Anatomy of Face-Ziermann

Question 1

What is the face?

Answer 1

front part of head that in humans extends from forehead to chin and includes mouth, nose, cheeks, and eyes

there are no EARS in the face
-ears belong to our neck

Question 2

What are the contents of the face?

Answer 2

1. bones (facial aspect neuro and viscerocranium)
2. Nerves (branches of trigeminal and facial nerve)
3. Muscles of facial expression
4. Blood supply (veins and arteries)
5. Other structures (buccal fat pad, pterygomandibular raphe, parotid gland)
6. Sinuses

Question 3

Describe the cranium.

Answer 3

Skull plus mandible

-inclusive of neurocranium and viscerocranium

Question 4

Describe the facial aspect of the cranium.

Answer 4

neurocranium
-frontal bone

viscerocranium

• zygomatic bone
• nasal bone
• mandible
• maxilla

Question 5

Describe the neurocranium and the viscerocranium.

Answer 5

• neurocranium: bony case of the brain

- viscerocranium: facial skeleton

Question 6

What are the nerves essential for our faces?

Answer 6

trigeminal nerve (CN V): sensory innervation for skin on the face

facial nerve (CN VII): motor innervation of muscles of facial expression

Question 7

What are the 3 parts of the trigeminal nerve?

Answer 7

• ophthalmic zone (related to the eye): exits from the supraorbital foramen
• maxillary: exits through the infraorbital foramen
• mandibular (most important as it innervates the muscles of mastication) as it exits the mental foramen

we also have the long buccal nerve that is not exiting through the mental foramen but also does sensory innervation of the midface

zone of sensory innervation are called by the division responsible for the sensation

Question 8

What are the branches of the trigeminal nerve?

branches are named after the region from which they receive sensory information

Answer 8

ophthalmic division (V1):

• Supraorbital n.: exits through the supraorbital foramen
• supratrochlear n: exits medial of the supraorbital foramen
• infratrochlear n:
• external nasal n.: exits on the side of the orbit
• lacrimal n.: exits on the side of the orbit

maxillary division (V2):

• zygomaticotemporal n. : crosses the zygomatic bone and goes toward the temporal region
• zygomaticofacial n.: crossing the zygomatic bone going towards the face
• infraorbital n.: exits via the infraorbital foramen and innervates the whole midface sensory (a giant one)

mandibular division (V3):

• auriculotemporal n.
• buccal n.
• mental n.

In the chin region is the great auricular, buccal, and mental nerves.

Furthermore there is a buccal branch of the FACIAL nerve that runs along the same chin region but one is a branch and the other is a nerve. The one coming from the trigeminal is the long buccal and the other from facial is called buccal branch of facial nerve.

-Great auricular nerve is part of our cervical plexus

Question 9

Trigeminal ganglion

Answer 9

in the middle cranial fossa

when you take the brain out you have 3 cranial fossa

-anterior: above the eye

• middle (behind ear); is where the trigeminal ganglion is and then it gives rise to 3 different divisions that give rise to different parts:
• ophthalmic division goes through the supraorbital fissure
• maxillary division via foramen ovale
• mandibular division via foramen rotundum

-posterior: where our cerebellum sits in

Question 10

The first nerve (supraorbital nerve exits through the supraorbital foramen which is part of our ophthalmic division. However our infraorbital nerve is V2. So depending in where you have an injury or infection you might get a different sensory feedback.

Answer 10

You may have an Infection in the back of the eye that leads to pain in the skull in front of your frontal bone. You might have some aberrant artery that leads to pain in your midface.

Question 11

The damages of the trigeminal nerve are quite common and there are what 3 main symptoms?

Answer 11

trigeminal neuralgia= tic douloureux (demyelination of axons in the sensory root of CN V)

Lesions of trigeminal nerve

Herpes Zoster (shingles) infection of Trigeminal Ganglion

trigeminal neuralgia= tic douloureux

-disorder of the sensory root of CN V that leads to demyelination of axons in the sensory the root that can be caused by an aberrant artery (an artery that is not supposed to be there but is running so close that its rubbing off the myelin off the axon sheets ) or a pathological process where the neurons are shedding the myelin; sharp sudden pain in the face that is long-lasting (that may be over 15 minutes); can reduce the pain by cutting off the nerve that is causing the pain at its terminal end (so either supraorbital foramen in the upper face, infraorbital foramen in the midface and mental foramen in the chin); is a minimally invasive procedure and reduces the suffering of the pt.; the nerves that are affected have a different priority; so the maxillary division (midface) is the most commonly affected followed by mandibular followed by ophthalmic is rarely affected; trigeminal neuralgia also affects those in middle-aged and elderly person

Question 12

What are the symptoms of lesions of the trigeminal nerve?

