopalatine ganglion (see Fig. 10.15).
The lesser petrosal nerve is a branch of the glossopharyngeal nerve and carries parasympathetic fibers to the otic ganglion. The nerve arises in the middle ear and passes on to the
floor of the middle cranial fossa through a hiatus in the petrous
part of the temporal bone. The nerve lies in a groove located
lateral to that of the greater petrosal nerve and runs toward the
foramen ovale and then enters the infratemporal fossa through
the foramen ovale to join the otic ganglion (see Fig. 10.12).

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I Intracranial Region and Skull


Anterior inferior cerebellar a.,
Facial n., Nervous intermedius,
Vestibulocochlear n.

Internal carotid a.
V2
Greater petrosal n. (cut)
(GSPN)
Tensor tympani m.

Anterior semicircular canal


Cochlea (opened)
V3

Middle meningeal a.
Eustachian tube
Chorda tympani

Geniculate ganglion
Posterior semicircular canal
Lateral semicircular canal
Facial n.
Chorda tympani

Mandibular fossa
(opened)

External acoustic meatus

Fig. 1.2. Middle fossa from above. The mandibular fossa and the roof of external acoustic meatus have been opened.

The trigeminal nerve supplies sensations to the face, mucous


membranes, and other structures of the head. It is the motor
nerve for the muscles of mastication and contains proprioceptive fibers. It exits the brain by a large sensory root and a
smaller motor root emerging from the pons at its junction
with the middle cerebral peduncle. It passes laterally to join
the trigeminal (gasserian or semilunar) ganglion in the trigeminal cave (Meckels cave) close to the apex of the petrous
part of the temporal bone, and then it appears as three major
(ophthalmic, maxillary and mandibular) divisions. After
removing the dura, the maxillary (V2) and mandibular (V3)
nerves are identified. The ophthalmic and maxillary nerves
pass through the lateral wall of the cavernous sinus. The mandibular nerve passes directly to the foramen ovale.
The tensor tympani muscle lies within a bony canal situated above the Eustachian tube in the anterior wall of the

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tympanic cavity. It draws the handle of the malleus medially,


and the muscle tenses the tympanic membrane and helps to
damp sound vibrations. The nerve to the tensor tympani
muscle is derived from the mandibular division of the trigeminal nerve.
The middle meningeal artery, which is a branch of the
maxillary artery (mandibular segment), enters the middle
cranial fossa through the foramen spinosum. This artery
has branches to the trigeminal ganglion and to the tympanic
cavity (superior tympanic branch). The superior tympanic
artery supplies the tensor tympani muscle. An accessory
meningeal artery, which is a branch of the maxillary
artery (mandibular segment), runs through the foramen
ovale into the middle cranial fossa to supply the trigeminal
ganglion and the dura lining the floor of the middle cranial
fossa.

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1 Intracranial Region

Temporal fascia

Middle fossa dura


Superior petrosal sinus

Anterior semicircular canal


Lateral semicircular canal
Short process of incus

Posterior fossa dura


Posterior semicircular canal
Sigmoid sinus

Facial n. (vertical part)


Endolymphatic sac
(blue sheet is in the sac)

Chorda tympani

Meningeal br. of occipital a., Emissary v.

Digastric ridge
Digastric m.
Facial n.
(extratemporal)

Occipital a.

Auricular br. of posterior auricular a.

Fig. 1.3. Lateral view of the mastoid after mastoidectomy

The mastoid process is a prominence projecting from the


undersurface of the mastoid portion of the temporal bone.
This process is a point of attachment for the splenius capitis,
the longissimus capitis, the digastric posterior belly, and the
sternocleidomastoid muscles.
The chorda tympani is given o just before the stylomastoid foramen. It is the branch from the nervus intermedius. It
contains parasympathetic fibers going to the submandibular
ganglion and taste fibers from the anterior two-thirds of the
tongue. It initially runs within its own canal before entering
the tympanic cavity to cross the malleus. It then enters
another canal before leaving the temporal bone through the
petrotympanic (squamotympanic) fissure.

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Within the facial canal, close to the pyramid, arises the


nerve to the stapedius muscle. The stapedius is the smallest
skeletal muscle in the human body. At just over 1 mm in
length, its purpose is to stabilize the smallest bone in the
body, the stapes. This muscle helps to damp excessive sound
vibrations and functions when sound is too loud.
The digastric ridge corresponds to the digastric groove
and marks the location of the facial canal just anterior to
it. This is a ridge of bone just deep or medial to the mastoid
tip.
Hypoglossal-facial nerve side-to-end anastomosis without
nerve grafting can be performed to cut the facial nerve at the
point just below the lateral semicircular canal.

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I Intracranial Region and Skull

Anterior fossa
Internal carotid a.
Mucosa of sphenoid sinus
Optic n. (with dura)

Oculomotor n.

Lateral edge of
superior orbital fissure

Trochlear n.

Orbital br. to lacrimal a.


(from middle meningeal a.)
V1
Foramen rotundum

Trigeminal ganglion

V2
Middle fossa
V3

Fig. 1.4. The superior orbital fissure and trigeminal nerve. The optic canal has been opened, and anterior clinoidectomy has been done.

The trigeminal nerve has three divisions: ophthalmic (V1),


maxillary (V2), and mandibular (V3). The ophthalmic nerve
passes into the orbit through the superior orbital fissure. The
maxillary nerve passes into the pterygopalatine fossa through
the foramen rotundum. The mandibular nerve passes into the
infratemporal fossa through the foramen ovale. All divisions
have meningeal branches. The dura mater is innervated by
the meningeal branches mainly from the trigeminal nerves.
The motor division of the mandibular nerve supplies
the muscles of mastication: masseter, temporalis, pterygoid,

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mylohyoid, and digastric. These muscles produce elevation,


depression, protrusion, retraction, and the side-to-side
movements of the mandible. The motor division also
supplies the tensor tympani and tensor veli palatini
muscles.
The meningo-orbital foramen is located in the lateral wall
of the orbit and links the orbit to the cranial cavity. It represents a passage for the artery connecting the orbital branch
of the anterior division of the middle meningeal artery and
lacrimal branch of the ophthalmic artery.

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Skull: External and Internal Views

Petrotympanic fissure
Vaginal process

Tympanic part of
temporal bone
Stylomastoid foramen
Foramen for stylomastoid artery

Spine of sphenoid bone


Foramen spinosum
Foramen ovale
Eustachian tube
Sphenopetrosal suture
Emissary foramen

Foramen lacerum
Petrooccipital fissure

Styloid process (cut)

Carotid canal
Jugular foramen
Intrajugular process

Occipital condyle

Fig. 2.1. The external surface of the skull base. Close-up view of the stylomastoid foramen.

The facial nerve exits from the stylomastoid foramen and is


supplied by the stylomastoid artery, which usually originates
from the posterior auricular artery. The stylomastoid artery
enters into the skull from the foramen adjacent to the stylomastoid foramen.
The foramen ovale allows passage between the middle
cranial fossa and the infratemporal fossa of the mandibular
division of the trigeminal nerve, the lesser petrosal branch of
the glossopharyngeal nerve, the accessory meningeal branch
of the maxillary artery, and some emissary veins. Behind the
foramen ovale lies the foramen spinosum, which transmits
the middle meningeal vessels and meningeal branch of the
mandibular division of the trigeminal nerve.
The jugular foramen is located between the temporal bone
and the occipital bone. The structures that traverse the jugular

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foramen are the sigmoid sinus and jugular bulb, the inferior
petrosal sinus, the meningeal branches of the ascending pharyngeal and occipital arteries, the glossopharyngeal, vagus,
and accessory nerves with their ganglia, the tympanic branch
of the glossopharyngeal nerve (Jacobsons nerve), the auricular branch (also known as the mastoid branch) of the vagus
nerve (Arnolds nerve), and the cochlear aqueduct. The intrajugular process is a small, curved process which partially or
completely divides the jugular foramen into lateral and medial
parts.
Behind the foramen spinosum, the bone is raised to form
the spine of the sphenoid to which the sphenomandibular
ligament is attached. The posterior margin here is grooved
and is related to the cartilaginous component of the Eustachian tube (see Fig. 10.18).

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I Intracranial Region and Skull

Zygomatic arch
Supramastoid crest
Articular tubercle
Mandibular fossa
External acoustic meatus
Mastoid process
Tympanomastoid suture (Drop-off point)
Mastoid notch (Digastric Groove)

Inferior orbital fissure


Infratemporal crest
Vaginal process
(Tympanic part)
Foramen spinosum

Stylomastoid foramen
Styloid process (cut)
Carotid canal
Jugular foramen

Lateral pterygoid plate


Foramen ovale
Eustachian tube
Pterygoid hamulus

Hypoglossal canal
Condylar canal
Occipital condyle

Vomer
Foramen Magnum

Fig. 2.2. Infratemporal fossa. The mandible has been removed.

The digastric muscle is attached to the mastoid notch (digastric groove) , the anterior end of which indicates the stylomastoid foramen. The tympanomastoid suture is a landmark
of facial nerve trunk. The facial nerve (stylomastoid foramen)
can be identified at 6 to 8 mm medial to the inferior dropo point of the tympanomastoid suture.
Jacobsons nerve arises from the petrous ganglion of the
glossopharyngeal nerve. It enters the tympanic cavity via the
inferior tympanic canaliculus and contributes to the tympanic plexus. It contains both sensory and parasympathetic
fibers. The sensory fibers supply the middle ear. The parasympathetic fibers leave the plexus as the lesser petrosal
nerve and enter the otic ganglion.
Arnolds nerve originates from the superior ganglion of the
vagus nerve below the jugular foramen. It passes behind the
internal jugular vein and ascends through the mastoid canaliculus on the lateral wall of the jugular fossa. It traverses the
substance of the temporal bone and crosses the facial canal

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above the stylomastoid foramen, where it gives o a branch


that joins the facial nerve. The nerve finally reaches the
surface by passing through the tympanomastoid suture. It
divides into two branches: one joins the posterior auricular
nerve, while the other innervates the skin of the concha and
a small area of the cranial surface near the mastoid (see Fig.
13.3).
The osseous boundaries of the infratemporal fossa are the
posterolateral maxillary surface anteriorly, the lateral pterygoid plate anteromedially, the mandibular ramus laterally,
and the tympanic part of the temporal bone and the styloid
process posteriorly. The fossa is domed anteriorly by the
infratemporal surface of the greater sphenoid wing, the site
of the foramina ovale and spinosum, and posteriorly by the
squamous part of the temporal bone. The inferior, posteromedial, and superolateral aspects are open without bony walls.
The infratemporal crest is the boundary between the temporal fossa and infratemporal fossa.

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2 Skull: External and Internal Views

Pterion
Superior temporal line

Temporal bone

Groove for
middle temporal a.

Frontozygomatic suture
Greater wing of
sphenoid bone

Supramastoid crest
Suprameatal spine (Henle)

Zygomatic bone
Zygomaticofacial foramina
Coronoid process

Mandibular
notch

Articular tubercle
External acoustic meatus
Condylar process
Tympanomastoid suture
Mastoid process
Occipital condyle

Fig. 2.3. Lateral view of the skull with the temporal bone highlighted.

The suprameatal triangle, a depressed area located below the


anterior part of the supramastoid crest and behind the posterosuperior margin of the external acoustic meatus, marks
the deep location of the mastoid antrum. The suprameatal
spine (the spine of Henle), which locates anterior part of the
suprameatal triangle, approximates the deep site of the tympanic facial nerve segment and the lateral canal.
The zygomaticofacial nerve is a sensory nerve of the cheek
and one of the two branches of the zygomatic nerve that
originated from the maxillary nerve. It comes out to the face
through the zygomaticofacial foramen. This foramen is sometimes doubled, and this figure shows two zygomaticofacial
foramina.

c02.indd 9

Pterion is the landmark for frontotemporal craniotomy. It


is the H-shaped region where the four calvarial bones (frontal,
sphenoid, parietal, and temporal) meet.
The superior temporal line begins at the zygomatic process
of the frontal bone and first curves superoposteriorly and
then inferiorly and anteriorly to the supramastoid crest. It
provides attachment for temporal fascia.
The groove for the middle temporal artery, which supplies
posterior and upper part of temporalis muscle, is sometimes
prominent on the temporal bone.
The base of the temporomandibular ligament is attached
to the zygomatic process of the temporal bone and the articular tubercle (see Fig. 9.1).

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10

I Intracranial Region and Skull


Lambdoid suture
Inion (External occipital
protuberance)

Asterion
Parietomastoid suture
Occipitomastoid suture

Inferior nuchal line

Mastoid foramen

External occipital crest

Mastoid process
External acoustic meatus
Mastoid notch
Occipital groove

Condylar canal
Foramen Magnum

Mandibular condyle
Occipital condyle

Fig. 2.4. Posterolateral view of the skull.

The mastoid notch (digastric groove), where the digastric


muscle is attached, and the occipital groove, where the occipital artery courses on, are parallel grooves on the posterior
aspect of the mastoid process.
The meningeal branch of the occipital artery and emissary vein penetrate the cranium through the mastoid
foramen.
The asterion located at the junction of the lambdoid, occipitomastoid, and parietomastoid sutures is usually located

c02.indd 10

over the junction of the lower part of the transverse and


sigmoid sinuses.
The external occipital protuberance is a projection of the
external surface of the occipital squama. It is situated approximately at the mid-point of the squama. It provides attachment for the medial fibers of the trapezius muscle. Below this
prominence is a crest that runs inferiorly to the back edge of
the foramen magnum. This crest, called the external occipital
crest, provides attachment for the nuchal ligament.

2/10/2015 1:39:29 PM

2 Skull: External and Internal Views

11

Frontal crest

Crista galli
Foramina of cribriform plate
Sphenoidal ridge
Lesser wing of
sphenoid bone
Optic canal
Anterior clinoid process
Tuberculum sellae

Superior orbital fissure


Greater wing of
sphenoid bone

Sella turcica (Pituitary fossa)

Foramen rotundum

Carotid groove
Dorsum sellae

Groove for middle


meningeal artery
Foramen ovale

Fig. 2.5. Anterior and middle skull base (internal surface).

The sensory innervation of the face is via the three divisions of


the trigeminal nerve: ophthalmic, maxillary, and mandibular.
The superior orbital fissure lies between the greater and
lesser wings of the sphenoid at the junction of the roof and
lateral wall of the orbit. It transmits the oculomotor nerve,
the trochlear nerve, and the sympathetic filaments from the
internal carotid plexus, the abducens nerve, and the ophthalmic division of the trigeminal nerve, together with the ophthalmic veins. It may also transmit the orbital branch of the
middle meningeal artery and the recurrent branch of the
lacrimal artery (see Fig. 3.1).
The foramen rotundum lies within the greater wing of the
sphenoid. It allows communication between the middle
cranial fossa and the pterygopalatine fossa. The maxillary
division of the trigeminal nerve passes through the foramen.
The foramen ovale is also in the greater wing of the sphenoid, and it communicates between the middle cranial fossa
above and the infratemporal fossa below. The mandibular
division of the trigeminal nerve, the lesser petrosal branch of
the glossopharyngeal nerve, the accessory meningeal branch

c02.indd 11

of the maxillary artery, and an emissary vein from the cavernous sinus to the pterygoid venous plexus pass through the
foramen.
The ophthalmic nerve supplies the forehead, upper eyelid,
and dorsum of the nose. The maxillary nerve supplies the
lower eyelid, the cheek, the upper lip, the ala of the nose, and
part of the temple, the maxillary teeth, and the nasal cavity.
The mandibular nerve has motor and sensory fibers. The
latter supplies the skin over the mandible, the lower cheek,
part of the temple and ear, the lower teeth, the gingival
mucosa, and the lower lip.
The crista galli is the thick crest of bone that projects above
the cribriform. The crest is thickest near its base and tapers
superiorly. It projects between the two cerebral hemispheres
with the falx cerebri attaching to its posterior margin.
The frontal crest is an anterior crest of bone in the midline
of the internal surface of the frontal bone. This sharp ridge of
bone is a continuation of the converging edges of the sulcus
for the superior sagittal sinus. The anterior part of the falx
cerebri attaches to the ridge.

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Orbit and Facial Bone

Frontal bone
Frontonasal suture

Fossa for lacrimal gland

Superior orbital fissure

Sphenofrontal suture
Meningo-orbital foramen

Frontomaxillary suture

Frontozygomatic suture
Greater wing of
sphenoid bone
Sphenozygomatic suture

Optic canal

Internasal suture

Inferior orbital fissure


Zygomatico-orbital foramen
Infraorbital sulcus (groove)

Fig. 3.1. Anterior view of the orbit.

The inferior orbital fissure lies at the junction of the lateral


wall and the floor of the orbit. Through this fissure pass the
infraorbital and zygomatic branches of the maxillary division
of the trigeminal nerve and accompanying vessels.
The infraorbital nerve is the terminal branch of the maxillary nerve. It courses along the orbital floor in the infraorbital
sulcus (groove) into a canal and onto the face at the infraorbital foramen.
The zygomatic nerve arises from the maxillary nerve in
the pterygopalatine fossa and passes through the inferior
orbital fissure to course along the lateral wall of the orbit,
where it divides into zygomaticofacial and zygomaticotemporal branches. The branches enter the zygomatico-orbital

c03.indd 12

foramina on the orbital surface of the zygomatic bone. When


one foramen is present, the zygomatic vessels and nerve enter
and then branch within the bone to exit dierent foramina as
the zygomaticofacial and zygomaticotemporal vessels and
nerve. The zygomaticotemporal nerve provides sensation to
the temporal skin, and the zygomaticofacial nerve provides
sensation to the skin over the prominence of the cheek.
Meningo-orbital foramen (lacrimal foramen) is located in
the greater wing of the sphenoid, anterior to the tip of the
superior orbital fissure, and is the source of an anastomosis
between the lacrimal artery and the orbital branch of the
middle meningeal artery. This foramen is present in approximately 50% of Caucasian people.

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3 Orbit and Facial Bone

Meningeal br. to falx


Crista galli

13

Crista galli
Anterior ethmoidal groove

Anterior ethmoidal a.(to the nasal cavity)

Cribriform plate

Anterior ethmoidal a.(from the orbit)

Posterior ethmoidal groove


Falx

c
Supraorbital foramen
Frontal bone

Frontal notch
Anterior ethmoidal foramen
Posterior ethmoidal foramen

Meningo-orbital foramen
Superior orbital fissure
Optic canal
Optic strut

Orbital plate
(Ethmoid bone)
Nasal bone

Foramen rotundum
Inferior orbital fissure

Anterior lacrimal crest


Lacrimal fossa
Posterior lacrimal crest

Maxilla

Infraorbital sulcus (groove)


Zygomaticofacial foramen

b
Fig. 3.2a-c. (a) Superior view of the cribriform plate. (b) Anteromedial view of the orbit. (c) Superior view of the ethmoid bone.

The supraorbital foramen, the frequency of which is 20 to


30%, is the passage mainly for the supraorbital nerve, especially its lateral branch, one of the medial branches, and its
concomitant small artery (see Fig. 5.3b). The main trunk of
the supraorbital artery generally passes under the supraorbital notch or just below the supraorbital rim. The supraorbital notch also transmits the supraorbital nerve. The frontal
notch, which is medial to the supraorbital notch, transmits
the supratrochlear nerve and artery.
The optic canal lies within the lesser wing of the sphenoid
and transmits the optic nerve and ophthalmic artery.
The anterior and posterior ethmoidal foramina for the same
nerves and vessels are situated at the medial wall. The anterior
ethmoidal nerve exits the orbit through the anterior ethmoidal foramen and enters the anterior cranial fossa. It runs
into the roof of the nose through small slits lying on each side
of the crista galli. The posterior ethmoidal nerve exits the orbit

c03.indd 13

through the posterior ethmoidal foramen to enter the nose. It


supplies the sphenoidal sinus and the posterior ethmoidal air
cells. The view of the ethmoid bone from above (Fig. 3.2c)
shows anterior and posterior ethmoidal grooves for the same
nerves and vessels, which are converted into foramina by
articulation with frontal bone. It is important that lowest point
of the cribriform plate (lowest point of the anterior skull base)
is generally below the anterior and posterior ethmoidal
foramen on the medial orbital wall (Fig. 3.2a).
The fossa for the lacrimal sac is formed by the lacrimal
incisure on the maxilla and a matching groove on the lacrimal
bone. When the adjacent grooves are combined, they form a
fossa and a canal that houses the lacrimal sac and transmits
the beginning of the lacrimal duct toward the nasal cavity.
The cribriform plate is the horizontal plate of the ethmoid
bone perforated with numerous foramina for the passage of
the olfactory nerve filaments from the nasal cavity.

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14

I Intracranial Region and Skull

Supraorbital foramen
Nasal bone
Fossa for lacrimal gland
Nasal septum
Middle nasal concha
Anterior nasal spine

Inferior nasal concha


Infraorbital foramen

Intermaxillary suture

Zygomatic arch
Coronoid process

a
Fig. 3.3a,b. (a) Anteroinferior view of the skull. (b) Anteroinferior view of the maxilla after removing the anterior and posterior
sinus walls to show the foramen rotundum.

The infraorbital foramen lies below the infraorbital rim. The


infraorbital branch of the maxillary nerve and infraorbital
vessels pass through the foramen.
The anterior and posterior walls of the left maxillary sinus
have been opened to see the pterygopalatine fossa and
foramen rotundum (Fig. 3.3b). Black string is passing from
the foramen rotundum to the infraorbital foramen. The pterygopalatine fossa is a cone-shaped paired depression deep to

c03.indd 14

the infratemporal fossa and posterior to the maxilla on each


side of the skull, located between the pterygoid process and
the maxillary tuberosity, close to the apex of the orbit. It is
the indented area medial to the pterygomaxillary fissure
leading into the sphenopalatine foramen. It communicates
with the nasal and oral cavities, the infratemporal fossa, the
orbit, the pharynx, and the middle cranial fossa through eight
foramina (see Fig. 8.4).

2/10/2015 1:39:34 PM

3 Orbit and Facial Bone

15

Foramen ovale
Pterygoid hamulus
Choana

Vomer
Lesser palatine foramen

Lesser palatine foramen

Posterior nasal spine


Greater palatine foramen

Horizontal plate of
palatine bone

Transverse palatine suture

Palatine process of
maxillary bone

Median palatine suture

Incisive fossa and canal

Infraorbital foramen

Fig. 3.4. Inferior view of the palatine bone.

The nasopalatine nerve, which is a branch of the pterygopalatine ganglion, enters the nasal cavity through the sphenopalatine foramen and runs obliquely downward and forward on
the nasal septum. It terminates as the incisive nerve, which
passes through the incisive canal with an accompany artery
onto the hard palate to supply oral mucosa around the incisive papilla. It communicates with the corresponding nerve
of the opposite side and with the greater palatine nerve.
The greater palatine nerve is a branch of the pterygopalatine ganglion that carries both general sensory and parasympathetic fibers. It passes through the grater palatine canal
and onto the hard palate at the greater palatine foramen.
It passes forward in a groove in the hard palate, nearly as far

c03.indd 15

as the incisor teeth. It supplies the gums, the mucous


membrane, and the glands of the hard palate, and it communicates in front with the terminal filaments of the nasopalatine nerve.
The lesser palatine nerve passes through the greater palatine canal and onto the palate at the lesser palatine foramen.
It runs backward to supply the soft palate. It also has nasal
branches that innervate the nasal cavity.
The pterygoid hamulus is the laterally deflected hook of
bone at the inferior end of the medial pterygoid plate. It
serves a pulley-like function for the tendon of the tensor veli
palatini muscle and serves as the attachment for the pterygomandibular raphe.

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16

I Intracranial Region and Skull

Supraorbital foramen
Glabella
Nasal part of frontal bone

Frontonasal suture
Frontal notch

Nasomaxillary suture

Frontomaxillary suture

Superior orbital fissure

Frontal process of maxilla

Inferior orbital fissure

Infraorbital foramen
Piriform aperture
Canine fossa
Canine eminence
Incisive fossa

Incisive fossa
Mental foramen

Mental protuberance

Fig. 3.5. Anterior view of the skull.

The orbicularis oculi muscle arises from the nasal part of the
frontal bone, the frontal process of the maxilla, and the medial
palpebral ligament.
The corrugator supercilii muscle arises from the medial
end of the supraorbital ridge on the frontal bone.
The procerus muscle arises from the nasal bone and the
lateral nasal cartilage.
The nasalis and depressor septi muscle arise from the
maxilla in the region overlying the root of the lateral incisor
and canine tooth.
The levator labii superioris muscle arises from the maxilla
at the inferior orbital rim, above the infraorbital foramen.
The levator labii superioris alaeque nasi muscle arises from
the frontal process of the maxilla.
The zygomaticus major muscle arises from the lateral
surface of the zygomatic bone, just in front of the

c03.indd 16

zygomaticotemporal suture. The zygomaticus minor muscle


also arises from the zygomatic bone, just in front of the origin
of zygomaticus major.
The canine eminence overlies the root of the canine tooth.
It separates the anterior surface of the maxilla into two
concave areas: a shallow, incisive fossa in front and a deeper,
canine fossa behind. The levator anguli oris muscle arises
from the canine fossa of the maxilla, immediately below the
infraorbital foramen.
The supraorbital foramen, the infraorbital foramen, and
the mental foramen are found approximately in line
vertically.
The piriform aperture (anterior nasal aperture) is a heartor pear-shaped bony nasal opening in the skull.

