Blood supply to the soft tissues of the face. Facial anatomy for cosmetologists: how to bypass danger zones (video)

Technological map of the practical lesson.

Operations for purulent processes of the face.

TOPIC: Topographic anatomy of the face.

Relevance of the topic: Knowledge of the features of the topographic anatomy of the facial part of the head is a necessary basis for accurate diagnosis and successful surgical treatment of purulent-inflammatory diseases and traumatic injuries in this area.

Lesson duration: 2 academic hours.

General purpose: To study the topographic anatomy of the lateral part of the facial part of the head and the technique of surgical interventions on it.

Specific goals (to know, be able to):

1. Know the boundaries, layered structure, projections of the buccal, parotid-masticatory areas and deep facial area.

2. To know the topographic and anatomical relationships of fascia and cellular spaces, organs, neurovascular formations in relation to the spread of purulent-inflammatory processes.

3. Be able to give a topographic and anatomical justification for incisions on the face.

Logistics of the lesson

1. Corpse, skull.

2. Tables and dummies on the topic of the lesson

3. A set of general surgical instruments

No. p / p.	Stages	Time (min.)	Tutorials	Location
1.	Checking workbooks and the level of students' preparation for the topic of the practical lesson		Workbook	study room
2.	Correction of knowledge and skills of students by solving a clinical situation		Clinical situation	study room
3.	Analysis and study of material on dummies, a corpse, viewing demonstration videos		Models, cadaveric material	study room
4.	Test control, solution of situational problems		Tests, situational tasks	study room
5.	Summing up the lesson		-	study room

Clinical situation

As a result of the accident, the patient has a lacerated wound on the side of the face. The radiograph shows a comminuted fracture of the mandibular branch at the level of the neck of the articular process. During the revision of the wound and the removal of free bone fragments from the depth of the wound, severe bleeding began.

Tasks:

1. What vessel is located near the neck of the articular process of the lower jaw?

2. Is the maxillary artery available to stop bleeding?

3. Which vessel should be tied up throughout?

The solution of the problem:

1. Near the neck of the articular process of the lower jaw is the maxillary artery.

2. The maxillary artery is not available for ligation.

3. It is necessary to ligate the external artery in the carotid triangle of the neck.

The facial region of the head includes the cavities of the eye sockets, nose, and mouth. These cavities with adjoining parts of the face are given as separate areas (regio orbitalis, regio nasalis, regio oris); the chin region adjoins the mouth area - regio mentalis. The rest of the face is considered as the lateral region of the face (regio facialis lateralis), consisting of three smaller regions: buccal (regio buccalis), parotid-chewing (regio parotideo-masseterica) and deep facial region (regio facialis profunda). Most of the facial muscles are located in the buccal region, as a result of which it can be called the region of facial muscles. In the parotid-masticatory region and the deep region of the face, there are organs related to the chewing apparatus, as a result of which they can be combined into the maxillo-masticatory region.

The skin of the face is thin and mobile. In the subcutaneous fatty tissue, the amount of which can change dramatically in the same person, mimic muscles, vessels, nerves and the parotid duct are laid.

The blood supply to the face is carried out mainly by the a.carotis externa system through its branches; aa.temporalis superficialis, facialis (a.maxillaris externa - BNA) and maxillaris (a.maxillaris interna - BNA) (Fig. 1). In addition, a.ophthalmica (from a.carotis interna) also takes part in the blood supply to the face. Vessels of the face form an abundant network with well-developed anastomoses, which ensures good blood supply to the soft tissues. Due to this, wounds of the soft tissues of the face, as a rule, heal quickly, and plastic surgery on the face ends favorably.

Rice. 1. Vessels and nerves of the infratemporal and pterygopalatine fossae.

1 - external carotid artery, 2 - buccal muscle, 3 - inferior alveolar artery, 4 - medial pterygoid muscle, 5 - facial nerve, 6 - middle meningeal artery, 7 - connecting branch with the facial nerve, 8 - accessory meningeal branch, 9 - auricular-temporal nerve, 10 - superficial temporal artery, 11 - deep temporal arteries, 12 - temporalis muscle, 13 - sphenoid-palatine artery, 14 - infraorbital artery, 15 - mandibular nerve, 16 - buccal artery, 17 - buccal nerve, 18 - mental artery and nerve, 19 - lingual nerve, 20 - inferior alveolar nerve. (From: Corning T.K. Topographic anatomy. - L., 1936.)

The deep venous network is represented mainly by the pterygoid plexus - plexus prerygoideus, lying between the branch of the lower jaw and the pterygoid muscles (Fig. 2). The outflow of venous blood from this plexus is performed along vv.maxilares. In addition, and this is especially important from a practical point of view, the pterygoid plexus is connected with the cavernous sinus of the dura mater through the emissaries and veins of the orbit, and the superior ophthalmic vein anastomoses, as already mentioned, with the angular vein. Due to the abundance of anastomoses between the veins of the face and the venous sinuses of the dura mater, purulent processes on the face (furuncles, carbuncles) are often complicated by inflammation of the meninges, phlebitis of the sinuses, etc.

The lymphatic vessels of the tissues of the medial parts of the face are sent to the submandibular and submental nodes. Some of these vessels are interrupted in the buccal nodes (nodi lymphatici buccales; faciales profundi - BNA) lying on the outer surface of the buccal muscle, some in the jaw nodes (nodi lymphatici mandibulares) lying at the anterior edge of the masticatory muscle, slightly above the edge of the lower jaw.

The lymphatic vessels of the tissues of the medial parts of the face, the auricle and the temporal region are sent to the nodes lying in the region of the parotid gland, and part of the lymphatic vessels of the auricle ends in the behind-the-ear lymph nodes (nodi lymphatici retroauriculares). In the region of gl.parotis, there are two groups of interconnected parotid lymph nodes, of which one lies superficially, the other is deep: nodi lymphatici parotidei superficiales and profundi. Superficial parotid nodes are located either outside the capsule of the gland, or immediately below the capsule; some of them lie in front of the tragus of the auricle (nodi lymphatici auriculares anteriores - BNA), others are below the auricle, near the posterior edge of the lower pole of the parotid gland. Deep parotid nodes lie in the thickness of the gland, mainly along the external carotid artery. From the parotid nodes, lymph flows into the deep cervical lymph nodes.

The lymphatic vessels of the orbit pass through the inferior orbital fissure and end partly in the buccal nodes, partly in the nodes located on the lateral wall of the pharynx.

The lymphatic sections from the anterior sections of the nasal and oral cavities end in the submandibular and chin nodes. Lymphatic vessels from the posterior sections of the oral and nasal cavities, as well as from the nasopharynx, are partly collected in the pharyngeal nodes located in the tissue of the peripharyngeal space, partly in the deep cervical nodes.

The motor nerves on the face belong to two systems - the facial nerve and the third branch of the trigeminal. The first supplies the mimic, the second - chewing muscles.

The facial nerve exits the bone canal (canalis facialis) through the foramen stylomastoideum enters the thickness of the parotid salivary gland. Here it breaks up into numerous branches that form a plexus (plexus parotideus); 5 groups of radially (in the form of a crow's foot) diverging branches of the facial nerve are noted - temporal branches, zygomatic, buccal, marginal branch of the lower jaw (ramus marginalis mandibulae) and cervical branch (ramus colli).

Rice. 2. Pterygoid venous plexus and its connections with the facial and ophthalmic veins:

1 - v.nasofrontalis; 2 - v.angularis; 3 - anastomosis between plexus pterygoidcus and v.ophthalmica inferior; 4, 8 - v.facialis anterior; 5 - v.facialis profunda; 6 - m.buccinator; 7 - v.submentalis; 9 - v.facialis communis; 10 - v.jugularis interna; 11 - v.facialis posterior; 12 - v.temporalis supetficialis; 13 - plexus venosus pterygoideus; 14 - v.ophthalmica inferior; 15 - plexus cavernosus; 16 - n.opticus; 17 - v. ophthalmica superior.

In addition, there is a posterior branch (n.auricularis posterior). The branches of the facial nerve generally run along the radius medially from a point 1.5-2.0 cm below the external auditory canal. This nerve supplies the facial muscles of the face, the frontal and occipital muscles, the subcutaneous muscle of the neck (m.platysma), m.stylohyoideus and the posterior belly of m.digastricus.

e

Rice. 3. Facial nerve, main branches:

a - r.temporalis, b - r.zygomaticus, c - r.buccalis, d - r.marginalis mandibulae, e - r.colli .

The passage of the nerve through the canal in the thickness of the temporal bone next to the inner and middle ear explains the occurrence of paralysis or paresis of the facial nerve, sometimes occurring as a complication of purulent inflammation of these departments. Therefore, surgical interventions performed here (especially in the vicinity of the mastoid part of the facial nerve canal) may be accompanied by nerve damage if the rules of trepanation are not followed. With peripheral paralysis of the facial nerve, the eye cannot close, the palpebral fissure remains open, the corner of the mouth on the affected side is lowered.

The third branch of the trigeminal nerve supplies, in addition to the chewing muscles - mm.masseter, temporalis, pterygoideus lateralis (externus - BNA) and medialis (internus - BNA), the anterior belly of m.digastricus and m.mylohyoideus.

