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Advances in Understanding the Surgical Anatomy of the Face
External Nasal Anatomy. Nasal Cavity Anatomy. Parotid Region. Parotid Gland. Submandibular Gland. Floor of the Mouth. Because traumatic injuries disrupt the anatomy, the surgeon who is to repair and replace these traumatized structures must have an in-depth knowledge of normal anatomy. In addition, the operator must consider possible variations of normal and other associated structures that may be in close relationship to the traumatized area. Although numerous texts have been written on basic anatomy, 1 — 11 it is thought that for completeness, this textbook should include a review of major head and neck anatomy.
Details on specific problems and treatment modalities are found in the appropriate chapters. It is the intent of this chapter to discuss the general anatomy, its inherent relationships, and some technical problem areas that should be considered in the management of traumatic facial injuries. The natural skin lines and wrinkles are major factors in determining the final soft tissue aesthetic result for the patient with facial trauma. The character and aesthetics of a scar are affected by its relationship to the location and direction of normal skin lines.
The natural skin lines and wrinkle lines are different from the lines of Langer, which denote the direction of the collagen fibers within the dermis. Langer believed that the skin was less extensible in the direction of the lines of tension that cross them. It is therefore recommended that elective incisions be made in or parallel to the lines of facial expression or the natural skin lines, when possible Fig.
Old scar lines and hairlines can also direct a surgeon to the most appropriate placement of an incision. Considerations as the ethnicity of the patient must also be taken into account because hyperpigmentation and hypopigmentation issues might arise. The scalp is made up of five layers, three of which are closely bound together.
These are the skin, dense connective tissue, and galea aponeurotica.
Anatomy, Skin, Superficial Musculoaponeurotic System (SMAS) Fascia Article - StatPearls
Beneath these layers are the loose connective tissue and the periosteum or pericranial layer. This firm union and the extensive blood supply frequently make bleeding excessive and often difficult to control rapidly with hemostats. Because of the nature of the loose connective tissue layer, dissection of the scalp is rather easy in this tissue plane. In a similar manner, however, the effusion of fluid spreads rapidly in this plane, leading to a boglike edema. From Aehlert B: Paramedic practice today , St. The innervation of the scalp comes from the trigeminal nerve anteriorly and laterally and from the cervical nerves C2 and C3 posteriorly.
In the supraorbital region, the superior orbital branch of the trigeminal nerve passes through a notch or foramen to innervate this area of the scalp. The supratrochlear nerve is located slightly medially and innervates the upper lid and the medial area of the forehead.
As with most areas of the anatomy, when the skeleton makes angles or muscles insert, there is a denser attachment of the skin and soft tissue. In the scalp, this attachment is most notable in the glabella and supraorbital regions. The skin of the face becomes specialized in the area of the eyelids, which are comprised of two structural lamellae: the external lamellae formed by the orbicularis muscle and its overlying skin and the internal lamellae of the tarsal plate and conjunctiva. The skin of the nose is tightly attached to the lower lateral cartilage in the tip area.
In other areas, the skin is less tightly adhered to the underlying infrastructure. The skin is thin in the nasal root and tip areas and thicker in the supratip region.
The bones will be considered in the traditional facial thirds Fig. B, Lateral view of skull. Facial thirds are noted. The maxilla, zygoma, lacrimal, nasal, palatine, inferior nasal concha, and vomer bones are collectively referred to as the middle third of the facial skeleton. The bones will be discussed separately, but their interconnections are of utmost importance. The maxilla Figs. Each hemimaxilla contains a large pyramid-shaped body, the maxillary sinus antrum of Highmore , and four prominent processes—the frontal, alveolar, zygomatic, and palatine processes.
B, Lateral aspect of maxilla. From Liebgott B: The anatomical basis of dentistry, ed 3, St.
