Scalp, Fascia of the neck and

Surface Anatomy
For 31st Batch 2009
Dr MB Samarawickrama
(MBBS MS)

Surface Anatomy
Helps
Land marking of internal structure
Identification of anatomical sites
Clinical judgment
Guide for investigations and management

Surface Anatomy
Nasion the depression between the two
supra-orbital margins
Glabella the ridge above the nasion
Superficial temporal artery crossing the
posterior extremity of the zygomatic arch

The Surface Anatomy

Anterior edge of the mastoid behind the
auricle
Mandible the whole superficial surface of
it is palpable except the coronoid process
Condyloid process can be felt by a finger
placed immediately in front, or within, the
external auditory meatus while the mouth is
opened and closed.

The Surface Anatomy

Symphysismenti ?
Mandibular foramen
Slight dimple in living 4cm behind the
symphysismenti

Zygomatic bone
The broad anterior part of the arch

The Surface Anatomy

Masseter clench the teeth and feel over
the ramus of the mandible
Temporalis clench the teeth and feel
above the zygomatic arch
Parotid duct can be rolled over the
tensed masseter

The Surface Anatomy of the

Opening of the parotid duct seen within the
mouth at the level of the 2nd upper molar tooth
A line drawn vertically between the 1st & 2nd premolar teeth passes through,
the mental foramen (passes mental branch of the
inferior alveolar nerve)
the infra-orbital foramen (passes infra-orbital nerve)
the supra-orbital notch (passes supra-orbital nerve)

The Surface Anatomy

Middle meningeal artery
Represented by a line drawn upwards and
somewhat forewards from a point along the
zygomatic arch, two fingers breadth behind the
jugalar point
( Jugalar point the junction between the
zygoma and the zygomatic arch)
The posterior branch passes backwards a
thumbs breadth above , and parallel to the
zygomatic arch

The Surface Anatomy of the

Neck
In the midline from above downwards
Symphysis menti
Hyoid bone C3 level
Thyroid cartilage C4 level
Cricoid cartilage C6 level
Isthmus of the thyroid gland- can be rolled
over the 3rd and 4th tracheal rings
Suprasternal notch

The Surface Anatomy

At the lower border of the cricoid

cartilage (C6)
1. The junction of the larynx with the trachea
2. The junction of the pharynx with the
oesophagus
3. The inferior thyroid artery and the middle
thyroid vein enter the thyroid gland
4. The vertebral artery enters the transverse
foramen in the C6 vertebra

The Surface Anatomy

5. Superior belly of the omohyoid crosses the
carotid sheath
6. Middle cervical sympathetic ganglion
7. Carotid artery can be compressed against
the transverse process of C6

The Surface Anatomy of the

Neck (contd)
Define the posterior triangle and the
anterior triangle by pressing the jaw
laterally against resistsnce

The Surface Anatomy

Platysma (shown by violently clenching
the jaw)
Passes from the mandible down over the
clavicles
Lies in the superficial fascia of the skin

The Surface Anatomy

External jugular vein (visible on
straining)
Lies immediately deep to the platysma
Crosses the sternomastoid into the posterior
triangle
Perforates the deep cervicle fascia just above
the clavicle
Enters the subclavian vein

The Surface Anatomy

Common carotid artery
Carotid artery pulse can be felt by pressing
backwards against the anterior tubercle of the
transverse process of C6

Line of carotid sheath

A line joining a point midway between the tip
of the mastoid process and the angle of the
jaw to the sterno-clavicular joint

The Surface Anatomy

Bifurcation of common carotid artery into
external and internal carotid arteries at the
level of the upper border of the thyroid
cartilage

Palpable pulses
Carotid against the anterior tubercle of
the C6
Facial- anterior border of the maseter over
the mandible
Superficial temporal- over the zygomatic
arch immediately in front of the auricle

Fascia of the neck

The cervical fascia
Compartmentalize the structures in the
neck
Afford the slipperiness that allows
structures in the neck to move and pass
over one another without difficulty

Fascia of the neck (contd)

Layers
Superficial cervical fascia (Subcutaneous
tissue)
Deep cervical fascia

Superficial cervical fascia

Is a thin layer of connective tissue
Lies between the dermis of the skin and
the investing layer of the deep cervical
fascia

Superficial cervical fascia

(contd)
Contains
Cutaneous nerves
Blood and lymphatic vessels
Fat
Platysma (anterolaterally)

Deep cervical fascia

Consists of
1.
2.
3.
4.