Innervation of the skin of the face is carried out mainly by the terminal branches of all three trunks of the trigeminal nerve, to a lesser extent - by the branches of the sewing plexus (in particular, the large ear nerve). The branches of the trigeminal nerve for the skin of the face come out of the bone canals, the openings of which are located on the same vertical line: foramen (or incisura) supraorbitale for n.supraorbitalis (n.frontalis comes out medially) - from the first branch of the trigeminal nerve, foramen infraorbitale for n.infraorbitalis - from the second branch of the trigeminal nerve and foramen mentale for n. mentalis - from the third branch of the trigeminal nerve. Connections are formed between the branches of the trigeminal and facial nerves on the face.

The projections of the bone holes through which the nerves pass are as follows. Foramen infraorbitale is projected 0.5 cm downward from the middle of the lower orbital margin. Foramen mentale is most often projected at the middle of the height of the body of the lower jaw, between the first and second small molar. Foramen mandibulare, leading to the mandibular canal and located on the inner surface of its branch, is projected from the side of the oral cavity onto the buccal mucosa at the middle of the distance between the anterior and posterior edges of the mandibular branch, 2.5-3.0 cm upward from the lower edge. The significance of these projections lies in the fact that they are used in the clinic for anesthesia or nerve blockade in neuritis.

Buccal region (regio buccalis)

The buccal region (regio buccalis) has the following boundaries: above - the lower edge of the orbit, below - the lower edge of the lower jaw, laterally - the anterior edge of the masticatory muscle, medially - nasolabial and nasobuccal folds.

Subcutaneous fat compared with other parts of the face in this area is especially developed. Bish's fat lump, corpus adiposum buccae (Bichat), delimited by a thin fascial plate, adjoins the subcutaneous tissue, which lies on top of the buccal muscle, between it and the masticatory muscle. From the fat body of the cheek, processes extend into the temporal, infratemporal, and pterygopalatine fossae. Inflammatory processes in the fatty body of the cheek, due to the presence of a capsule, are limited, but in the presence of purulent fusion (phlegmon), the swells quickly spread along the processes, forming secondary phlegmon in deep cellular spaces.

In the subcutaneous layer lie the superficial mimic muscles (the lower part of m.orbicularis oculi, m.quadratus labii superioris, m.zygomaticus, etc.), blood vessels and nerves. The facial artery (a.maxillaris externa - BNA), bending over the edge of the lower jaw at the anterior edge of the chewing muscle, rises up between the buccal and zygomatic muscles to the inner corner of the eye (here it is called the angular artery - a.angularis). On the way, a.facialis anastomoses with other arteries of the face, in particular with a.buccalis (buccinatoria - BNA) (from a.maxillaris), with a.transversa faciei (from a.temporalis superficialis) and with a.infraorbitalis (from a. maxillaris), and in the area of ​​the corner of the eye - with the terminal branches of a.ophthalmica. The facial artery is accompanied by v.facialis located behind it, and the artery usually has a tortuous course, while the vein always goes straight.

The facial vein, which in the region of the eye (here it is called the angular vein) anastomoses with the superior orbital vein, can be involved in the inflammatory process with suppuration localized on the upper lip, wings of the nose and its outer surface. Under normal conditions, the outflow of venous blood from the face occurs downward, towards the internal jugular vein. In pathological conditions, when the facial vein or its tributaries are thrombosed or squeezed by edematous fluid or exudate, the blood flow may have a different direction (retrograde) - upwards and a septic embolus can reach the cavernous sinus, which leads to the development of sinus phlebitis, sinus thrombosis, meningitis or pyemia.

The sensory nerves of the buccal region are branches of the trigeminal, namely n.infraorbitalis (from n.maxillaris) and nn.buccalis (buccinatorius - BNA) and mentalis (from n.mandibularis); the motor nerves going to the facial muscles are branches of the facial nerve.

Behind the subcutaneous tissue, superficial mimic muscles and the fatty body of the cheek is fascia buccopharyngea, deeper than which is the deep mimic muscle - buccal (m.buccinator). It starts from the upper and lower jaws and is woven into the mimic muscles surrounding the mouth opening. The buccal muscle, and often the fatty body of the cheek, is perforated by the excretory duct of the parotid salivary gland ductus parotideus.

Parotid-chewing (regio parotideomasseterica) region

The parotid-masticatory (regio parotideomasseterica) region is delimited by the zygomatic arch, the lower edge of the lower jaw, the external auditory meatus and the end of the mastoid process, the anterior edge of the masticatory muscle.

In the subcutaneous tissue are numerous branches of the facial nerve, going to the mimic muscles.

After removal of the superficial fascia, its own, the so-called fascia parotideomasseterica, opens. The fascia is attached to the bony prominences (zygomatic arch, lower edge of the lower jaw and its angle). It forms a capsule of the parotid gland in such a way that it splits at its posterior edge into two leaves, which converge at the anterior edge of the gland. Further, the fascia covers the outer surface of the masticatory muscle to its anterior edge. The parotid-chewing fascia is a dense sheet in front. It not only surrounds the gland, but also gives rise to processes penetrating into the thickness of the gland between its lobules. As a result, a purulent inflammatory process in the gland (purulent parotitis) develops unevenly and not everywhere at the same time.

Parotid gland (glandula parotis)

The parotid gland (glandula parotis) lies on the chewing muscle and a significant part of it is located behind the lower jaw. Surrounded by fascia and muscles, it, together with the vessels and nerves passing through its thickness, fills the muscular-fascial space (spatium parotideum), which is also called the bed of the gland. This space is delimited by sheets of fascia parotideomasseterica and muscles: m.masseter and m.pterygoideus (between them - the lower jaw), m. sternocleidomastoideus. In the depths of the face, this space is delimited by muscles starting from the styloid process of the temporal bone, and from below by the posterior belly of m.digastricus. At the top, the spatium parotideum adjoins the external auditory canal, the cartilage of which has cuts that allow lymphatic vessels to pass through. Here is a “weak spot” in the fascial cover of the gland, which is subject to rupture with purulent mumps, more often opening into the external auditory canal. At the bottom, the spatium parotideum is delimited from the bed of gl.submandibularis by a dense fascial sheet connecting the angle of the lower jaw with the sheath of the sternocleidomastoid muscle.

Spatium parotideum not closed on the medial side, where the pharyngeal process of the parotid gland fills the gap between the styloid process and the internal pterygoid muscle, being devoid of a fascial cover (the second “weak spot” is in the fascial case of the gland); here the process directly adjoins the anterior part of the parapharyngeal space (Fig. 4). This makes it possible for the purulent process to move from one space to another.

Rice. 4. Parotid gland and peripharyngeal space.

1 - the longest muscle of the head, 2 - sternocleidomastoid muscle, 3 - posterior belly of the digastric muscle, 4 - stylohyoid muscle, 5 - mandibular vein, 6 - external carotid artery, 7 - styloglossus muscle, 8 - stylo-pharyngeal muscle, 9 - parotid gland, 10 - parotid fascia, 11 - medial pterygoid muscle, 12 - branch of the lower jaw, 13 - chewing muscle, 14 - chewing fascia, 15 - buccal-pharyngeal fascia, 16 - parotid duct, 17 - buccal muscle, 18 - vestibule mouth, 19 - upper dental arch, 20 - incisive papilla, 21 - transverse palatine folds, 22 - suture of the palate, 23 - hard palate, 24 - palatoglossal arch, 25 - soft palate, 26 - palatopharyngeal arch, 27 - upper constrictor of the pharynx, 28 - uvula, 29 - anterior parapharyngeal space, 30 - pharyngeal space, 31 - pharyngeal tonsil, 32 - posterior peripharyngeal space, 33 - prevertebral fascia, 34 - pharyngeal-vertebral fascia, 35 - stylopharyngeal fascia, 36 - internal carotid artery, 37 - internal yoke vein. (From: Sinelnikov R.D. Atlas of human anatomy. - M., 1972.- T. II.)

The external carotid artery, the retromaxillary vein, the facial and ear-temporal nerves pass through the thickness of the gland. A.carotis externa is divided in the thickness of the gland into terminal branches:

1) a.temporalis superficialis, giving away a.transversa faciei and going, accompanied by n.auriculotemporalis, to the temporal region;

2) a.maxillaris, passing into the deep region of the face.

N.facialis forms a plexus - plexus parotideus, located closer to the outer surface of the gland. Lymph nodes (nodi parotidei) lie in the thickness of the gland and directly under its capsule.

A purulent process that develops in the parotid gland (spatium parotideum) can cause paralysis of the facial nerve or severe bleeding from vessels destroyed by pus that pass through the thickness of the gland (external carotid artery, retromaxillary vein).

The excretory duct of the parotid gland, ductus parotideus, is located on the anterior surface of the chewing muscle at a distance of 2.0-2.5 cm from top to bottom from the zygomatic arch. On its way to the vestibule of the oral cavity, the ductus parotideus pierces the buccal muscle (and often the fatty body of the cheek) near the anterior edge of m. masseter. The place where the duct flows into the vestibule of the mouth in about half of the cases lies at the level of the gap between the first and second upper molar, in about 1/4 of the cases - at the level of the second molar.