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3 Orbit and Facial Bone

17

Condylar head
Coronoid process
Condylar neck

Retromolar fossa

External oblique line

Incisive fossa

Mental foramen

Mental tubercle

Mental protuberance

Fig. 3.6. Anterior view of the mandible.

The depressor labii inferioris muscle arises from the mandible


just in front of the mental foramen.
The depressor anguli oris muscle arises from an extensive
area around the external oblique line of the mandible.
The platysma muscle arises from the superficial fascia of
the upper part of the thorax. It runs up to the neck to insert
into the lower border of the body of the mandible, the skin of
the lower part of the mouth, and the mimetic muscles around
the angle of the mouth.
The mentalis muscle originates from the incisive fossa of
the mandible.
The buccinator muscle is attached to the alveolar margin
of the maxilla and mandible in the region of the molar teeth.

c03.indd 17

There are fibers by which the orbicularis oris muscle is


connected with the maxilla and the septum of the nose above
and with the mandible below.
A distinct prominence, the mental protuberance, lies at the
inferior margin in the midline of the mandible. On each side
of the protuberance are the mental tubercles. Above the
mental protuberance lie a shallow depression called the incisive fossa. The mental foramen is in the region of the premolar teeth. The mental nerve, which originated from the inferior
alveolar nerve, and the accompanying vessels pass onto the
face through this foramen.

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18

I Intracranial Region and Skull

Coronoid process
Condyle Head

Mandibular
notch

Pterygoid fovea
Condyle Neck
Temporal crest
Lingula
Mandibular foramen
Ramus
Mylohyoid groove
(groove for mylohyoid n.)
Sublingual fossa
Mylohyoid line

Angule

Body

Submandibular fossa

Fig. 3.7. Posterolateral view of the mandible.

The temporalis muscle inserts onto the apex, the anterior and
posterior borders, and the medial surface of the coronoid
process. The insertion extends down the anterior border of
the ramus near the third molar tooth. Many of the fibers have
a tendinous insertion. The temporal crest is a ridge along
anteromedial aspect of the coronoid process and upper ramus
of the mandible into which the temporalis muscle inserts.
A small depression, the pterygoid fovea, is a site of attachment of the lower head of lateral pterygoid muscle. It is situated on the anterior part of the neck of the condyle. The upper
head of the lateral pterygoid muscle insets into the capsule
and medial aspect of the articular disc of the temporomandibular joint.
The masseter muscle inserts into the lateral surface of the
angle, ramus, and coronoid process of the mandible.

c03.indd 18

The medial pterygoid muscle inserts into the roughened surface of the angle of the mandible on its medial
aspect.
The mandibular foramen, through which the inferior alveolar nerve and vessels pass into the mandibular canal, lies in
the center of the medial surface of the ramus.
A bony process, the lingula, extends from the anterosuperior surface of the foramen and gives attachment to the sphenomandibular ligament.
The mylohyoid groove is where the mylohyoid nerve runs
down from the posteroinferior surface of the mandibular
foramen.
The sublingual gland lies adjacent to the sublingual fossa.
The submandibular fossa is a depression for the submandibular gland.

2/10/2015 1:39:37 PM

II

c04.indd 19

Upper Facial and


Midfacial Region

2/10/2015 1:39:39 PM

c04.indd 20

2/10/2015 1:39:39 PM

Upper Facial and Midfacial


Region Overview
Temporoparietal fascia
(Superficial temporal fascia)
Superficial temporal a.
Auriculotemporal n.
Zygomatico-orbital a.
Orbicularis oculi m.

Levator labii superioris m.


Zygomaticus minor m.
Zygomaticus major m.

Parotid fascia

Levator anguli oris m.


Buccal fat pad
Facial a.
Risorius m.

Platysma

Fig. 4.1. Lateral view of the face. The superficial musculoaponeurotic system (SMAS) is shown after removing the skin.

In the scalp, the superficial musculoaponeurotic system


(SMAS) is represented by the galea aponeurotica, which then
splits to ensheath the frontalis, the occipitalis, the procerus,
and some of the periauricular muscles. In the temporal region,
the SMAS, the superficial temporal fascia, and the temporoparietal fascia are synonymous. In the cheek, the SMAS is
represented by the parotid fascia as a remnant of the primitive platysma. The SMAS is relatively thick over the parotid
gland. However, it thins considerably, thereby making it difficult to dissect medially. The SMAS is continuous with the
platysma below and extends to the zygoma above. The precise
anatomy of the SMAS, its regional variations, and even the
existence of the SMAS are still debated.
The facial nerve and its branches are under the SMAS. The
frequency of appearance of certain mimetic muscle is known to

c04.indd 21

vary. Some mimetic muscles, such as the levator labii superioris


and the zygomaticus major, are almost always present, whereas
the risorius muscle is relatively uncommon. Moreover, there is a
striking degree of variability in their size and shape from individual to individual. Many of the mimetic muscles are attached
to the facial skeleton and insert into the skin. Mimetic muscles
cause movement of the facial skin to reflect emotions.
The risorius muscle does not arise from bone but originates from the connective tissue overlying the parotid gland.
The muscle runs horizontally across the face to insert into the
skin at the corner of the mouth. It pulls the corner of the
mouth laterally, as in grinning.
The facial artery runs superficially above the SMAS layer
at the buccal (on the buccinator muscle) and nasolabial (on
the orbicularis oris muscle) region.

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22

II Upper Facial and Midfacial Region

Frontalis m.

Parietal br. of superficial


temporal a.
Galea aponeurotica

Frontal br. of superficial


temporal a.
Superior auricular m.
Auriculotemporal n.
Corrugator supercilii m.
Orbicularis oculi m.
Zygomatico-orbital a.
Superficial temporal a., v.

Occipitalis m.
Posterior auricular v.
Occipital a.
Posterior auricular m.

Temporal brs.
Zygomatic br.
Transverse facial a.
Levator labii superioris m.
Parotid duct
Zygomaticobuccal brs.
Levator anguli oris m.
Zygomaticus major m.
Orbicularis oris m.
Modiolus
Buccinator m.
Marginal mandibular br.
Facial a., v.
Depressor anguli oris m.
Depressor labii inferioris m.

Greater occipital n.
Splenius capitis m.
Posterior auricular a.
Parotid gland
Masseter m. (with fascia)
Lesser occipital n.
Sternocleidomastoid m.
Accessory n.
Great auricular n.
Cervical br.
External jugular v.
Platysma m.

Fig. 4.2. Lateral view of the face. The superficial musculoaponeurotic system (SMAS) has been removed to show the facial nerve
branches. Every mimetic muscle and part of the temporoparietal fascia and galea are preserved.

Mimetic muscles, with the exception of the buccinator, the


levator anguli oris, and the mentalis, are innervated from
their deep surface by the facial nerve branches. These muscles
are located in the deepest layer among the mimic muscles and
are innervated from their superficial surface. The superior
auricular muscle arises from the temporoparietal fascia and
inserts into the upper part of the cranial surface of the auricle.
It is innervated by the temporal branch of the facial nerve. It
displaces the auricle superiorly.
The facial artery and vein are independently running
obliquely from the mandibular angle toward the medial
canthus. The superficial temporal artery is one of the terminal branches of the external carotid artery. The artery
passes upward toward the scalp, crossing the zygomatic

c04.indd 22

process of the temporal bone. It divides into anterior


(frontal) and posterior (parietal) branches. A transverse facial
artery arises from the superficial artery within the parotid
gland and crosses the masseter muscle above the parotid
duct.
The superficial temporal vein is formed above the zygomatic arch by the union of anterior and posterior tributaries.
The superficial temporal vein then enters the substance of the
parotid gland. It unites first with the middle temporal vein
and then with the maxillary vein to form the retromandibular
vein in the gland. When the superficial temporal vein is
poorly developed or, as occasionally happens, is absent, the
posterior auricular vein usually compensates for it, as shown
in this figure.

2/10/2015 1:39:40 PM

Forehead and Orbital Region

Lateral br. of
supraorbital n.
Frontalis m.

Medial brs. of
supraorbital n.

Temporoparietal
fascia

Frontal br. of
superficial temporal a.
Supraorbital v.
Superficial brs. of
supraorbital a. and
supratrochlear a.

Auriculotemporal n.
Orbicularis oculi m.
Zygomatico-orbital a.

Fig. 5.1. The frontotemporal region. The skin has been removed to show the frontalis muscle and galeal layer.

The galea aponeurotica extends from the external occipital


protuberance and supreme nuchal lines to the eyebrows.
The aponeurotica is continuous laterally with the temporoparietal fascia overlying the temporal fascia. The galea
aponeurotica contains the occipitofrontal muscle. Each frontal
belly of the frontalis muscle arises from the anterior margin
of the galea aponeurotica and passes forward to merge with
the orbicularis oculi muscle. The main function of the occipitofrontalis muscle is to elevate the eyebrows to produce
transverse furrows of the forehead. This frontalis muscle is
innervated by the temporal branch of the facial nerve.

c05.indd 23

The forehead sensation is supplied by the supraorbital and


supratrochlear nerves. The supratrochlear nerve provides
sensation to the medial side of the forehead. The supraorbital
nerve has medial (superficial) and lateral (deep) branches.
The former provides sensation to the forehead region, and the
latter supplies sensation to the frontoparietal region. The
lateral branch penetrates the frontalis muscle and galeal layer
at the forehead, usually above the hairline.
The superficial temporal artery and vein run on the galeal
aponeurotica. The superficial branches of the supraorbital
and supratrochlear arteries communicate with the superficial
temporal artery on the galeal layer.

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24

II Upper Facial and Midfacial Region

Communicating br.
Deep br. of
supraorbital a.
Lateral br. of
supraorbital n.
Superficial br. of
supraorbital a.

Frontal br. of superficial


temporal a.

Pericranium
Temporoparietal fascia

Orbicularis oculi m.
Temporal fascia

Temporal brs. of facial n.

Fig. 5.2. The frontotemporal region. The frontalis muscle has been separated from the orbicularis oculi muscle and lifted.

The temporal branches of the facial nerve generally course


along the undersurface of the temporoparietal fascia and in
the subgaleal fat pad. The temporoparietal fascia (galea) and
its extension frontalis muscle are elevated to leave the temporal branches of the facial nerve on the temporal fascia in
this specimen.
The deep (lateral) division of the supraorbital nerve runs
cephalad across the lateral forehead between the frontalis
muscle and galeal layer and the pericranium as the sensory

c05.indd 24

nerve to the frontoparietal scalp. There is a loose areolar


tissue between the galea aponeurotica and the pericranium
that allows scalp mobility.
The arterial communication between the superficial temporal artery and the deep branch of the supraorbital artery
is shown.
The pericranium is continuous with the temporal fascia
in the temporal region.

2/10/2015 1:39:45 PM

5 Forehead and Orbital Region

25

Lateral br. of
supraorbital n.
Deep brs.
Medial br. of supraorbital n.
Supraorbital a.
Superficial br.

Pericranium (with loose areolar tissue)


Lateral br. of
supraorbital n.

Pericranial v.

Supratrochlear a.
(Deep br.)
Corrugator supercilii m.
(separated to leave the
attachment)
Supratrochlear a., n., v.

Supraorbital a.
(Deep brs.)
Supraorbital v.
Supraorbital n.
(Medial br.)
Supraorbital n.
to skin(cut)
Rt. Eye

Frontalis m.

a
Fig. 5.3a,b. (a) The supraorbital region. The forehead skin and frontalis muscle have been reflected inferiorly.
(b) Medial view of the supraorbital region.

The frontalis muscle has been reflected inferiorly. The attachment of the corrugator supercilii muscle is shown at the
medial side on the frontal bone.
The supraorbital nerve has two divisions: a superficial
(medial) division that passes shortly over the pericranium
and then pierces the frontalis muscle, providing sensory
supply to the forehead skin, and a deep (lateral) division that
runs cephalad across the lateral forehead between the galea
aponeurotica and the pericranium as the sensory nerve to the
frontoparietal scalp. The deep division consistently courses
approximately 1 cm medial to the superior temporal line,
which is the attachment of the temporal fascia. It can be
identified at the level of hair line just beneath the galea aponeurotica. In contrast, the supratrochlear nerve has only a
superficial branch.

c05.indd 25

The main trunk of the supraorbital and supratrochlear arteries course below the orbital roof and divide near or above the
supraorbital rim into superficial and deep branches (Fig. 5.3b).
The superficial branch run in the galea-frontalis layer of the
scalp, and the deep branches ascend in and supply the pericranium. The deep branch of the supratrochlear artery generally
penetrates the corrugator supercilii muscle before reaching the
pericranium. The forehead pericranium is supplied dominantly
from the deep branches of the supraorbital artery.
Both the deep veins from the pericranial layer and the superficial veins from the galea-frontalis layer empty into a transverse channel in the supraorbital area that courses between the
galea-frontalis layer and the pericranium. This transverse
venous trunk joins the supratrochlear veins on the medial side
and the superficial temporal veins on the lateral side.

2/10/2015 1:39:45 PM

26

II Upper Facial and Midfacial Region

Levator palpebrae
superioris m.

Ophthalmic a.
Supraorbital a.

Frontal n.
Superior oblique m.
Lacrimal a.
Superior rectus m.
Lacrimal n.

Nasociliary n.
Superior ophthalmic v.

Ophthalmic a.
Optic n.
Trochlear n.

Fig. 5.4. Superior view of the orbit without orbital fat. Extraocular muscles above the optic nerve have been retracted laterally
to show the ophthalmic artery.

The ophthalmic nerve passes along the lateral dural wall


of the cavernous sinus and gives o three main branches
just before the superior orbital fissure. The three branches are
the lacrimal nerve, the frontal nerve, and the nasociliary
nerve.
The lacrimal nerve enters the orbit through the superior
orbital fissure. It passes forward along the lateral wall of the
orbit on the superior border of the lateral rectus muscle. It
passes through the lacrimal gland to supply the conjunctiva
and the skin of the lateral part of the upper eyelid. The lacrimal nerve communicates with the zygomaticotemporal
branch of the maxillary nerve. The parasympathetic fivers to
the lacrimal gland are conveyed via the zygomatic branch of
the maxillary nerve.
The frontal nerve enters the orbit through the superior
orbital fissure and passes forward on the levator palpebrae
superioris muscle. It divides into the supraorbital and the
supratrochlear nerves.

c05.indd 26

The nasociliary nerve passes into the orbit through the


superior orbital fissure and runs forward and medially across
the optic nerve. The nasociliary nerve gives rise to the sensory
branches to the ciliary ganglion, the long ciliary branches, and
the posterior ethmoidal nerves. The posterior ethmoidal nerve
leaves the orbit through the posterior ethmoidal foramen to
enter the nose. It supplies the sphenoidal sinus and the posterior ethmoidal air cells. Near the anterior ethmoidal foramen,
the nasociliary nerve divides into its terminal branches: the
anterior ethmoidal and the infratrochlear nerves.
The ophthalmic artery arises from the internal carotid
artery, and it traverses the optic canal below the optic nerve.
It passes from the lateral side to the medial side immediately
beneath the superior rectus muscle. Then, it runs with the
nasociliary nerve and passes between the superior oblique
and medial rectus muscles. The ophthalmic artery terminates
near the medial canthus by dividing into the dorsal nasal and
the supratrochlear arteries.

2/10/2015 1:39:46 PM

5 Forehead and Orbital Region

27

Supraorbital a., n.

Supraorbital n.
Superior ophthalmic v.
Supratrochlear n.
Lacrimal gland
Ophthalmic a.

Levator palpebrae
superioris m.
Superior rectus m.

Nasociliary n.

Lacrimal a.

Lacrimal n.

Superior oblique m.

Lateral rectus m.
Frontal n.
Superior ophthalmic v.
Periorbita
Recurrent meningeal a.

Fig. 5.5. Superior view of the orbit without orbital fat.

The supraorbital nerve emerges from the orbit through the


supraorbital notch and foramen (only some of its branches
always pass through whenever there is a foramen [see Fig.
5.3]). It supplies most of the forehead and upper lid, except
for its lateral region.
The supratrochlear nerve emerges from the orbit above the
trochlea and gives a descending branch to the infratrochlear
nerve. It ascends onto the medial part of the forehead through
the frontal notch.
The nasociliary nerve divides into the anterior ethmoidal
and the infratrochlear nerves near the anterior ethmoidal
foramen.
The infratrochlear nerve passes forward along the medial
wall of the orbit below the pulley of the superior oblique
muscle. It passes above the medial palpebral ligament to
reach the side of the nose to supply the skin of the medial
aspect of the upper eyelid.

c05.indd 27

The anterior ethmoidal nerve exits the orbit through


the anterior ethmoidal foramen. It enters the anterior
cranial fossa where the cribriform plate of the ethmoid bone
meets the orbital part of the frontal bone. It then runs into
the roof of the nose through a small foramen at the side of
the crista galli. The anterior ethmoidal nerve terminates
on the face as the external nasal nerve to supply the skin of
the nasal tip.
The ophthalmic artery gives rise to four branches
within the orbit to supply the face: the lacrimal artery,
the supraorbital artery, the supratrochlear artery, and the
dorsal nasal artery. The lacrimal artery reaches the skin
through the upper lateral corner of the orbit and supplies
the lateral part of the eyelids. Within the orbit, the lacrimal
artery gives o zygomaticofacial and zygomaticotemporal
arteries.

2/10/2015 1:39:47 PM

28

II Upper Facial and Midfacial Region

Frontalis m.

Procerus m.
Oblique head
(corrugator supercilii m.)
Transverse head

Corrugator supercilii m.

Supratrochlear a.
(Deep brs.)
Medial br. of supraorbital n.

Supraorbital a.
(Deep brs.)

Lateral br. of supraorbital n.

Lateral br. of
supraorbital n.
Pericranium (with loose areolar tissue)

Fig. 5.6. The supraorbital region. The skin and frontalis muscle have been reflected.

The corrugator supercilii muscle originates from the medial


end of the supraorbital ridge on the frontal bone, deep to the
orbicularis oculi muscle. It passes upward and outward
through the orbicularis oculi muscle to insert into the skin
of the middle of the eyebrow. This muscle has two
muscle bellies: a transverse head and an oblique head. This
muscle produces vertical ridges above the bridge of the nose
when frowning by drawing the eyebrow downward and
inward.
The frontalis muscle mingles with the corrugator supercilii
and orbicularis oculi muscles. The medial fibers of frontalis
muscle are continuous with procerus muscle.
The lateral branch of the supraorbital nerve, which
supplies the frontoparietal scalp, courses obliquely along
the superior temporal line on the pericranium with
concomitant artery. The lateral division consistently

c05.indd 28

courses approximately 1 cm medial to the superior temporal


line.
The deep branches of the supratrochlear and supraorbital
arteries, which supply the pericranium, and the medial
branches of the supraorbital nerve, penetrate the corrugator
supercilii muscle.
The scalp consists of five layers: the skin, the connective
tissue, the galea (aponeurosis), the loose areolar tissue, and
the pericranium. The first three layers are bound together as
a single unit. This unit can move along the loose areolar tissue
over the pericranium, which is adherent to the calvaria. The
pericranium is the external periosteum that covers the outer
surface of the skull.
The pericranial flap consists of the pericranium and loose
areolar tissue. The main blood supply to the flap is from the
deep branches of the supratrochlear and supraorbital vessels.

2/10/2015 1:39:48 PM

5 Forehead and Orbital Region

29

Supratrochlear n.
Frontal br. of superficial
temporal a.

Supratrochlear a.
Corrugator supercilii m.
Procerus m.
Supratrochlear v.
Dorsal nasal a.
Infratrochlear n.
Angular v.

Zygomatico-orbital a.
Palpebral part
Orbicularis oculi m.

Angular a.
Nasalis m.
Nerve to nasalis m.
Levator labii superioris
alaeque nasi m.
Levator labii superioris m.
Lateral nasal a.

Orbital part

Zygomaticus minor m.

Temporal br. of facial n.


Zygomaticobuccal br.
to orbicularis oculi m.
Upper zygomatic br.
of facial n.
Facial v.
Transverse facial a.
Inferior palpebral br.(V)
Zygomaticus major m.
Zygomaticobuccal br.
of facial n.

Fig. 5.7. The orbital region. The skin has been removed.

The temporal branch of the facial nerve does not always reach
the corrugator supercilii muscle, while the zygomaticobuccal
branch (see Fig. 7.5) usually reaches the corrugator supercilii
and procerus muscles.
The lower orbicularis oculi, zygomaticus major, levator
anguli oris, zygomaticus minor, risorius, levator labii superioris, levator labii superioris alaeque nasi, corrugator supercilii, procerus, nasalis, and depressor septi muscles are
innervated by the zygomaticobuccal branches.
The lower orbicularis oculi muscle is generally innervated
from its inferomedial side by one or two zygomaticobuccal
branches.
The levator labii superioris muscle arises from the maxilla
at the infraorbital rim, above the infraorbital foramen. Some
of the fibers pass downward to insert into the skin overlying
the upper lip. Other fibers merge with those of orbicularis
oris muscle. It elevates the upper lip.

c05.indd 29

The levator labii superioris alaeque nasi muscle arises from


the frontal process of the maxilla. This inserts into the skin
and the greater nasal cartilage of the nose and into the skin
and muscle of the upper lip. It elevates the upper lip and
dilates the nostril.
The infratrochlear nerve is a branch from the nasociliary
nerve. It supplies the skin over the bridge of the nose and at
the medial corner of the upper eyelid. It leaves the orbit below
the trochlea.
The dorsal nasal artery is one of the terminal branches of
the ophthalmic artery. It accompanies the infratrochlear
nerve and emerges between the trochlea of the superior
oblique muscle and the medial palpebral ligament and supplies the upper part of the nose. It anastomoses with the
angular artery of the facial artery.

2/10/2015 1:39:49 PM

30

II Upper Facial and Midfacial Region

Pericranium
Supratrochlear a., v., n.
Corrugator supercilii m.
(oblique head)
Corrugator supercilii m.
(transverse head)
Orbicularis oculi m.
(orbital part)
Angular v.
Procerus m.
Dorsal nasal a.
Medial palpebral ligament
Orbicularis oculi m.
(lacrimal part)
Angular v.
Levator labii superioris
alaeque nasi m.
Nasalis m.

Supraorbital a., v., n.

Orbital septum
Tarsus of upper lid
Superior palpebral a.

Tarsus of lower lid


Inferior palpebral a.
Orbicularis oculi m.

Fig. 5.8. The orbital region. The mimetic muscles have been cut and partially removed to leave their attachments.

The procerus muscle arises from the nasal bone and the
upper lateral nasal cartilage and reaches into the skin between
the eyebrows. It produces transverse wrinkles over the bridge
of the nose.
The orbicularis oculi muscle is composed of three parts: the
orbital, the palpebral, and the lacrimal. The muscle is a sphincter of the eyelids. The orbital part is the largest and arises from
the nasal part of the frontal bone, the frontal process of the
maxilla, and the medial palpebral ligament. The fibers pass
around the orbit in concentric loops. The orbital part is involved
in forced closure. The palpebral part is the central part and is
confined to the eyelids. It arises from the medial palpebral ligament and runs across the eyelids to insert into the lateral palpebral ligament. The palpebral part closes the eyelids gently in
involuntary or reflex blinking. The palpebral part is divided
into three parts: the pretarsal, the preseptal, and the ciliary
part. The lacrimal part arises from the lacrimal bone and

c05.indd 30

passes behind the lacrimal sac where some fibers insert into
the lacrimal fascia. The lacrimal part dilate the lacrimal sac,
thereby aiding the flow of tears into the sac.
The upper orbicularis muscle is innervated by temporal
branches, and the lower orbicularis muscle is innervated by
the zygomatic and zygomaticobuccal branches.
The lacrimal nerve is a small branch of the ophthalmic
nerve. It emerges from the upper lateral margin of the orbit
to supply the lateral part of the upper eyelid.
The supraorbital, the supratrochlear, the dorsal nasal, and
the superior and inferior medial palpebral arteries are the
branches of the ophthalmic artery. The superior and inferior
lateral palpebral arteries are the branches from the lacrimal
artery. The eyelids derive their blood supply from the medial
and lateral palpebral arteries. The supraorbital, supratrochlear, and angular veins form the superior ophthalmic vein in
the orbit.