Answer 12

causes widespread anesthesia involving the
basically everywhere where the trigeminal nerve passes:
-corresponding anterior half of scalp
-face (except area around angle of mandible b/c that is the great auricular nerve that comes from our cervical plexus): cornea and conjunctiva
-mucous membranes of mouth, nose, and anterior part of tongue

Lesions that affect the motor part: paralysis of muscles of mastication and tensor veli palanti

REMEMBER: great auricular as it is the area around the angle of the mandible

Question 13

What are symptoms of Herpes Zoster?

Answer 13

-is an infection of the trigeminal ganglion (20% of cases)
-typical presentation of lesions of the nerves causes interruption of the vesicles and their following EXACTLY the innervation pattern of the respective division of the nerve (ie. ophthalmic/maxillary/ mandibular herpes zoster,
(the boundaries of different herpes zoster are well defined)
-V1 (ophthalmic division) is most often affected where we also have innervation of our cornea and the infection can actually cause an ulceration of the cornea which can scar and lead to blindness (now we can remove and exchange them but in the past it caused a lot of disabilities)

Question 14

Facial nerve (CN VII)

Answer 14

• exits the skull through the stylomastoid foramen (btw the styloid and mastoid process)
• the nerve exits and gives off a branch to the posterior side of the ear where the occipital muscle resides which is called the posterior auricular nerve)
• posterior auricular nerve IS NOT PART OF THE FACE
• “anterior” division enters/transverses the parotid gland, open up and divides into 5 main branches (deep to skin) = parotid plexus
• there will be a lot of anastomoses between these nerves in the parotid plexus

Question 15

What are the nerves of the anterior division of the facial nerve that make up the parotid plexus?

Answer 15

• Parotid plexus is the branch point of the facial nerve
• 5 main branches of the facial nerve form this plexus
• temporal (goes into the temporal region)
• zygomatic (crosses our zygomatic bone)
• buccal (crosses our buccal muscle)
• marginal mandibular (runs along the margin of the mandible)
• cervical (goes to the neck; is the one that innervates the platysma muscle)

use your 5 fingers and put it on your face

Question 16

Damage to the facial nerve causes what 2 main symptoms?

Answer 16

Facial palsy= Bell’s palsy
Lyme disease

Facial palsy= Bell’s palsy
-muscles of facial expression on ONE side is paralyzed or becomes weak
typical symptoms
-muscles on the affected side is not functioning; it only affects one side of the face at a time causing it to droop or become stiff on that side
-often unknown cause (you may have it for a couple of month and then overtime you can heal)
-caused by some kind of trauma to the facial nerve
-since there is no sensation in those nerve fibers anymore you don’t feel that there is a problem
-more common in ppl with DM or are recovering from viral infections (herpes simplex 1 virus)

Question 17

Lyme’s disease

Answer 17

• infection with Borrelia burgdorferi via tick bites can cause Lyme disease
• of pt’s affected with Lyme disease, 10% develop facial paralysis with 25% of these pts presenting with bilateral palsy

facial paralysis= paralysis of muscles of facial expression

-ask for pt to close eyes and smile

Question 18

Platysma muscle

Answer 18

-a really thin muscle and is the only muscle of facial expression that spans over neck region

origin:
- fascia overlying pectoralis major and deltoid muscles

insertion:
-inferior border of mandible and skin of lower face

main action:

• depresses corners of mouth
• depression of mandible
• tenses the skin of neck (shaving)
• expands neck during heavy breathing

Innervation: cervical branch of the facial nerve

Question 19

All muscles (of head and neck) coming from inferior and attaching to something superior do what to the structure that they are attaching to?

