FACE AND FRONTAL REGION OF HEAD 121 



the margins of the lids together. Distend the cheeks and lips slightly by 

 placing tow or cotton wool steeped in preservative solution in the vestibule 

 of the mouth that is, between the cheeks and lips externally and the teeth 

 and gums internally ; then stitch the red margins of the lips together. 



Reflect the skin by means of three incisions, a median longitudinal and 

 two transverse. Commence the median incision midway between the root 

 of the nose and the external occipital protuberance, carry it anteriorly to the 

 forehead and then downwards along the median line of the forehead, the 

 nose and the lips, to the tip of the chin. Commence the upper horizontal 

 incision at the level of the rima palpebrarum ; carry it laterally from the 

 longitudinal incision to the medial commissure, then round the margins of 

 the rima to the lateral commissure, and, finally, posteriorly to the ear. The 

 lower horizontal incision should run from the angle of the mouth to the 

 posterior border of the ramus of the mandible. Reflect the upper and 

 middle flaps and leave them attached posteriorly. Reflect the lower flap 

 downwards to the lower border of the mandible. Note, whilst reflecting 

 the skin, that many of the superficial fibres of the facial muscles are 

 implanted into its deep surface. It is these fibres which tend to displace 

 the margins of wounds of the face, and necessitate the application of 

 numerous and firmly tied sutures in order to secure quick and accurate 

 union. Whilst reflecting the skin the dissector must be careful to keep his 

 knife playing against its deep surface ; otherwise he is certain to injure the 

 sphincter muscle of the eyelids, and the superficial extrinsic muscles of the 

 ear which lie in the temporal region. 



After the skin is reflected the superficial muscles must be 

 cleaned. That which will first attract attention is the orbicu- 

 laris oculi around the orbit. Above the orbicularis oculi is the 

 frontalis belly of the epicranial muscle. To the medial side 

 of the orbicularis oculi lie the muscles of the nose, and below 

 it the muscles of the upper lip pass downwards to the 

 orbicularis oris. Passing anteriorly and upwards, over the 

 posterior part of the lower border of the mandible, are the 

 upper and posterior fibres of the platysma, and more medially 

 are the muscles of the lower lip. 



Commence with the Orbicularis Oculi (O.T. Orbicularis 

 Palpebrarum). Pull the eyelids laterally and note a prominent 

 cord-like band which extends from the frontal process of the 

 maxilla to the medial commissure, where it becomes continuous 

 with both eyelids ; this is the medial palpebral ligament 

 (O.T. internal tarsal ligament). A somewhat similar band, the 

 lateral palpebral raphe (O.T. external tarsal ligament), extends 

 from the lateral commissure to the zygomatic bone. After 

 the medial palpebral ligament has been recognised, clean first 

 the thicker orbital part of the orbicularis oculi, which covers 

 the superficial bony boundaries of the orbit, and then the 

 thinner palpebral portion, which lies in the eyelids. The 

 palpebral part is not only thin but also pale, and its fibres, in 