Deep area of ​​the face (regio facialis profunda)

The deep region of the face (regio facialis profunda) contains various formations related mainly to the masticatory apparatus. Therefore, it is also called the maxillo-chewing area. The basis of the region is the upper and lower jaws and the chewing muscles starting mainly from the sphenoid bone: m.pterygoideus lateralis, attached to the articular process of the lower jaw, and m.pterygoideus medialis, attached to the inner surface of the angle of the lower jaw.

By removing the branch of the lower jaw, vessels, nerves and loose fatty tissue are revealed. N.I. Pirogov was the first to describe the cellular spaces of the deep region of the face, located between the branch of the lower jaw and the tubercle of the upper jaw. He called this part of the face the intermaxillary region and distinguished two gaps here. One of them, the temporal-pterygoid gap (interstitium temporopterygoideum), is enclosed between the final section of the temporal muscle, which is attached to the coronoid process of the lower jaw, and the lateral pterygoid muscle; the other, interpterygoid gap (interstitium interpterygoideum), is enclosed between both pterygoid muscles - lateral and medial.

In both intervals, communicating with each other, pass vessels and nerves surrounded by fiber. The most superficial is the venous plexus - plexus pterygoideus. It lies for the most part on the outer surface of the lateral pterygoid muscle, between it and the temporal muscle, i.e. in the temporal pterygoid space. Another part of the plexus is located on the deep surface of m.pteryoideus lateralis. Deeper than the venous plexus and mainly in the interpterygoid space are the arterial and nerve branches.

A.maxillaris is often seen in both intervals. This is explained by the fact that three arcs are formed along the artery, of which the last two, as shown by N.I. Pirogov, are located in the interpterygoid and temporal pterygoid spaces. Numerous branches depart from the artery, of which we note some. A.meningea media penetrates through the spinous opening into the cranial cavity; a.alveolaris inferior enters the mandibular canal, accompanied by the nerve and vein of the same name; aa.alveolares superiores through holes in the upper jaw are sent to the teeth; a.palatina descendens goes to the pterygopalatine canal and further to the hard and soft palate.

N.mandibularis emerges from the foramen ovale, covered by the lateral pterygoid muscle, and soon splits into a number of branches. Of these, n.alveolaris inferior passes between the adjacent edges of both pterygoid muscles and the inner surface of the lower jaw branch, then descends to the opening of the mandibular canal; posterior to it are the same name artery and vein. N.lingualis, to which chorda tympani joins at some distance from the oval opening, lies similarly to n.alveolaris inferior, but anterior to it and, passing under the mucous membrane of the bottom of the mouth, gives branches to it and to the mucous membrane of the tongue.

The location of n.alveolaris inferior on the inner surface of the branches of the lower jaw is used to produce the so-called mandibular anesthesia. A puncture of the mucous membrane and the introduction of a solution of novocaine are performed at the same time slightly above the level of the lower molars. When removing the upper molars, anesthesia is carried out by intraoral injection of a solution of novocaine into the region of the tubercle of the upper jaw.

The transition of infection from the tooth to the jaw can lead to the development of an infiltrate that compresses the vessels and nerves passing into the bones. Compression of the n.alveolaris inferior infiltrate leads to impaired nerve conduction, resulting in anesthesia of half of the lip and chin. If v.alveolaris inferior thrombophlebitis develops, it causes swelling of the face within the corresponding half of the lower jaw and lower lip.

Branches to the masticatory muscles also arise from the mandibular nerve, in particular nn.temporales profundi; buccal nerve n.buccalis, which perforates the buccal muscle and supplies the skin and mucous membrane of the cheeks; n.auriculotemporalis, which goes through the thickness of the parotid gland to the temporal region. On the deep surface of the mandibular nerve, immediately below the foramen ovale, is the ear node, ganglion oticum, in which the parasympathetic fibers of the glossopharyngeal nerve for the parotid gland are interrupted. Postganglionic secretory fibers for this gland are part of the ear-temporal nerve and through the branches of n.facialis reach the tissue of the gland.

In the deepest part of the region, in the pterygopalatine fossa, there is a ganglion pterygopalatinum. The second branch of the trigeminal nerve also enters here, from which the pterygopalatine nerves (nn.pterygopalatini) approach the ganglion. In addition to the latter, the nerve of the pterygoid canal approaches the ganglion. From the ganglion arise nn. palatini, going through canalis pterygopalatinus to the hard and soft palate (together with a.palatina descendens), and nn.nasales posteriores, going into the nasal cavity (through foramen sphenopalatinum).

The fiber of the temporal-pterygoid and interpterygoid spaces passes into neighboring areas either directly or along the vessels and nerves. Spreading upward, it covers the temporal muscle, and then at the anterior edge of the latter passes behind the zygomatic arch into the buccal region, where this fiber is known as the fatty body of the cheek (Bish), located between the mm.masseter and buccinator. Surrounding these vessels and nerves, the tissue of the temporal-pterygoid and interpterygoid spaces reaches the openings at the base of the skull, in the direction of the back and medially, it reaches the pterygopalatine fossa and orbit. Along the course of the lingual nerve, the fiber of the interpterygoid space reaches the bottom of the oral cavity. The cellular spaces of the intermaxillary region can be involved in a purulent inflammatory process in the so-called osteophlegmons, i.e. suppuration of cellular tissue with a primary focus in the bone.

The most common cause of osteophlegmon, in particular perimandibular, are lesions of the lower molars. At the same time, the medial pterygoid muscle is involved in the process, resulting in trismus, i.e. inflammatory contracture of the named muscle, which makes it difficult to open the mouth. Further spread of the infection can lead to phlebitis of the veins of the pterygoid plexus, followed by the transition of the inflammatory process to the veins of the orbit. Suppuration of the tissue of the temporal-pterygoid space can pass to the dura mater along a. meningea media or branches of the trigeminal nerve (through the spinous, oval or round opening).

In the development of deep phlegmon, a significant role is also played by the fiber of two spaces located in the circumference of the pharynx - the retropharyngeal and peripharyngeal. The peripharyngeal space (spatium parapharyngeale) surrounds the pharynx from the sides. It is separated from the pharyngeal space, located behind the pharynx, by a lateral septum, which is formed by a fascial sheet stretched between the prevertebral fascia and the fascia of the pharynx (aponeurosis pharyngoprevertebralis).

The peripharyngeal space is enclosed between the pharynx (inside) and the bed of the parotid gland and the medial pterygoid muscle (outside). At the top, it reaches the base of the skull, and below - the hyoid bone, and m.hyoglossus is separated from the submandibular salivary gland and its capsule. In the peripharyngeal space, two sections are distinguished: anterior and posterior. The border between them is formed by the styloid process with muscles starting from it (mm.stylopharyngeus, styloglossus and stylohyoideus) and a fascial sheet stretched between the styloid process and the pharynx (aponeurosis stylopharyngea).

The anterior part of the parapharyngeal space is adjacent: from the inside - the palatine tonsil, from the outside (in the gap between the medial pterygoid muscle and the styloid process) - the pharyngeal process of the parotid gland. Vessels and nerves pass in the posterior part of the parapharyngeal space: v.jugularis interna is located outside, inside of it - a.carotis interna and nn.glossopharyngeus, vagus, accessorius, hypoglossus and sympathicus. The uppermost group of deep cervical lymph nodes is also located here.

In the anterior part of the parapharyngeal space, there are branches of the ascending palatine artery and veins of the same name, which play a role in the spread of the inflammatory process from the tonsil region (for example, with a peritonsillar abscess).

The pharyngeal space (spatium retropharyngeale) is located between the pharynx (with its fascia) and the prevertebral fascia and stretches from the base of the skull to the level of the VI cervical vertebra, where it passes into the spatium retroviscerale of the neck. Usually the pharyngeal space is divided by a septum located in the midline , into two departments - right and left (A.V. Chugay). This explains the fact that retropharyngeal abscesses, as a rule, are unilateral.

Infection of the peripharyngeal space is often observed with lesions of the seventh and eighth teeth of the lower jaw and fiber of the interpterygoid space. The transition of the purulent process from this interval to spatium parapharyngeale is possible either due to secondary infection of spatium parotideum, or through the lymphatic tract. Inflammation of the tissue of the peripharyngeal space leads to the appearance of symptoms such as difficulty swallowing, and in severe cases, difficulty breathing. If the infection from the anterior part of the spatium parapharyngeale penetrates into the posterior (destruction of aponeurosis stylopharyngea), then its further spread can occur along the spatium vasonervorum of the neck into the anterior mediastinum, and when the infection passes to the spatium retropharyngeale, along the esophagus into the posterior mediastinum.

With a purulent lesion of the tissue of the posterior part of the peripharyngeal space, there is a danger of necrosis of the wall of the internal carotid artery (with subsequent heavy bleeding) or the development of septic thrombosis of the internal jugular vein.

Cuts on the face with purulent processes.