2/10/2015 1:39:51 PM

5 Forehead and Orbital Region

Hiatus semilunaris
Accessary maxillary ostium
Orifice of nasolacrimal duct

31

Inferior concha

b
Supratrochlear n.
Trochlea

Supratrochlear a.

Lacrimal gland
(orbital part)

Infratrochlear n.

Superior medial
palpebral a.

Dorsal nasal a.
Medial palpebral ligament
lacrimal canaliculus

Inferior medial
palpebral a.

Lacrimal sac
Inferior oblique m.
Periorbita

Nasolacrimal duct

Levator labii
superioris m.

External nasal a.

a
Fig. 5.9a,b. (a) The orbital region. The lacrimal apparatus has been exposed. (b) Medial view of the lateral nasal wall.

The lacrimal apparatus consists of lacrimal gland, the lacrimal canaliculi, the lacrimal sac, and the nasolacrimal duct.
The lacrimal gland is divided into two parts: orbital and
palpebral. The orbital is larger and lies in a fossa in the frontal
bone. The innervation of the lacrimal gland is associated with
pterygopalatine ganglion. Postganglionic parasympathetic
fibers pass into the maxillary nerve and run with its zygomatic branch into the orbit. They join the lacrimal nerve,
derived from the ophthalmic nerve, to reach the lacrimal
gland. Sensory fibers associated with the gland are derived
from the lacrimal nerve.

c05.indd 31

The lacrimal sac lies adjacent to the lacrimal groove in the


anterior part of the medial wall of the orbit. The sac is bounded
anteriorly by the anterior lacrimal crest of the maxilla and
posteriorly by the posterior lacrimal crest of the lacrimal
bone.
The nasolacrimal duct passes downward from the lacrimal
sac to the anterior portion of the inferior meatus on the
lateral wall of the nose. The duct lies in a bony canal and
produces a ridge in the medial wall of the maxillary sinus.
The shape and position of the opening of the nasolacrimal
duct into the inferior meatus varies (Fig. 5.9b).

2/10/2015 1:39:52 PM

Temporal Region

Zygomatico-orbital a.
Superior auricular a.

Superficial temporal a., v.

Temporal br. to
superior auricular m.
(blue rubber under it)
Auriculotemporal n.

Subgaleal fat pad


Temporal brs. of
facial n.(anterior br.)
Transverse facial a.
(The masseteric fascia
has been opened)
Zygomatic br.
of facial n.

Temporal br. of facial n.


(posterior br.)

Parotid gland

Fig. 6.1. The temporal region. A part of the temporoparietal fascia has been removed to show the temporal branches.

The temporal branches and communication branches are


shown. The temporal branches of the facial nerve leave the
parotid gland immediately inferior to the zygomatic arch. The
nerve provides motor innervation to the frontalis, to the
upper orbicularis oculi muscles, and occasionally, to the corrugator muscle. There are 3 to 5 temporal branches and the
most auricular sided (blue rubber under it) branch innervates
the superior auricular muscle. The other branches innervate
the frontalis and upper orbicularis muscles.
The auriculotemporal nerve ascends on the side of the
head with superficial temporal vessels. It supplies the skin of
the temple and the upper part of the auricle.

c06.indd 32

The zygomatico-orbital artery is a constant branch from


the superficial temporal artery to the orbicularis oculi muscle.
The superior auricular artery is a branch from the superficial temporal artery, and it runs onto the upper part of the
helix.
The transverse facial artery is shown after opening the
masseteric fascia. The zygomatic branches are also under this
fascia and run forward with the artery.
The superficial temporal vein runs superficially on the
superficial temporal artery in front of the auricle and temporal region. However, the artery runs superficially on the vein
in the vertex region (see Fig. 13.2a).

2/10/2015 1:39:55 PM

6 Temporal Region

Frontal branch of
superficial temporal a.

Frontalis m.

33

Superior auricular m.

Superficial temporal a., v.


Auriculotemporal n.
Zygomatico-orbital a.

Orbicularis oculi m.

Subgaleal fat pad


Temporal br.
of facial n.

Parotid gland

Fig. 6.2. The temporal region. The temporal branches and their innervation to the frontalis and orbicularis oculi muscles are shown.

The temporal branches entering the frontalis muscle and


the upper orbicularis oculi muscle are shown (blue rubbers
under branches) after removing a part of the temporoparietal
fascia. The temporal branches of the facial nerve travel in the
subgaleal fat pad. The temporal branches divide into mean

c06.indd 33

three rami with numerous twigs, entering deeply into the


lateral end of orbicularis oculi muscle and the frontalis
muscle. The temporal branches of the facial nerve generally
run below the frontal branch of the superficial temporal
artery.

2/10/2015 1:39:56 PM

34

II Upper Facial and Midfacial Region

Temporoparietal fascia
Sentinel v.
Zygomaticotemporal n.

Temporoparietal fascia
(reflected)
Transparent superficial fat pad

Superficial layer of
temporal fascia
Superior auricular a.
Superficial temporal a.
Zygomatic arch
Superficial temporal v.
Auriculotemporal n.

Zygomatic br.
Facial n.
Transverse facial a.
Zygomaticus major m.
Masseter m.
Zygomaticobuccal br.

Retromandibular v.
Transverse facial a.
External carotid a.
Buccal branch
Parotid duct

Fig. 6.3. The temporal region. The temporoparietal fascia and subgaleal fat pad have been reflected anteriorly.

The sentinel vein is the signal for the proximity of the temporal branch of the facial nerve. The temporal branch of the
facial nerve, which courses along the undersurface of the temporoparietal fascia, is generally found cephalad to the sentinel
vein. This vein is located approximately 5 mm lateral to the
frontozygomatic suture line and is a tributary of the internal
maxillary vein draining the temporal region.
The zygomaticotemporal nerve provides sensation to the
temporal skin. This nerve emerges from the orbit into
the temporal fossa at approximately 14 mm inferior to the
frontozygomatic suture and 10 mm lateral to the lateral

c06.indd 34

margin of the orbit. This nerve is located about 1 cm lateral


to the sentinel vein that passed between a perforation in
the temporal fascia and the skin surface. The temporal branch
of the facial nerve has a communication with the zygomaticotemporal nerve at the temporal region. The zygomaticotemporal nerve gives a branch to the lacrimal nerve in
the orbit, and parasympathetic fibers that are associated with
the pterygopalatine ganglion are conveyed to the lacrimal
gland.
The superficial fat pad is the interfascial fat pad between
the superficial and deep layer of the temporal fascia.

2/10/2015 1:39:56 PM

6 Temporal Region

Superficial fat pad


(Interfascial fat pad)
Sentinel v.

35

Superficial layer of
temporal fascia

Deep layer of
temporal fascia

Zygomaticotemporal n.
Middle temporal v.
Transparent deep fat pad
Temporoparietal fascia
(reflected)
Zygomatic arch

Temporoparietal fascia
(reflected downward)
Superficial temporal a., v.
Retromandibular v.
Facial n.

Transverse facial a.

Fig. 6.4. The temporal region. The superficial layer of the temporal fascia has been reflected upward.

The facial nerve branches mostly course on the lateral side of


the retromandibular vein. There may be some parotid tissue
between the nerve and the vein.
The sentinel vein passes backward, inferiorly and deeply,
through the temporal fascia to the middle temporal vein. The
middle temporal vein passes deeply on the temporalis muscle
and comes up to be joined by the superficial temporal vein
below the zygomatic arch to form the retromandibular vein in

c06.indd 35

the parotid gland. The retromandibular vein is joined by the


maxillary vein in the parotid gland. Near the tail of the parotid
gland, it usually divides into anterior and posterior branches.
The deep fat pad, which is between the temporalis muscle
and the deep layer of the temporal fascia, is transparent
through the deep layer of the temporal fascia. The temporal
fascia splits into the superficial and the deep layer below the
level of the superior orbital rim.

2/10/2015 1:39:57 PM

36

II Upper Facial and Midfacial Region

Temporalis m.

Zygomaticotemporal n.

Middle temporal v.
Middle temporal a.
Superficial temporal a., v.

Zygomatic arch
Retromandibular v.
Facial n.

Fig. 6.5. The temporal region. The deep layer of the temporal fascia and the deep fat pad have been removed.

The middle temporal artery arises from the superficial temporal artery at the level of the zygomatic arch or 1 or 2 cm
below it. This artery supplies the temporal fascia and approximately 20% of the posterior and upper parts of the temporalis
muscle. This artery may leave a groove on the temporal bone
(see Fig. 2.3).
The middle temporal vein arises at approximately the
same level as the middle temporal artery and accompanied it
closely into the deep fascia.

c06.indd 36

The temporal fascia is attached above to the superior temporal line on the cranium. The superficial layer of the temporal fascia is attached onto the lateral border of the zygomatic
arch, while the deep layer of the temporal fascia is attached
onto the medial border of the arch and merges with connective tissue beneath the masseter muscle.

2/10/2015 1:39:58 PM

6 Temporal Region

37

Temporoparietal fascia
(galea) and subgaleal
fat pad
Sentinel v.
Superficial layer of
temporal fascia
Superficial fat pad
(Interfascial fat pad)
Deep layer of
temporal fascia

Upper rim of orbit


Middle temporal v.

Temporalis m.

Vertex side

Fig. 6.6. The temporal region. The superficial and deep layers of the temporal fascia have been separated.

The temporal branch of the facial nerve courses on the


underside of the temporoparietal fascia and into the subgaleal
fat pad. Several techniques in frontotemporal craniotomy
preserve the temporal branch of the facial nerve. The dissection between the deep layer of the temporal fascia and
the temporalis muscle is the most reliable technique for
facial nerve preservation. However, postoperative temporal
hollowing after the coronal approach is related to a
decrease in the volume of the superficial temporal fat pad.
Therefore, the better cosmetic result can be achieved by
suprafascial (superficial layer of the temporal fascia)
dissection.

c06.indd 37

The temporal fascia is the fascia of the temporalis muscle.


The thick layer arises from the superior temporal line, where
it fuses with the pericranium. The temporalis muscle arises
from the deep surface of the temporal fascia and the entire
temporal fossa. At the level of the upper orbital rim, the temporal fascia splits into the superficial layer and the deep layer.
The former attaches to the lateral border and the latter to the
medial border of the zygomatic arch. The fat pad between the
superficial and deep layer of the fascia is superficial fat pad
(interfascial fat pad).
There are three fat pads in the temporal region: subgaleal,
superficial (interfascial), and deep.

2/10/2015 1:39:58 PM

Superficial Structures in the


Midfacial Region

Zygomaticofacial n.

Inferior palpebral branch


of infraorbital n.
Zygomaticobuccal br.
of facial n.

Temporal brs.

Transverse facial a.
Zygomatic br.

Zygomatic br. to
zygomaticus major m.

Fig. 7.1. The midfacial region. The lower lateral portion of the orbicularis oculi muscle has been reflected.

Innervation to the lower orbicularis oculi muscle and zygomaticus major muscle are shown. The zygomaticus major
muscle is innervated by the zygomatic branches and also
from the zygomaticobuccal branches (see Fig. 7.5) in its lower
part of the muscle. The lower orbicularis muscle is innervated
from its inferolateral side by one or two zygomatic branches
and temporal branches.

c07.indd 38

The zygomaticofacial nerve (shown in Fig. 7.1 with blue


sheet under it) is a sensory nerve, which supplies the small
region of the cheek, and it is divided from the zygomatic
nerve in the orbit.
The transverse facial artery, which originates from the
superficial temporal artery within the parotid gland, courses
anteriorly beneath the masseteric fascia above the parotid duct.

2/10/2015 1:40:02 PM

7 Superficial Structures in the Midfacial Region

39

Temporal brs.

Orbicularis oculi m.
Lateral nasal a.

Zygomatic brs.
Transverse facial a.

Levator labii superioris m.

Buccal br.
Infraorbital n.

Parotid duct

Zygomaticobuccal brs.
Parotid gland

Levator anguli oris m.


Zygomaticus major m.

Masseteric fascia

Buccinator m.
Great auricular n.
Premasseteric a.
Marginal mandibular br.

Orbicularis oris m.
Depressor anguli oris m.

External jugular v.
Cervical br.
Facial a., v.
Platysma m.

Sternocleidomastoid m.

Fig. 7.2. The midfacial region.

The buccinator muscle, upper orbicularis oris muscle, and


levator anguli oris muscle are innervated by the zygomaticobuccal branches (see Fig. 7.5). The buccinator muscle and the
levator anguli oris muscle are the deep-seated muscles and
they are innervated from their superficial surface.
The anterior margin of the parotid gland is a site which is
suitable to identify the zygomatic and buccal branches for
facial reanimation surgery. Several zygomatic and buccal
branches can be exposed via the small skin incision made just
below the zygomatic arch and anterior to the mandibular
notch. The notch can be identified by palpation. These

c07.indd 39

branches can also be exposed via preauricular skin incision.


The careful selection of the donor facial nerve branches is
mandatory for facial reanimation surgery because some of
the buccal and zygomaticobuccal branches might not innervate the zygomaticus major muscle, which is the target
muscle for smile reconstruction.
The levator anguli oris muscle arises from the canine fossa
of the maxilla, immediately below the infraorbital foramen,
and passes downward toward the corner of the mouth. It
elevates the corner of the mouth.

2/10/2015 1:40:02 PM

40

II Upper Facial and Midfacial Region


Auriculotemporal n.
Zygomatico-orbital a.

Superficial temporal a., v.


Orbicularis oculi m.

Temporal brs.

Zygomatic brs.

Levator labii superioris m.

Transverse facial a.

Facial v.

Buccal br.

Infraorbital n.
Parotid duct

Facial a.
Zygomaticus major m.

Parotid gland
Masseteric fascia

Levator anguli oris m.

Fig. 7.3. The midfacial region. Close-up view of upper branches of the facial nerve.

The facial nerve branches do not always run on the same


plane. Some of the zygomatic branches run beneath the masseteric fascia anterior to the parotid gland. It is also an important surgical point that we can only divide the parotid gland
just over the facial nerve branch during the dissection of the
facial nerve branches in the parotid gland.

c07.indd 40

The buccal branch of the facial nerve has a close relationship with the parotid duct. The branch is most likely inferior
and within 1 cm to the duct.

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7 Superficial Structures in the Midfacial Region

Orbicularis oculi m.

Inferior palpebral br.


of Infraorbital n.
Levator labii superioris m.
and zygomaticus minor m.
(reflected medially)
Infraorbital n., a.
Communicating br.
Lateral nasal a.

41

Temporal brs.
of facial n.
Masseteric fascia
Transverse facial a.
Zygomatic brs.
of facial n.
Parotid gland
Parotid duct
Buccal brs. of facial n.

Levator anguli oris m.


Zygomaticus major m.
Orbicularis oris m.

Masseteric fascia
Facial v.

Buccinator m.

Fig. 7.4. The midfacial region. Deep seated mimetic muscles and the infraorbital nerve are shown.

Some of the zygomaticobuccal branches (see Fig. 7.5) course


downward along the parotid duct, pass under the zygomatic
major muscle, then course upward to reach the lower orbicularis oculi muscle, and finally end up at the medial canthal
region. The upper orbicularis oris muscle is generally innervated by the zygomaticobuccal branches. The branches reach
its upper lateral side, which is medial to the zygomaticus
major muscle.

c07.indd 41

The levator anguli oris and buccinator muscles are in


the deepest layer of the mimetic muscles and are innervated
from their superficial surface. The levator anguli oris muscle,
which originated from the canine fossa, inserts into the
modiolus.
The facial nerve branches have communications with the
branches of the infraorbital nerve.

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42

II Upper Facial and Midfacial Region

Orbicularis oculi m.

Superficial temporal a., v.


Temporal brs.

Inferior palpebral br.

Levator labii superioris m.


and zygomaticus minor m.
Parotid duct
Levator anguli oris m.
Zygomaticus major m.
Buccinator m.

Zygomatic br.
Retromandibular v.
Transverse facial a.

Temporofacial division
Cervicofacial division
Buccal brs.
Masseter m.
without the fascia

Fig. 7.5. The midfacial region. Zygomaticobuccal plexus is shown. The superficial lobe of the parotid gland has been removed.

The facial nerve divides into temporofacial (upper trunk) and


cervicofacial (lower trunk) divisions just before entering the
parotid gland. These divisions generally pass forward over the
retromandibular vein in the parotid gland.
The facial nerve and its branches course in the parotid
gland, thereby dividing the parotid gland into deep and superficial lobes. There is no anatomical plane between the lobes.
The inferior zygomatic branches usually form a zygomaticobuccal plexus (see circled area) with the buccal branches.
The mimetic muscles (zygomaticus major, zygomaticus
minor, risorius, lower orbicularis oculi, corrugator supercilii,

c07.indd 42

procerus, nasalis, depressor septi, levator anguli oris, and


levator labii superioris) are generally innervated by the zygomaticobuccal branches.
The zygomaticus major muscle originates from the lateral
surface of the zygomatic bone, just in front of the zygomaticotemporal suture. It pulls the corner of the mouth upward
and outward.
The zygomaticus minor muscle originates from the zygomatic bone just in front of the origin of zygomaticus major
and runs downward and forward to insert into the upper lip.
It elevates the upper lip.

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7 Superficial Structures in the Midfacial Region

43

Superficial temporal a.,


Retromandibular v.

Tragal pointer
Great auricular n.
Auricular br. of posterior
auricular a.
Temporofacial division
Facial n.

Buccal brs.

Occipital a.
Occipital br. of
posterior auricular a.
Posterior auricular a.
Cervicofacial division

Marginal mandibular br.

Posterior auricular v.

Marginal mandibular br.,


Cervical br.

Posterior belly
of digastric m.
Retromandibular v.

Fig. 7.6. The midfacial region. The intraparotid facial nerve branches are shown.

The buccal branches generally originate from both the upper


and lower trunk of the facial nerve and connect with the
marginal mandibular branch.
The tragal pointer or cartilage, which lies anterior to the
opening of the external acoustic meatus, points directly to the

c07.indd 43

facial nerve on exiting the stylomastoid foramen. The facial


nerve exits about 1 cm below and medial to the tip of the
tragal pointer. However, the cartilage is mobile and asymmetrical, with a blunt irregular tip, so it might be dicult to
decide on the position of the tragal pointer.

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44

II Upper Facial and Midfacial Region

Superficial temporal a.
Auriculotemporal n.,
Communicating brs.
Zygomatic brs.
Transverse facial a.

Zygomaticus major m.

Retromandibular v.
Facial n.

Zygomaticobuccal brs.

Condylar process
Buccal brs.
Parotid gland

Masseter m.

Fig. 7.7. The midfacial region. The substance of the parotid gland has been removed.

The facial nerve communicates with the trigeminal nerve.


The auriculotemporal nerve courses from the posteromedial aspect of the neck of the mandibular condyle to an anterolateral direction to wrap around the neck of the condyle. It
emerges approximately 1.5 cm below the condylar head. This
nerve innervates the capsule of the temporomandibular joint.
On entering the parotid gland, it turns to emerge superficially
between the temporomandibular joint and external acoustic

c07.indd 44

meatus. Study shows that the branches of the auriculotemporal nerve constantly communicate with the upper trunk of the
facial nerve in the parotid gland. These communications might
convey proprioceptive impulses from the upper facial muscles
to the trigeminal nuclei of the brainstem.
The retromandibular vein in the parotid gland is a landmark for the facial nerve branches. The vein mostly courses
just beneath the facial nerve.

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7 Superficial Structures in the Midfacial Region

Supratrochlear v.
Supraorbital v.

45

Corrugator supercilii m.
Orbital septum
Procerus m.

Superior palpebral a.
Angular v.

Medial palpebral ligament

External nasal v.
Inferior palpebral a.
Alar arcade from
lateral nasal a.
Lateral nasal a.

Orbicularis oculi m.
Levator labii superioris
alaeque nasi m.
Alar cartilage
Levator labii superioris m.

Levator labii superioris m.


Infraorbital n., a., v.

Facial V.
Levator anguli oris m.

Septal a.
Columellar a.

Septal a.

Fig. 7.8. The midfacial region. The mimetic muscles have been removed to leave their attachments.

The angular vein is formed by the confluence of the supraorbital and supratrochlear veins at the medial eyelid area.
The transverse supraorbital vein, which joins the supratrochlear veins on the medial side and the superficial temporal
vein on the lateral side, is located in the supraorbital area (see
Fig. 5.3). The angular vein becomes the facial vein at its junction with the superior labial vein, but the latter is not invariably present. The external nasal vein drains the external nose
and empties into the angular or facial vein. The facial vein
does have venous valves, particularly around the level of

c07.indd 45

the mandible. The angular vein also has valves in its tributaries. There is a communication between the facial vein
and cavernous sinus via the supratrochlear and superior ophthalmic veins. The infraorbital vein links the facial vein with
the pterygoid venous plexus in the infratemporal fossa (see
Fig. 10.4).
The septal artery and columellar artery, which supplies the
nasal septum and columella, generally originate from
the superior labial artery. Bilateral lateral nasal arteries form
the alar arcade on the dorsum of nose.

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46

II Upper Facial and Midfacial Region

Zygomaticobuccal brs.
to procerus and
corrugator supercilii m.
Dorsal nasal a.

Orbicularis oculi m.

Facial v.
Nasalis m.
(transverse part)
External nasal br.
(Infraorbital n.)
Zygomaticobuccal br.
to nasalis m.

Levator labii superioris m.


Zygomaticus minor m.
Zygomaticus major m.
Infraorbital n., a.

Lateral nasal a.
Superior labial br.
(Infraorbital n.)
Levator anguli oris m.

Septal a., Columellar a.


Superior labial a.

Zygomaticobuccal br.
of facial n.
Zygomaticus major m.
Facial v.

Fig. 7.9. The midfacial region. The proximal site of the zygomaticobuccal branches are cut and dislocated downward.

Innervation to the procerus, corrugator supercilii and nasalis


muscles are shown. These muscles are dominantly innervated
by the zygomaticobuccal branches (see Fig. 7.5), although the
corrugator supercilii muscle might be innervated by the temporal branches of the facial nerve.
The communications between the infraorbital nerve and
zygomaticobuccal branches are shown.

c07.indd 46

The facial artery bifurcates into the lateral nasal artery and
superior labial artery at the angle of the mouth. After the
bifurcating, the facial artery terminates as the angular artery,
which communicates with the dorsal nasal artery of the ophthalmic artery.

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7 Superficial Structures in the Midfacial Region

Levator labii superioris


alaeque nasi m.

47

Orbicularis oculi m.

Nasalis m.
(transverse part)

Levator labii superioris m.


Infraorbital n., a.

Lateral nasal a.

Facial v.
Levator anguli oris m.

Nasalis m.
(alar part)
Periosteum of the Maxilla
Septal a.

Facial a. (cut)

Depressor septi m.
Columellar a.

Gingiva

Fig. 7.10. The midfacial region. The levator labii muscles have been removed to leave their attachments.

The nasalis muscle arises from the maxilla, overlying the root
of the canine tooth (transverse part) and the lateral incisor
(alar part). The transverse part of nasalis inserts into the
lateral nasal cartilage and also passes over the dorsum of the
nose to join the opposite side. The alar part of nasalis inserts
into the greater nasal cartilage. The former compresses the
nasal aperture and the latter dilate the nostril. Nasal obstruction in facial nerve paralysis is due to the nasalis muscle
weakness.
The depressor septi muscle arises from the incisor region
of the maxilla and passes upward from beneath the orbicularis oris muscle to insert into the nasal septum. It pulls the
nasal septum downward and constricts the nostril.

c07.indd 47

The levator labii superioris muscle arises from the maxilla


at the infraorbital rim, above the infraorbital foramen.
The levator anguli oris muscle arises from the canine
fossa of the maxilla, immediately below the infraorbital
foramen.
The infraorbital nerve emerges from the infraorbital
foramen just below the origin of levator labii superioris
muscle, and it divides into four branches: inferior palpebral
branch, which innervates the lower eyelid skin and conjunctiva; the external nasal branch, which innervates the lateral
surface of nose; the internal nasal branch, which innervates
the nasal vestibule and nasal septum; and the superior labial
branch, which innervates the upper lip skin and mucosa.

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48

II Upper Facial and Midfacial Region

External nasal n.
Lateral nasal wall

Levator labii superioris


alaeque nasi m.
Orbicularis oculi m.
External nasal n.
Upper lateral cartilage

Infraorbital n., a.

Communication between
external nasal a.
and lateral nasal a.

External nasal v.
Levator anguli oris m.

Alar cartilage

Facial v.
Lateral nasal a.

Columellar a.
Nasalis m.,
Depressor septi m.

Septal a.

a
Fig. 7.11a,b. (a) The midfacial region. The nasalis and depressor septi muscles have been removed to leave their attachments,
(b) Medial view of the lateral nasal wall.

