The buccal region is bounded above by the lower edge of the orbit, below by the lower edge of the lower jaw, in front by the nasolabial groove and behind by the anterior edge masticatory muscle.
Leather thin, easily moved. Subcutaneous tissue is quite pronounced.
In fiber The facial artery (a. facialis) passes through the area. The artery, bent over the edge of the lower jaw at the anterior edge of the masticatory muscle, follows to the corner of the mouth, and then goes to the inner corner of the palpebral fissure. On the way, the vessel gives off aa according to the level of the lips. labiales superiores et inferiores, anastomoses with a. transversa faciei, a. buccinatoria, a. infraorbitalis.
The artery is accompanied by v. facialis. This vein collects blood from the nose, lips, and side of the face. It anastomoses with the pterygopalatine venous plexus, located in the deep region of the face, through v. angularis - with the veins of the orbit, and through this system - with the sinus cavernosus. The presence of these anastomoses makes dangerous development inflammatory process in the tissue accompanying the facial vein, and in severe cases makes it necessary to recommend ligation of the veins connecting with the veins of the orbit and pterygopalatine fossa.
Lymphatic vessels areas pass together with v. facialis. They carry lymph to the submandibular, parotid, and deep cervical lymph nodes.
Cutaneous innervation carried out through branches n. infraorbitalis (second branch of the trigeminal nerve), n. buccinatorius and n. mentalis (third branch of the trigeminal nerve).
In the superficial tissue layer there is a fascial layer, under which there is a significant lump of adipose tissue (corpus adiposus Buccae), corresponding to the position of the buccal muscle and extending into the adjacent areas. The relatively poor vascularization of the lump explains its preservation despite general weight loss in the body. The buccal region is crossed by branches of the facial nerve. Under the fatty lump on the buccal muscle are located their branches a. buccinatoria (from the maxillary artery), veins and nerve of the same name. Lymph nodes with lymph drainage pathways to the submandibular and parotid nodes are also found here.
The fascia buccopharyngea is located under the fatty lump., lining the buccal muscle and posterior to it passing onto the lateral wall of the pharynx.
Next is the buccal muscle. It is lined on the inside with the mucous membrane of the vestibule of the mouth. On the mucous membrane opposite the 1st-2nd upper molars there is a slight elevation corresponding to the mouth of the duct parotid gland. From the superficial layers, the duct enters here, passing through the fatty sac of the cheek and the buccal muscle. During its contractions, the buccal muscle compresses the duct of the parotid gland and thereby regulates the flow of saliva into the vestibule of the oral cavity.
Infraorbital artery, a. infraorbitalis, - branch of the maxillary. The vein of the same name joins the inferior ophthalmic vein or the pterygoid venous plexus. Infraorbital nerve, n. infraorbitalis, is the terminal branch of n. maxillaris (II branch of the trigeminal nerve) innervates the skin of the infraorbital region, the skin and mucous membrane of the upper lip, the upper jaw and upper teeth. The mental vascular-nerve bundle emerges from the opening of the same name in the lower jaw and is located on the periosteum. N . mentalis terminal branch n. alveolaris inferior(III branch of the trigeminal nerve), innervates the skin and mucous membrane of the lower lip. A. mentalis - branch a. alveolaris inferior, extending from a. maxillaris. The vein of the same name is the source v. alveolaris inferior, going into the deep area of the face.
Cheek fat pad (bisha fat pad) enclosed in a fascial sheath made of thin but quite durable fascia. Outside surface This sheath is everywhere fused with the fascial sheaths of the masticatory muscles surrounding the fatty body. The fascial sheath of the temporal process of the fatty body of the cheek along its entire length fuses with the fascial sheaths of the temporal and partly the masticatory muscles.
The size and shape of the cheek fat pad varies depending on age and degree of development of fatty tissue. In an adult, the fat body reaches a size of 3x9 cm. It consists of three fairly large lobes, each measuring up to 2x3 cm. The lower lobe of the cheek fat pad is located in the buccal region, the middle lobe penetrates under the zygomatic arch, and the upper lobe lies in the anterior temporal region.
Anterior edge of the fat pad the cheeks of an adult reaches the level of the second small molar upper jaw, and its posterior edge penetrates into the recess between the branch of the lower jaw and the masticatory muscle, partially covering its anterior bundles. The lower border of the fat body reaches the line connecting the earlobe with the corner of the mouth. In the superomedial section, the fatty body penetrates under the zygomatic arch and further spreads into the temporal region, lying in the deep part of the temporal fossa. It is covered from the outside and behind by the temporal muscle. In the area between the upper jaw and the anterior edge of the ramus of the lower jaw, limited above zygomatic bone, the fatty body of the cheek is closely adjacent to the tissue of the upper part of the pterygomaxillary space, as well as to the tissue of the pterygopalatine fossa, and more medially temporal muscle goes directly into fatty tissue interpterygoid space.
Thus, the fatty body of the cheek connects the tissue of the buccal area with each other, interpterygoid, temporopterygoid, subgaleal temporal tissue spaces and tissue of the pterygopalatine fossa, and in some cases also tissue of the orbit.
It is most pronounced among representatives of the Mongoloid race.
Bisha's lumps - what are they? On a baby's face, chubby cheeks look touching. But not on every adult face are they as attractive.
To achieve clear facial contours, many women follow strict diets and strive to lose extra pounds, but this does not change the shape of their cheeks. Why do they stay round? The culprit is Bish's lumps.