To make incisions on the face, it is necessary to strictly follow anatomical landmarks in order to avoid possible damage to the branches of the facial nerve, leading to functional disorders and facial deformity (Fig. 5). Based on the topographic and anatomical distribution of the main branches of the facial nerve, it is necessary to choose the most “neutral” spaces between them for incisions. This requirement is met by radial incisions running from the external auditory canal fan-shaped towards the temporal region, along the zygomatic arch, to the wing of the nose, to the corner of the mouth, to the corner of the lower jaw and along its edge.

V.F. Voyno-Yasenetsky for opening phlegmon in the retromandibular region (parotitis, parapharyngeal phlegmon) recommends making an incision in the skin and fascia near the angle of the lower jaw, and penetrating deep into the blunt way (preferably with a finger). With such an incision, n.colli intersects, which does not cause significant disorders; sometimes the n.marginalis mandibulae (innervates the muscles of the chin) can be damaged. The phlegmon of the cheek in the m.masseter area, which is most often the spread of mumps, is opened with a transverse incision running from the lower edge of the earlobe (2 cm ahead) towards the corner of the mouth. The incision passes between the branches of the facial nerve; they are damaged by such incisions only in rare cases. Periomandibular phlegmon involving the buccal fat pad (corpus adiposum buccae) is recommended to be opened with an incision starting 2-3 cm outward from the wing of the nose and continuing in the direction of the earlobe by 4-5 cm. here you can damage v.facialis and stenons duct. The branches of the facial nerve are rarely damaged in such an incision. With perimaxillary phlegmon, it is better to make an incision through the mucous membrane of the vestibule of the mouth on the buccal-maxillary fold.

In the temporal region, the main typical incision should be an incision behind the frontal process of the zygomatic bone between the fan-shaped diverging temporal branches of the facial nerve.

Rice. 5. The most typical incisions on the face.

(From: Elizarovsky SI., Kalashnikov R.N. Operative surgery and topographic anatomy. - M., 1967.)

Theoretical questions for the lesson:

1. Borders, division into regions of the lateral region of the face.

2. External landmarks and projections (of the neurovascular formations, the parotid gland and its duct).

3. Buccal area of ​​the face, layered topography, contents: cheek fat body, its processes.

4. Parotid-chewing area: layered structure; parotid gland: bed, excretory duct, vessels and nerves.

5. Deep area of ​​the face: fasciae, cellular spaces, muscles, vessels and nerves.

6. Pathways for the spread of purulent-inflammatory processes and anatomical rationale for incisions in the lateral region of the face.

7. Malformations of the facial department of the head.

8. Features of primary surgical treatment of facial wounds.

Practical part of the lesson:

1. Be able to determine the projection of the main vessels and nerves of the face, the excretory duct of the parotid salivary gland.

2. Master the technique of layer-by-layer preparation of the lateral area of ​​the face.

Questions for self-control of knowledge

1. What are the boundaries and external landmarks of the lateral area of ​​the face?

2. What is the border between the parotid-masticatory and buccal regions?

3. What are the branches of the facial nerve?

4. Name the formations that are located under the capsule of the parotid salivary gland.

5. What is the structural feature of the bed of the parotid salivary gland?

6. What areas are weak spots of the gland?

7. What cellular spaces are isolated in the deep area of ​​the face?

8. List the neurovascular formations of the deep region of the face.

9. What incisions are used for purulent-inflammatory processes on the face?

10. What is trismus?

11. What complications occur when the facial nerve is damaged?

Tasks for self-control

Task 1

To drain the suppurative process from Bish's lump, the surgeon made an incision along the anterior edge of the masticatory muscle. Was the incision made correctly and what formations will the surgeon encounter?

Task 2

Can pus from the parotid salivary gland in case of purulent mumps spread into the ocolopharyngeal cellular space? If yes, then in what way?

Task 3

To drain the suppurative process of the parotid salivary gland, the surgeon made 5 incisions running from the base of the earlobe radially towards the temporal bone, to the corner of the eye, to the wing of the nose, to the corner of the mouth, to the corner of the lower jaw and along its edge. Did the surgeon make the incisions correctly?

Task 4

A patient with purulent parotitis began to have profuse erosive arterial and venous bleeding. From what vessels is bleeding possible in this case?

Task 5

A patient with purulent parotitis developed symptoms of lowering the corner of the mouth, smoothing of the nasolabial and nasolabial folds. What is the reason for their appearance?

5 (100%) 1 vote

Before proceeding with the exercises, you should get acquainted with the anatomy of the face. It is important to know what muscles we have to work on and what the structure of the face is.

Anatomical features of the face

The structure of the skull

The external appearance of a person largely depends on the facial part of the skull, which consists of the frontal, nasal, temporal, lower jaw, sphenoid, zygomatic, lacrimal and some other bones.

The shape of the bones determines its proportions, they form the relief of the face, for example, the width depends on the bone of the lower cheekbone. The size of the eyes is directly related to the size of the eye sockets. From the angle at which the bone of the nose departs from the bones of the forehead, its shape will depend.

The layers of the face do not have clear boundaries - sometimes they pass from one to another, in some cases they intertwine with each other or delaminate.

A distinctive feature of the facial muscles is that they are not attached to the skin, which means that if they become flaccid, the skin also sags. Signs of aging appear, such as bags under the eyes, a double chin and nasolabial folds.

Muscles are divided into main groups:

• chewing;
• muscles of the oral cavity and sublingual;
• mimic;
• neck and nearby areas;
• oculomotor.

This division is rather arbitrary, the same muscles can belong to one or more groups. The state of the face is more influenced by facial muscles, which have a peculiarity - they are attached to the skin at one end, and to the bones at the other.

The main task of facial muscles is to take part in the appearance of emotions on the face. Emotions are manifested due to the stretching of the skin and the formation of folds. The folds run across the direction in which the muscles contract.

Most of the muscles of the face are paired, they are located on the left and right sides of the face, which makes it possible for them to contract separately.

Muscles of the upper, middle and lower parts of the face:

• Frontal.
• surrounding eye.
• Anovrotic helmet.
• Raising the corner of the mouth - lowering the corner of the mouth.
• Large zygomatic - small zygomatic.
• Temporal.
• Rhizorius.
• Chin.
• Raising the upper lip.
• Surrounding the mouth.
• Muscles of the cheeks.
• Chewing.
• Superficial necks.

With age, muscle tone weakens, they narrow and become smaller in volume. To maintain attractiveness for a long time, you should train your muscles even before the appearance of wrinkles. Face-gymnastics exercises give a stable and stable result.

lymphatic system

Lymph is a colorless liquid that seeps through the thin walls of capillaries and passes through the entire body. The role of lymph is to remove toxins, with its help, the exchange of useful substances between the circulatory system and tissues takes place. It is a reliable protection against infection.

The lymphatic system consists of nodes and vessels that are located along the course of the lymph nodes. In the facial area are located on the cheeks, cheekbones or chin. There are several groups of lymph glands:

• chin;
• facial (buccal, mandibular and nameless);
• submandibular;
• superficial and deep parotid.

The chin and submandibular are located in the neck and chin. The location of the lymph nodes on the face depends on how developed the facial muscles and subcutaneous tissue are, as well as on the genetic predisposition.

The skin is an important organ that has many functions, including aesthetic, and the appearance of a person largely depends on its condition. To properly care for the skin, you should know the anatomy of the structure of the cover. It has a multilayer structure:

1. The outer layer is the epidermis, it consists of layers:

• germinal (or basic) - melanin is present in it;
• spiny - lymph flows in this layer, with its help cells are supplied with useful elements and waste products are removed;
• granular layer, contains the substance keratohyalin;
• transparent layer - it contains the protein substance eleidin.

In the upper, stratum corneum, keratin is formed. The cells of this layer gradually exfoliate and die off, new ones appear in their place.

The main role of the epidermis is to protect against microbes, fungi and viruses, damage, sunlight and cold. The epidermis is involved in thermoregulation and protects against moisture loss.

2. Derma. Beneath the epidermis is the dermis, which consists of the papillary and reticular layers. Collagen and elastin are produced in the dermis, they give the skin elasticity, make it strong and elastic.

This layer contains sweat glands that help regulate temperature. As well as the sebaceous glands, which are involved in the synthesis of fat, which ensures the impermeability of the dermis from moisture.

3. Adipose tissue. It is permeated with blood vessels and nerve endings. This layer contains nutrients, without which the epidermis would not be able to function normally. An important role of the subcutaneous fat layer is to provide thermoregulation.

The structure of the skin is different in different areas, on the face it is the most tender and mobile due to the striated muscles.

In the human body, everything is closely connected - any disease can affect the state of the upper layer of the epidermis. Therefore, it is important not only to carefully care for the skin itself, but the right lifestyle.

Vascular and nervous tissue of the face

In the facial area, the vessels form a well-developed network, which makes it possible for wounds to heal quickly enough.

The blood supply to the face is mostly carried out through the external arteries. They pass under the facial muscles from the neck to the face, bending around the lower jaw from below, then go to the corners of the lips and further to the eye sockets.

The largest branch goes to the corners of the upper and lower lips. Another artery passes through the zygomatic arch. The deep parts of the face supply the branches of the maxillary artery.