The anterior ethmoidal nerve and artery enter the roof of the
nasal cavity and give rise to the lateral and medial internal
nasal branches. The lateral internal branches pass to the
lateral wall of the nose, whereas the medial internal nasal
branches run to the nasal septum. These branches supply an
area in front of the nasal conchae and the anterior extremities
of the middle and inferior conchae. Then, the nerve and artery
run under the surface of the nasal bone (Fig. 7.11b) and pass

c07.indd 48

between the nasal bone and the lateral nasal cartilage. When
the anterior ethmoidal nerve and artery emerge at the inferior margin of the nasal bone, they become the external nasal
nerve and artery. The external nasal nerve and artery supply
the nasal tip, with the exception of the nasal alar region.
The lateral nasal artery or superior labial artery gives o
the septal artery to the nasal septum, and the former communicates with the external nasal artery.

2/10/2015 1:40:08 PM

Maxillary Region

Nasal bone

Deep temporal n.
Zygomaticofacial n.
Zygomaticofacial foramen

Nasomaxillary suture
External nasal n.
Infraorbital n., a.

Zygomatic bone
Zygomaticomaxillary suture
Buccal n.

External nasal a.
Anterior superior alveolar
n., a.

Maxillary a.

Nasal septum

Lateral pterygoid plate


Maxillary bone

Maxillary tuberosity

Fig. 8.1. The maxillary region. The mimetic muscles have been removed.

The infraorbital nerve and zygomaticofacial nerve pass


through each foramen respectively. The zygomaticofacial
nerve supplies the skin over the prominence of the cheek.
The anterior superior alveolar nerve arises from the infraorbital nerve within the infraorbital canal and runs within
the bone of the anterior maxillary wall. It supplies the anterior third of half side of teeth.
The middle superior alveolar nerve is an inconsistent
branch that arises from the infraorbital nerve or maxillary
nerve. It supplies the sinus mucosa, the middle third of half
side of teeth when it presents. In the majority of cases, it is

c08.indd 49

nonexistent, so the posterior superior alveolar nerve alone


innervates the premolars and molars.
The infraorbital artery originates from the pterygopalatine
segment of the maxillary artery. It enters the orbit through
the inferior orbital fissure, runs on the floor of the orbit in the
infraorbital groove and canal, and emerges onto the face at
the infraorbital foramen.
The anterior superior alveolar artery originates from
the infraorbital artery within the infraorbital canal. It supplies the anterior teeth and the anterior part of the maxillary
sinus.

2/10/2015 1:40:10 PM

50

II Upper Facial and Midfacial Region

Orbit
Nasolacrimal duct

Infraorbital n., a.
Maxillary ostium
Orbital floor

Nasolacrimal torus

Posterior wall of maxillary sinus


Gingiva

Masseter m.

Fig. 8.2. The maxillary region. The anterior wall of the maxilla has been removed to expose the sinus and nasolacrimal duct.

The infraorbital nerve and vessels run on the roof of the maxillary sinus. The maxillary ostium is seen at a high position
behind the nasolacrimal duct on the medial wall of the sinus.
An accessory ostium is sometimes present behind the major
ostium.
The innervation of the maxillary sinus is derived from the
maxillary nerve via its infraorbital and anterior, middle, and
posterior superior alveolar nerves.

c08.indd 50

The bony canal for the nasolacrimal duct has been


partially opened to expose the nasolacrimal duct. The
duct forms a bony torus on the medial wall of the maxillary
sinus.

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8 Maxillary Region

51

Orbit
Nasolacrimal duct

Maxillary ostium

Infraorbital n., a.

Nasolacrimal torus
Ethmoid sinus

Sphenoid sinus
Gingiva
Maxillary n.

Sphenopalatine a.
Pterygopalatine ganglion
Greater palatine n., a.

Masseter m.

Fig. 8.3. The maxillary region. The posterior and medial walls of the maxilla have been opened.

The ethmoid sinus and the sphenoid sinus have been opened
through the medial maxillary wall. The infraorbital nerve and
vessels are exposed by removing the bony roof of the maxillary sinus.
The sphenopalatine artery enters the lateral wall of the
nose through the sphenopalatine foramen. The artery

c08.indd 51

accompanies the posterior superior nasal nerve and supplies


the posterior part of the lateral nasal wall before crossing
the roof of the nasal cavity to accompany the nasopalatine
nerve and supply the posterior-inferior part of the nasal
septum.

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52

II Upper Facial and Midfacial Region


Ethmoidal sinus
Sphenoid sinus

Infraorbital n.

Zygomatic n.
Foramen rotundum
V2

Ganglionic branches

Middle superior alveolar n.


Infraorbital a.
Posterior superior alveolar n.

Sphenopalatine a.
Pterygopalatine ganglion
Greater & Lesser palatine n.
Posterior superior alveolar a.
Maxillary a.
Greater & Lesser palatine a.
Lateral pterygoid m.
Pterygoid plate

Fig. 8.4. The maxillary region. The veins have been removed.

The pterygopalatine ganglion is a parasympathetic ganglion


found in the pterygopalatine fossa and largely innervated by
the greater petrosal nerve. It is situated just below the maxillary nerve. The ganglionic branches, usually two in number,
connect the maxillary nerve to the pterygopalatine ganglion.
The pterygopalatine ganglion supplies the lacrimal gland, the
paranasal sinuses, the glands of the mucosa of the nasal
cavity and pharynx, the gingiva, and the mucous membrane
and glands of the hard palate.
The pterygopalatine fossa contains blood vessels and
nerves supplying the nose, palate, and upper jaw, including
the maxillary division of the trigeminal nerve which passes
through the foramen rotundum; the nerve of the pterygoid
canal and accompanying vessels which pass through the pterygoid canal; the nasopalatine and posterior superior nasal
nerves and the sphenopalatine vessels which pass through
the sphenopalatine foramen; the greater and lesser palatine
nerves, which together with accompanying vessels pass
through the greater and lesser palatine foramina. The pharyngeal branch of the pterygopalatine ganglion runs through the
palatovaginal canal to supply the nasopharyngeal mucosa.

c08.indd 52

The nasopalatine nerve and sphenopalatine vessels run


into the nasal cavity through the sphenopalatine foramen,
and they pass across the roof of the nasal cavity to reach the
nasal septum and supply the posteroinferior part of the nasal
septum.
The zygomatic nerve arises in the pterygopalatine fossa
from the maxillary nerve. It enters the orbit by the inferior
orbital fissure and divides at the back of that cavity into
two branches, the zygomaticotemporal nerve and the zygomaticofacial nerve. The zygomatic nerve carries sensory
fibers from the skin. It also carries postsynaptic parasympathetic fibers (originating in the pterygopalatine ganglion) to
the lacrimal nerve via a communication. These fibers will
eventually provide innervation to the lacrimal gland. These
parasympathetic postganglionic fibers come from the facial
nerve.
The third segment of the maxillary artery is the pterygopalatine segment. It has five branches: the posterior superior
alveolar artery, the infraorbital artery, the artery of the pterygoid canal, the descending palatine artery, and the sphenopalatine artery.

2/10/2015 1:40:12 PM

8 Maxillary Region

53

Incisive a., n.

Greater palatine a., n.


Lesser palatine a.
Palatine aponeurosis
Pterygoid hamulus
Levator veli palatini m.
Ascending palatine a.

Fig. 8.5. The palatal region. The palatal mucosa has been removed on the right side and the soft palate has been removed
on the left side.

The greater and lesser palatine nerves and arteries pass from
the pterygopalatine fossa down the greater palatine canal
at the back of the lateral wall of the nose. The greater palatine
nerve and artery run through the greater palatine foramen
and onto the back of the hard palate. They pass toward
the front of the hard palate. They supply the palatal mucosa
and palatal gingiva. Within the greater palatine canal, the
nerve and artery give o nasal branches that innervate
the posteroinferior part of the lateral wall of the nasal cavity.

c08.indd 53

The lesser palatine nerve and artery emerge onto the palate
at the lesser palatine foramen. They run backward into the
soft palate.
The nasopalatine nerve terminates as the incisive nerve
which passes through the incisive canal with an accompany
artery onto the hard palate to supply oral mucosa around the
incisive papilla. It communicates with the corresponding
nerve of the opposite side and with the greater palatine
nerve.

2/10/2015 1:40:14 PM

54

II Upper Facial and Midfacial Region

Hard palate
Deep temporal n.,
Masseteric n.
Greater palatine a., n.
Lesser palatine a.
Posterior edge of
nasal septum
Palatine aponeurosis

Pterygoid hamulus
Tensor veli palatini m.

Levator veli palatini m.

Ascending palatine a.

Maxillary a.

Inferior alveolar n.

Buccinator m.

Soft palate
Lingual n.

Fig. 8.6. The palatal region. The levator and tensor veli palatini muscles are shown on the left side.

The tensor veli palatini muscle arises from the scaphoid


fossa of the sphenoid bone (at the root of the pterygoid plate)
and from the lateral side of the cartilaginous part of the
Eustachian tube. The fibers converge toward the pterygoid
hamulus, where the muscle becomes tendinous. The tendon
bends at right angles around the hamulus to become the
palatine aponeurosis. The aponeurosis is attached to the posterior border of the hard palate. This muscle pulls the soft
palate laterally. This muscle is innervated by the branch of the
mandibular nerve via the nerve to the medial pterygoid
muscle.
The levator veli palatini muscle originates from the base of
the skull at the apex of the petrous part of the temporal bone
and from the medial side of the cartilaginous part of the

c08.indd 54

Eustachian tube. The muscle curves downward, medially, and


forward to enter the palate immediately below the opening
of the Eustachian tube. This muscle produces upward and
backward movement of the soft palate. This muscle is innervated by the accessory nerve via the pharyngeal plexus.
The ascending palatine artery originates from the facial
artery in the neck. It divides near the levator veli palatini
muscle into two branches. One supplies and follows the
course of this muscle and, winding over the upper border of
the superior pharyngeal constrictor, supplies the soft palate
and the palatine glands. The other pierces the superior pharyngeal constrictor and supplies the palatine tonsil and auditory tube, anastomosing with the tonsillar branch of the facial
artery and the ascending pharyngeal artery.

2/10/2015 1:40:15 PM

Masseteric Region

Zygomaticotemporal n.

Temporalis m.

Zygomatic arch
Orbicularis oculi m.
(reflected)
Zygomaticus major m.

Muscle br.
Masseter m.

Middle temporal a.
Middle temporal v.
Superficial temporal a.
Middle temporal a.
Superficial temporal v.
Auriculotemporal n.
Lateral ligament
Retromandibular v.
Auriculotemporal n.
Facial n.
Transverse facial a.
Mandibular condyle

Parotid duct

Fig. 9.1. The masseteric region. The parotid gland and the facial nerve branches have been removed.

The zygomaticus major muscle, the masseter muscle, and the


temporal fascia and lateral ligament are the structures which
are attached to the zygomatic arch.
The origin of the zygomaticus major muscle is the subzygomatic fossa, which is located posterior and inferior to the malar
eminence and anterior to the zygomaticotemporal suture. The
subzygomatic fossa is usually an easily palpable landmark.
The retromandibular vein usually divides into anterior and
posterior branches near the tail of the parotid gland. Outside
the gland, anterior branch joins the facial vein to form the
common facial vein, while the posterior branch unites with

c09.indd 55

the posterior auricular vein to form the external jugular vein.


The common facial vein drains into the internal jugular vein
(see Fig. 11.2 and Fig. 12.3).
The temporomandibular joint has one major ligament, the
temporomandibular ligament, also termed the lateral ligament, which is actually the thickened lateral portion of the
capsule. It has two parts: an outer oblique portion and an
inner horizontal portion. The base of this triangular ligament
is attached to the zygomatic process of the temporal bone and
the articular tubercle. Its apex is fixed to the lateral side of
the neck of the mandible.

2/10/2015 1:40:17 PM

56

II Upper Facial and Midfacial Region

Zygomatic arch

Zygomaticus major m.

Lateral ligament

Attachment of superficial
part of masseter m.
Middle part of
masseter m.
Masseteric n., a., v.
Buccal fat pad
Masseter m.
(superficial part)

Parotid duct
(cut and reflected)
Buccinator m.

Fig. 9.2. The masseteric region. The superficial part of the masseter muscle has been reflected.

The masseter muscle is one of the muscles of mastication. It


is quadrilateral in shape and consists of three layers. The
layers are fused anteriorly, but diverge posteriorly. The most
pronounced layer is superficial. It originates from the anterior
two-thirds of the inferior border of the zygomatic arch up to
the zygomatic process of the maxilla. Initially, it is aponeurotic and passes obliquely in an inferomedial direction. It
inserts into the inferior border of the external surface of the
angle of the mandible. Its insertion extends anteriorly to the
junction of the ramus with the body of the mandible.
The chief muscles of mastication are the temporalis, masseter, medial pterygoid, and lateral pterygoid. The first three
muscles raise the mandible against the maxilla with great

c09.indd 56

force. The lateral pterygoid muscle assists in opening the


mouth, but its main action is to draw forward the condyle
and articular disk so that the mandible is protruded and
the inferior incisors projected in front of the upper. In this
action, it is assisted by the medial pterygoid muscle. The
mandible is retracted by the posterior fibers of the temporalis
muscle. The medial and lateral pterygoid muscle of two sides
contract alternately to produce side-to-side movement of the
mandible.
The transfer of functional innervated musculature into the
face oers the possibility of meaningful facial movement. And
the temporalis, masseter, and digastric muscles can be used
for facial reanimation.

2/10/2015 1:40:18 PM

9 Masseteric Region

57

Middle temporal v.
Orbicularis oculi m.
(reflected)
Zygomatic arch
Zygomaticus major m.
Attachment of
middle part
Attachment of
superficial part
Deep part of masseter m.

Superficial temporal a., v.

Lateral ligament
Retromandibular v.
Masseteric n., a., v.
Facial n.

Buccal fat pad


Middle part of masseter m.
Parotid duct
(cut and reflected)

Fig. 9.3. The masseteric region. The middle part of the masseter muscle has been reflected.

The masseteric nerve and vessels course anteroinferiorly on


the deep part of the masseter muscle after passing the mandibular notch.
The middle part of masseter muscle originates from the
middle third of the zygomatic arch. It blends with the superficial part at the mandibular insertion and anteriorly. The
posterior divergence of fibers between the superficial and

c09.indd 57

deep parts of masseter muscle permits the entry of its blood


supplythe masseteric arterywhich is a branch of the maxillary artery. The deep part of masseter muscle has a similar
course to the middle part but is separated from it by the masseteric nerve. Similar to the artery, the nerve enters posteriorly where the layers diverge.

2/10/2015 1:40:18 PM

58

II Upper Facial and Midfacial Region


Middle temporal v.
Superficial temporal a.
Temporalis m.
Zygomatic arch

Superficial temporal v.

Auriculotemporal n.
Lateral ligament
Retromandibular v.

Zygomaticus major m.

Mandibular condyle
Facial n.

Coronoid process
Tendon of temporalis m.
Buccal fat pad

Masseteric n.
Mandibular notch
External carotid artery
Masseter m.
(middle, deep part)

Facial v.

Masseter m.
(superficial part)

Parotid duct
(reflected)

Fig. 9.4. The masseteric region. The every part of the masseter muscle has been reflected downward.

The upper border of the ramus of mandible is thin and is


surmounted by two processes, the coronoid process anteriorly and the condylar process posteriorly. These are separated
by a deep concavity, the mandibular notch, or sigmoid notch.
It allows the passage of the masseteric nerve, the masseteric
artery, and the masseteric vein.
The masseteric nerve leaves the infratemporal fossa
through the mandibular notch. At this level, the nerve usually
consists of one or more branches. Several intraoperative

c09.indd 58

landmarks can be used to identify the masseteric nerve. The


mandibular notch is a palpable and reliable bony landmark
for identifying the masseteric nerve, which is located just
above the notch on the deep part of the masseter muscle. The
masseteric nerve is a potential source of axons for facial reinnervation when the proximal facial nerve stump is not available but the distal facial nerve and facial musculature are
present and functional.

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9 Masseteric Region

59

Middle temporal v.

Temporal extension
of buccal fat pad
(Deep temporal fat pad)

Superficial temporal v.
Superficial temporal a.
Auriculotemporal n.
Facial n.

Tendon of temporalis m.
Buccal extension
of buccal fat pad

Masseteric n.

Ramus
Retromandibular v.

Fig. 9.5. The masseteric region. The zygomatic arch has been removed and the deep temporal fat pad preserved.

The buccal fat pad is located superficial to the buccinator


muscle at the anterior edge of the masseter muscle and provides fullness to the cheek inferior to the malar prominence.
It has three main extensions: buccal, pterygoid, and temporal.
These extensions are each contained within a separate

c09.indd 59

capsule. The proposed function is to provide a surface for the


gliding motion of the muscles of mastication. The temporal
extension of the buccal fat pad is identical to the deep temporal fat pad, which is situated between the temporalis
muscle and the deep layer of the temporal fascia.

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60

II Upper Facial and Midfacial Region

Middle temporal v.
Superficial temporal a.

Zygomaticotemporal n.

Middle temporal a.
Superficial temporal v.
Lateral ligament,
Joint capsule

Temporalis m.

Masseteric n.
Facial n.
Occipital a.
External carotid a.
Buccal fat pad

Ramus

Parotid duct

Retromandibular v.
Posterior belly of
digastric m.
Stylohyoid m.

Buccinator m.

Masseter m.

Fig. 9.6. The masseteric region. The deep temporal fat pad has been removed.

The temporalis muscle arises from the floor of the temporal


fossa and from the overlying temporal fascia. The fibers converge toward their insertion onto the apex, the anterior and
posterior borders, and the medial surface of the coronoid
process, and the anterior border of the ramus almost as far as
the third molar tooth. Many of the fibers have a tendinous
insertion. The anterior (vertical) fibers of the temporalis
muscle elevate the mandible; the posterior (horizontal) fibers
retract it.
The temporalis muscle is an alternative muscle for reanimation of the smile. It serves as a static support to the oral

c09.indd 60

commissure and provides trigeminally controlled dynamic


movement.
The middle temporal artery, which is a branch of the
superficial temporal artery, arises immediately above the
zygomatic arch, and, perforating the temporal fascia, gives
branches to the temporalis muscle, anastomosing with the
deep temporal artery. It supplies the posterior part and the
upper part of the temporalis muscle.

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10

Deep Structures in the Midfacial Region

V2
V3

Semicircular canal
Geniculate ganglion
(GSPN cut)
Internal carotid a.
Incus
Tensor tympani m.

Zygomaticotemporal n.
Frontozygomatic suture
Zygomaticotemporal foramen

Middle temporal a.
Superficial temporal a., v.

Deep temporal n., a., v.

Auriculotemporal n.
Root of zygomatic arch
Temporalis m. (reflected)
Zygomaticofacial n.

Fig. 10.1. Superior view of the middle fossa and temporal fossa.

The neurovascular bundle is shown on the deep surface of the


temporalis muscle. The dissection of the muscle from the
temporal bone might cause the muscle to atrophy because of
damage to its motor nerves.
The zygomaticotemporal nerve is a terminal branch of
the maxillary division of the trigeminal nerve. The zygomatic nerve enters the orbit through the inferior orbital
fissure, and it divides into the zygomaticotemporal and
zygomaticofacial nerves along the lateral wall of the orbit. The

c10.indd 61

zygomaticotemporal nerve emerges from the orbit into the


temporal fossa at approximately 14 mm inferior to the frontozygomatic suture and 10 mm lateral to the lateral margin of
the orbit through the zygomaticotemporal foramen. Then, it
passes through the temporalis muscle and pierces the temporal fascia about 2 cm above the zygomatic arch. The foramen
is always found posterolateral to the edge of the lateral orbital
rim. It is a sensory nerve that provides sensation to the skin
of the temporal region.

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62

II Upper Facial and Midfacial Region


Mandibular n.,
Foramen ovale
Middle meningeal a.

Buccal n., Anterior


deep temporal nerve

Br. to upper head of


Lateral pterygoid m.

Upper head of
lateral pterygoid m.
Middle and Posterior
deep temporal n.
Masseteric n.

Anterior deep temporal a.

Posterior deep temporal a.


Temporalis m.

Masseter m. (deep part)


Zygomatic arch

Fig. 10.2. Superior view of the middle fossa without bone.

The buccal nerve and the anterior deep temporal nerve generally pass between the upper and lower heads of the lateral
pterygoid muscle. The middle and posterior deep temporal
nerve and masseteric nerve run on the superior surface of the
upper head.
The temporalis muscle is innervated predominantly by the
deep temporal nerves, which are branches of the anterior
trunk of the mandibular nerve. The number of the deep temporal nerves generally vary from one to five. The temporal
branches, which innervate the temporalis muscle, also arise
from the buccal nerve and the masseteric nerve. They innervate the anterior and posterior part of the temporalis muscle
respectively.

c10.indd 62

Three main arteries supply the temporalis muscle: the


anterior deep temporal, the posterior deep temporal, and the
middle temporal. The anterior deep temporal artery, which
arises from the pterygoid segment of the internal maxillary
artery, enters the anterior portion of the muscle and supplies
about 30% of the muscle. The posterior deep temporal artery,
which arises from the same segment of the maxillary artery,
enters the central part of the muscle and supplies about 50%
of the muscle. The middle temporal artery. which arises from
the superficial temporal artery, supplies the temporal fascia
and approximately 20% of the posterior and upper parts of
the temporalis muscle.

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10 Deep Structures in the Midfacial Region

Deep temporal n.
Zygomaticofacial n.
Lateral pterygoid m.
(upper head)

63

Masseteric n. (reflected)
Superior, inferior joint
space
Articular disc
Superficial temporal a.
Mandibular condyle
Auriculotemporal n.

Infraorbital a.
Maxillary a.
Buccal n.
Posterior superior
alveolar n., a., v.
Lateral pterygoid m.
(lower head)

Facial n.
Deep temporal a.

External carotid a.

Deep facial v.

Medial pterygoid m.
(superficial head)

Buccinator m.

Buccal a., lingual br.


Inferior alveolar n., a.

Minor salivary gland


Lingual n.
Facial v.
Parotid duct

Mandible
(partially removed)

Fig. 10.3. Infratemporal fossa. The temporalis muscle and the coronoid process have been removed to show
the infratemporal fossa.

The lingual nerve is a branch of the posterior trunk of


the mandibular nerve. It is essentially a sensory nerve. It
emerges from the inferior border of the lateral pterygoid
muscle and curves downward and forward in the space
between the ramus of the mandible and the medial pterygoid
muscle.
The maxillary artery is a terminal branch of the external
carotid artery. It arises at the posterior border of the mandibular neck. It is divided into three segments. The first is the
mandibular segment, which lies behind the mandible and
courses horizontally between the neck of the mandible and
lateral to the sphenomandibular ligament. This segment has
five branches and all enter bone, where the segment lies parallel to and a little below the auriculotemporal nerve. It
crosses the inferior alveolar nerve and runs along the lower
border of the lateral pterygoid muscle. These branches include
the deep auricular artery, the anterior tympanic artery, the

c10.indd 63

middle meningeal artery, an accessory meningeal artery, and


the inferior alveolar artery.
The inferior alveolar artery and vein descend downward
and forward to join the inferior alveolar nerve. They descend
to the mandibular foramen on the medial surface of the
ramus of the mandible and run along the mandibular canal
in the substance of the bone. Opposite the first premolar
tooth, they divide into two branches: incisor and mental.
The temporomandibular joint (TMJ) is formed by the
condyle of the mandible articulating in the mandibular fossa
(glenoid fossa) of the temporal bone. The joint cavity is
divided into two by an intra-articular disc. Its margins merge
with the joint capsule. The TMJ is basically a hinge joint, but
it also allows for some gliding movements. Sensory innervation of the temporomandibular joint is derived from the
auriculotemporal nerve and the articular branch from the
masseteric nerve.

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64

II Upper Facial and Midfacial Region


Masseteric n. (reflected)
Deep temporal n.

Zygomaticofacial n.
Deep temporal a.
Inferior orbital fissure

Lateral pterygoid m.
(upper head)

Infraorbital a., n.

Lateral pterygoid m.
(lower head)
Buccal n.

Maxillary v.

Maxillary a.
Posterior superior
alveolar n., a., v.
Deep facial v.

Fig. 10.4. Infratemporal fossa. The probe is passing through the inferior orbital fissure.