Investing layer
Pretracheal layer
Prevertebral layer
Carotid sheath

Support the viscera, muscles, vessels,

deep lymph nodes

Investing layer of deep cervical fascia

The most superficial layer of deep cervical
fascia
Surrounds the entire neck deep to the skin and
subcutaneous tissue
Splits into superficial and deep layers to
Encloses the
sternocleidomastoid and trapezius muscles
the submandibular and parotid glands
Suprasternal and supra clavicular spaces
Form the fibrous capsule of the parotid gland

Suprasternal
space

Investing layer of deep cervical fascia

Attachments
Superiorly

External occipital protubarance

Superior nuchal line
Mastoid process
Zygomatic arches
Inferior border of the mandible

Inferiorly
Manubrium
Clavicles
Acromions and spines of the scapulae

Investing layer of deep cervical fascia

Posteriorly
Ligamentum nuchae
Spine of the C7

Anteriorly
Symphysismenti
Hyoid bone

Pretracheal layer of deep cervical fascia

Thin
Limited to the anterior part of the neck
Extends inferiorly from the hyoid bone into
the thorax
Blends with the fibrous pericardium

Pretracheal layer of deep cervical fascia

Encloses the
infrahyoid muscles
Omohyoid
Sternothyroid
Sternohyoid
Thyrohyoid

Thyroid gland

Pretracheal layer of deep cervical fascia

Is continuous posteriorly and superiorly

with buccopharyngeal fascia
Blends laterally with the carotid sheaths

Pretracheal layer of deep cervical fascia

Attachments
Superiorly
Hyoid bone
Oblique line of thyroid cartilage
Cricoid cartilage

Inferiorly
blends with the arch of the aorta

On either side
Blends with the carotid sheath

Carotid sheath
Is a dense tubular fibrous investment
Extends from the base of the cranium to the root
of the neck
Blends anteriorly- with the investing and
pretracheal layers of fascia
Blends posteriorly with the prevertebral layer of
deep cervical fascia

Carotid sheath
It contains
common and internal carotid arteries
Internal jugular veins
Vagus nerve

Prevertebral layer of deep cervical fascia

Forms a tubular sheath for the vertebral
column and muscles associated with it
Extends from the base of the cranium to
T3 or T4 vertebra
At T3 it fuses with the anterior longitudinal
ligament

Prevertebral layer of deep cervical fascia

Cervical and brachial plexus lie behind the
prevertibral fascia
It extends laterally as the axillary sheath

Scalp
Consists of
Skin
Subcutaneous tissue

Covers the cranium

From the superior nuchal line of the occipital
bone
To the supraorbital margins of the frontal bone

Scalp (contd)

1.
2.
3.
4.
5.

Laterally it extends over the temporal

fascia to the zygomatic arches
Consists of five layers
Skin
Connective tissue
Aponeurosis
SCALP
Loose connective tissue
Pericranium

Skin
Thin except in the occipital region
Contains many sweat glands, sebaceous
glands and hair follicles
Has an abundant arterial supply and good
venous and lymphatic drainage

Connective tissue
Forms the thick, dense, richly
vascularized, subcutaneous layer
Is well supplied with cutaneous nerves
The space is divided by fibrous septa

Aponeurosis
Is the tendon of the occipito frontalis
muscle
Is found between the frontal and occipital
bellies of the occipitofrontalis muscle and
the superior auricular muscle
It has no boney attachment

Loose connective tissue layer

Like a sponge
Has many potential spaces
Allows free movement of the scalp proper
over the underlying calvaria
Is relatively avascular

Pericranium
Is the periosteum of the skull bone
Is firmly attached
but can be stripped fairly easily from the
calvaria of living persons except in the
cranial sutures

Innervation of the scalp

Anterior to the auricles
By branches of all three divisions of the
trigeminal nerve

Posterior to the auricles

Spinal cutaneous nerves (C2 and C3)

Arteries of the scalp

Run in the layer two (connective tissue)
Are held by the dense connective tissue
Thus tend to remain open when cut
Have abundant anastomoses

Arteries of the scalp (contd)

Derived from the
External carotid arteries through the
Occipital arteries
Posterior auricular arteries
Superficial temporal arteries

Internal carotid arteries by way of the

Supratrochlear arteries
Supraorbital arteries

Arteries of the scalp

Supply very little boold to the bones of the
calvaria (supplied by the middle meningeal
artery)
Thus loss of the scalp does not produce
death of the bones forming the calvaria

Venous drainage
Of the superficial parts of the scalp by
Supraorbital vein

Supratrochlear vein

Angular vein

Facial vein

Venous drainage (contd)

Superficial temporal veins
Posterior auricular veins
Occipital veins

Venous drainage (contd)

Of the deep parts of the scalp
Via emissary veins that communicates with
the dural sinuses
Through deep temporal veins (are tributaries
of the pterygoid venous plexus) in the
temporal region

Lymphatic drainage
Into the superficial ring (pericervical collar)
of lymph nodes
Submental
Submandibular
Parotid
Mastoid (retroauricular)
Occipital

Lymphatic drainage (contd)

From the superficial ring nodes to the
deep cervical lymph nodes along the
internal jugular vein
There are no lymph nodes in the scalp