Louis, , Mosby. The body of the maxilla is hollow and contains the maxillary sinus. The anterior wall of the sinus is the facial surface of the maxilla and is usually thin. The medial wall is the lateral nasal wall. The sinus opens superiorly and medially into the nasal cavity at the semilunar hiatus in the middle meatus.
The superior wall or roof of the sinus is the orbital floor, and the floor of the sinus is the palatine and alveolar processes of the maxilla. The frontal process arises from the anteromedial corner of the body and articulates with the frontal bone to form the medial orbital rim. The medial portion of the frontal process fuses with the nasal bone and may therefore be termed the nasofrontal process. Posteriorly, the process articulates with the lacrimal bone to form the anterior portion of the medial orbital wall.
This area of articulation with the frontal bone, nasal bone, and lacrimal bone is prominent in the facial skeleton and is frequently fractured by blunt trauma. The inferiorly extending portion of the maxilla is the alveolar process, which contains the maxillary teeth. The teeth are key to the accurate management of many midfacial fractures. The alveolar process may be fractured by direct trauma and therefore may be functionally separate from other portions of the maxilla. The palatine process arises horizontally from the lower edge of the medial surface of the body.
It joins the opposite process and forms the major portion of the hard palate. The zygomatic process of the maxilla arises from the anterolateral corner of the maxilla and articulates laterally with the zygoma. Together, they form the inferior orbital rim and the greatest portion of the orbital floor. The infraorbital foramen is on the anterior surface of the zygomatic process of the maxilla. Surgical Note: The classic Le Fort I fracture passes through the anterior wall of the maxilla, extending posteriorly to the pterygoid plates.
It is important to remember that this is a paired bone and, even though it is fused in the midline, in adults it behaves like two separate bones when manipulated. It may often be separated along the midpalatal suture in the more extreme facial fractures. The zygoma zygomatic bone, malar bone is a paired bone that makes up the essence of the cheek prominence Fig.
The frontal process forms the lateral orbital wall and articulates with the frontal bone at the frontozygomatic suture. It is this articulation that is separated or rotated in isolated zygomatic fractures. The temporal process forms the zygomatic arch and articulates with the temporal bone. The maxillary process articulates with the maxilla to form the infraorbital rim and part of the floor of the orbit. Finally, the fourth process joins the maxilla on the lateral wall, producing the zygomatic eminence. This is an area of thickened bone that is usually available for fixation in the treatment of zygomaticomaxillary complex ZMC fractures.
Along the crest of the zygoma, on the inferior aspect, is the insertion of the masseter muscle. The direction of force for this muscle is down and backward and its contraction contributes to displacement of the complex fracture of the zygoma, which may precipitate redisplacement in the improperly fixated fracture. The zygoma articulates with the sphenoid bone on the posterior aspect of the frontal process.
This articulation is with the greater wing of the sphenoid bone and forms the lateral wall of the orbit. The only foramina of the zygomatic bone are the zygomaticofacial foramen, which opens from the orbital surface of the bone and passes to the eminence, and the zygomaticotemporal foramen, which opens to the infratemporal fossa. The zygomaticofacial and zygomaticotemporal branches of the second division of the trigeminal nerve pass from within the orbit to the surface and give sensory innervation to the associated structures.
Surgical Note: The classic zygomaticomaxillary fracture tripod, zygomaticomaxillary complex, and trimalar involves this bone and its articulations. Details on the fracture and its management are found in Chapter The options of surgical manipulation for reduction are discussed in the following sections. The only structure of anatomic importance is the superficial temporal artery. This vessel courses across the area of the incision and can be identified through palpation and thus avoided by the properly placed incision. If it is encountered, it can be ligated and cut without complications.
The temporalis fascia runs to the arch of the zygoma. An incision is made through this fascia to expose the muscle and develop a path for the passage of instruments to manipulate the zygoma. The main anatomic concern is being too superficial to the fascia, thus introducing the elevator lateral to the arch. Again, no major anatomic structures lie in close approximation. The incision is made full thickness to the bone, and the periosteum is reflected to expose the fracture. Generally, some form of elevator is placed posteriorly in the infratemporal fossa to aid in elevation of the fracture.