The lateral pterygoid muscle runs in the horizontal plane


and occupies most of the infratemporal fossa. It has two
distinct heads: a smaller upper infratemporal head and a
lower pterygoid one. The infratemporal head originates at
the lateral surface of the greater sphenoid wing and the
infratemporal crest of the sphenoid bone. It runs parallel to
the floor of the middle cranial fossa and merges posteriorly
with the pterygoid head. The pterygoid head originates from
the lateral surface of the lateral pterygoid plate and runs
laterally and superiorly. Both heads were inserted in a depression at the anterior aspect of the neck of the mandible. The
muscle assists in opening the jaws by pulling forward the
mandibular condyle and the articular disc of the temporomandibular joint. The muscle is innervated by the mandibular nerve.
The posterior superior alveolar artery arises from the maxillary artery (pterygopalatine segment), frequently in conjunction with the infraorbital artery just as the maxillary

c10.indd 64

artery is passing into the pterygopalatine fossa. It runs onto


the maxillary tuberosity and supplies the maxillary molar
and premolar teeth through the alveolar canal (see Fig.
10.13b), the buccal gingiva, and the maxillary air sinus. The
posterior superior alveolar vein drains into the pterygoid
venous plexus or the maxillary vein.
The inferior orbital fissure transmits the maxillary nerve
and its zygomatic branch, the infraorbital vessels, the ascending branches from the pterygopalatine ganglion, and a vein
that connects the inferior ophthalmic vein with the pterygoid
venous plexus. The orbitalis muscle (Mllers muscle) occupies the lateral part of the inferior orbital fissure and forms a
lamina of smooth muscle fibers that cover the inferior orbital
fissure. The orbitalis muscle is a rudimentary smooth muscle
that crosses from the infraorbital groove and sphenomaxillary fissure and is intimately united with the periosteum of
the orbit. It lies at the back of the orbit and spans the infraorbital fissure.

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10 Deep Structures in the Midfacial Region

65

Masseteric n.
(reflected upward)
Deep temporal n.
Deep temporal a.
Infraorbital a., n.

Superior joint space


Articular disc
Auriculotemporal n.
Superficial temporal a.

Posterior superior
alveolar a., n.
Maxillary a., v.
Buccal n.
Deep facial v.

Pterygoid venous plexus


(deep component)
Facial n.

Lateral pterygoid plate


Medial pterygoid m.
Buccinator m.
(attachment)
Lingual n.

External carotid a.
Buccal a.
Retromandibular v.
Inferior alveolar n.

Fig. 10.5. Infratemporal fossa. The mandibular condyle and lateral pterygoid muscle have been removed.

The medial pterygoid muscle originates in the pterygoid fossa


from the medial surface of the lateral pterygoid plate. Its
fibers pass inferiorly to attach to the medial surface of the
ramus and angle of the mandible. It elevates the mandible.
The pterygoid segment, which is the second segment of
the maxillary artery, is related to the pterygoid head of the
lateral pterygoid muscle. It runs between the infratemporal
and pterygoid heads of the lateral pterygoid muscle or laterally to the pterygoid head of the lateral pterygoid muscle. It
has five branches: the deep temporal arteries (anterior and
posterior), the pterygoid artery, the masseteric artery, the
buccal artery, and a small lingual branch.

c10.indd 65

The pterygoid venous plexus has superficial and deep


components. The latter is more prominent and is located
between the lateral and medial pterygoid muscles, posterior
to the lateral pterygoid plate, around the lingual and inferior
alveolar nerves. It communicates with the cavernous sinus,
the facial vein, the retromandibular vein, the inferior ophthalmic vein, and the pharyngeal plexus. The primary drainage of
the pterygoid venous plexus is posteriorly through the retromandibular vein via the maxillary vein. The deep facial vein
connects the facial vein with the pterygoid venous plexus in
the infratemporal fossa.

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66

II Upper Facial and Midfacial Region


Masseteric n.
Deep temporal a., n.
Mandibular fossa

Infratemporal crest

Infraorbital a., n.

Superficial temporal a.

Anterior trunk
Sphenomandibular ligament

Buccal n.
Posterior superior
alveolar a., n.

Auriculotemporal n.,
middle meningeal a.
Facial n.

Accessory meningeal a.

Posterior trunk

Maxillary a., v.

External carotid a.
Styloid process
Buccinator m.

Buccal a.
Inferior alveolar a., v.

Medial pterygoid m.

Mandible (cut)
Inferior alveolar n.

Lingual n.

Fig. 10.6. Infratemporal fossa. The pterygoid venous plexus has been removed.

The auriculotemporal nerve originates from the posterior


trunk of the mandibular nerve primarily in one or two
branches. The middle meningeal artery is encircled by them
in the latter. The two branches then converge to form a single
nerve. This nerve is essentially sensory but it also distributes
autonomic fibers to the parotid gland. The auriculotemporal
nerve crosses medially to the neck of the mandible and
changes its direction upward in the parotid gland between the
temporomandibular joint and the external acoustic meatus.
The infratemporal fossa is the anatomic space under the
floor of the middle cranial fossa and posterior to the maxilla.

c10.indd 66

The roof is the infratemporal surface of the greater sphenoid


wing. The medial wall is the lateral pterygoid plate anteriorly
and the tensor veli palatine and medial pterygoid muscles
posteriorly. The anterior wall is the posterior surface of the
maxilla. The fossa extends posteriorly to the glenoid fossa and
the temporomandibular joint. Superiorly and laterally, the
fossa blends into the temporal fossa and the belly of the temporalis muscle. The infratemporal crest is a transverse ridge
of the greater sphenoid wing that separates the temporal
fossa from the infratemporal fossa. The inferior boundary of
the fossa is open.

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10 Deep Structures in the Midfacial Region

Deep temporal a.

67

Mastoid tip
Facial n.

Maxillary a., v.
Sphenomandibular ligament

Deep auricular a.
Stylomandibular ligament
Occipital a.
Accessory n.

Mandible (cut)
Inferior alveolar n.

Transverse process of atlas

Internal jugular v.

Fig. 10.7. Infratemporal fossa. The accessory ligaments of the temporomandibular ligament.

The accessory ligaments of the temporomandibular ligament


are the stylomandibular ligament, the sphenomandibular
ligament, and the pterygomandibular raphe (ligament). The
stylomandibular ligament extends from the tip of the styloid
process and from the styloid ligament to the angle of the
mandible. The sphenomandibular ligament attaches to the

c10.indd 67

spine of the sphenoid bone and descends to the lingula near


the mandibular foramen in the medial surface of the ramus
of the mandible. The deep auricular artery is the first branch
from the mandibular segment of the maxillary artery. It
supply the skin of the external acoustic meatus and part of
the tympanic membrane.

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68

II Upper Facial and Midfacial Region


Deep temporal n., a.,
Masseteric n.

Infratemporal crest
Infraorbital a., n.

Mandibular fossa
Superficial temporal a.

Deep facial v.

Auriculotemporal n.
Middle meningeal a.,
Maxillary a.
Facial n.

Facial v.
Lateral pterygoid plate
Buccinator m.
(attachment)
Tensor veli palatini m.
Superior pharyngeal
constrictor m.

External carotid a.
Posterior auricular a.
Occipital a.
Transverse process of atlas
Stylopharyngeus m.
Inferior alveolar n., a., v.

Pterygomandibular raphe
Lingual n.
Tongue
Styloglossus m.
Mylohyoid n.

Internal carotid a.
Ascending palatine a.
Hypoglossal n.
Internal jugular v.
Facial a.

Fig. 10.8. Infratemporal fossa. The medial pterygoid muscle and the mandible have been removed.

The tensor veli palatini muscle pulls the soft palate laterally.
When this muscle and the levator veli palatini muscle act
together, the palatine aponeurosis becomes taut and horizontal and provides a platform upon which other palatini muscle
may act to change the position of the soft palate (see Fig. 8.6).
The facial artery gives o the ascending palatine artery, the
tonsillar artery, branches to the submandibular gland, and the
submental artery in the neck.
The pterygomandibular raphe is a ligamentous band
between the superior pharyngeal constrictor muscle and the

c10.indd 68

middle portion of the buccinator muscle. It attaches to the


pterygoid hamulus superiorly and to the posterior end of the
mylohyoid line of the mandible.
The superior pharyngeal constrictor muscle originates
mainly from the posterior border of the pterygomandibular
raphe. This raphe provides the site of origin for both the
superior constrictor and buccinator muscles. This muscle
constricts the upper part of the pharynx, and it is innervated
from the accessory nerve.

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10 Deep Structures in the Midfacial Region


Deep temporal a., n.,
Masseteric n.

69

External acoustic meatus


Superficial temporal a.
Chorda tympani n.
(petrotympanic fissure)
(Spine of sphenoid bone
has been removed)
Auriculotemporal n.,
Middle meningeal a.
Mastoid tip
Facial n.
Stylomastoid a.
Br. to digastric m.
Rectus capitis lateralis m.

Infraorbital a., n.
Posterior superior
alveolar a., n.
Maxillary a.
Buccal n.
Deep facial v.
Lateral pterygoid plate

Styloid process
Posterior auricular a.
Tensor veli palatini m.

Occipital a.
Ascending palatine a.
External carotid a.

Alveolar process
Lingual n.

Accessory n.
Internal jugular v.

Inferior alveolar n., a. v.

Fig. 10.9. Infratemporal fossa. The mandibular fossa has been drilled.

The mandibular nerve is the largest division of the trigeminal


nerve and has motor and sensory fibers. The sensory fibers
supply the mandibular teeth, the anterior two-thirds of the
tongue and the floor of the mouth, the skin of the lower part of
the face, and parts of the temporal and auricular region. The
mandibular nerve lies on the tensor veli palatini muscle after
passing through the foramen ovale. After a short distance, the
nerve divides into a smaller anterior trunk and a larger posterior
trunk. Prior to this division, the main trunk gives o the meningeal branch and the nerve to the medial pterygoid muscle.
The anterior trunk has four branches: the masseteric
nerve, the deep temporal nerve, the nerve to the lateral pterygoid muscle, and the buccal nerve. The posterior trunk has

c10.indd 69

three branches: the auriculotemporal nerve, the lingual


nerve, and the inferior alveolar nerve.
The lingual nerve is essentially a sensory nerve, but following union with the chorda tympani branch of the facial
nerve, it also contains parasympathetic fibers. The nerve lies
on the tensor veli palatini muscle deep to the lateral pterygoid
muscle. Then the chorda tympani nerve, which has entered
the infratemporal fossa via the petrotympanic fissure, joins
the posterior surface of the lingual nerve.
The tensor veli palatini muscle lies lateral to the Eustachian
tube. It runs downward toward the pterygoid hamulus at the
inferior border of the medial pterygoid plate, and its tendon
inserts in the soft palate.

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70

II Upper Facial and Midfacial Region

Superficial temporal a.
Maxillary a.

Chorda tympani
Tympanomastoid suture
Facial n.
Mylohyoid n.

Levator veli palatini m.


Tensor veli palatini m.

Posterior auricular a.
Occipital a.
Inferior alveolar n., a., v.

Ascending palatine a.
Superior pharyngeal
constrictor m.
Stylopharyngeus m.
Lingual n.
Glossopharyngeal n.

Transverse process of atlas


Accessory n.
Hypoglossal n.
Internal jugular v.
Vagus n.

Fig. 10.10. Infratemporal fossa. The tensor veli palatini muscle has been lifted to show the levator veli palatini muscle.

The levator veli palatini muscle is medial and slightly posterior to the tensor veli palatini muscle. It spreads to attach
widely to the soft palate. This muscle forms a U-shaped muscular sling. When the palatine aponeurosis is stiened by the
tensor muscles, contraction of the levator muscles produces
an upward and backward movement of the soft palate. This
muscle is innervated by the accessory nerve via the pharyngeal plexus.
The ascending palatine artery arises close to the origin of
the facial artery and passes up between the styloglossus and
stylopharyngeus to the side of the pharynx along which it

c10.indd 70

continues between the superior pharyngeal constrictor


muscle and the medial pterygoid muscle to near the base of
the skull.
The stylopharyngeus muscle elevates the pharynx
and larynx, and it is innervated from the glossopharyngeal
nerve.
The styloglossus muscle draws up the sides of the tongue
to create a trough for swallowing, and it is innervated by the
hypoglossal nerve like all muscles of the tongue except the
palatoglossus muscle, which is innervated by the pharyngeal
plexus of vagus nerve.

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10 Deep Structures in the Midfacial Region

Deep temporal n.,


Masseteric n. (reflected)

71

Superficial temporal a.
Deep temporal a.
Chorda tympani
Auriculotemporal n.

Maxillary a.
Buccal n.

Middle meningeal a.
Facial n.

Lateral pterygoid plate

Occipital a.
Levator veli palatini m.
Inferior alveolar n., a., v.

Eustachian tube
(probe is in the tube)

Ascending palatine a.
Mylohyoid n.

Lingual n.

Internal jugular v.

Fig. 10.11. Infratemporal fossa. The tensor veli palatini muscle has been removed.

The mylohyoid nerve, which is given o from the inferior


alveolar nerve just before the mandibular foramen, has motor
and sensory components. It supplies the mylohyoid muscle
and the anterior belly of digastric muscle. It also supplies the
skin of the submental region (see Fig. 11.4).
The Eustachian tube is also called the auditory tube. It
links the lateral wall of the nasopharynx to the anterior wall
of the tympanic cavity. The Eustachian tube runs anteriorly
and inferiorly from the middle ear to the nasopharynx. It has
a bony part in the petrous bone and a cartilaginous part that
lies in the infratemporal fossa. The cartilaginous part gives

c10.indd 71

attachment to the tensor veli palatini muscle, the levator veli


palatini muscle, and the salpingopharyngeus muscle. The
tensor veli palatini intervenes between the tube and the mandibular nerve, the otic ganglion, the chorda tympani nerve,
and the middle meningeal artery. The functions of the Eustachian tube are pressure equalization and mucus drainage.
Under normal circumstances, the human Eustachian tube is
closed, but it can open to let a small amount of air through to
prevent damage by equalizing pressure between the middle
ear and the atmosphere. The Eustachian tube drains mucus
from the middle ear.

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72

II Upper Facial and Midfacial Region


Deep temporal a.
Deep temporal n.
& Masseteric n.
Infraorbital a., n.

Inferior alveolar n., a.


(reflected)
Mandibular fossa (opened)

Buccal n.
Greater palatine a.

Lingual n.
Branch to medial
pterygoid m.
Otic ganglion

Maxillary a.
Middle meningeal a.
Auriculotemporal n.
Vaginal process

Eustachian tube (lateral


wall of cartilaginous part)

Internal carotid a.
Levator veli palatini m.

Fig. 10.12. Infratemporal fossa. The mandibular nerve has been lifted to show the otic ganglion.

The otic ganglion is a parasympathetic ganglion, which lies on


the medial surface of the main trunk of the mandibular nerve
immediately below the foramen ovale. It is concerned primarily with supplying the parotid gland. The parasympathetic,
sympathetic, and sensory components reach the parotid gland
by way of the auriculotemporal nerve. The preganglionic

c10.indd 72

parasympathetic fibers originate from the inferior salivatory


nucleus in the brain stem. The fibers pass out in the glossopharyngeal nerve, appearing as the lessor petrosal nerve from the
tympanic plexus in the middle ear cavity. Its sympathetic postganglionic fibers consists of a filament from the plexus surrounding the middle meningeal artery.

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10 Deep Structures in the Midfacial Region

73

Alveolar canals

Maxillary tuberosity
Deep temporal n.,
Masseteric n.

Inferior orbital fissure


(Lateral part)

Infraorbital a., n.
Deep temporal a.

Posterior superior
alveolar n., a.

Greater palatine a.
Anterior trunk

pterygomaxillary fissure

Posterior trunk

Buccal n.

Auriculotemporal n.
Lateral pterygoid plate
Maxillary tuberosity
Maxillary a.
Lingual n.

Tensor veli palatini m.


Br. to medial pterygoid m.

Inferior alveolar n.

a
Fig. 10.13a,b. Infratemporal fossa. (a) The maxillary artery has been lifted to show the greater palatine artery. (b) Lateral view of
the skull with the maxillary tuberosity highlighted.

The posterior superior alveolar nerve arises from the maxillary nerve in the pterygopalatine fossa. It descends onto the
posterior wall of the maxilla and divides into dental and gingival branches. The dental branches and vessels enter the

c10.indd 73

maxilla and run in the posterior alveolar canals (Fig. 10.13b)


above the roots of the molar teeth. The three superior alveolar
nerves (anterior, middle and posterior superior alveolar) form
a plexus just above the roots of the maxillary teeth.

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74

II Upper Facial and Midfacial Region

Deep temporal a.
Infraorbital a.
External acoustic meatus
Superficial temporal a.
Pterygoid
plate (fractured)
Greater palatine a., n.
Maxillary a.
Facial n.

Maxillary tuberosity

External carotid a.
Inferior alveolar n., a.

Eustachian tube
Nasopharynx
(Soft palate has been
removed in the
left side)

Stylohyoid ligament (cut)


Lingual n.

Fig. 10.14. Infratemporal fossa. The pterygoid plate has been fractured.

The pterygopalatine fossa communicates with the


infratemporal fossa through the pterygomaxillary fissure.
At the base of the pterygopalatine fossa, the greater
and lesser palatine nerves, which arise from the pterygopalatine ganglion together with accompanying vessels (greater
and lesser palatine arteries), pass into the hard palate to

c10.indd 74

emerge at the greater and lesser palatine foramina (see Fig.


8.5).
The pterygomaxillary fissure transmits the maxillary
artery from the infratemporal fossa. The fissure continues
above with the posterior end of the inferior orbital fissure in
the floor of the orbit.

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10 Deep Structures in the Midfacial Region

75

V1
Nerve to inferior
oblique m. (III)
Inferior ophthalmic v.
Inferior orbital fissure
Infraorbital n., a.
Posterior superior
alveolar a., n.
Orifice of maxillary sinus

V2
Pterygopalatine ganglion
V3

Nerve of pterygoid canal


(GSPN, Deep petrosal n.),
A., V. of the pterygoid canal

Posterior trunk of V3
Posterior superior
alveolar a., n.
Tensor veli palatini m.
Buccal n.
Maxillary a.
Buccinator m.

Fig. 10.15. The nerve of pterygoid canal. The pterygoid canal, orbit, and maxillary sinus have been opened.

The pterygoid canal (also known as the vidian canal) is a


passage in the skull leading from just anterior to the foramen
lacerum in the middle cranial fossa to the pterygopalatine
fossa. The greater petrosal nerve (preganglionic parasympathetic), the deep petrosal nerve (postganglionic sympathetic),
and accompanying vessels (artery and vein of the pterygoid
canal), which originate from the pterygopalatine segment of
the maxillary artery, enter the pterygoid canal. On leaving the
pterygoid canal, the nerves emerge into the pterygopalatine
fossa and join the pterygopalatine ganglion. From the superior cervical ganglion, sympathetic fibers pass to the internal

c10.indd 75

carotid plexus and appear as the deep petrosal nerve. The


deep petrosal nerve innervates the blood vessels of the lacrimal gland. The fibers do not synapse at the ganglion and pass
to the lacrimal gland along the same course as the parasympathetic innervation.
The buccal nerve courses between the two heads of the
lateral pterygoid muscle (see Fig. 10.2, Fig. 10.3, and Fig.
10.4) underneath the tendon of the temporalis muscle and
then under the masseter muscle to connect with the zygomaticobuccal branches of the facial nerve on the surface of
the buccinator muscle (see Fig. 11.6).

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76

II Upper Facial and Midfacial Region


Chorda tympani
(Spine of sphenoid bone
has been removed.)
Mandibular n.,
Middle meningeal a.

Mastoid tip
Vaginal process

Stylomastoid a.

Levator veli palatini m.


Ascending pharyngeal a.
Internal carotid a.

External carotid a.
(reflected)
Superior pharyngeal
constrictor m.
Glossopharyngeal n.
Pharyngeal plexus

Facial n.
(reflected posteriorly)
Styloid process (cut)
Occipital a. (cut)
Rectus capitis lateralis m.

Accessory n.
Transverse process of atlas
Internal jugular v.
Hypoglossal n.
Levator scapulae m.
Vagus n.

Fig. 10.16. Structures adjacent to the facial nerve trunk. The styloid process has been cut and the facial nerve has been
reflected laterally.

The stylomastoid artery, which generally originates from the


posterior auricular artery or the occipital artery, supplies the
facial nerve trunk and enters into the skull, close to the facial
nerve, through the stylomastoid foramen.
The hypoglossal nerve passes between the internal jugular
vein and the internal carotid artery to the level of the transverse process of the atlas, where it turns abruptly forward
along the lateral surface of the internal carotid artery toward
the tongue, leaving only the ansa cervicalis to descend with
the major vessels. It then runs anteriorly between the internal
and external carotid arteries and onto the stylopharyngeus
muscle. It passes below the submandibular gland onto the
hyoglossus muscle to be distributed to the muscle of the
tongue (see Fig. 12.2). The hypoglossal nerve is a source of
axons for facial reinnervation when the proximal facial nerve
stump is not available but the distal facial nerve and facial
musculature are present and functional.
Through the jugular foramen, the accessory nerve descends
obliquely, crosses the internal jugular vein (usually on its

c10.indd 76

lateral surface), and runs then backward and downward to


reach the upper part of the sternocleidomastoid muscle (see
Fig. 12.3). Approximately 30% of nerves descend along the
medial, rather than the lateral, surface of the internal jugular
vein. The spinal accessory nerve provides motor innervation
to two muscles of the neck: the sternocleidomastoid and the
trapezius.
The glossopharyngeal nerve leaves the skull through the
jugular foramen and passes between the internal jugular vein
and the internal carotid artery. The glossopharyngeal nerve
is mostly sensory, with only one motor component. Glossopharyngeal nerve gets pain, temperature, and touch from the
tongue, ear, insides of the throat, and so on. It gets taste from
the back one-third of the tongue.
The pharyngeal plexus, with fibers from CN IX, CN X, and
cranial part of CN XI, innervates all the muscles of the pharynx
except the stylopharyngeus muscle, which is innervated by
CN IX. The plexus provides sensory innervation of the oropharynx and laryngopharynx.

2/10/2015 1:40:35 PM

10 Deep Structures in the Midfacial Region

Mandibular fossa
(opened)
Handle of malleus
Superficial temporal a.,
Auriculotemporal n.
Chorda tympani
(Spine of sphenoid bone
has been removed.)
Deep temporal a.
Maxillary a.
Chorda tympani
Lingual n.

77

Semicircular canals
Sigmoid sinus
Chorda tympani
Tympanomastoid suture
Digastric ridge
Digastric groove

N. to digastric m.,
Posterior auricular n.
Facial n.
Stylomastoid a.
Posterior auricular a.

Tensor veli palatini m.


Styloid process

Accessory n.
Occipital a.

Fig. 10.17. Structures adjacent to the facial nerve trunk. The tympanic membrane has been removed to show the course of the
chorda tympani.

The chorda tympani is given o just before the stylomastoid


foramen from the mastoid segment of the facial nerve. This
is the branch from the nervus intermedius. It contains parasympathetic fibers going to the submandibular ganglion and
taste fibers from the anterior two-thirds of the tongue. The
nerve initially runs within its own canal before entering
the tympanic cavity. It travels through the middle ear, where
it runs from posterior to anterior across the tympanic

c10.indd 77

membrane. It passes between the malleus and the incus on


the medial surface of the neck of the malleus. The nerve
continues through the petrotympanic fissure, after which it
emerges from the skull into the infratemporal fossa. It soon
combines with the lingual nerve at the infratemporal fossa.
The digastric ridge, which is a ridge of bone, corresponds
to the digastric groove and marks the location of the facial
canal just anterior to it.

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78

II Upper Facial and Midfacial Region

Middle meningeal a.
Chorda tympani
(Spine of sphenoid bone
has been removed.)
Eustachian tube (opened)
Lingual n.
Levator veli palatini m.

Vaginal process

Facial n.
Stylomastoid a.
Styloid process (cut)
Ascending pharyngeal a.

Maxillary a.

Glossopharyngeal n.
Pharyngeal br. of vagus n.

Accessory n.
Internal carotid a.
Internal jugular v.
Hypoglossal n.

Fig. 10.18. Structures adjacent to the facial nerve trunk. The Eustachian tube has been opened.

The ascending pharyngeal artery is the smallest branch of the


external carotid artery. It arises from the posterior surface of
the external carotid artery, passing vertically upward to the
pharynx. It terminates near the base of the skull. The meningeal branches from the ascending pharyngeal artery enter
through the foramen lacerum and the hypoglossal canal.
The middle cranial fossa is innervated by the meningeal
branch of the mandibular division of the trigeminal nerve. It
enters the cranial cavity through the foramen spinosum.

c10.indd 78

The middle meningeal artery is the main source of blood


to the meninges and to the bones of the vault of the skull. It
ascends between the two roots of the auriculotemporal nerve
and leaves the infratemporal fossa through the foramen
spinosum.
Both the jugular foramen and carotid canal are situated
behind the vaginal process, which encloses the root of the
styloid process and forms the posterior wall of the condylar
fossa.

