anatomy of the layers of scalp with surgical aspect

1. Dr ARJUN SHENOY
DEPT OF OMFS

2. CONTENTS
EXTENT
LAYERS
BLOODY SUPPLY
VENOUS DRAINAGE
LYMPHATICS
NERVE SUPPLY
APPLIED CLINICAL ANATOMY
SCALP AVULSION INJURIES

3. EXTENT
The scalp extends from the top of the
forehead in front to the superior nuchal line
behind.
Laterally it projects down to the zygomatic
arch and external acoustic meatus

4. CONSISTS OF FIVE LAYERS
Skin
Subcutaneous tissue
Occipitofrontalis (epicranius) and it’s
aponuerosis
Subaponuerotic aereolar tissue
pericranium

6. SKIN
The skin is thick and hairy.
It is adherent to the epicranial
aponuerosis through the dense superficial
fascia.

7. SUPERFICIAL FASCIA
It is more fibrous and dense in the centre
than at the periphery of the head.
Provides the proper medium for passage
of vessels and nerves of the skin

8. EPICRANIAL APONUEROSIS
It is freely movable on the pericranium
along with the overlying and adherent
scalp and fascia.
On each side it is attached to the superior
temporal lines.
Anteriorly ,it receives the insertion of the
frontalis.
Posteriorly ,receives insertion of the
occipital bellies.

9. LOOSE AEREOLAR TISSUE
Extends anteriorly into the eyelids.
Posteriorly to the highest and superior
nuchal lines and on each side to the
superior temporal lines.

10. PERICRANIUM
Loosely attached to the surface of the
bones,but is firmly adherent to the
sutures where the sutural ligaments bind
the pericranium to the endocranium.

11. BLOOD SUPPY

13. ARTERIAL SUPPLY
IN FRONT OF AURICLE-Supratrochlear
Supraorbital
Superficial temporal arteries
BEHIND THE AURICLE
Posterior auricular
Occipital arteries

14. VENOUS DRAINAGE
Emissary veins connect the extracranial
veins with the intracranial venous sinuses
to equalise the pressure.

15. The superficial temporal vein joins the
maxillary vein to form retromandibular
vein.
The supratrochlear and the supra orbital
vein unite at the medial angle of eye to
form angular vein
The posterior division of retromandibular
vein unites with the posterior auricular
vein to form external jugular vein
Frontal diploic- sphenoparietal sinus
occipital diploic- transverse sinus

16. LYMPHATIC DRAINAGE
Lymph vessels from the frontal region above
the root of the nose drain into the
submandibular nodes
Vessels from rest of the forehead,temporal
region,upper half of the lateral auricular
aspect and anterior wall of the external
acoustic meatus drain into superficial parotid
nodes,just anterior to the tragus ,on or deep
to the parotid fascia.

17. The occipital region of the scalp is drained by
the occipital nodes,and partly by the vessel
that runs along the posterior borderof the
sternocleidomastoid to the lower deep
cervical nodes
A strip of the scalp above the auricle drains
to the upper deep cervical and retro auricular
nodes.
The retro auricular in turn drain to deep
cervical.

19. NERVE SUPPLY
Scalp supplied by ten nerves on each
side.
Five nerves (4 sensory and one motor)
enter scalp in front of the auricle.
Remaining five(4 sensory one motor)
enter behind the auricle.

21. IN FRONT OF AURICLE BEHIND THE AURICLE
SUPRATROCHLEAR POSTERIOR DIVISION OF
GREAT AURICULAR
SUPRAORBITAL LESSER OCCIPITAL
ZYGOMATICOTEMPORAL GREATER OCCIPITAL
AURICOTEMPORAL THIRD OCCIPITAL
MOTOR MOTOR
TEMPORAL BRANCH OF
FACIAL
POSTERIOR AURICULAR
BRANCH OF FACIAL

22. Supratrochlear nerve- smaller terminal
branch of frontal nerve
Supplies the skin of the lower forehead near
the midline
supraorbital-
Divides into medial and lateral branches
which supply the skin of the scalp nearly as
far back as the lambdoid suture
The medial perforates the muscle to reach
the skin
Lateral pierces the epicranial aponuerosis

23. Zygomaticotemporal-
Supplies skin of temple as it pierces the
deep layer of temporal fascia it sends a
slender wig between the two layers
towards the lateral angle of the eye.
Lesser occipital-supplies the scalp above
and behind the ear . Branch of cervical
plexus
Greater auricular-derived from anterior
rami of second and third cervical spinal
nerves.

24. Opthalmic nerve- skin over the
forehead

25. CLINICAL ANATOMY
Since there are numerous sabaceous
glands, the scalp is the commonest site
for sabaceous cyst

26. Scalp lacerations bleed profusely because
elastic fibres of underlying galea
aponuerotica prevent initial vessel
retraction, the wounds may be associated
with significant blood loss which can result
in clinical shock.

27. It is very easy to raise a flap within the
plane between the galea and the
pericranium without compromising the
blood or nerve supply of the scalp.
Similar flaps are seen in traumatic scalp
avulsion,when hair is trapped in moving
machinery

28. Scalp flaps can be used in craniofacial
surgery for correction of congenital
deformity,for release of craniosynostosis,
treatment of craniofacial fractures and for
repair of scalp defects after excision of
skin tumors

29. When suturing scalp lacerations, it is
essential to control all bleeding points
before repairing the scalp itself
Usually it is necessary to tie off larger
arterioles and veins and use bipolar
diathermy to control smaller arterioles
and veins.
Repair of scalp require full thickness
tension sutures because galea
aponuerotica will otherwise gape as the
occipital and frontal bellies contract.

30. Failure to control bleeding points as a
separate step can result in significant
hematomas,often subgaleal , leading to
breakdown of the orginal wound and
sometimes necessitating surgical drainage

31. LOCATING THE INCISION LINE
AND PREPARATION

32. INCISION

33. ELEVATION OF CORONAL
FLAP AND EXPOSURE OF
ZYGOMATIC ARCH

34. SUBPERIOSTEAL EXPOSURE OF
THE PERIORBITAL AREAS

35. HARVESTING CRANIAL
BONE GRAFTS

36. SCALP AVULSION INJURIES

39. Dr. S. Raja Sabapathy, Dr. Ravindra Bharathi, Dr. Hari Venkataramani, Dr.
Deepak . K.L., Dr. Divakar Raju. K.
(Department of Plastic and Reconstructive Micro Surgery)BMMSRC

41. HANDLING THE AVULSED SCALP

42. The inner smooth surface of the avulsed scalp is
first placed on a spherical vessel or container.
This is done before clipping any hair. The long
hair is then clipped and shaving commences from
front to back and side to side, taking care not
to shave the eyebrows. After the shaving is
complete, the scalp is washed thoroughly in
running tap water and only after all hair has
been removed completely, the scalp is taken off
the container. In this way, the scalp is well
prepared and no hair is found on the inner side.
This step hardly takes 10 min.

44. All patients had acceptable recovery of
sensation of forehead and scalp by 6–
9 months after replantation. In two of our
cases, the line of avulsion was along the
level of medial canthus.Hair growth in all
patients has been satisfactory and the
cosmetic result excellent.

45. REFERENCES
Journal of Plastic, Reconstructive &
Aesthetic Surgery
Volume 59, Issue 1, January 2006, Pages
2–10
GREYS ANATOMY