Care should be taken not to lever against the temporal bone and displace any nondiagnosed, nondisplaced skull fractures. The incision is generally placed in the hair of the brow. The usual rule of making an incision perpendicular to the skin margin can be altered in this area because the incision should be made with the long axis of the hair follicle to prevent damaging the follicles, which could prevent the regrowth of hair.
This hair should not be shaved for numerous reasons. The hair will grow back, but slowly, and it will be of a different texture and may often be sparse. The most notable problem is that of aligning the hair-bearing skin margins during suturing. If this is not performed properly, there will be an unsightly step in the brow when the hair does regrow. These approaches provide access to the inferior orbital rim, orbital floor, lacrimal duct area and, in some cases, medial and lateral orbital walls. There are few anatomic problems if care is used to locate the layers of the inferior lid, most specifically the orbicularis oculi muscle, orbital septum, and inferior orbital rim.
The approaches from the skin include the infraciliary incision and a lower incision through an existing skin crease. The infraciliary incision is aesthetically pleasing but may result in excessive and prolonged edema of the eyelid. The lateral extent of this incision, combined with the frequently needed lateral brow incision, compromises the lymphatic drainage of the lower lid. The skin is thin in this area and the skin flap must be developed carefully. The incision through the orbicularis oculi muscle is performed longitudinally to expose the inferior orbital rim.
The incision through the periosteum should be on the facial aspect of the bone but above the infraorbital nerve. The floor of the orbit and infratemporal fossa can be approached through a buccal mucosa incision in the posterior maxillary vestibule. The maxillary sinus can be entered and the floor of the orbit, inferior rim, and eminence of the zygoma can be elevated from within. The infratemporal fossa can be entered posteriorly and superiorly, and the zygomatic arch and zygomatic body may be elevated. The buccal fat pad often interferes with visualization but is generally of no notable anatomic concern.
The final approach to the orbital floor is via the transconjunctival incision. In the case of trauma, this is usually not a major factor. The incision is made through the conjunctiva at the lower border of the inferior tarsal plate, with the lower lid retracted inferiorly.
A preseptal or retroseptal dissection can be made, although the preseptal dissection offers better control of the orbital fat. The approach to the orbital floor is otherwise the same and there are no notable anatomic problems associated with any of these approaches. The nasal bones Fig. At the superior articulation, they are relatively thick, but inferiorly, they are much thinner.
Surgical Anatomy of the Face
It is in this area that most fractures occur. The nasal bones articulate posteriorly with the frontal process of the maxilla. The ethmoid bone is an unpaired bone that is central to the facial structure Fig. The perpendicular plate forms the superior and anterior portions of the nasal septum and attaches to the cribriform plate. It articulates posteroinferiorly with the vomer and posterosuperiorly with the sphenoid bone. The cribriform plate articulates anteriorly and laterally with the frontal bone and posteriorly with the sphenoid bone. Hanging bilaterally from the cribriform plate are the superior and middle nasal conchae.
The middle concha has thin-walled ethmoidal air cells, which extend laterally to it. The multiple septa, which pass relatively perpendicular to the conchae, extend laterally to the thin plate of bone that constitutes most of the medial orbital wall. This bone is the lamina orbitalis of the ethmoid bone.
It is extremely thin; hence the term lamina papyracea. Surgical Note: The thin lamina orbitalis may be fractured in blunt orbital trauma. Because this artery is one of the terminal branches of the ophthalmic artery, which is a branch of the internal carotid artery, it is not affected by the usual measures to control facial bleeding and may require direct ligation via a medial canthal approach. The anterior ethmoid foramen is approximately 1.