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III

c11.indd 79

Lower Facial and Posterolateral


Neck Region

2/10/2015 1:40:39 PM

c11.indd 80

2/10/2015 1:40:40 PM

11

Lower Facial Region

Frontal br. of superficial


temporal a.

Parietal br. of superficial


temporal a.

Frontalis m.

Temporoparietal fascia
Corrugator supercilii m.

Superior auricular m.

Orbicularis oculi m.

Auriculotemporal n.
Zygomatico-orbital a.

Procerus m.

Superficial temporal a., v.


Temporal brs.

Lateral nasal a.
Transverse facial a.

Zygomatics minor m.,


Levator labii superioris m.
Zygomatic br.,
Zygomatics major m.
Levator anguli oris m.

Parotid gland
Buccal br., parotid gland
Posterior auricular a.
Buccinator m.
Masseteric fascia
Premasseteric a.
Great auricular n.

Modiolus

Marginal mandibular br.


Facial a., v.
Cervical br.
External jugular v.

Depressor anguli oris m.


Orbicularis oris m.
Depressor labii inferioris m.

Sternocleidomastoid m.
Platysma m.

Fig. 11.1. Lateral oblique view of the face. The skin has been removed.

The modiolus is a nodular region at the corner of the mouth


where several mimetic muscles converge and interlace. It is
contributed by the orbicularis oris, buccinator, levator anguli
oris, depressor anguli oris, zygomatics major, and risorius
muscles.
The depressor labii inferioris muscle is partly covered
by the anterior fibers of the depressor anguli oris
muscle.

c11.indd 81

The levator anguli oris, the buccinator, and the mentalis


muscles are deep-seated muscles that are innervated on their
superficial surface by the facial nerve branches.
The facial vein begins as the angular vein at the medial
corner of the eye. The angular vein is formed by the confluence of the supraorbital and supratrochlear veins. The facial
vein passes downward behind the facial artery independently
to the inferior border of the mandible.

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82

III Lower Facial and Posterolateral Neck Region

Buccal brs.
(masseteric fascia is opened)
Buccinator m.

Tail of parotid gland


Sternocleidomastoid m.

Masseteric fascia
Premasseteric artery
Marginal mandibular br.

Posterior auricular v.,


posterior br. of
retromandibular v.
Lesser occipital n.
Great auricular n.
Cervical brs.

Facial a., v.

External jugular v.
Anterior br. of
retromandibular v.
Transverse cervical n.

Fig. 11.2. The lower facial region. Close up view of the parotid tail and mandibular angle.

The marginal mandibular branches of the facial nerve emerge


from the lower border of the parotid gland, and the branch
runs near the inferior border of the mandible. Initially, it may
pass into the neck below the angle of the mandible, but after
crossing the facial artery it usually comes up above the lower
border of the mandible to the face. It innervates the depressor
anguli oris, the depressor labii inferioris, the mentalis, and
the lower orbicularis oris muscles.
The cervical branch passes downward from the lower
border of the parotid gland to supply the platysma muscle in
the neck. Some of the its branches frequently innervate
the depressor labii inferioris and the depressor anguli oris
muscles.
One of the buccal branches runs beneath the masseteric
fascia in this figure. However, most of the marginal mandibular branches generally run on the fascia.

c11.indd 82

At the inferior border of the mandible near the anterior


edge of the masseter muscle, the facial artery and the vein
course closely.
The premasseteric artery arises at the lower border of the
mandible from the facial artery and ascends along the anterior edge of the masseter muscle.
The great auricular nerve perforates the deep cervical
fascia and ascends upon the sternocleidomastoid muscle
beneath the platysma to the parotid gland, where it divides
into an anterior and a posterior branch. It provides sensory
innervation for the skin over the parotid gland and the
mastoid process, as well as both surfaces of the caudal region
of the auricle.

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11 Lower Facial Region

83

Zygomaticus major m.
Zygomaticobuccal brs.
Levator anguli oris m.
Lateral nasal a.
Superior labial a.

Buccinator m.

Modiolus

Facial v.
Depressor anguli oris m.
Facial a.

Orbicularis oris m.
Inferior labial a.

Fig. 11.3. The lower facial region. Close up view of the oral commissure.

The modiolus may be fixed by the action of some of


the muscles to provide a base for the action of other
muscles.
The orbicularis oris muscle is a complex of muscles in the
lips that encircle the mouth. This muscle closes the mouth
and puckers the lips when it contracts. It is innervated by
the zygomaticobuccal branch and the marginal mandibular
branch.

c11.indd 83

The facial artery passes upward and forward from the


mandible and lies deep to the zygomaticus major muscle and
superficial to the buccinator muscle. It lies either superficial
or deep to the levator anguli oris muscle and levator labii
superioris muscle. The branches of the facial artery on the
face are the inferior labial and superior labial. It terminates
as lateral nasal arteries or the angular artery. The former two
branches are situated deep to the orbicularis oris muscle.

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84

III Lower Facial and Posterolateral Neck Region

Depressor anguli oris m.


(reflected upward)

Inferior alveolar a., v., n.


(The mandibular canal
has been opened)

Facial a., v.
Inferior labial a.
Orbicularis oris m.

Mylohyoid n.
Marginal mandibular br.

Mental n., a., v.

Mylohyoid m.

Depressor labii inferioris m.

Submental a.

Depressor anguli oris m.

Anterior belly of
digastric m.

Mentalis m.
Platysma m.

Fig. 11.4. The lower facial region. The platysma and depressor anguli oris muscles have been removed to leave their attachments.

The mentalis muscle is in the deepest layer among the


mimetic muscles. It originates from the incisive fossa of the
mandible. Its fibers descend to insert into the skin of the chin.
This muscle raises and protrudes the lower lip.
The depressor labii inferioris muscle arises from the mandible just in front of the mental foramen. The fibers pass
upward and medially to converge with the orbicularis oris
muscle in the lower lip. This muscle depresses the lower lip
and draws it laterally.
The depressor anguli oris muscle arises from an extensive
area around the external oblique line of the mandible. Its
fibers pass upward to the corner of the mouth. This muscle
depresses the corner of the mouth.

c11.indd 84

The platysma muscle is a flat muscle which inserts into


the subcutaneous tissues of the subclavicular and acromial
regions inferiorly and then inserts into the chin at the commissures of the mouth and in the anterior one-third of the
oblique line of the mandible. This muscle is a depressor of the
lower lip innervated by the cervical branch of the facial nerve.
The digastric muscle stretches between the mastoid process
of the cranium to the mandible. Part of the way between, it
becomes a tendon that passes through a tendinous pulley
attached to the hyoid bone. The anterior belly of the digastric
muscle arises from a depression on the inner side of the lower
border of the mandible called the digastric fossa, which is close
to the symphysis, and passes downward and backward.

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11 Lower Facial Region

85

Superficial temporal a.
Maxillary a.

Mandibular condyle

Posterior superior
alveolar n., a.

Lateral pterygoid m.
Posterior belly of
digastric m.
Medial pterygoid m.

Deep facial v.
Parotid duct

Lingual n.
Inferior alveolar a., n., v.

Lateral nasal a.
Zygomaticus major m.

Buccinator m.

Levator anguli oris m.


Superior labial a.

Facial a.

Depressor anguli oris m.


Retromandibular v.
Facial v.
Common facial v.
Facial a.
Submental a.
Submandibular gland

Inferior labial a.
Mental n., a., v.

Fig. 11.5. The lower facial region. The mandibular canal has been opened.

The buccinator muscle is in the deepest layer among the


mimetic muscles, and it functions principally during mastication. An important relationship is with the parotid duct,
which pierces the muscle opposite the maxillary third molar
and then runs forward to open into the oral cavity opposite
the maxillary second molar. This muscle has two main origins.
First, it arises from the anterior margin of the pterygomandibular raphe. Second, it is attached to the alveolar margins
of the maxilla and mandible in the region of the molar teeth.
The fibers eventually run into the orbicularis oris muscle.
The inferior alveolar nerve arises from the mandibular
nerve and emerges from beneath the lateral pterygoid muscle.
Then, it gives o a mylohyoid branch which has motor and

c11.indd 85

sensory components. It next enters the mandible with the


vessels via the mandibular foramen. While in the mandibular
canal within the mandible, the main trunk of the inferior
alveolar nerve divides near the premolars into mental and
incisive nerves. The mental nerve and vessels run for a short
distance in a mental canal before leaving the body of the
mandible at the mental foramen to emerge onto the face. It
supplies the skin and mucosa of the lower lip and the labial
gingivae of the mandibular anterior teeth. The mental nerve
has communication with the marginal mandibular branch of
the facial nerve. The mental artery arises from the mandibular segment of the maxillary artery as a terminal branch of
the inferior alveolar artery.

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86

III Lower Facial and Posterolateral Neck Region

Zygomaticus major m.
Auriculotemporal n.
Masseteric a., n.
Tendon of temporalis m.

Facial n.

Ascending ramus
Parotid duct
Buccal a.
Buccinator m.

Buccal n.
Masseteric n.
Masseter m. (reflected)

Fig. 11.6. The lower facial region. The masseter muscle has been reflected inferiorly to show the ascending ramus of mandible.

The buccal nerve runs into the upper part of the retromolar
fossa at the anterior border of the ramus of the mandible. The
buccal nerve divides into several branches within the buccinator muscle. It innervates both the mucosa and the skin of
the cheek and buccal gingivae of the mandibular cheek teeth.
The buccal nerve has communication with zygomaticobuccal
branches of the facial nerve.

c11.indd 86

The buccal artery is a branch of the pterygoid segment


of the maxillary artery. It emerges onto the face from the
infratemporal fossa and crosses the buccinator muscle to
supply the cheek. The masseteric artery is also a branch of
the pterygoid segment of the maxillary artery and courses
close to the same nerve anteroinferiorly in the masseter
muscle.

2/10/2015 1:40:43 PM

11 Lower Facial Region


Lateral pterygoid m.
External carotid a.
Posterior belly of
digastric m.
Lingual n.
Parotid duct (probe is
in the duct)

Infraorbital n.
Zygomaticobuccal br.
of facial n.
Lateral nasal a.
Septal a.

Buccinator m.

Columellar a.

87

Inferior alveolar n., a.

Superior labial a.

Mandible

Tongue

Inferior labial a.
Mental n., a, v.
Mentalis m.
Depressor anguli oris m.

Internal jugular v.
Facial a., v.
Submandibular gland
Common facial v.
Submental a.
Mylohyoid n.
Anterior belly of
digastric m.
Platysma m.

Fig. 11.7. The lower facial region. The upper and lower lip have been removed to leave the facial artery.

The facial artery usually lies anterior to the facial vein throughout its course and courses close to the vein on the mandible.
The superior labial artery is larger and more egregious
than the inferior labial artery. It courses along the edge of the
upper lip, lying between the mucous membrane and the orbicularis oris muscle, and it anastomoses with the artery of the
opposite side. It supplies the upper lip and gives o in its
course two branches that ascend to the nose: a septal branch
ramifies on the nasal septum and a columellar branch supplies the columella of the nose.
The inferior labial artery arises near the angle of the
mouth. It passes upward and forward beneath the depressor

c11.indd 87

anguli oris muscle and, penetrating the orbicularis oris


muscle, runs in a tortuous course along the edge of the lower
lip between this muscle and the mucous membrane. It supplies the labial glands, the mucous membrane, and the
muscles of the lower lip, and it anastomoses with the artery
of the opposite side
The submental artery is a branch of the facial artery, given
o just as that vessel leaves the submandibular gland. It runs
forward upon the mylohyoid, just below the body of the mandible and beneath the digastric muscle. It supplies the surrounding muscles and also a territory of skin in the submental
area.

2/10/2015 1:40:44 PM

12

Oral Floor and Upper Neck Region

Inferior alveolar n., a., v.


Posterior belly of
digastric m.

Tongue

Lingual n.
Facial a., v.

Ducts of
sublingual gland

Submandibular ganglion
Hyoglossus m.
Mylohyoid n.
Hypoglossal n.

Sublingual gland

Common facial v.
Mylohyoid m.
Sublingual a.

Internal jugular v.

Geniohyoid m.

Submandibular Gland

Submental a.

Anterior belly of
digastric m.

Fig. 12.1. The oral floor from the side. Part of the mandible has been removed.

The submandibular ganglion is parasympathetic ganglion


that is found in the floor of the mouth on the superficial
surface of the hyoglossus muscle. It lies between the lingual
nerve and the deep part of the submandibular gland. It
is suspended by two roots from the lingual nerve. The submandibular ganglion is responsible for innervation of the
submandibular gland and sublingual gland. Preganglionic
parasympathetic fibers originate from the superior salivary
nucleus in the brain stem. The fibers pass with the nervus
intermedius of the facial nerve into the internal acoustic
meatus and exit the skull with the chorda tympani at the
petrotympanic fissure. The chorda tympani nerve joins the
lingual nerve.
The inferior alveolar nerve branches o the mylohyoid
nerve before entering the mandibular canal. The mylohyoid nerve courses inferiorly and anteriorly in the mylohyoid
groove beneath the mylohyoid line (see Fig. 3.7). It supplies

c12.indd 88

the mylohyoid muscle and the anterior belly of digastric


muscle. It also supplies the skin of the submental region.
The lingual nerve courses toward the floor of the mouth
from the infratemporal fossa. It supplies the mucosa covering
the anterior two-thirds of the dorsum of the tongue, the
ventral surface of the tongue, the floor of the mouth, and the
lingual gingivae of the mandibular teeth. The rest of the posterior part of the tongue are innervated by the glossopharyngeal nerve.
The mylohyoid muscle arises from the mylohyoid line on
the medial surface of the body of the mandible. Its fibers
interdigitate with the contralateral fibers to form a medial
raphe. This raphe is attached above to the mandible and
below to the hyoid bone. The muscle raises the floor of the
mouth during the first stages of swallowing. It also helps to
depress the mandible when hyoid bone is fixed. Conversely,
it aids in elevation of the hyoid bone.

2/10/2015 1:40:46 PM

12 Oral Floor and Upper Neck Region


Cerebellum
Stylomastoid a.

Mandible
Stylomandibular ligament
Stylopharyngeus m.
Ascending pharyngeal a.
Pharyngeal plexus
Ascending palatine a.
Mylohyoid n.
Lingual a.
Styloglossus m.
Glossopharyngeal n.
Lingual n.

89

Facial n.
Auricular br. of posterior
auricular a.
Posterior auricular a.
Occipital a.
Accessory n.
Internal carotid a.
Internal jugular v.
(displaced laterally)
Sternocleidomastoid m.
(cut and reflected)
Upper root of ansa cervicalis
Vagus n.

Tongue

Cervical plexus
Superior laryngeal n.

Facial a.
Hypoglossal n.
Hyoglossus m.
Submental a.

Common carotid a.
Superior thyroid a.

Fig. 12.2. The upper neck region. The branches of the external carotid artery.

The common carotid artery divides at the upper border of the


thyroid cartilage, which is generally on a level with the upper
border of the fourth cervical vertebra. At its origin, the external carotid artery is actually anteromedial to the internal
carotid artery. The external carotid artery ascends anteriorly
to the internal carotid artery through the parotid gland, deep
to the retromandibular vein. Proximal to its terminal bifurcation into the maxillary and the superficial temporal arteries,
it gives rise to six branches: the superior thyroid artery, the
ascending pharyngeal artery, the lingual artery, the facial
artery, the occipital artery, and the posterior auricular artery.
The superior thyroid artery is the first branch of the external carotid artery. It arises at the level of the greater horn of
the hyoid bone and supplies the thyroid, the sternocleidomastoid muscle, and the larynx.

c12.indd 89

The ascending pharyngeal artery is the smallest branch of


the external carotid artery. It is a long, slender vessel, deeply
seated in the neck beneath the other branches of the external
carotid and under the stylopharyngeus muscle. It arises from
the posterior surface of the external carotid artery and passes
vertically upward between the internal carotid and the side
of the pharynx to under the surface of the base of the skull,
lying on the longus capitis muscle.
The lingual artery arises from the external carotid artery
just above the superior thyroid artery and passes beneath the
hyoglossus muscle to enter the tongue. Its branches are the
infrahyoid artery and the sublingual artery, with the deep
lingual artery as its terminal branch.

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90

III Lower Facial and Posterolateral Neck Region


Retromandibular v.
Posterior auricular a.
Temporofacial division
Cervicofacial division

Cerebellum

Mastoid process
(digastric groove)
Facial n. (main trunk)
Br. to digastric m. and
stylohyoid m. (facial n.)
Occipital a.
Digastric m. (posterior belly)
Superior oblique m.
Sternocleidomastoid br.
of occipital a.

Masseter m.

Accessory n. (br. to
sternocleidomastoid m.)
Hypoglossal n.

Facial a.
Stylohyoid m.
Anterior br. of the
retromandibular v.
Facial a., v.
Submandibular gland
Common facial v.

Internal jugular v.
Vagus n.
Internal carotid a.
Superior thyroid a.
Ansa cervicalis
Sternocleidomastoid m.
(reflected)

Fig. 12.3. The lower facial and upper neck region. Suboccipital craniotomy has been done and the posterior belly of the digastric
muscle has been detached from the digastric groove.

The branches of the facial nerve to the posterior belly of the


digastric and stylohyoid muscles arise close to the stylomastoid foramen. The stylohyoid muscle is inserted into the body
of the hyoid bone. When it contracts, it elevates the hyoid.
This action is primarily brought about during swallowing. The
muscle is perforated near its insertion by the intermediate
tendon of the digastric muscle.
The ansa cervicalis is a loop of nerves that are part of the
cervical plexus. The upper root of the ansa cervicalis is derived
from the ventral ramus of the first cervical nerve. This branch
first appears as the hypoglossal nerve loops around the occipital artery. It passes down on the carotid sheath covering the
carotid arteries and is joined by the lower root of the ansa
cervicalis from the cervical plexus to form the ansa cervicalis.
Branches from the ansa cervicalis innervate most of the infra-

c12.indd 90

hyoid muscle, including the sternothyroid muscle, the sternohyoid muscle, and the omohyoid muscle.
The facial artery arises from the external carotid artery
immediately above the greater horn of the hyoid bone. It runs
upward behind the submandibular gland deep to the stylohyoid muscle and posterior belly of digastric muscle. Above
the stylohyoid muscle, it turns downward and forward
between the lateral surface of the submandibular gland and
the medial pterygoid muscle to reach the lower border of the
mandible.
The vagus nerve exits through the jugular foramen and
passes into the carotid sheath between the internal carotid
artery and the internal jugular vein down below the head to
the neck, the chest, and the abdomen, where it contributes to
the innervation of the viscera.

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13

Posterior Neck and Occipital Region

Cranium
Pericranium
Occipitalis m.
Ascending br.
of occipital a.
Transverse br.
of occipital a.
Tendinous arch
Descending br. of
occipital a.(cutaneous br.)
Lesser occipital n.

Inion
Medial br. of
greater occipital n.
Lateral br. of
greater occipital n.
Splenius capitis m.
Posterior auricular v.

Posterior auricular a.
Lesser occipital n.
Dorsal rami of cervical n.
(C3~C5)
Sternocleidomastoid m.
Trapezius m.

Fig. 13.1. The posterior neck region. The skin and the galea have been removed to leave the occipitalis muscle on the left side.

The occipitalis muscle has two muscle bellies that are separated in the midline by the aponeurosis. Each occipital belly
arises from the lateral two-thirds of the supreme nuchal line
of the occipital bone and from the mastoid process of the
temporal bone. The muscle extends forward to become continuous with the galea aponeurotica. It is a part of the occipitofrontalis muscle, along with the frontalis muscle. It is
innervated by the posterior auricular branch of the facial
nerve. Its function is to move the scalp back.
The greater occipital nerve and occipital artery reach the
subcutaneous tissues by passing between the attachment
of the trapezius and sternocleidomastoid muscles to the
superior nuchal line. The occipital artery crosses deep to
the greater occipital nerve approximately 4 cm lateral to the
external occipital protuberance (inion). After it pierces the
deep fascia, it gives rise to three major cutaneous branches:
descending, transverse, and ascending. The greater occipital
nerve branches into medial and lateral branches around the

c13.indd 91

superior nuchal line. It supplies the skin over the occipital


part of the scalp up to the vertex of the skull.
The lesser occipital nerve has a variable origin either from
the second or the second and third cervical ventral rami. The
lesser occipital nerve lies at approximately 7 cm lateral to the
external occipital protuberance. This nerve supplies the skin
over the scalp and cranial surface of the upper part of the
auricle.
The medial branches of the dorsal rami of the third, fourth,
and fifth cervical nerves pierce the trapezius muscle at
its paramedian position to supply skin over the back of the
neck.
The trapezius muscle covers the back of the head and neck.
It extends from the medial half of the superior nuchal line,
the external occipital protuberance, and the spinous processes of the cervical and thoracic vertebrae and converges
on the shoulder to attach to the scapula and the lateral third
of the clavicle.

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92

III Lower Facial and Posterolateral Neck Region


Midline

Parietal foramen

Parietal br. of
superficial temporal a.

Parietal br. of
superficial temporal a.

Anastomotic a.
Galea
Occipital a.

Occipital a.

Midline

Fig. 13.2a-c. (a) The scalp from above. The skin has been removed to show the galea. (b) The scalp from above. The scalp without
pericranium has been reversed. (c) The skull from above.

The branches from the superficial temporal, posterior auricular, occipital, supraorbital, and supratrochlear arteries freely
anastomose in the scalp.
This figure shows the meningeal branch (anastomotic
artery) from the occipital artery bilaterally which is passing
through the parietal foramen. The well-developed anastomotic artery is found in approximately 50% of specimens, and
it develops the vascular network of the galea and scalp. The
rich vascular connection in the galea and scalp contributes
rich vascularity to galeal and scalp flap in the head.
The parietal foramen is found in more than 60% of
skulls. It may be unilateral or bilateral or duplicate on one

c13.indd 92

or both sides. The vertical distance from the inion to the level
of the parietal foramen is approximately 8 cm, and the
distance from the midline to the foramen is within 10 mm
(Fig. 13.2c).
The superficial temporal artery that supplies the galea
does not cross the midline or anastomose with the contralateral superficial temporal artery on the galeal layer. The
vein on the galea generally runs superficially on the artery
except for the vertex region. The artery in the vertex region
courses more superficially on the vein and anastomoses
with the contralateral artery in the subcutaneous layer (Fig.
13.2a).

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13 Posterior Neck and Occipital Region

93

Perforating artery from


posterior auricular a.
Arnolds nerve

b
Occipitalis m.

Occipital a.
Posterior auricular m.
Posterior auricular v.
Tendinous arch
Posterior auricular n.
Greater occipital n.
Occipital br. of
posterior auricular a.

Parotid gland

Splenius capitis m.
Great auricular n.

Lesser occipital n.
Sternocleidomastoid m.

a
Fig. 13.3a,b. (a) The posterior neck region. (b) Lateral view of the auricular cartilage.

The posterior auricular nerve is the first extracranial branch


of the facial nerve. It originates from the facial nerve close to
the stylomastoid foramen and then courses posteriorly and
upward on the surface of the mastoid bone. There, it is joined
by a filament from the auricular branch of the vagus (see the
text accompanying Fig. 2.2), which supplies the auricular
concha as the Arnolds nerve (Fig. 13.3b) and communicates
with the posterior branch of the great auricular, as well as the
lesser occipital, nerve. It supplies the posterior auricular and

c13.indd 93

occipital muscles. The posterior auricular muscle arises from


the mastoid bone and inserts into cranial surface of the
concha. It displaces the auricle backward.
The occipital branch of the posterior auricular artery runs
back over the insertion of sternomastoid muscle to supply the
skin of behind the ear. The posterior auricular vein is variable.
The well-developed posterior auricular vein might be found
to compensate for the underdeveloped superficial temporal
vein (see Fig. 4.2).

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94

III Lower Facial and Posterolateral Neck Region

Temporalis m.

Sternocleidomastoid m.

Occipital a.
Medial br. of greater occipital n.

Lateral br. of greater occipital n.

Posterior auricular v.
Auricular br. of
posterior auricular a.
Great auricular n.

Semispinalis capitis m.

Greater occipital n.

Splenius capitis m.
Trapezius m.
Occipital br. of
posterior auricular a.
Lesser occipital n.

Fig. 13.4. The posterior neck region. The galea and occipitalis muscle have been removed.