Answer 19

DEPRESSES

Question 20

Epicranius

Answer 20

two muscles that are joined by the galea aponeurotica: frontalis and occipitalis

frontalis m.
Origin: galea aponeurotica/epicranial aponeurosis
Insertion: skin of eyebrows
Innervation: temporal branches of the facial nerve

occipitalis m.
Origin: superior nuchal line
Insertion: galae aponeurotica
Innervation: posterior auricular branch/ nerve

ACTION:
epicranius elevates eyebrows and wrinkles forehead; pulls scalp back and forth

Question 21

Orbicularis oculi

Answer 21

origin: MEDIAL palpebral ligament
insertion:
- orbital part: skin of lateral cheek
- palpebral part (below the ye no bone there): lateral palpebral ligament

ACTION: closes the eyelids; protects eye
Innervation: temporal and zygomatic branches

-everything ABOVE the fissure when you close the eyelids is the temporal branch of facial nerve and everything
BELOW is the zygomatic branch of the facial nerve

Question 22

What are muscles located in the face but are not facial muscles?

Answer 22

• temporalis and masseter muscles
• dorsal muscles of mastication
• neck muscles

Question 23

Procerus

Answer 23

a muscle that is most often ignored in anatomy lab
-a muscle that LOOKS like the extension of the frontal muscle but actually originates from the basal bone

Origin: nasal bone
Insertion: skin between the eyebrows
Action: depresses the medial corners of the eyebrows
Innervation: temporal branch of facial nerve

this one makes the lines of wrinkles when you’re frowning (Chibunma has a lot)
-horizontal lines of the head

Question 24

What are the muscles surrounding the mouth leading to movement of the mouth?

Answer 24

lip (labii) and the ring (alaeque) of the nose(nasi)

A. levator labii superioris alaeque nasi 
B. levator labii superioris 
C. zygomaticus minor 
D. zygomaticus major 
E. Risorius
F. Depressor anguli oris 
G. Depressor labii inferioris 
H. Orbicularis oris 
I. Levator anguli oris 

we have more muscles to smile than to be sad

ORIGINS: 
ABI: Maxilla 
CD: Zygomatic none 
EH: fascia, (H also skin) 
FG: Mandible 

INSERTIONS:
All insert onto mouth/lips: 
DEFI: angle of mouth 
ABC: upper lip 
G: lower lip 
H: surrounds mouth opening 

FUNCTIONS:
AB: lift upper lip (and A: wing of nose)
CD: Zmile (lift D: angle of mouth and C: upper lip)
E: subtle retraction of angle of mouth
FG: Depresses angle of F: mouth/ G: lower lip

INNERVATION:
ABCEHI: buccal branch of the facial nerve
D: Zygomatic and buccal branches
F: marginal mandibular and buccal branches
G: marginal mandibular branch

Question 25

What are the innervation for the muscles surrounding the mouth?

Answer 25

ABCEHI: buccal branch of the facial nerve
D: Zygomatic and buccal branches
F: marginal mandibular and buccal branches
G: marginal mandibular branch

Question 26

Mentalis muscle

Answer 26

-a frowning muscle

origin: anterior mandible
insertion: skin of chin
nerve: mandibular branch of facial nerve
actions: elevates and wrinkles skin of chin, protrudes lower lip

-gentlemen with goatee( chin hair) can wrinkle the goatee and move the goatee

Question 27

Buccinator muscle

Answer 27

very important muscle involved in our chewing process

origin:

• pterygomandibular raphe
• maxilla lateral to molar teeth
• mandible

insertion:

• angle of mouth
• lateral portion of both lips

action:

• pulls the corner of mouth laterally
• presses the cheek against the teeth

innervation: buccal branches of facial nerve

important in mastication, but is innervated by buccal nerve of facial (motor) NOT the long buccal branch from trigeminal V3 (sensory)

• mandibule also has molar teeth
• prevents food from going in between the cheek and teeth

Question 28

Vessels: Veins follow arteries and have the same name as their respective nerves.

Moving from the neck upwards: arterial supply

Moving from skin/face downward or backwards:
drainage of the face

Answer 28

supratrochlear a and v
supraorbital a and v 
angular a and v
superior labial a and v 
inferior labial a and v 
facial a and v 
external carotid a and v 
transverse facial a and v 
superficial temporal a and v 
occipital a and v 
external jugular a and v 
intenral jugular a and v ???

