scalp

Scalp
Illustration depicting the layers of the scalp and meninges
Latin	scalpus
Gray's	subject #105 378
Artery	supratrochlear, supraorbital, superficial temporal, occipital
Vein	superficial temporal, posterior auricular, occipital
Nerve	supratrochlear, supraorbital, greater occipital, lesser occipital
Lymph	occipital, mastoid
MeSH	Scalp

The scalp is the anatomical area bordered by the face anteriorly and the neck to the sides and posteriorly.

Layers

It is usually described as having five layers, which can conveniently be remembered as a mnemonic:^[1]

• S: The skin on the head from which head hair grows. It contains numerous sabaeceous glands and hair follicles
• C: Connective tissue. A thin layer of fat and fibrous tissue lies beneath the skin.
• A: The aponeurosis called epicranial aponeurosis (or galea aponeurotica) is the next layer. It is a tough layer of dense fibrous tissue which runs from the frontalis muscle anteriorly to the occipitalis posteriorly.
• L: The loose areolar connective tissue layer provides an easy plane of separation between the upper three layers and the pericranium. In scalping the scalp is torn off through this layer. It also provides a plane of access in craniofacial surgery and neurosurgery. This layer is sometimes referred to as the "danger zone" because of the ease by which infectious agents can spread through it to emissary veins which then drain into the cranium. The loose areolar tissue in this layer is made up of random collagen I bundles, collagen III. It contains the major blood vessels of the scalp, which bleed profusely upon injury, partly due to the absence of venous valves found in the circulation below the neck. It will also be rich in glycosaminoglycans (GAGs) and will be constituted of more matrix than fibers.
• P: The pericranium is the periosteum of the skull bones and provides nutrition to the bone and the capacity for repair. It may be lifted from the bone to allow removal of bone windows (craniotomy).

The clinically important layer is the aponeurosis. Scalp lacerations through this layer mean that the "anchoring" of the superficial layers is lost and gaping of the wound occurs; this requires suturing. This can be achieved with simple or vertical mattress sutures using a non-absorbable material, which are subsequently removed at around days 7-10.

Blood supply

The blood supply of the scalp is via five pairs of arteries, three from the external carotid and two from the internal carotid:

• internal carotid
  • the supratrochlear artery to the midline forehead. The supratrochlear artery is a branch of the ophthalmic branch of the internal carotid artery.
  • the supraorbital artery to the lateral forehead and scalp as far up as the vertex. The supraorbital artery is a branch of the ophthalmic branch of the internal carotid artery.
• external carotid
  • the superficial temporal artery gives off frontal and parietal branches to supply much of the scalp
  • the occipital artery which runs posteriorly to supply much of the posterior aspect of the scalp
  • the posterior auricular artery, a branch of the external carotid artery, ascends behind the auricle to supply the scalp above and behind the auricle.

Note: The walls of the blood vessels are firmly attached to the fibrous tissue of the superficial fascial layer, hence cut ends of vessels here do not readily retract; Even a small scalp wound may bleed profusely.

Innervation

Innervation is the connection of nerves to the scalp: the sensory and motor nerves innervating the scalp. The scalp is innervated by the following:^[2]

• Supratrochlear nerve and the supraorbital nerve from the ophthalmic division of the trigeminal nerve
• Greater occipital nerve (C2) posteriorly up to the vertex
• Lesser occipital nerve (C2) behind the ear
• Zygomaticotemporal nerve from the maxillary division of the trigeminal nerve supplying the hairless temple
• Auriculotemporal nerve from the mandibular division of the trigeminal nerve

The innervation of scalp can be remembered using the mnemonic, "Z-GLASS" for, Zygomaticotemporal nerve, Greater occipital nerve, Lesser occipital nerve, Auriculotemporal nerve, Supratrochlear nerve and Supraorbital nerve.^[2]

Lymphatic drainage

There are no lymph nodes in the scalp; lymphatic drainage is to the pre- and post-auricular nodes.

Role in aesthetics

The scalp plays an important role in the aesthetics of the face. Androgenic alopecia, or male pattern hair loss, is a common cause of concern to men. It may be treated with varying rates success by medication (eg finasteride, minoxidil) or hair transplantation. If the scalp is heavy and loose, a common change with ageing, the forehead may be low, heavy and deeply lined. The brow lift procedure aims to address these concerns.

Hair transplantation

All the current hair transplantation techniques utilize the patient's existing hair. The aim of the surgical procedure is to use such hair as efficiently as possible. The right candidates for this type of surgery are individuals who still have healthy hair on the sides and the back of the head in order that hair for the transplant may be harvested from those areas. Different techniques are utilized in order to obtain the desired cosmetic results; Factors considered may include hair color, texture, curliness, etc.

The most utilized technique is the one known as micro grafting because it produces naturalistic results. It is akin to Follicular Unit Extraction although less advanced. A knife with multiple blades is used to remove tissue from donor areas. The removed tissue is then fragmented into smaller chunks under direct vision inspection (i.e., without a microscope).^[3]

Redness in scalp after surgery

After the surgery is complete, and during healing, scalp redness may occur. The main reason is that, during this period, areas of the head where transplantation has taken place are softer than normal. This is an expected consequence of the medical procedure. The plastic surgeon will usually have explained the likelihood of symptoms of apparent irritation, also having provided a series of indications and follow-up procedures to facilitate proper recovery. Such recommendations might include the application of ice and abstaining from strenuous physical activity in the short term.^[4]

Pathology

The scalp is a common site for the development of tumours including:

• epidermoid cyst
• pilar cyst
• actinic keratosis and squamous cell carcinoma
• basal cell carcinoma
• merkel cell carcinoma

Scalp conditions

• Dandruff -- A common problem due to the excessive shedding of dead skin cells from the scalp
• Seborrhoeic dermatitis -- a skin disorder causing scaly, flaky, itchy, red skin
  • Cradle Cap -- a form of this disorder which occurs in newborns
• Cutis verticis gyrata -- A descriptive term for a rare deformity of the scalp.
• Head lice
• Tycoon's cap, also known as acne necrotica miliaris, characterized by pustules and itching.

See also

• Trichology -- the scientific study of hair and scalp
• Trichodynia -- burning scalp syndrome
• Scalping -- the act of removing the scalp, usually with the hair, as a portable proof or trophy of prowess in war.
• Dermatillomania - obsessive skin picking

Additional images

• 

  Diagrammatic section of scalp.

References

v · d · eHuman regional anatomy (TA A01.1) Head Forehead · Ear · Jaw · Face (Cheek, Eye, Nose, Mouth, Chin) · Occiput · Scalp · Temple Neck Throat · Adam's apple Trunk Chest (Breast) · Abdomen (Navel) · Back · Pelvis (Sex organs) Limbs Upper limb Shoulder · Axilla · Arm Elbow · Forearm Wrist · Hand · Finger (Thumb · Index · Middle · Ring · Little) Lower limb/ (see also leg) Hip · Buttocks · Thigh Knee · Calf · Crus Ankle · Heel · Foot · Toe (Hallux · Long  • Third  • Fourth  • Fifth) · Sole General anatomy: systems and organs, regional anatomy, planes and lines, superficial axial anatomy, superficial anatomy of limbs

External links

• Histology at BU 08601ooa - "Integument: scalp, transverse"
• Histology at BU 08801ooa - "Integument: scalp"
• lesson1 at The Anatomy Lesson by Wesley Norman (Georgetown University)
• http://www.dartmouth.edu/~humananatomy/figures/chapter_47/47-1.HTM