Venous blood passes through superficial and deep vascular networks. Almost throughout the veins are located in two layers, with the exception of the forehead.

The external veins penetrate the subcutaneous adipose tissue, forming multi-loop networks. Their thickness varies from person to person. This also explains the difference in bleeding from wounds or during surgical operations - some people have a little bleeding, others profuse, which is difficult to stop.

Superficial veins, through which the blood of the skin flows, flows into a vein that runs parallel to the branches of the arteries of the face.

Deep veins carry blood to the pterygoid venous plexus. From here it is diverted along the maxillary vein to the mandibular vein.

facial nerves

The task of the facial nerve is to provide the motor function of the face, but it also has taste and secretory fibers.

The facial nerve consists of:

1. From the nerve trunk (more precisely, its processes).

2. Nuclei (between the bridge and the medulla oblongata).

3. Lymph nodes and capillaries that feed the nerve cells.

4. Spaces of the cerebral cortex.

The facial nerve is divided into branches - temporal, zygomatic, buccal, mandibular and cervical, and the trigeminal nerve - into the maxillary, mandibular and optic.

Looking much younger than your age is not so difficult - you need to be able to take care of yourself: do massage, gymnastics, use cosmetics. After all, there is not always time and opportunity to turn to a professional cosmetologist. But in order to do everything right and not harm yourself, you should know the anatomy of the face.

Ruddy, rosy-cheeked, blood with milk - this is how our great-grandfathers spoke about young, beautiful girls. Ideas about beauty change over time, and what at a young age, due to closely spaced vessels, was considered a healthy complexion, over the years can turn into an uneven blush with telangiectasias.

Or, on the contrary, excessive pallor is often perceived as a painful condition. But at any age, the influence of blood circulation in the skin on the processes of its aging remains unchanged.

FACTORS OF YOUTH SKIN

The youthfulness of the skin is often determined by subjective parameters, such as color. However, skin color is due to several factors: RED - the presence of oxidized hemoglobin in the capillaries, BLUE - reduced hemoglobin in the veins, yellow skin color depends on the content of carotenoids, and BROWN - on the content and distribution of melanin in it. The ratio of pigments in the skin determines its shade.

Another important parameter of youthful skin is its ELASTICITY and MOISTURE, and these factors depend on the effective blood supply to the skin of the face. It is carried out by the facial artery, which branches off from the carotid. Inside the skin itself, blood supply occurs due to two intradermal circulatory networks: deep and superficial.

A deep flat network with larger arteries is located in the hypodermis, small arteries form a superficial circulatory network that passes through the dermis and rises to the epidermis. The venous vessels run parallel to the arterial ones and also form two layers - upper and lower. These two vascular systems, as well as the lymphatic capillaries, form the microvasculature of the skin.

The state of the microcirculatory bed determines a number of age-related changes. Complexion, skin hydration, wrinkle depth, the presence of pastosity, gravitational deformation of the face - all these factors largely depend on microcirculation disorders.

MANIFESTATIONS OF SKIN AGING

With age, the blood supply to the skin worsens, the dermo-epidermal interaction weakens, the basement membrane loses its waviness, the number of skin capillaries and the thickness of the epidermis decrease, the proliferation of keratinocytes slows down, the intensity of free radical reactions increases, the number of melanocytes decreases, skin dryness occurs and the epidermal barrier is disturbed.

Involutive changes in the dermis are expressed in its atrophy, reduction in the number of mast cells, fibroblasts, collagen, glycosaminoglycans, and blood vessels. The most common age-related processes that affect skin aging are described below.

Hormonal aging. It is known that estrogens stimulate the proliferation of keratinocytes, promote skin repair, restore the epidermal barrier, stimulate the synthesis of melanin, and have antioxidant activity. These hormones activate the secretion of mucopolysaccharides and hyaluronic acid, "flooding" the dermis and contributing to its thickening. Estrogens also stimulate collagen synthesis, maintaining skin turgor, promote vasodilation and enhance skin vascularization.

Androgens stimulate the proliferation of keratinocytes, have a positive effect on the processes of skin repair and pigmentation. As soon as the production of these hormones is disturbed with age, skin aging immediately manifests itself.

Chronoaging(biological, related to age). In this case, the following processes predominate in the skin:

• tissue regeneration slows down;
• the thickness of the epidermis decreases;
• the border between the dermis and the epidermis thickens;
• the number of blood vessels decreases;
• the number of Langerhans cells and melanocytes decreases;
• the amount of collagen decreases (by 1% annually), elastin and ground substance (due to a decrease in the number of fibroblasts).

Photoaging(associated with the influence of the external environment, especially UVI) is manifested by the following features:

• hyperkeratosis;
• age spots (solar lentigo);
• elastosis (thickening of the dermis due to increased synthesis of altered elastic fibers);
• a decrease in the amount of collagen in the dermis (associated with the destruction of its MMPs, which are activated under the influence of ultraviolet radiation);
• some vessels are obliterated, the rest are significantly expanded, forming telangiectasias;
• Langerhans cells are damaged, and immunological protection is also reduced.

SKIN AGING MORPHOTYPES

According to the classification of aging morphotypes proposed by Tiina Orasmäe-Meder and Ekaterina Glagoleva in the article “Improvement of skin microcirculation as part of the aesthetic correction of external manifestations of aging”, four main aging morphotypes are distinguished in relation to disorders in the microcirculatory bed:

• "tired";
• finely wrinkled;
• deformation;
• muscular.

"TIRED" morphotype- is considered the most favorable option, a kind of marker of the physiological course of aging. This option is typical for thin women with an oval or diamond-shaped face.

Skin characteristic: initially normal or prone to dryness, subcutaneous fat is moderately developed, there is an infraorbital and/or nasopharyngeal (cheek-zygomatic) groove, moderate ptosis of the lower third of the face, nasolabial folds and “marionette wrinkles” of medium depth are observed. Muscle tone and skin turgor are reduced. Ptosis and deformation changes are not expressed, manifestations of photoaging of the skin are moderate. These changes give the face a tired, tired look, which is most evident in the evening.

Correction methods: in aesthetic correction, it is recommended to use basic care with modeling, collagen, thermoactive masks, cryotherapy, vacuum-roller massage, microcurrents. This type of skin responds well to mechanical stimulation - microdermabrasion , mesoscooters. Mesotherapy is performed with vitamin antioxidant cocktails, biorevitalization is carried out with boosters. Glycolic peels up to 70%, TCA peels 15-20%, fractional photothermolysis are recommended. Mesothreads are an effective method of correction for this morphotype.

FINE-WRIPPED morphotype- women with such skin have an oval face in their youth, with age this shape persists, rarely approaches a rectangular one. Among them, asthenics predominate, who do not have a tendency to overweight.

Skin characteristics: thin, sensitive, often dry; subcutaneous fat is poorly expressed, wrinkles are present in large numbers - from small to deep, moderate ptosis of the lower third of the face is noted. Muscle tone is reduced slightly, and therefore the sagging of the soft tissues of the face is weakly expressed. Finely wrinkled type closely correlates with manifestations of skin photoaging.

Methods of correction: Moisturizing, nourishing and brightening programs predominate in basic care. Recommended iontophoresis, phonophoresis with moisturizing, stimulating serums, microcurrents. Peelings are gentle, combined (with acids: glycolic - up to 30%, salicylic - 2-5%, lactic, kojic, phytic, with resorcinol), hydrodermabrasion and fractional photothermolysis are useful, mesotherapy with active regenerating and stimulating cocktails with growth factors, biorevitalization , plasmolifting.

DEFORMATION morphotype- aging with this morphotype is characterized by the predominance of swelling of facial tissues, lymphostasis phenomena, severe flabbiness, especially in the lower third of the face. Along with this, wrinkling and pigmentation disorders are not typical, the skin is quite dense, shiny, sometimes porous; facial features are large.

Characteristics of the skin: in women with a deformation morphotype, a pronounced skin reaction is observed in response to damage, which is manifested by a tendency to swelling and inflammation; deformity of the lower third of the face, nasolabial folds may eventually merge with "marionette wrinkles", a double chin is often present. Some women may have pronounced reddening of the cheeks due to persistently dilated small vessels (couperosis), telangiectasias can often be found. This morphotype of aging usually manifests itself in women with a dense physique, prone to fullness. Excessive subcutaneous fat layer on the face leads to a pronounced deformation of its contours, the formation of a second chin, “flaws”, folds on the neck, bags under the eyes and overhanging upper eyelids.

Correction methods. Basic care necessarily includes lymphatic drainage massages, contrast compresses, cryotherapy, microcurrents, vacuum-roller stimulation (in the absence of rosacea). Peelings are recommended combined superficial-median and median. When carrying out mesotherapy in the lower third of the face, not only the usual tightening, but also lipolytic cocktails are used: silicon 0.5% + hofitol + procaine, L-carnitine + procaine, phosphatidylcholine + deoxychol and new acid, as well as ready-made cocktails for the treatment of local lipodystrophy ( Mesoline). In this case, the skin is taken in a fold so that the solution enters directly into the hypodermis. Mesothreads are used to create a frame supporting mesh.