Question 29

Face venous drainage: Normal vs. Danger

Answer 29

NORMAL FLOW

• starts at medial angle of eye by union of supraorbital and supratrochlear veins
• connected to cavernous sinus (in the middle cranial fossa) by superior and inferior ophthalmic veins and to pterygoid venous plexus (is in the infratemporal fossa) by deep facial vein

zygomatic bone–> masseter muscle and below that is –> soft part which is the parotid gland–>behind the parotid gland above muscular portion of our temporalis muscle and below the temporal bones is the pterygoid venous plexus

cavernous communicates with veins with two routes:

• superior and inferior ophthalmic veins which pass via superior orbital fissure (an opening btw the medial and anterior cranial fossa)
• foramen ovale is the same foramen where our mandibular portion of the trigeminal nerve goes through; and it also goes through foramen of Vesalius which is variable (may or may not be present)

-inferior ophthalmic vein also drains into the pterygoid plexus

DANGER

• flow can reverse as the pterygoid plexus has valves that can act as a section pump (yawn and get a pressure change with valves opening in the wrong direction and pushing backwards the venous drainage up to the cavernous sinus)
• this presents danger for infection between angular and deep facial veins

Question 30

What is the dangerous zone of face?

Answer 30

• is a triangle bounded by lines from root of nose to angle of mouth
• venous drainage from this area (face and orbit) communicate with cavernous sinus via superior and inferior ophthalmic veins and deep facial vein (via pterygoid plexus)

-risk spread of infection which can lead to sinus thrombosis

with runny nose or medial infection of the eye you can
take infection and move it into the cavernous sinus

Question 31

What is an infection of the cavernous sinus so dangerous?

Answer 31

b/c of the content of the cavernous sinus that has so many cranial nerves (TOM Of CAT)

• trochlear nerve
• ophthalmic nerve
• maxillary nerve
• oculomotor nerve
• cavernous part of internal carotid artery (blood supply from our brain that makes the circle of Willis-which Dr. Wilson loves)
• abdusence nerve
• trigeminal nerve

ALL of these structures have a connection to the brain (you may lead the infection to your brain)

ie. Thrombosis of the Cavernous Sinus
- an infection leading to blood clot caused by the complication of an infection in the paranasal or central face sinuses
- symptoms include fatigue, seizures

Question 32

Arteries we need to know for now from the carotid triangle which is an area with no muscle–> 6/8 branches are of the external carotid artery

Answer 32

Some Anatomist Like Freaking Out Poor Medical Students (inferior to superior)

S: superior thyroid artery
A: Ascending pharyngeal artery 
L: lingual artery 
F: facial artery
O: Occipital artery 
P: Posterior auricular artery 
M: maxillary artery
S: superficial temporal artery

F, M, and S we need to know now

-Superficial temporal and maxillary artery are terminal branches of our external carotid artery which originate behind the angle of the mandible NOT the carotid triangle

Deep temporal artery is a branch of the maxillary artery.

Question 33

Facial artery

Answer 33

-Facial NERVE originates in the carotid triangle, passes through the mandibular under the face

• submental artery: arises at lower body of mandible; supplies skin of chin and lower lip
• inferior labial artery: arises near angle of mouth, runs medially in lower lip, anastomosis with fellow of opposite site
• superior labial artery: runs medially in upper lip and gives branches of to septum and ala of nose
• angular artery: termination of facial artery, supplies area around eye

Question 34

Superficial temporal artery

Answer 34

• terminal branch of the external carotid artery
• ascends in front of ear (palpable) to supply temporal and anterior portion of scalp
• transverse facial artery runs above parotid duct to supply the cheek region (almost always cut off in the dissections)

Question 35

Maxillary artery

Answer 35

-infratemporal fossa (lecture in January) where our pterygoid plexus
-we also have a huge branch crossing over the maxilla called the
maxillary artery with a lot of branches: the ones below are actually crossing the face:
-infra-orbital artery: enters the face through the infra-orbital foramen and supplies the lower eyelid, upper lip, and the area btw these structures (everything in the midface)
-buccal artery: enters the face on the superficial surface of the buccinator muscle and supplies structures in this area
-mental artery: enter the face through the mental foramen and supplies the chin