Surgical Anatomy of the Face
Rarely is any surgical manipulation of this bone necessary or possible. The vomer see Fig. It articulates with the palatine, maxillary, and ethmoid bones and rarely is of notable concern in the primary management of facial trauma. The paired palatine bones connect the maxilla with the sphenoid bone Fig. The horizontal plate articulates anteriorly with the maxilla and with the palatine bone of the opposite side in the midline to form the posterior aspect of the hard palate. Note orbital surface and nasal and palatal aspects.
The vertical plate passes superiorly behind the maxilla and articulates posteriorly with the lateral pterygoid plate of the sphenoid bone. A ledge of the vertical plate terminates in a small contribution to the orbital floor at the posteromedial aspect. The junction of the sphenoid and palatine bones forms the sphenopalatine foramen. This foramen attaches the posterior aspect of the nasal cavity with the pterygopalatine fossa.
Surgical Note: Manipulation of the maxilla generally accomplishes adequate reduction of the palatine bones. The inferior nasal concha is a paired bone 2 that forms the bony support of the inferior turbinate bilaterally. It is of surgical importance only when it obstructs the inferior meatus and the nasal lacrimal duct. The frontal bone Fig. The importance of this bone in facial trauma is its relationship to the anterior midfacial skeleton and the paranasal sinuses.
The frontal bone articulates laterally with the zygoma and medially with the maxilla and nasal bones. Inferiorly and deep in the middle of the face, it articulates with the ethmoid and lacrimal bones and posteroinferiorly articulates with the wings of the sphenoid bone. The frontal bone articulates posterolaterally with the parietal bones. Note articulation with the nasal and ethmoid bones.
Louis, , Saunders. The frontal bone forms a great portion of the roof of the orbit. Its thickened projections articulate laterally with the zygoma at the frontozygomatic suture and form the lateral orbital walls. The thickening of the frontal bone in the anterior region forms the supraorbital ridges. These curved elevations connect the zygomatic portion of the frontal bone with its midportion, articulating with both the maxilla and nasal bones.
The supraorbital notch or foramen crosses this rim and transmits the frontal vessels and nerves. The frontal sinus lies in the frontal bone in an area superior to the articulation with the nasal bones. The sinus is not a simple chamber but rather is subdivided into compartments or recesses by incomplete bony partitions.
There is usually an intrasinus septum that divides the left from the right. Drainage into the nose is by a well-formed duct, the nasofrontal duct. The duct itself is soft tissue and may follow a serpentine course to the anterior middle meatus of the nose, where it empties. The frontal sinuses are protected somewhat from injury by the supraorbital ridges. The anterior wall of the sinus has low resistance, but the ridges are highly resistant. Surgical Note: There are multiple incisions and techniques of management for the frontal sinus.
The major anatomic point of concern is the inner table, which, when fractured, demands a neurosurgical evaluation. Other areas of concern are the supraorbital nerves, which can usually be saved with careful dissection and removal from the supraorbital foramen by the use of a small osteotome.
The neurovascular bundle can then be retracted with the orbital contents. The sphenoid bone Fig. This complex bone has many processes that have delicate articulations with the adjacent cranial and facial bones. From Liebgott B: The anatomical basis of dentistry , ed 3, St. The sphenoid bone articulates with the temporal and occipital bones to form the cranial base. It joins the parietal and frontal bones anteriorly and superiorly to complete the cranial complex.
It meets the vomer and ethmoid bones in the midline anteriorly and meets the zygoma, palatine bones, and sometimes the tuberosity of the maxilla to complete its articulation with the facial skeleton. The body of the sphenoid bone is hollow and forms two cavities separated by a thin bony septum. The hollow cavities are the sphenoidal sinuses; these drain into the sphenoethmoid recess above and behind the superior nasal concha.
Although air-fluid levels can frequently be noted on radiographs, surgical management in the trauma patient is rarely necessary. Despite the fact that the mandible Figs. Mandibular fractures occur twice as often as midfacial fractures 29 , 32 ; however, it has been shown in cadaver experiments that almost four times as much force is required to fracture the mandible versus the maxilla.
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