MUSCULAR morphotype- not typical for the Slavs. As a rule, representatives of the Mongoloid race grow old this way. It is mainly characterized by a violation of pigmentation, wrinkling of the eyelids, pronounced nasolabial folds, “puppet wrinkles”. At the same time, the skin of the cheeks remains even and smooth, and the oval of the face remains unchanged until old age. This is due to the fact that in individuals of the muscular type, facial muscles are well developed in combination with a genetically small amount of subcutaneous fat.

In women over 55 years of age, the listed aging morphotypes are mixed, and, as a rule, one can already speak of their combined types with the predominance of one or another type of aging.

As a percentage, the frequency of the occurring morphotype can be represented as follows:

• fine wrinkled - 10.7%;
• "tired" - 26.4%;
• deformation - 62.1%.

The more pronounced the signs of skin aging, the more important it is to improve the blood supply to the skin of the face.

METHODS FOR IMPROVING FACE SKIN MICROCIRCULATION

Considering possible options for improving microcirculation, it is necessary to divide them into groups depending on the main acting factor:

• hardware (microcurrents, vacuum, ultrasound, darsonval, fractional photothermolysis) and non-hardware (basic care, massage, cryotherapy);
• invasive (mesotherapy, mesoscooters, plasmolifting, mesothreads) and non-invasive (peelings).

On the front of the head(in the face area) allocate the anterior and lateral regions. To anterior region include the mouth, orbit, nose, chin and infraorbital regions. ATside area includes the buccal, parotid-chewing, zygomatic regions and the deep region of the face (Fig. 2).

Rice. 2.

1 - small supraclavicular fossa; 2 - scapular-clavicular triangle; 3 - scapular-trapezoid triangle; 4 - sternocleidomastoid region; 5 - sublingual region; 6 - sleepy triangle; 7 - submandibular triangle; 8 - supradiolingual region; 9 - chin area; 10- mouth area; 11 - buccal region; 12 - nose area; 13 - fronto-parieto-occipital region; 14 - Temple area; 15 - region of the eye socket; 16 - infraorbital region; 17 - zygomatic area; 18- parotid chewing area

Layered structure of the soft tissues of the face

Leather the face is thin and mobile, contains a large number of sweat and sebaceous glands. In men, the skin of the chin, upper and lower lips is covered with hair. Areas of least facial skin tension (Langer lines) correspond to the locations of skin folds (eg, chin-labial or nasolabial) or wrinkles that appear in old age. To achieve a cosmetic effect, skin incisions on the face should be made parallel to the Langer lines. The facial skin is innervated by the terminal branches of the trigeminal nerve and the cutaneous branch from the cervical plexus:

• the skin of the upper eyelid, back of the nose and forehead is innervated by branches of the optic nerve (from the 1st branch of the trigeminal nerve);
• in the skin of the lower eyelid, nose wing, anterior cheeks and zygomatic region, the terminal branches of the infraorbital and zygomatic nerves (from the 2nd branch of the trigeminal nerve) end;
• innervation of the skin of the posterior parts of the cheek, lower lip and chin, partially of the auricle and external auditory canal is carried out by the branches of the mandibular nerve (3rd branch of the trigeminal nerve);
• the skin of the parotid-masticatory region above the parotid gland is innervated by the large ear nerve (a branch of the cervical plexus).

Subcutaneous tissue well developed. The superficial fascia (a continuation of the superficial fascia of the neck) divides it into two layers. In the superficial layer lie the skin nerves and there are partitions that go to the skin. These partitions divide the surface layer into separate compartments: nasolabial; medial, middle and lateral temporo-buccal; upper, lower orbital, etc. With age, the decrease in the volume of fiber in the compartments occurs at different rates, as a result of which the contours of the face change, the smooth transition between concavities and convexities, usually associated with youth and beauty, disappears. Due to the superficial fascia, cases are formed for the outer layer of facial muscles. Together with the muscles, the fascia forms a single superficial musculoaponeurotic system (English, superficial muscu- loaponeurotic system - SMAS), which is associated with the skin and ensures the integrated functioning of facial muscles. The plastic of this system is performed during the cosmetic surgery SMAS -lifting, performed for the purpose of surgical correction of age-related changes in the face.

Facial muscles (mimic muscles) located mainly around the natural openings of the skull. Some of them lie circularly and narrow the openings, while others, on the contrary, are oriented radially and expand the entrance to the orbit, nasal and oral cavities. The muscles of the face lie in two layers. Surface layer form circular muscle of the eye; muscle that lifts the upper lip and nose wing; muscle that raises the upper lip; muscle that lowers the lower lip; muscle that lowers the corner of the mouth; big and small zygomatic muscle; laughter muscle; subcutaneous muscle of the neck and circular muscle of the mouth. AT deep layer lie muscle that raises the corner of the mouth, buccal and chin muscles. The branches of the facial nerve enter the muscles of the superficial layer from the inner surface, while they approach the muscles of the deep layer from their outer surface. Between the anterior surface of the body of the upper jaw and the muscles of the face that make up the upper lip (the muscle that lifts the upper lip and the muscle that raises the corner of the mouth), there is a cellular canine fossa space. Along the course of the angular vein and along the infraorbital canal, it communicates with fatty body of the orbit. Outside of the buccal muscle, covered bucco-pharyngeal fascia, located intermuscular space of the cheek(English) buccal space- buccal space). It is limited: in front - by the muscles that form the corner of the mouth; outside - the muscle of laughter and the subcutaneous muscle of the neck; behind - the front edge of the masticatory muscle. Space contains cheek fat body encapsulated adipose tissue. It is especially well developed in children. The fatty body of the cheek has temporal, orbital and pterygopalatine processes, which penetrate into the corresponding topographic and anatomical areas of the head and can serve as conductors of inflammatory processes of an odontogenic nature.

AT subcutaneous tissue and between facial muscles arteries, veins and nerves lie:

• facial artery (a. facialis) - hits the face, bending over the base of the lower jaw at the intersection with the anterior edge of the masseter muscle (about 4 cm anterior to the angle of the lower jaw). At this point, you can palpate its pulsation. Further, the artery goes to the medial corner of the eye, giving off branches along the way to the upper and lower lips (in this place the artery is strongly tortuous). First, the vessel lies in the subcutaneous tissue, and its final branch (angular artery) - in the interval between the facial muscles;
• infraorbital artery (a. infraorbitalis) - is the terminal branch of the maxillary artery. It exits to the surface of the face through the infraorbital foramen, which is projected to the width of a finger below the point of intersection of the infraorbital margin with a vertical line drawn through the middle of the crown of the second upper premolar. The infraorbital foramen lies in line with the supraorbital notch and mental foramen. The branches of the artery go to the medial corner of the eye, the lacrimal sac, the wing of the nose and the upper lip;
• facial vein(v. facialis)- originates from the medial angle of the eye and behind the artery of the same name goes to the base of the lower jaw. Her face tributaries are angular, supratrochlear, supraorbital veins of the lower eyelid, external nasal veins; upper and lower labial veins; branches of the parotid gland, external palatine, submental vein and deep vein of the face. In the region of the medial angle of the eye, the angular vein anastomoses with nasolabial vein from the system superior ophthalmic vein which empties into the cavernous sinus. Deep vein of the face connects the facial vein with pterygoid plexus, which through the venous plexus of the oval and ragged holes is connected with the cavernous sinus. Venous anastomoses are a potential route for hematogenous spread of infection in acute inflammatory processes (boils, carbuncles, phlegmon) localized on the face above the level of the mouth. In connection with the developing edema and compression of the facial vein, the outflow of blood is carried out retrograde, as a result of which sinus thrombosis may develop. Retrograde blood flow is facilitated by the absence of valves in the facial vein;
• infraorbital nerve (P. infraorbitalis)- branch of the maxillary nerve; enters the face through the infraorbital foramen along with the artery of the same name and splits fan-shaped into terminal branches forming a small "crow's foot";
• mental nerve (p. mentalis) - terminal branch of the inferior alveolar nerve mandibular nerve); goes to the surface of the face through the hole of the same name, which is projected in the gap between the alveolar elevations corresponding to the root of the first and second premolars in the middle of the distance between the base of the lower jaw and the upper edge of its alveolar part;
• stem exit point lfacial nerve (p. facialis) from the skull is 1 cm deep from the point of attachment of the posterior belly of the digastric muscle to the mastoid process of the temporal bone. Below the stylomastoid foramen from the facial nerve depart posterior auricular nerve(innervates the ear muscles and the occipital belly of the occipital-frontal muscle), the digastric and stylohyoid branches. Then, in the thickness of the parotid gland, the facial nerve forms the parotid plexus. Branches originate from this plexus, which emerge from under the anterior edge of the parotid gland and spread in the radial direction, localizing in the gap between the superficial and deep layers of the facial muscles. Temporal branches cross the zygomatic arch and go to the muscles located above the palpebral fissure and near the auricle. zygomatic branches go to the lateral corner of the eye, innervate the lateral part of the circular muscle of the eye and the muscles of the face, located between the eye and oral fissures. buccal branches go horizontally forward and below the infraorbital edge form a plexus that innervates the buccal muscle and facial muscles located around the oral fissure. Due to the anatomical proximity of the buccal branches and the excretory duct of the parotid gland, these anatomical structures can be damaged simultaneously. marginal branch the lower jaw provides innervation of the facial muscles located below the oral fissure. cervical branch lies below the base of the lower jaw and goes to the subcutaneous muscle of the neck (enters the muscle from its inner surface).