The sternocleidomastoid muscle passes obliquely downward


across the side of the neck from the lateral half of superior
nuchal line and mastoid process to the upper part of the
sternum and adjacent part of the clavicle. The sternocleidomastoid muscle is innervated by the accessory nerve. The
function of this muscle is to rotate the head to the opposite
side or obliquely rotate the head. When the muscle and nerve
act together, the neck flexes and the head extends. The sternocleidomastoid branches of the occipital artery supply the
cephalic end of sternocleidomastoid muscle. The spinal part
of the accessory nerve supplies the sternocleidomastoid

c13.indd 94

muscle and passes through or deep to it to emerge into the


posterior triangle on the way to the trapezius muscle (see
Fig. 12.3).
The sternocleidomastoid muscle divides the side of the
neck into an anterior triangle and a posterior triangle. The
anterior triangle is bounded posteriorly by the anterior border
of the sternocleidomastoid, above by the mandible, and anteriorly by the median line of the neck; the posterior triangle is
bounded in front by the posterior border of the sternocleidomastoid, below by the middle third of the clavicle, and behind
by the anterior margin of the trapezius muscle.

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13 Posterior Neck and Occipital Region

95

Temporalis m.

Occipital a.
Semispinalis capitis m.
Mastoid process
Greater occipital n.
Posterior auricular v.
Auricular br. of
posterior auricular a.

Splenius capitis m.

Facial n., Parotid gland


Posterior auricular a.
Digastric m.
Transverse process of atlas
Accessory n.

Internal jugular v., Carotid a.

Lesser occipital n.
Trapezius m.

Sternocleidomastoid m.
(reflected)

Fig. 13.5. The posterior neck region. The sternocleidomastoid muscle has been reflected laterally.

The posterior auricular artery is a small artery that arises


from the external carotid artery above the digastric muscle
and stylohyoid muscle opposite the apex of the styloid
process. It ascends over the digastric muscle between the
auricular cartilage and the mastoid process, pierces the deep
fascia at the level of the external auditory meatus, and divides
into auricular and occipital branches. The auricular branch
ascends deep to posterior auricular muscle and anastomoses

c13.indd 95

with the superficial temporal artery. The auricular branch has


small branches which pierce the auricular cartilage to reach
the external surface (see Fig. 13.3b).
The splenius capitis, situated deep to and partially covered
by trapezius and sternocleidomastoid, extends from the bone
below the lateral third of the superior nuchal line to the
spinous processes of the lower cervical and upper thoracic
vertebrae.

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96

III Lower Facial and Posterolateral Neck Region


Temporalis m.
Asterion
Occipital a.
Mastoid emissary v.,
Meningeal br. of occipital a.
Mastoid process

Transverse br. of occipital a.


(cutaneous br.)

Longissimus capitis m.
Auricular br. of
posterior auricular a.
Facial n., Parotid gland
Posterior auricular a

Greater occipital n.
Descending br. of occipital a.
(muscle br.)

Digastric m.
Transverse process of atlas
Levator scapulae m.
Accessory n.
Sternocleidomastoid m.
(reflected)

Semispinalis capitis m.
Trapezius m.,
Splenius capitis m.

Fig. 13.6. The posterior neck region. The splenius capitis and trapezius muscle have been reflected medially.

The mastoid foramen is a large hole in the posterior border


of the temporal bone. It transmits a mastoid emissary vein
connecting the sigmoid sinus and a small meningeal branch
of the occipital artery, the posterior meningeal artery, to the
dura mater.
The semispinalis capitis muscle, situated deep to the splenius capitis and sternocleidomastoid muscle, attaches below
to the upper thoracic and lower cervical vertebrae. The longissimus capitis muscle, situated deep to the splenius capitis

c13.indd 96

and sternocleidomastoid muscle, attaches above to the posterior margin of the mastoid process.
The greater occipital nerve ascends obliquely between the
inferior oblique and the semispinalis capitis muscle. It pierces
the semispinalis capitis and the trapezius muscles near their
attachments to the occipital bone. It supplies the semispinalis
capitis muscle, ascends with the occipital artery, and supplies
the scalp as far forward as the vertex.

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13 Posterior Neck and Occipital Region

Temporalis m.

97

Ascending br. of occipital a.


(cutaneous br.)

Superior nuchal line


Transverse br. of occipital a.
(cutaneous br.)
Digastric m.
Mastoid process
Occipital a.
Great auricular n.
Facial n.
Superior oblique m.

Greater occipital n.
Descending brs. of occipital
a. (muscle br.)
Semispinalis capitis m.

Inferior oblique m.
Transverse process of atlas
Sternocleidomastoid m.

Trapezius m.,
Splenius capitis m.

Longissimus capitis m.

Fig. 13.7. The posterior neck region. The longissimus capitis muscle has been reflected inferiorly.

The occipital artery arises from the posterior surface of the


external carotid opposite the facial artery and runs posteriorly. At its origin, it is crossed by the hypoglossal nerve. On
its way to the mastoid process, it crosses the internal carotid
artery, the internal jugular vein, and the hypoglossal and
spinal accessory nerves. It passes beneath the lower portion
of the parotid gland. It runs horizontally backward through
the occipital groove of the temporal bone, covered by all the
muscles attached to the mastoid process: the sternocleidomastoid, splenius capitis, and the posterior belly of the digastric. It lies upon the superior oblique and semispinalis capitis
muscle. The artery reaches the subcutaneous tissue by passing
between the attachment of the trapezius and sternocleidomastoid muscle to the superior nuchal line.
The descending branch of occipital artery, the largest
branch of the occipital, descends on the back of the neck and
divides into a superficial and deep portion. The superficial
portion runs beneath the splenius, giving o branches that

c13.indd 97

pierce that muscle to supply the trapezius muscle. The deep


portion runs down between the semispinalis capitis muscle
and anastomoses with the vertebral artery.
The suboccipital muscles, located in the next layer, are a
group of muscles situated deep to the splenius, semispinalis,
and longissimus capitis in the suboccipital area. This group
includes the superior oblique, which extends from the area
lateral to the semispinalis capitis between the superior and
inferior nuchal lines to the transverse process of the atlas; the
inferior oblique, which extends from the spinous process and
lamina of the axis to the transverse process of the atlas; the
rectus capitis posterior major, which extends from and below
the lateral part of the inferior nuchal line to the spine of the
axis; and the rectus capitis posterior minor, which is situated
medial to and is partially covered by the rectus capitis posterior major, and extends from the medial part and below the
inferior nuchal line to the tubercle on the posterior arch of
the atlas.

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98

III Lower Facial and Posterolateral Neck Region

Temporalis m.

Superior nuchal line

Digastric m.
Occipital a.
Facial n.
Superior oblique m.

Ventral ramus of C2
Vertebral a.
Levator scapulae m.

Inferior nuchal line


Rectus capitis posterior
minor m.
Descending br. of occipital a.
Rectus capitis posterior
major m.
Inferior oblique m.
Greater occipital n.
(dorsal ramus of C2)

Fig. 13.8. The posterior neck region. The semispinalis capitis muscle has been reflected inferiorly.

The suboccipital triangle is a region bounded above and medially by the rectus capitis posterior major, above and laterally
by the superior oblique, and below and laterally by the inferior
oblique. The floor of the triangle is formed by the posterior
atlanto-occipital membrane and the posterior arch of the atlas.
The structures in the triangle are the terminal extradural
segment of the vertebral artery and the first cervical nerve.
The C2 nerve emerges between the posterior arch of the
atlas and the lamina of the axis where the spinal ganglion is
located extradurally, medial to the inferior facet of C1 and the
vertebral artery. The nerve divides into a large dorsal and a
smaller ventral ramus. After passing below and supplying the

c13.indd 98

inferior oblique muscle, the dorsal ramus divides into a large


medial branch and a small lateral branch. It is the medial
branch that forms the greater occipital nerve. The lateral
branch sends filaments that innervate the splenius, longissimus, and semispinalis capitis, and is often joined by the corresponding branch from the C3 nerve. The C2 ventral ramus
courses between the vertebral arches and transverse processes of the atlas and axis and behind the vertebral artery.
Two branches of the C2 and C3 ventral rami, the lesser occipital and great auricular nerves, curve around the posterior
border and ascend on the sternocleidomastoid muscle to
supply the skin behind the ear.

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13 Posterior Neck and Occipital Region

99

Mastoid process
Digastric m.
Superior oblique m.
Occipital a.
Facial n., Parotid gland

Descending br. of occipital a.


Rectus capitis posterior
major
Dorsal ramus of C1
Vertebral venous plexus
Br. to inferior oblique m.

Transverse process of atlas


Ventral ramus of C2
Vertebral a.
Sternocleidomastoid m.
(reflected)

Inferior oblique m.

Fig. 13.9. The posterior neck region. The innervation to the muscles from dorsal ramus of C1 is shown.

The C1, C2, and C3 nerves divide into dorsal and ventral rami.
The dorsal rami divide into medial and lateral branches that
supply the skin and muscles of the posterior region of the
neck. The C1 nerve, called the suboccipital nerve, leaves the
vertebral canal between the occipital bone and atlas and has
a dorsal ramus that is larger than the ventral ramus. The
dorsal ramus courses between the posterior arch of the atlas
and the vertebral artery to reach the suboccipital triangle,

c13.indd 99

where it sends branches to the rectus capitis posterior major


and minor, the superior and inferior oblique, and the semispinalis capitis. Occasionally, it has a cutaneous branch that
accompanies the occipital artery to the scalp. The C1 ventral
ramus courses between the posterior arch of the atlas and the
vertebral artery and passes forward, lateral to the lateral mass
of the atlas and medial to the vertebral artery, and supplies
the rectus capitis lateralis.

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100

III Lower Facial and Posterolateral Neck Region

Temporal fascia

Asterion
Middle temporal a.

Posterior edge of external acoustic


meatus
Mastoid emissary v., Meningeal br.
of occipital a.

Posterior auricular v.

Digastric m.

Facial n.
Auricular br. of
posterior auricular a.

Occipital a. (dissected from the groove)

Posterior auricular a.

Superior oblique m.

Fig. 13.10. Lateral view of the mastoid.

The posterior belly of the digastric muscle arises from


the mastoid notch (digastric groove), which is on the inferior
surface of the skull, medial to the mastoid process of
the temporal bone. The posterior belly is supplied by the
digastric branch of facial nerve. When the digastric muscle
contracts, it acts to elevate the hyoid bone. If the hyoid

c13.indd 100

bone is being held in place (by the infrahyoid muscles), it will


tend to depress the mandible (open the mouth). The stylomastoid foramen is at the anterior end of the digastric notch.
The asterion, defined as the junction among the lambdoid,
parietomastoid, and occipitomastoid sutures, is used as a
landmark for the transverse-sigmoid sinus junction.

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13 Posterior Neck and Occipital Region

101

Sigmoid sinus

Mastoid segment
Temporal br.

Digastric m.

Zygomatic br.
Transverse facial a.
Buccal br.

Occipital a.
Auricular br. of
posterior auricular a.

Zygomaticobuccal brs.
Transverse process of atlas
Temporofacial division
Cervicofacial division
Marginal mandibular br.

Greater occipital n.
Cervical br.

Fig. 13.11. The posterior neck region. The superficial lobe of the parotid gland has been removed and mastoidectomy
has been completed.

After emerging from the base of the skull at the stylomastoid


foramen, the facial nerve gains access to the face by passing
through the substance of the parotid gland.
The branches in the face include the posterior auricular
nerve, the nerve to the digastric and stylohyoid muscles, and

c13.indd 101

the temporal, zygomatic, buccal, marginal mandibular, and


cervical branches. The Inferior branches of the zygomatic
branch usually form a zygomaticobuccal plexus with the
buccal branches (see Fig. 7.5).

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14

Lateral Neck Region

Lesser occipital n

Prevertebral fascia
Erbs point
Accessory n.

Greater occipital n.
Posterior auricular v.
Lesser occipital n.

Splenius capitis m.
Sternocleidomastoid m.
Accessory n.
Great auricular n.
Supraclavicular n.
External jugular v.
Vagus n.

a
Fig. 14.1a,b. (a) The lateral neck region. (b) Posterolateral view of the posterior triangle.

The cervical plexus is a plexus of the ventral rami of the first


four cervical spinal nerves, which are located from C1 to C4
in the cervical segment in the neck. The branches of the cervical plexus emerge from the posterior triangle at Erbs point,
a point midway on the posterior border of the sternocleidomastoid. The cervical plexus has two types of branches: cutaneous and muscular. The cutaneous branches are the lesser
occipital nerve (C2), the great auricular nerve (C2, 3), the
transverse cervical nerve (C2, 3), and the supraclavicular
nerves (C3, 4). The muscular branches are the ansa cervicalis,
phrenic, and segmental.
The lesser occipital nerve arises from the lateral branch of
the ventral ramus of the second cervical nerve (C2). It curves
around the accessory nerve and ascends along the posterior
border of the sternocleidomastoid, where pierces the deep

c14.indd 102

fascia near the cranium to supply the skin over the lateral
scalp and posterior surface of the auricle. The great auricular
and transverse cervical nerves only just enter the posterior
triangle, turning sharply around the posterior border of the
sternocleidomastoid muscle (Erbs point). The supraclavicular
nerves emerge from beneath the sternocleidomastoid and
pass across and down the posterior triangle toward the clavicle. The transverse cervical nerve supplies the skin anterolateral parts of the neck. The supraclavicular nerves supplies
the skin over the pectoralis major and deltoideus and upper
and posterior parts of the shoulder.
The prevertebral fascia is prolonged downward and laterally behind the carotid vessels and in front of the scaleni and
forms a sheath for the brachial nerves and subclavian vessels
in the posterior triangle of the neck.

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14 Lateral Neck Region

103

Posterior auricular v.
Greater occipital n.
Temporal br.
Lesser occipital n.

Posterior auricular a.
Parotid gland
Sternocleidomastoid m.

Splenius capitis m.

Accessory n.
Great auricular n.
External jugular v.
Transverse cervical n.
Internal jugular v.

Supraclavicular n.
Vagus n.

Fig. 14.2. The lateral neck region. The sternocleidomastoid muscle has been retracted anteriorly to show the cervical plexus.

The great auricular nerve is derived from the anterior rami of


the C2 and C3 nerves. It appears at the posterior border of the
sternocleidomastoid muscle and passes forward and upward
across the muscle to reach the angle of the mandible on and
beneath the parotid fascia. It supplies the skin overlying the
mastoid process, lower part of the auricle, the parotid region,
and the angle of the mandible. The great auricular nerve and
sural nerve are the most commonly selected nerves for facial
nerve grafting, but only 7 to 10 cm of the great auricular nerve
can be harvested safely, which limits its use in extensive
repairs. Disadvantages include a sensory deficit of the earlobe
when using the great auricular nerve.

c14.indd 103

The accessory nerve also emerges from sternocleidomastoid muscle into the posterior triangle. The accessory
nerve is found approximately 1cm above Erbs point. It runs
obliquely downward on the levator scapulae muscle to enter
trapezius.
The external jugular vein lies on the lateral surface of the
sternocleidomastoid muscle. It arises by the confluence of the
posterior branch of the retromandibular vein and posterior
auricular vein. It drains into the subclavian vein or internal
jugular vein (see Fig. 11.2).

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c14.indd 104

2/10/2015 1:41:01 PM

Index

A
Abducens nerve, 11
Accessory meningeal artery, 4, 63, 66
Accessory nerve, 7, 22, 67, 69, 70, 77, 78,
89, 90, 94, 95, 96, 102, 103
Alar cartilage, 45, 48
Alveolar canals, 73
Anastomatic artery, 92
Angular artery, 46, 83
Angular vein, 45, 81
Ansa cervicalis, 90, 102
upper root, 89
Anterior clinoid process, 11
Anterior deep temporal artery, 62
Anterior deep temporal nerve, 62
Anterior ethmoidal artery, 48
Anterior ethmoidal foramen, 13
Anterior ethmoidal groove, 13
Anterior ethmoidal nerve, 26, 48
Anterior inferior cerebellar artery, 4
Anterior lacrimal crest, 13
Anterior nasal spine, 14
Anterior semicircular canal, 3, 4, 5
Anterior superior alveolar artery, 49
Anterior superior alveolar nerve, 49
Anterior trunk, 66
Anterior tympanic artery, 63
Arnolds nerve, 7, 8, 93
Articular disc, 63, 65
Articular tubercle, 8, 9
Ascending palatine artery, 53, 54, 68, 69,
70, 71
Ascending pharyngeal artery, 76, 78, 89
meningeal branch, 7
Asterion, 10, 96, 100
Atlas, transverse process, 67, 68, 70, 76, 96,
97, 99, 101
Auditory tube. See Eustachian tube
Auricular cartilages, lateral view, 93
Auriculotemporal nerve, 22, 23, 32, 34, 40,
44, 55, 58, 59, 61, 63, 65, 66, 68, 69,
71, 72, 77, 81, 86
B
Buccal artery, 65, 66, 86
lingual branch, 63
Buccal branches, of facial nerve, 39, 40, 41,
42, 43, 44
Buccal fat pad, 56, 57, 58, 60
buccal extension, 59
pterygoid extension, 59
temporal (deep temporal) extension, 59

bindex.indd 105

Buccal nerve, 49, 62, 63, 65, 66, 69, 71, 72,
73, 75, 86
Buccinator muscle, 17, 21, 22, 39, 41, 54,
56, 60, 63, 66, 75, 81, 82, 83, 85,
86, 87
attachment, 65, 68
in facial region, 42
as modiolus component muscle, 81
C
Calvarial bones, 9
Canine eminence, 16
Canine fossa, 16
Carotid artery. See also External carotid
artery; Internal carotid artery
in posterior neck region, 95
Carotid canal, 7, 8, 78
Carotid groove, 11
Cervical branch, 39, 43
Cervical 1 (C1) nerve
dorsal ramus, 99
ventral ramus, 99
Cervical 2 (C2) nerve
dorsal ramus, 98, 99
ventral ramus, 98, 99
Cervical 3 (C3) nerve, 98
dorsal ramus, 99
ventral ramus, 99
Cervical nerve(s), dorsi rami, 91
Cervical plexus, 89, 102, 103
Cervicofacial division, 42, 43, 90, 101
Choana, 15
Chorda tympani, 3, 4, 5, 70, 71, 76, 77
with sphenoid bone spine removed, 76,
77, 78
Clinoidectomy, anterior, 6
Cochlea, opened, 4
Columellar artery, 45, 47, 48, 87
Common carotid artery, 89
Common facial nerve, 88
Common facial vein, 55, 85, 87, 90
Communicating branches, of facial nerve,
in midfacial region, 41, 44
Condylar canal, 8, 10
Condylar head, 17, 18
Condylar neck, 17, 18
Condylar process, 9, 44, 58
Contralateral artery, 92
Coronoid process, 9, 14, 17, 18, 58
Corrugator supercilii muscle, 16, 22, 25, 42,
45, 46, 81
Cranial nerve IX, 76

Cranial nerve X, 76
Cranial nerve XI, 76
Craniotomy
frontotemporal, 9
facial nerve temporal branch in, 37
suboccipital, 90
Cranium, 92
Cribiform plate, 13
foramina, 11
superior view, 13
Crista galli, 11, 13
D
Deep auricular artery, 63, 67
Deep facial nerve, 68, 69, 85
Deep facial vein, 63, 64, 65
Deep petrosal nerve, 75
Deep temporal artery, 61, 63, 64, 65, 66,
67, 68, 69, 71, 72, 73, 74, 77
Deep temporal fat pad, 59
Deep temporal nerve, 49, 54, 61, 63, 64,
65, 66, 68, 69, 71, 72, 73
Deep temporal vein, 61
Depressor anguli oris muscle, 17, 22, 39,
81, 82, 83, 84, 85, 87
attachments, 84
defected upward, 84
as modiolus component muscle, 81
Depressor labii inferioris muscle, 17, 22,
81, 82, 84
Depressor septi muscle, 16, 42, 47, 48
attachments, 48
Descending palatine artery, 52
Digastric groove (mastoid notch), 10, 100
with digastric muscle posterior belly
detached, 90
Digastric muscle, 5, 6, 8, 77, 84, 95, 96, 97,
98, 99, 100, 101
anterior belly, 71, 84, 87, 88
in facial reanimation, 56
posterior belly, 5, 43, 60, 85, 87, 88, 90,
100
detached from digastric groove, 90
Digastric ridge, 5, 77
Dorsal nasal artery, 26, 46
Dorsum sellae, 11
E
Emissary foramen, 7
Emissary vein, 5
Endolymphatic sac, 5
Erbs point, 102, 103

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106

Index
Ethmoid bone, superior view, 13
Ethmoid sinus, 51, 52
Eustachian tube, 4, 7, 8, 54, 71, 74
bony part, 71
cartilaginous part, 7, 71
opened, 78
External acoustic meatus, 4, 8, 9, 10, 69, 74
opened, 4
posterior edge, 100
External carotid artery
branches, 89
in lower facial region, 87
in masseteric region, 58
in midfacial region, 60, 63, 65, 66, 68, 69,
74, 76
reflected, 76
in temporal region, 34
External jugular vein, 39, 55, 81, 82, 102,
103
External nasal artery, 48, 49
External nasal nerve, 48, 49
External nasal vein, 45, 48
External oblique line, 17
External occipital crest, 10
External occipital protuberance (inion), 10,
91
F
Face
lateral oblique view, 81
lateral view, 21, 22
sensory innervation, 11
Facial artery, 21, 22
bifurcation, 46
cut, 47
inferior labial branch, 83
in lower facial region, 81, 82, 83, 84, 85,
87, 90
in midfacial region, 39, 40, 68
in oral floor, 88
relationship to facial vein, 87
superior labial branch, 83
in upper neck region, 89, 90
Facial bone, 1218
Facial expression, 3
Facial nerve, 4, 34, 35, 81
branch to digastric and stylohyoid
muscles, 90
buccal branches, 82, 101
cervical branches, 81, 82, 101
course of, 3
digastric branch, 100
exit site, 7
extratemporal segment, 3, 5
intracranial (pontine or cisternal)
segment, 3
intraparotid branches, 42
intratemporal segment, 3
landmark for branches of, 44
in lower facial region, 86

bindex.indd 106

marginal mandibular branch, 22, 43, 82,


84, 85, 101
in masseteric region, 55, 57, 58, 59, 60
in mastoid region, 100
in midfacial region, 63, 65, 66, 67, 68, 69,
70, 71, 74, 77, 78
reflected posteriorly, 76
motor fibers, 3
pontine segment, 3
in posterior neck region, 95, 96, 97, 98,
99
sensory nerve fibers, 3
temporal branches, 24, 32, 33, 34, 35, 36,
37, 38, 39, 40, 41, 42, 101, 103
trunk
main, 90
posterior, 66
structures adjacent to, 7678
upper branches, 40
in upper neck region, 89
venous valves, 45
vertical part, 5
zygomatic branches, 38, 39, 40, 41, 42,
44, 101
zygomaticobuccal branches, 38, 39, 75,
83, 87
Facial nerve grafting, 103
Facial region
lower, 8187, 90
with depressor anguli oris muscle
removed, 84
with lips removed, 87
with opened mandibular canal, 85
with platysma muscle removed, 84
upper, overview, 2122
Facial reinnervation surgery, 39, 56
hypoglossal muscle in, 76
masseteric nerve in, 58
Facial vein, 22, 39, 81
in lower facial region, 82, 83, 84, 87
in lower neck region, 90
in masseteric region, 58
in midfacial region, 40, 41, 46, 48, 63
in oral floor, 88
relationship to facial artery, 87
in upper neck region, 90
Foramen ovale, 3, 7, 11, 15, 62
Foramen rotundum, 6, 11, 13, 14, 52
Foramen spinosum, 7, 8
Forehead, 2326
Frontal bone, 9
nasal part, 16
Frontal crest, 11
Frontalis muscle, 21, 22, 23, 24, 32, 33, 81
frontal belly, 23
reflected inferiorly, 25
separated from orbicularis oculi
muscle, 24
Frontal nerve, 26
Frontal notch, 13, 16

Frontomaxillary suture, 12, 16


Frontonasal suture, 12, 16
Frontotemporal region, 23, 24
Frontozygomatic suture, 9, 12, 61
G
Galea aponeurotica, 21, 22, 23, 91
Galeal layer, 23
Ganglionic branches, 52
Geniculate ganglion, 4, 61
Geniohyoid muscle, 88
Gingiva
maxillary, 50, 51
palatal, 53
Glossopharyngeal nerve, 7, 8, 70, 72, 76,
78, 89
branches, 3, 7
Great auricular artery, 97
Great auricular nerve, 22, 39, 43, 81, 93,
102, 103
Greater occipital nerve, 22, 82, 93, 94, 95,
96, 101, 102, 103
lateral branch, 91, 94
medial branch, 91, 94
Greater palatine artery, 51, 53, 54, 72, 73,
74
Greater palatine canal, 53
Greater palatine foramen, 15, 74
Greater palatine nerve, 15, 51, 52, 54, 74
Greater petrosal nerve, 3, 4, 75
H
Hyoid bone, 100
Hypoglossal canal, 8
Hypoglossal-facial nerve side-to-end
anastomosis, 5
Hypoglossal nerve, 68, 70, 76, 78, 89,
97
Hypoglossus muscle, 88
I
Incisive artery, 53
Incisive fossa, 16, 17
and canal, 15
Incus, 77
short process, 5
Inferior alveolar artery, 63, 66, 68, 69, 71,
74, 84, 85, 87, 88
reflected, 72
Inferior alveolar nerve, 54, 63, 65, 66, 67,
68, 69, 71, 73, 74, 84, 85, 87, 88
mylohyoid branch, 85
reflected, 72
Inferior alveolar vein, 66, 68, 69, 71, 84, 85,
88
Inferior joint space, midfacial region, 63
Inferior labial artery, 83, 84, 85, 87
Inferior nuchal line, 10, 98
Inferior oblique muscle, 75, 97, 98, 99
Inferior ophthalmic vein, 75