Question 36

Supraorbital and infraorbital aa

Answer 36

like the nerves, the arteries with the same name also have different origins but again you can relate the arteries to the nerve

supraorbital a . arises from ophthalmic a. which arises from internal carotid a. (has only branches in the head and NOT the neck)
-supraorbital nerve arises from the ophthalmic division of the trigeminal nerve

infraorbital a. arises from maxillary a. (3rd part) which arises from external carotid artery
-infraorbital nerve is the termination of our maxillary nerve

Question 37

Buccal fat pad

Answer 37

• one of many encapsulated fat pads in the cheek
• also called Bichat’s fat pad after Marie Francois Xavier Bichat

can use for reconstructive surgery; just for your knowledge will not ask

• buccal fat pad reduction: common cosmetic facial surgery procedure that is performed to slim the cheeks or face
• many congenital and acquired defects occur in the maxillofacial area. The buccal fat pad flap is a simple and reliable flap for the treatment of many of these defects because of its rich supply and location, which is close to the location of various intraoral defects
• can insert fad pad into region you want to heal; need vascularization for the healing process
• application of buccal fat pad for the treatment of cleft palate

Question 38

Pterygomandibular raphe

Answer 38

from mouth to oropharynx: orbicularis oris, buccinator, superior pharyngeal constrictor
-sphincter to oropharynx (keep food btw teeth= helps to get our food into our throat area

raphe is always a connection between muscles

-they anesthetized this portion when they gave me my crown

Question 39

Parotid gland

Answer 39

• largest of 3 paired salivary glands
• irregular shaped–> parotid bed: anterio-inferior external acoustic meatus which is wedged between ramus of mandible and mastoid process
• fatty tissue between lobes: flexibility of gland to accommodate motion of mandible
• facial nerve plexus, retromandibular vein, and external carotid artery are embedded in parotid gland
• enclosed within tough, fascial capsule, the parotid sheet (on sheet and within gland: parotid lymph nodes)

Question 40

Parotid duct

Answer 40

• parotid duct passes horizontally from anterior edge of gland
• at anterior border of masseter, the duct runs medially pierces the buccinator, and enters oral cavity through small office opposite of 2nd maxillary tooth

Having an infection through the mouth where the parotid duct is can pass to the parotid gland

Question 41

Parotidectomy

Answer 41

• 80% of salivary gland tumors in parotid gland
• most are benign
• surgical excision (parotidectomy) often part of treatment

TAKE CARE OF FACIAL PLEXUS

Question 42

Paranasal sinuses

Answer 42

• small air-filled spaces located within bones surrounding the nose
• sinuses develop from invaginations of nasal cavity that extend into bones: 2 during FETAL development and 2 POSTNATALLY
• ADULT: 4 paired sinuses: maxillary sinuses, ethmoid sinuses, frontal sinuses, sphenoid sinuses

IMPORTANCe of paranasal sinuses:

• sinuses shape/reshape face through enlargement of air-filled space
• keep weight of head low while growing (reduces the weight of our head)

Question 43

What are types of paranasal sinuses?

Answer 43

5 months NOT 1 month !!!

• maxillary sinuses: FIRST one to develop; 3rd fetal month; invaginations of nasal sac that extends within maxillary bones
• ethmoid sinuses: 5th fetal month; invagination of middle meatus of nasal passages (space underlying middle nasal concha) and grow into ethmoid bone
• sphenoid sinuses: 5th postnatal month; extensions of ethmoid sinuses into sphenoid bone

-frontal sinuses: appears at 5/6 y/o; each frontal sinus consists of two independent spaces that develop from different sources:
one forms by expansion of ethmoid sinus into frontal bone
one develops from independent invagination of middle meatus of nasal passages

-the problem is when the maxillary sinus enlarges too much, you have the roots of your maxillary teeth breaking through and then you can get an
infection of maxillary sinus via your oral cavity

Question 44

Sinusitis (sinus infection)

Answer 44

• inflammation of the membranes lining the paranasal sinuses
• can be caused by infection or other health problem
• symptoms include facial pain and nasal discharge
• can determine which sinus is inflamed depending on location on face:
• sphenoid sinuses most painful and annoying as they are in the back of our head