Own (deep) fascia of the face includes in its composition masticatory fascia and fascia of the parotid gland. The superficial and deep fascia of the face are tightly adjacent to each other along the zygomatic arch, parotid gland and the anterior edge of the masticatory muscle, and loose tissue separates them for the rest. Under the deep fascia of the face are the parotid gland, its excretory duct, the branches of the facial nerve and the fatty body of the cheek.

The bone basis of the face is made up of the upper and lower jaws, the zygomatic and nasal bones.

• To prevent nerve damage, the upper border of the incisions during surgical operations on the neck should not be higher than the line connecting the mastoid process and the angle of the lower jaw.

In this article, we will look at the topography of blood vessels and nerves in relation to the muscles of the face, but we will go from deep layers to superficial ones.

Rice. 1-41. The external carotid artery passes anterior to the auricle and continues into the superficial temporal artery, which divides into parietal and anterior branches. Also, the maxillary and facial branches depart from the external carotid artery, most of which are not visible when viewed from the front. departs from the external carotid and, bending over the edge of the lower jaw, goes to the corner of the mouth, where it gives off branches to the upper and lower lips, and itself goes up and inward to the inner corner of the palpebral fissure. The section of the facial artery passing lateral to the external nose is called the angular artery. At the inner canthus, the angular artery anastomoses with the dorsal nasal artery, which originates from the supratrochlear artery, which, in turn, is a branch of the ophthalmic artery (from the system of the internal carotid artery). The main trunk of the supratrochlear artery rises to the middle of the forehead. The region of the superciliary arches is supplied with blood by the supraorbital artery, which emerges from the supraorbital foramen. The infraorbital region is supplied with blood by the infraorbital artery, which emerges from the foramen of the same name. The mental artery, which arises from the inferior alveolar artery and emerges from the mental foramen, nourishes the soft tissues of the chin and lower lip.

Rice. 1-42. The veins of the forehead form a dense, variable network and usually merge anteriorly into the supratrochlear vein, also called the frontal. This vein runs in the midface medially from the orbit to the edge of the mandible and eventually joins the internal jugular vein. The name of this vein varies depending on the anatomical region. On the forehead, it is called the frontal vein. In the region of the glabella, it connects with the supraorbital vein, and medially from the orbit - with the superior orbital, thus providing an outflow from the veins of the orbit and the cavernous sinus. Near the bony part of the external nose, it connects with the veins of the upper and lower eyelids (venous arch of the upper and lower eyelids) and is called the angular vein. On its way along the external nose, it collects blood from the small veins of the nose and cheeks, and also anastomoses with the infraorbital vein emerging from the infraorbital foramen. In addition, blood from the zygomatic region enters this vein through the deep vein of the face. On the cheek, the main vein connects with the superior and inferior labial veins and is called the facial vein. Connecting with the veins of the chin, the facial vein bends over the edge of the lower jaw and flows into the internal jugular vein on the neck. The veins of the parietal region unite into the superficial temporal vein, which, in turn, flows into the external jugular vein.

Rice. 1-43. The face is innervated by fibers of the trigeminal (mainly sensory fibers; motor fibers innervate the masticatory muscles) and facial nerves (motor fibers). In addition, the large ear nerve, which belongs to the spinal nerves, takes part in the sensitive innervation of the face.
The trigeminal nerve (5th pair of cranial nerves, CN V) has three branches: the ophthalmic (CN V1), maxillary (CN V2), and mandibular (CN V3) nerves.

The ophthalmic nerve divides into the frontal, lacrimal, and nasociliary nerves. The frontal nerve runs in the orbit above the eyeball and divides into the supratrochlear and supraorbital nerves. The supraorbital nerve has two branches, the larger one, the lateral one, exits the orbit to the face through the supraorbital foramen or supraorbital notch and innervates the skin of the forehead up to the crown, as well as the conjunctiva of the upper eyelid and the mucous membrane of the frontal sinus. The medial branch of the supraorbital nerve exits the orbit medially through the frontal notch and branches in the skin of the forehead.
Another branch of the frontal nerve, the supratrochlear nerve, exits at the inner canthus and innervates the skin of the nose and conjunctiva.

The outer corner of the palpebral fissure is innervated by the lacrimal nerve. It separates from the optic nerve in the cavity of the orbit and, before leaving it, gives branches to the lacrimal gland. The nasociliary nerve, a branch of the ophthalmic nerve, gives off the anterior ethmoid nerve, the terminal branch of which, the external nasal nerve, in turn passes through the cells of the ethmoid labyrinth.

Through the infraorbital foramen, the infraorbital nerve, a large branch of the maxillary nerve (CN V2), exits to the face. Its other branch, the zygomatic nerve, passes laterally in the orbit and enters the zygomatic region through separate canals in the zygomatic bone. The zygomatic-temporal branch of the zygomatic nerve innervates the skin of the temple and forehead. The zygomatic-facial branch of the zygomatic nerve exits through the zygomatic-facial foramen (sometimes there may be several openings) and branches in the skin of the cheekbone and lateral canthus.

The auricular-temporal nerve, a branch of the mandibular nerve, runs under the foramen ovale. Having passed along the inner surface of the lower jaw branch, it goes around it from behind, innervates the skin in the region of the condylar process and the external auditory canal, perforates the parotid salivary gland and ends in the skin of the temple. The maxillary teeth are innervated by the maxillary nerve. The teeth of the mandible are innervated by the inferior alveolar nerve, which originates from the mandibular nerve (CN, V3) and enters the mandibular canal through the mandibular foramen. The branch of the mandibular nerve emerging from the mental foramen is called the mental nerve; it provides sensitive innervation to the skin of the chin and lower lip.

Mimic muscles are innervated by the facial nerve(CHN V2). It emerges from the stylomastoid foramen and gives off numerous branches to the muscles of the face. The branches of the facial nerve include the temporal branches going to the temporal region and innervating the muscles of the forehead, temple and eyelids; zygomatic branches innervating the zygomatic muscles and muscles of the lower eyelid; buccal branches to the muscles of the cheeks, the muscles surrounding the oral fissure, and the muscle fibers around the nostrils; the marginal mandibular branch innervating the muscles of the chin, and the cervical branch to the platysma.

Rice. 1-44. General view of the arteries, veins and nerves of the face.

Rice. 1-45. Deep arteries, veins (right) and nerves of the face (left).

Rice. 1-45. Vessels and nerves of the face, passing in the bone canals and openings, are located close to each other. On the right half of the face, deep arteries and veins and their outlets to the face are shown. Branches of the ophthalmic artery from the system of the internal carotid artery pass through the septum of the orbit in one or several places - the supratrochlear artery and the medial arteries of the eyelids (pass through the upper edge of the septum). The veins of the face also pass through the septum of the orbit, forming the superior ophthalmic vein.

The supraorbital artery and vein pass through the supraorbital foramen. Sometimes this hole may be open and called the supraorbital notch, by analogy with the medially located supratrochlear notch, through which the supratrochlear artery and vein pass. Even more medially, the branches of the dorsal artery of the nose and the upper branches of the ophthalmic artery pass, connecting with the arterial arch of the upper eyelid. Venous outflow is carried out in the superior ophthalmic vein.
From the ophthalmic artery to the lower eyelid, the lateral and medial arteries of the eyelids depart, forming the arterial arch of the lower eyelid and giving branches to the back of the nose. All arterial branches are accompanied by veins of the same name. The infraorbital artery and vein pass through the infraorbital foramen. They branch out in the tissues of the lower eyelid, cheek, and upper lip and have many anastomoses with the angled artery and vein.

Through the zygomatic-facial opening, the zygomatic-facial vessels enter the face.

Through the mental foramen, which opens the canal of the lower jaw, the mental branches of the mandibular artery and nerve pass. Through the same opening, the mental branch of the inferior alveolar vein enters the canal of the lower jaw. In the figure, the facial artery and vein at the edge of the lower jaw are crossed. At the lower edge of the zygomatic arch, the transverse artery of the face is shown. The superficial temporal artery and vein were transected at the entrance to the temporal fossa.
The exit points of the nerves are also shown on the left half of the face. The supraorbital nerve passes through the supraorbital foramen, extending from the ophthalmic nerve (the first branch of the trigeminal nerve CN V1), which provides sensitive innervation of the supraorbital region. Inside the orbit, the supratrochlear nerve departs from the optic nerve, which, passing through the hole in the orbital septum (septum), divides into medial, lateral, and palpebral branches. Through the infraorbital canal, which opens with the infraorbital foramen, passes the infraorbital nerve, a branch of the maxillary nerve (the second branch of the trigeminal nerve, CN V2). It provides sensory innervation to the lower lip, cheeks and partially to the nose and upper lip.