2/10/2015 1:39:20 PM

Index
Inferior orbital fissure, 12, 13, 16, 64, 75
lateral part, 73
Inferior orbital fossa, 8
Inferior palpebral artery, 45
Inferior palpebral branch, 42
Inferior petrosal sinus, 7
Infrahyoid muscles, 100
Infraorbital artery, 41, 45, 47, 49, 50,
51, 52, 63, 64, 65, 66, 68, 69, 72,
74, 75
Infraorbital foramen, 15, 16
Infraorbital nerve, 12, 14, 39, 41, 45, 47,
48, 49, 50, 51, 52, 64, 65, 66, 68, 69,
72, 75, 87
inferior palpebral branch, 38, 41
Infraorbital sulcus (groove), 12, 13
Infraorbital vein, 40, 45
Infratemporal crest, 8, 66, 68
Infratemporal fossa, 8, 6374, 86
with accessory ligaments of the
temporomandibular ligament, 67
anterior wall, 66
with coronoid process removed, 63
with drilled mandibular fossa, 69
with elevated mandibular nerve, 72
with elevated tensor veli palatini
muscle, 70
with fractured pterygoid plate, 74
inferior boundary, 66
inferior orbital fissure in, 64
with lateral pterygoid muscle
removed, 65
with mandible removed, 68
with mandibular condyle removed, 65
with maxillary artery elevated, 73
with medial pterygoid muscle
removed, 68
medial wall, 66
osseous boundaries, 8
with pterygoid plexus removed, 66
roof, 66
with temporalis muscle removed, 63
with tensor veli palatini muscle
removed, 71
Infratrochlear nerve, 26
Inion (external occipital protuberance), 10,
91
Interfascial fat pad, 34
Intermaxillary suture, 14
Internal acoustic meatus, roof, 3
Internal carotid artery, 4, 6, 7, 61, 68, 72,
76, 89
Internal carotid plexus, sympathetic
filaments from, 11
Internal jugular vein
displaced laterally, 89
in lateral neck region, 103
in lower facial region, 87, 90
in midfacial region, 7, 55, 67, 68, 69, 70,
71, 76

bindex.indd 107

in posterior neck region, 95


in upper neck region, 89, 90
Internasal suture, 12
Intracranial region, 36
Intrajugular process, 7
Intraorbital nerve, 46
J
Jacobsons nerve. See Glossopharyngeal
nerve
Joint capsule, 60
Jugular bulb, 7
Jugular foramen, 7, 8, 76, 78
L
Lacrimal artery, 26
Lacrimal fossa, 12, 13, 14
Lacrimal gland, 3
Lacrimal nerve, 26
Lambdoid suture, 10
Laryngopharynx, sensory innervation,
76
Lateral cartilage, upper, 48
Lateral ligament, 55, 56, 57, 58, 60
Lateral nasal artery, 39, 41, 45, 46, 47, 48,
81, 83, 85, 87
alar arcade from, 45
communication with external nasal
artery, 48
Lateral nasal wall, 48
Lateral neck region, 102103
posterior triangle posterolateral
view, 102
with sternocleidomastoid muscle
retracted, 103
Lateral pterygoid muscle, 18, 52, 56, 75,
85, 87
lower head, 63, 64
pterygoid head, 65
upper head, 62, 63, 64
Lateral pterygoid plate, 8, 49, 65, 68, 69,
71, 73
Lateral semicircular canal, 4, 5
Lesser occipital nerve, 22, 82, 91, 93, 94,
95, 102, 103
Lesser palatine artery, 53, 54
Lesser palatine foramen, 15, 74
Lesser palatine nerve, 15, 52, 74
Lesser petrosal nerve, 3, 72
Levator anguli oris muscle, 16, 22, 39, 40,
41, 42, 45, 46, 47, 48, 81, 83, 85
as modiolus component muscle, 81
Levator labii muscles, attachments, 47
Levator labii superioris alaeque nasi
muscle, 45, 47, 48
Levator labii superioris muscle, 16, 21, 22,
39, 40, 41, 42, 45, 46, 47, 81
Levator palatini muscle, 78
Levator palpebrae superioris muscle, 26
Levator scapulae muscle, 76, 96, 98

107

Levator veli palatini muscle, 54, 70, 71, 72,


76
Lingual artery, 89
Lingual nerve, 54, 63, 65, 66, 68, 69, 70, 71,
73, 74, 76, 78, 85, 87, 88, 89
branch to medial pterygoid muscle, 72
Lingula, 18
Longissimus capitis muscle, 5, 96
reflected inferiorly, 97
M
Malleus, 3
handle, 77
Mandible, 87, 89, 100
anterior view, 17
ascending ramus, 86
cut, 66, 67
muscles, 6
partially removed, 63, 88
posterolateral view, 18
upper border of ramus, 58
Mandibular angle, 82
Mandibular canal, opened, 84, 85
Mandibular condyle, 10, 55, 58, 63, 85
Mandibular foramen, 18, 85
Mandibular fossa, 8, 66, 68, 69
opened, 4, 72, 77
Mandibular nerve, 4, 6, 11, 62, 69, 76
anterior trunk, 69
motor division, 6
posterior trunk, 69
Mandibular notch, 9, 39, 58
Marginal mandibular branch, of facial
nerve, 8, 22, 43, 84, 85, 101
Masseteric artery, 56, 57, 86
Masseteric fascia, 39, 41, 81, 82
opened, 82
Masseteric nerve, 54, 56, 57, 59, 60, 62, 66,
68, 72, 73, 86
intraoperative landmarks, 58
reflected, 63, 64, 71
Masseteric region, 5560
with deep temporal fat pad removed,
60
with facial nerve branches removed,
55
with parotid gland removed, 55
with zygomatic arch removed, 59
Masseteric vein, 56
Masseter muscle, 6, 18, 34, 44, 50, 51, 55,
90
deep part, 57, 58
for facial reanimation, 56
with fascia, 22
middle part, 56, 57, 58
reflected, 57
reflected, 86
downward, 58
inferiorly, 86
upward, 65

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108

Index
Masseter muscle (cont.)
superficial part, 58
attachment, 56, 57
reflected, 56
without fascia, 42
Mastication, muscles of, 6, 56
Mastoid
after mastoidectomy, 5
lateral view, 100
Mastoid antrum, 9
Mastoidectomy, 101
mastoid after, 5
Mastoid emissary vein, 96, 100
Mastoid foramen, 10, 96
Mastoid notch (digastric groove), 10, 100
with digastric muscle posterior belly
detached, 90
Mastoid process, 5, 8, 9, 10, 84, 95, 96, 97,
99
Mastoid segment, 101
Mastoid tip, 67, 69, 76
Maxilla
with anterior wall removed, 50
anteroinferior view, 14
frontal process, 16
with posterior and medial walls
opened, 51
Maxillary artery, 49, 52, 54, 63, 64, 65, 66,
67, 68, 69, 70, 71, 72, 73, 74, 75, 78, 85
pterygoid segment, 86
pterygopalatine segment, 52
segments, 63
Maxillary bone, 49
palatine process, 15
Maxillary nerve, 4, 6, 11, 51
infraorbital branch, 14
zygomaticotemporal branch, 26
Maxillary ostium, 50, 51
Maxillary region, 4954
with mimetic muscles removed, 49
with veins removed, 52
Maxillary sinus
orifice, 75
posterior wall, 50
Maxillary tuberosity, 49, 73
Maxillary vein, 64, 65, 66, 67
Meckels cave, 4
Medial palpebral ligament, 16, 45
Medial pterygoid muscle, 18, 56, 65, 66,
69, 73, 85
superficial head, 63
Median palatine suture, 15
Meningo-orbital (lacrimal) foramen, 6, 12,
13
Mental artery, 84, 85, 87
Mental foramen, 16, 17
Mentalis muscle, 17, 22, 81, 82, 84, 87
Mental nerve, 17, 84, 85, 87
Mental protuberance, 16, 17

bindex.indd 108

Mental tubercle, 17
Mental vein, 84, 85, 87
Middle cranial fossa, 78
Middle deep temporal nerve, 62
Middle ear, innervation, 8
Middle fossa, 3, 4
dura, 5
superior view, 61
without bone, 62
Middle meningeal artery, 3, 4, 62, 63, 66,
68, 69, 71, 72, 76, 78
groove for, 11
orbital branch to lacrimal artery, 6
Middle nasal concha, 14
Middle superior alveolar nerve, 49, 52
Middle temporal artery, 36, 55, 60, 61,
100
groove for, 9
Middle temporal vein, 35, 36, 37, 55, 57,
58, 59, 60
Midfacial region
deep structures, 6178
overview, 2122
superficial structures, 3848
Mimetic muscles, 21, 22, 45
deep seated, 41
modiolus, 22, 81, 83
Minor salivary gland, 63
Modiolus, 22, 81, 83
Mylohyoid groove, 18
Mylohyoid line, 18
Mylohyoid muscle, 6, 84, 88
Mylohyoid nerve, 68, 70, 71, 84, 87, 89
N
Nasal bone, 13, 14, 49
Nasalis muscle, 16, 42, 46, 48
alar part, 47
attachments, 48
transverse part, 46, 47
Nasal septum, 14
posterior edge, 54
Nasociliary nerve, 26
Nasolacrimal duct, 50, 51
Nasolacrimal torus, 50, 51
Nasomaxillary suture, 16, 49
Nasopalatine nerve, 15, 52, 53
Nasopharynx, 74
Neck
posterior triangle, 102
upper region, 8990
Nervus intermedius, 4, 5, 77
Neurovascular bundle, 61
Nuchal ligament, attachment site, 10
O
Occipital artery, 5, 10, 22, 43, 60, 67, 68,
69, 70, 71, 77, 90, 92, 93, 94, 95, 96,
97, 98, 99, 101

cut, 76
anastomosis in scalp, 92
ascending branch, 91, 97
descending branch, 91, 96, 97, 98,
99
dissected from the groove, 100
meningeal branch, 5, 7, 96, 100
sternocleidomastoid branch, 90, 94
transverse (cutaneous) branch, 91,
96
Occipital condyle, 7, 8, 9, 10
Occipital groove, 10
Occipitalis muscle, 21, 22, 91, 93
bellies, 91
Occipital region, 91101
Occipitofrontalis muscle, 23
Occipitomastoid suture, 10
Oculomotor nerve, 6, 11
Olfactory nerve, 13
Ophthalmic artery, 26
frontal nerve branch, 26
lacrimal nerve branch, 6, 26
nasociliary nerve branch, 26
Ophthalmic nerve, 4, 6, 11
Ophthalmic veins, 11
Optic canal, 11, 12, 13
opened, 6
Optic nerve, 26
with dura, 6
Optic strut, 13
Oral commissure, 83
Oral floor, from the side, 88
Orbicularis oculi muscle, 16, 22, 33,
38, 39, 40, 41, 42, 45, 46, 47, 48,
81, 83
function, 83
as modiolus component muscle, 81
reflected, 38, 55, 57
upper, 32, 41
Orbicularis oris muscle, 17, 22, 39, 41, 81,
82, 84
upper, 39
Orbit, 1216, 50, 51
anterior view, 12
anteromedial view, 13
superior view, 26
Orbital floor, 50
Orbitalis (Mllers) muscle, 64
Orbital region, 2326
Orbital septum, 45
Oropharynx, sensory innervation, 76
Otic ganglion, 3, 72
P
Palatal region, 5354
Palatine aponeurosis, 53, 54
Palatine artery, ascending, 89
Palatine bone, 15
Palatoglossus muscle, 70

2/10/2015 1:39:20 PM

Index
Parietal bone, 9
Parietal foramen, 92
Parietomastoid suture, 10
Parotid duct, 22
in lower facial region, 85, 86, 87
in masseteric region, 55, 60
cut and reflected, 56, 57
reflected, 58
in midfacial region, 39, 40, 41, 42, 63
relationship with buccinator
muscle, 85
Parotid gland, 22
buccal branch, 81
deep lobe, 42
in lateral neck region, 103
in midfacial region, 44
in posterior neck region, 93, 99
with substance removed, 44
with superficial lobe removed, 42, 101
tail, 82
in temporal region, 33, 34, 42
Periauricular muscle, 21
Pericranial vein, 25
Pericranium, 91
Petrotympanic (squamotympanic)
fissure, 5, 7, 69, 77
Pharyngeal plexus, 76, 89
Phrenic muscle, 102
Piriform (anterior nasal) aperture, 16
Pituitary fossa (sella turcica), 11
Platysma muscle, 17, 22, 81, 84, 87
attachments, 84
Posterior alveolar canals, 73
Posterior atlanto-occipital membrane,
98
Posterior auricular artery, 22, 69, 70, 81,
90, 91, 95, 100
branches
anastomosis in scalp, 92
auricular branch, 5, 43, 89, 94, 95, 96,
100, 101
occipital branch, 43, 93, 94
perforating artery from, 93
Posterior auricular muscle, 22, 93
Posterior auricular nerve, 8, 22, 77, 91, 93,
102, 103
Posterior auricular vein, 22, 82, 93, 94, 95,
103
Posterior circular artery, 68
Posterior deep temporal nerve, 62
Posterior ethmoidal foramen, 13
Posterior ethmoidal groove, 13
Posterior ethmoidal nerve, 26
Posterior fossa dura, 5
Posterior lacrimal crest, 13
Posterior nasal spine, 15
Posterior neck region, 91101
with galea and occipitalis muscle
removed, 94

bindex.indd 109

with longissimus capitis muscle reflected


inferiorly, 97
with parotid gland superficial lobe
removed, 101
with semispinalis muscle reflected
inferiorly, 98
with skin and galea removed, 91
with splenius capitis muscle reflected
medially, 96
with sternocleidomastoid muscle
reflected laterally, 95
with trapezius muscle reflected
medially, 96
Posterior semicircular canal, 3, 4
Posterior superior alveolar artery, 52, 63,
64, 65, 66, 69, 73, 75, 85
Posterior superior alveolar nerve, 52, 63,
64, 65, 66, 69, 73, 75, 85
dental branch, 73
gingival branch, 73
Posterior superior alveolar vein, 63, 64
Premasseteric artery, 39, 81, 82
Prevertebral fascia, 102
Procerus muscle, 16, 21, 42, 45, 46, 81
Pterion, 9
Pterygoid canal
artery of, 52
nerve of, 75
vein of, 75
Pterygoid fovea, 18
Pterygoid hamulus, 8, 15, 53, 54
Pterygoid muscle, 6
Pterygoid plate, 52
fractured, 74
Pterygoid venous plexus, 45
deep component, 65
Pterygomandibular raphe (ligament), 67,
68
Pterygomaxillary fissure, 73, 74
Pterygopalatine fossa, 14, 52, 74, 75
Pterygopalatine ganglion, 34, 51, 52, 74, 75
R
Rectus capitis lateralis muscle, 69, 76
Rectus capitis posterior major muscle, 97,
98, 99
Rectus capitis posterior minor muscle, 97,
98
Retromandibular vein, 34, 36, 42, 43, 44,
55, 57, 58, 59, 60, 65, 85, 90
anterior branch, 82, 90
posterior branch, 82, 103
Retromolar fossa, 17, 86
Risorius muscle, 21
as modiolus component muscle, 81
S
Salpingopharyneus muscle, 71
Scalp, from above, 92

109

Segmental muscle, 102


Sella turcica (pituitary fossa), 11
Semicircular canals, 61, 77
Semispinalis capitis muscle, 94, 95, 97
Sensation, facial nerve-based, 3
Sentinel vein, 34, 35, 37
Septal artery, 45, 46, 47, 48, 87
Sigmoid sinus, 5, 7, 77, 101
Skull
from above, 92
anterior view, 16
anteroinferior view, 14
external and internal views, 711
lateral view, 9, 73
posterolateral view, 10
Skull base
anterior (internal surface), 11
external surface, 7
middle (internal surface), 11
Soft palate, 68
Sphenofrontal suture, 12
Sphenoidal ridge, 11
Sphenoid bone, 9
greater wing, 9, 11, 12
lesser wing, 11
scaphoid fossa, 54
spine, 7
with spine removed, 69
Sphenoid sinus, 51, 52
mucosa, 6
Sphenomandibular ligament, 66, 67
Sphenopalatine artery, 51, 52
Sphenopalatine foramen, 14
Sphenopetrosal suture, 7
Sphenozygomatic nerve, 12
Spinal accessory nerve, 76
Splenius capitis muscle, 5, 22, 91, 93, 94,
95, 96, 97, 102, 103
Stapedius muscle, 5
Stapes incus, 3
Sternocleidomastoid muscle, 5, 22, 39, 76,
81, 82, 91, 93, 94, 97, 102, 103
anterior triangle, 94
cut and reflected, 89
posterior triangle, 94
reflected, 90, 95, 99
laterally, 95
medially, 96
retracted anteriorly, 103
Styloglossus muscle, 68, 89
Stylohyoid ligament, cut, 74
Stylohyoid muscle, 60, 90
Styloid process, 66, 69, 77
cut, 7, 8, 76, 78
Stylomandibular ligament, 67, 89
Stylomastoid artery, 76, 78, 89
branch to digastric muscle, 69
foramen, 7
Stylomastoid foramen, 7, 8, 100

2/10/2015 1:39:20 PM

110

Index
Stylopharyngeus muscle, 68, 70, 89
Subclavian vein, 103
Subgaleal fat pad, 32, 33, 37
reflected, 34
Sublingual artery, 88
Sublingual fossa, 18
Sublingual gland, 3, 18
ducts, 88
Submandibular fossa, 18
Submandibular ganglion, 5, 88
Submandibular gland, 3, 85, 87, 88, 90
Submental artery, 68, 84, 85, 87, 88, 89
Submental region, cutaneous
innervation, 71
Suboccipital muscles, 97
Suboccipital nerve. See Cervical 1 (C1)
nerve
Suboccipital triangle, 98, 99
Subzygomatic fossa, 55
Superficial (interfascial) fat pad, 34, 35,
37
Superficial musculoaponeurotic system
(SMAS), 21
Superficial temporal artery, 22, 32, 33, 34,
35, 36, 40, 42, 43, 44, 55, 57, 58, 59,
60, 61, 63, 65, 66, 68, 69, 70, 71, 74,
77, 81, 85
frontal branch, 22, 23, 24, 33, 81
parietal branch, 22, 81, 92
Superficial temporal fascia, 21
Superficial temporal vein, 22, 32, 33, 34,
35, 36, 40, 42, 55, 57, 58, 59, 60, 81
Superior alveolar nerves, 73
Superior auricular artery, 32, 34
Superior auricular muscle, 22, 32, 33, 81
Superior constrictor muscle, 68
Superior joint space, 63, 65
Superior labial artery, 46, 48, 83, 85, 87
Superior laryngeal nerve, 89
Superior nuchal line, 91, 97, 98
Superior oblique muscle, 26, 90, 97, 98, 99,
100
Superior ophthalmic vein, 26
Superior orbital fissure, 6, 11, 12, 13, 16
lateral edge, 6
Superior palpebral artery, 45
Superior petrosal sinus, 5
Superior pharyngeal constrictor
muscle, 68, 70, 76
Superior rectus muscle, 26
Superior temporal line, 9
Superior thyroid artery, 89, 90
Superior tympanic artery, 3, 4
Supraclavicular nerve, 102, 103
Supramastoid crest, 8, 9
Suprameatal spine (Henle), 9
Suprameatal triangle, 9
Supraorbital artery, 25, 26
branches
anastomosis in scalp, 92

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communicating branch, 24
deep branches, 24, 25
superficial branches, 23, 24
Supraorbital foramen, 13, 14, 16
Supraorbital nerve, 13, 23
branches
lateral (deep) branch, 23, 24, 25
medial (superficial) branch, 23, 25
to skin (cut), 25
Supraorbital region, 25
medial view, 25
Supraorbital vein, 23, 25, 45, 81
Supratrochlear artery, 25, 26
branches
anastomosis in scalp, 92
deep branch, 25
superficial branches, 23
Supratrochlear nerve, 23, 25
Supratrochlear vein, 25, 45, 81
T
Tegmen tympani, 3
Temporal bone, 9, 36
tympanic part, 7
Temporal branches, of facial nerve, 24, 32,
33, 34, 35, 36, 37, 38, 40, 41, 42, 101,
103
Temporal branches, of the facial
nerve, 38, 39, 40, 41, 42
Temporal crest, 18
Temporal fascia, 24, 37, 100
deep layer, 35, 37
removed, 36
reflected anteriorly, 34
superficial layer, 34, 35, 37
reflected upward, 34
Temporal fossa, 8
superior view, 61
Temporalis muscle, 18, 36, 37, 55, 56, 58,
60, 62, 94, 95
for facial reanimation, 56
fascia of. See Temporal fascia
reflected, 61
tendon, 58, 59, 75, 86
Temporal muscle, 6
Temporal region, 3237, 34, 36, 37
fat pads. See Deep fat pad; Subgaleal fat
pad; Superficial fat pad
with temporoparietal fascia
reflected, 34, 35
Temporofacial division, 42, 43, 90,
101
Temporomandibular joint, 55, 63
Temporomandibular ligament, 9, 55
accessory ligaments, 67
Temporoparietal fascia, 21, 23, 24, 32, 37,
81
reflected, 34
Tendinous arch, 91, 93
Tensor tympani membrane, 4

Tensor tympani muscle, 4, 6, 61


Tensor veli alatini muscle, 6
Tensor veli palatini muscle, 54, 68, 69, 70,
75, 77
branch to medial pterygoid muscle, 73
Tongue, innervation of, 3, 76
Tonsillar artery, 68
Tragal pointer (cartilage), 43
Transparent deep fat pad, 35
Transparent superficial fat pad, 34
Transverse cervical nerve, 82, 102, 103
Transverse facial artery, 22, 32, 34, 35, 38,
39, 40, 41, 44, 55, 81
Transverse facial nerve, 38, 42
Transverse palatine suture, 15
Transverse-sigmoid sinus junction, 100
Transverse supraorbital vein, 45
Trapezius muscle, 91, 94, 95, 97
reflected medially, 96
Trigeminal (gasserian or semilunar)
ganglion, 3, 4, 6
Trigeminal nerve, 4, 6, 44
infraorbital branch, 12
mandibular division, 6, 11
maxillary division, 6, 11
ophthalmic division, 6, 11
zygomatic branch, 12
Trochlear nerve, 6, 11, 26
Tuberculum sellae, 11
Tympanic cavity, 3
Tympanomastoid fissure, 8
Tympanomastoid suture, 9, 70, 77
drop-o point, 8
U
Upper neck region, 8990
V
Vaginal process, 7, 8, 72, 78
Vagus nerve, 7, 70, 76, 89, 102, 103
auricular (mastoid) branch, 7
pharyngeal branch, 78
Vertebral artery, 98, 99
Vertebral venous plexus, 99
Vestibulocochlear nerve, 3, 4
Vidian canal. See Pterygoid canal
Vomer bone, 8, 15
Z
Zygomatic arch, 14, 34, 35, 36, 55, 56, 57,
58, 62
root, 61
Zygomatic bone, 9, 49
Zygomatic branches, of facial nerve, 38, 39,
40, 41, 42, 44, 101
Zygomatic minor muscle, 81
Zygomatic nerve, 12, 52
branches, 12, 61
Zygomaticobuccal branches, of facial
nerve, 38, 39, 41, 44, 46, 75, 83, 87

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Index
Zygomaticobuccal nerve, 38, 75
Zygomaticobuccal plexus, 42, 101
Zygomaticofacial foramen, 9, 13, 49
Zygomaticofacial nerve, 12, 38, 49, 61, 63,
64
Zygomaticomaxillary suture, 49

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Zygomatico-orbital artery, 22, 23, 32, 40, 81


Zygomatico-orbital foramen, 12
Zygomaticotemporal foramen, 61
Zygomaticotemporal nerve, 12, 26, 34, 35,
36, 55, 61
Zygomaticotemporal suture, 55

111

Zygomaticulotemporal nerve, 60
Zygomaticus major muscle, 16, 21, 22, 34,
38, 39, 40, 41, 42, 44, 46, 55, 56, 57,
58, 81, 83, 85, 86
as modiolus component muscle, 81
Zygomaticus minor muscle, 16, 41, 42, 46

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