Thus, the lower eyelid is innervated by two nerves: the palpebral branch of the subtrochlear nerve (from the ophthalmic nerve) and the lower palpebral branches of the infraorbital nerve (from the maxillary nerve).

The zygomaticofacial nerve exits the face from the foramen of the same name and provides sensory innervation to the zygomatic region. The mental nerve exits the mandibular canal through the mental foramen and carries sensory fibers to the mental region and lower lip. To avoid loss or disturbance of sensation in the lower lip due to damage to this nerve during complicated extraction of the wisdom tooth and osteotomy of the mandibular branch, it is necessary to know its topography in the mandibular canal well.

Rice. 1-46. Separate branches of the supratrochlear and supraorbital arteries and veins run very close to the bone and are covered with fibers of the muscle that wrinkles the eyebrow. Other branches run in a cranial direction above the muscle. The lateral and medial branches of the supraorbital and supratrochlear nerve go under and over the fibers of the muscle that wrinkles the eyebrow, and also through them. The motor innervation of this muscle is provided by the anterior temporal branches of the facial nerve (CN VII).
The temporal muscle is supplied with blood by the deep temporal arteries and veins. Sensitive innervation of this area is carried out by the deep temporal nerve (from CN V3). The muscle receives motor innervation from the temporal branches of the facial nerve.

The superficial temporal artery and vein, together with the temporal branches (from the facial nerve), run above the zygomatic arch and are crossed in this figure.

Vessels and nerves emerging from the infraorbital foramen (artery, vein, and infraorbital nerve) supply the area around it, and also branch into the tissues of the lower eyelid (branches of the lower eyelid), muscles of the nose, and upper lip.
The facial artery and vein bend over the edge of the lower jaw anteriorly from. Medially, they cross the buccal muscle and arcuately branch in an oblique direction, located more superficially than the branches of the infraorbital artery and vein. At the intersection of the branches of the lower jaw, the pulsation of the artery is palpated.
The buccal muscle is innervated by the buccal branches of the facial nerve.

The neurovascular bundle of the mandibular canal enters the face through the mental foramen. The mental artery, the mental branch of the inferior alveolar vein and the nerve of the same name branch in the soft tissues of the lower lip and chin. The motor innervation of the adjacent muscles is carried out by the marginal branches of the lower jaw, extending from the facial nerve (CN V2).

Rice. 1-47. Topography of arteries and veins (right half) and nerves of the face (left half) in relation to facial muscles.

Rice. 1-47. The branches of the supratrochlear and supraorbital arteries and veins pass through the frontal belly of the occipital-frontal muscle. The lateral and medial branches of the supratrochlear and supraorbital nerves pass through and over the muscle. The motor innervation of this muscle is carried out by the anterior temporal branches of the facial nerve.
The dorsum of the nose is innervated by external nasal branches arising from the anterior ethmoid nerve. This nerve passes between the nasal bone and the lateral cartilage of the nose and runs along the surface of the cartilage. In the wings of the nose, branches of the infraorbital nerve (external nasal branches) branch. The motor innervation of the muscles is carried out by the zygomatic branches of the facial nerve (CN V2).

Rice. 1-48. Topography of arteries and veins (right half) and nerves of the face (left half) in relation to facial muscles.

Rice. 1-48. Additional venous outflow from the forehead is carried out through additional branches of the supratrochlear nerve.
The circular muscle of the eye, covering the septum of the orbit (septum), is supplied with blood by thin branches of the medial and lateral arteries of the eyelids, and the venous outflow is carried out through the venous arches of the upper and lower eyelids. The lateral artery of the eyelids originates from the lacrimal artery, and the medial artery from the ophthalmic artery. Both of these arteries belong to the system of the internal carotid artery. Venous blood from the upper and lower eyelids flows into the veins of the same name, which flow medially into the angular vein, and laterally into the superior ophthalmic (upper eyelid) and inferior ophthalmic veins (lower eyelid).
Through the muscle of the proud and the muscle that lowers the eyebrow, which are located in the glabella and supraorbital region, the lateral and medial branches of the supratrochlear nerve pass. The motor innervation of the muscles is obtained from the temporal branches of the facial nerve (CN, V2).

The muscles of the nose are supplied with blood by branches of the angular artery. Somewhat cranial to the angular artery, its terminal branch departs - the dorsal artery of the nose. Venous blood flows through the external nasal veins, which empty into the angular vein. Also, part of the venous blood flows into the infraorbital vein. Sensitive innervation is carried out by branches of the external nasal nerve, extending from the ethmoid nerve (branch of the frontal nerve), motor innervation of the adjacent muscles - by the zygomatic branches of the facial nerve.

The muscle that raises the angle of the mouth, covering the upper and lateral parts of the circular muscle of the mouth, is supplied with blood by the facial artery and vein, and is innervated by the upper labial branches, which extend from the infraorbital nerve that runs along the surface of this muscle.

The chin opening is closed by a muscle that lowers the lower lip.

Rice. 1-49. Topography of arteries and veins (right half) and nerves of the face (left half) in relation to facial muscles.

Rice. 1-49. Venous outflow from the superficial epifascial layers of the forehead and parietal region is carried out through the parietal branches of the superficial temporal vein. Here it also anastomoses with the supratrochlear vein. The main artery in this area is the superficial temporal artery. At the inner corner of the palpebral fissure, the angular vein connects with the supratrochlear one. Thus, the superficial veins of the face are connected to the superior ophthalmic vein, which opens into the cavernous sinus. It is also possible to connect with the subtrochlear vein, which is also called the nasolabial. The external nasal vein collects blood from the back of the nose and opens into the angular vein.

The angular vein accompanies the medial angular artery. Upon reaching the muscle that raises the upper lip, the vein passes above it, and the artery - below it.

Blood from the upper lip flows into the superior labial vein, which, in turn, connects to the facial. The infraorbital vein enters the infraorbital foramen, closed by the muscle that lifts the upper lip. Its branches connect with the branches of the angular vein and thus connect the superficial veins of the face with the pterygoid venous plexus. Blood from the lower lip drains into the facial vein through the inferior labial vein. The arterial blood supply of the upper lip is carried out by the upper labial, and the lower lip by the lower labial arteries. Both of these vessels depart from the facial artery. The lower lateral part of the chin is closed by a muscle that lowers the corner of the mouth, which receives motor innervation from the marginal mandibular branch of the facial nerve. Sensitive innervation of this area is carried out by branches of the mental nerve, extending from the inferior alveolar nerve.

Rice. 1-50. Topography of arteries and veins (right half) and nerves of the face (left half) in relation to facial muscles.

Rice. 1-50. In the forehead area, the supratrochlear vein also forms anastomoses with the anterior branches of the superior temporal vein.
The angular artery and vein pass in a long groove between the muscle that lifts the upper lip and wing of the nose and the circular muscle of the eye and is partially covered by the medial edge of the latter. The facial vein runs under the levator lip muscle, and the artery runs above it. Both of these vessels pass under the zygomaticus minor muscle, with the exception of individual arterial branches, which can run along the surface of the muscle, and then pass under the zygomaticus major muscle. The topography of neurovascular formations in this area is very variable.
Further, the artery and vein are located in the space between the masticatory muscle and the muscle that lowers the corner of the mouth, and cross the lower edge of the lower jaw.

Rice. 1-51. Topography of arteries and veins (right half) and nerves of the face (left half) in relation to facial muscles.

Rice. 1-51. Most of the masseter muscle is covered by the parotid salivary gland. The gland itself is partially covered by the laughter muscle and platysma. All arteries, veins, and nerves in the area pass through these muscles.

Rice. 1-52. Topography of arteries and veins (right half) and facial nerves (left half) in the subcutaneous fat layer.

Rice. 1-52. The muscles and superficial fascia of the face are covered with a subcutaneous fat layer of varying thickness, through which blood vessels can be seen in some places. Through a layer of fat to the skin are small arteries, veins and nerve endings.

Rice. 1-76. Facial arteries, lateral view.

Rice. 1-76. The external carotid artery runs anterior to the auricle and gives off the superficial temporal artery, which branches into the parietal and anterior branches. Also, branches depart from the external carotid artery to the face and upper jaw: under the auricle, the posterior auricular artery departs, even lower - the occipital artery, at the level of the lobe - the maxillary artery, which goes medially under the branch of the lower jaw, at the level between the lobe and the external auditory canal - the transverse artery of the neck, which runs along the branch of the lower jaw. The facial artery bends over the lower edge of the lower jaw and goes to the corner of the mouth.

The main artery of the face is considered to be the maxillary artery, which gives off many large branches, which will be described later.

From the facial artery to the corner of the mouth depart the lower and upper labial arteries. The terminal branch of the facial artery leading to the external nose is called the angular artery. Here, at the medial canthus, it anastomoses with the dorsal nasal artery, which originates from the ophthalmic artery (from the system of the internal carotid artery). In the upper part of the face, the supratrochlear artery goes to the middle of the frontal region. The supraorbital and infraorbital regions are supplied with blood, respectively, by the supraorbital and infraorbital arteries, which exit through the openings of the same name. The mental artery, a branch of the inferior alveolar artery, enters the face through the opening of the same name and supplies blood to the soft tissues of the chin and lower lip.