What are Bisha's lumps and where do they come from?
Bisha's lumps are fatty deposits surrounded by a capsular membrane. They are located deep in the dermis under the facial muscles, in the space between the lower jaw and cheekbones.
They were first described by the anatomist Bichat from France, and they were named after his surname.
There are two such lumps on a person’s face, one on each cheek. They consist of three lobes concentrated around the duct of the parotid gland, which secretes saliva. Visually, they round the lower part of the oval of the face.
It is often combined with other operations in the facial area, for example, with the introduction of zygomatic prostheses.
The choice of surgical technique for excision of Bisha's lumps is determined by the personal characteristics of each patient.
Depending on the desired effect, the plastic surgeon decides whether to use one surgical technique or combine several techniques.
The operation to remove Bisha's lumps can be done in two ways:
- classical method;
- through endoscopic equipment.
Since fatty formations are located between the skin of the face and the mucous membrane of the cheek, there may be the following exits to them:
- Interior. The mucous membrane of the cheek is cut for about two centimeters from the side of the oral cavity. In this case, the muscles are separated, the doctor tightens the fatty lumps, peels them off from nearby tissues and excises them along with the membrane.
- External. The doctor removes fat deposits from the patient through an incision in the skin. This method is preferable in cases where the removal of Bisha's lumps is in addition to other plastic surgery on the face.
It is worth noting that to remove Bisha’s lumps, not just a scalpel, but a laser beam can be used.
This procedure is called a bishectomy. It is less traumatic, a person recovers faster after surgery, since the laser instantly seals the vessels.
The doctor decides exactly how much excess fat to excise, based on the wishes of the patient and the characteristics of the oval of the face.
As already mentioned, sometimes the surgeon does not remove fat, but moves it to the cheekbones to give them additional volume. After surgical manipulation A cosmetic suture is placed on the incision.
As a result of aesthetic manipulation to remove Bisha's lumps, the patient receives:
- reduction in cheek volume, noticeable weight loss in the lower part of the face;
- formation of a clear line of pronounced cheekbones;
- formation of clear contours of the oval of the face, eliminating its “drooping” and the effect of swollen cheeks.
For women mature age the effect of such surgical intervention is equivalent to the results. Bish's lumps are eliminated only once; repeated operations are not required.
before and after photos, Megan Fox
Question answer
These lumps are beneficial for newborns. They provoke a decrease in friction of muscle fibers when the baby chews. They also help with the sucking process, which is important for infants. With age, they lose this purpose and become useless.
The doctor can use any type of anesthesia. But many are inclined to use local anesthesia, since the operation is not traumatic and is carried out quickly.
Removing Bisha's lumps will not transform a round face into an oval one. Often, for chubby girls, the effect is not visible at all. In addition, such an operation can lead to a change in facial expression (not always in positive side). The absence of lumps can worsen the face, make it look exhausted in older age, and provoke asymmetry.
How does the recovery period proceed?
After excision of Bisha's lumps, the patient, after leaving the hospital, can go home on the same day.
Anna Avaliani
practicing cosmetologist
The operation to cut out Bisha's lumps is of questionable effectiveness, since often there is no particular difference in the before and after photos. I think that such an intervention could be a complement to some more complex plastic surgery. In addition, I advise you to pay attention to cosmetic procedures that will help reduce these lumps. These are myostimulation of facial muscles, mesotherapy, RF lifting. It is also worth reconsidering your diet, you can use endermological massage.
Alison Pontius
plastic surgeon
These lumps add swelling to the face. Eliminating them adds elegance and makes the cheekbones more pronounced. Often, girls aged 20-25 years come to us with a desire to remove Bisha lumps. For women over 40, this operation is only an addition to a general facelift. The fact is that tone decreases with age, so it becomes dangerous to carry out such an intervention. Otherwise, the woman will look exhausted.
There are few people who would be completely satisfied with their appearance. This is especially true for the face - some people dream of a different eye shape, some want to remove wrinkles and tighten the oval, and some want to make it visually thinner.
One of the most popular aesthetic operations in this area today is removal of Bisha's lumps - a fatty body that is located below the cheekbone, between the skin of the face and the buccal mucosa. It is these lumps, located between the chewing and cheek muscles, that form additional volume in the lower part of the face.
This operation is often resorted to by patients who are unable to lose weight naturally - fat deposits from the face disappear extremely slowly, and even after achieving a slim figure, you can be left with overly plump cheeks. Removal of fatty lumps is no less in demand among people whose skin and facial muscle tone has weakened with age, which has led to their sagging and the formation of “jowls” - unesthetic folds that descend on both sides of the lower jaw.
What are Bisha's lumps?
The fatty tissues in the cheeks are called Bichat's lumps (lumps) after the French anatomist who first described their characteristics and properties. In the body they perform two main functions:
- make it easier for babies to suck (that’s why almost all children have such chubby cheeks)
- ensure smooth gliding of the chewing and cheek muscles while eating, and also protect them from possible external injuries.
With age, the need for lumps disappears; they gradually decrease in size, or rather, they do not grow against the background of the development of other tissues. Childhood swelling disappears from the cheeks, dimples appear, and cheekbones stand out more clearly.
Indications for surgery
Fat deposits under the skin of the cheeks can cause patients only aesthetic inconvenience; from a medical point of view, they are not a pathology, regardless of size and shape. As a rule, they are removed, reduced or moved if the patient:
- there are obvious excess fat on the cheeks;
- initially round face shape, reinforced by fat deposits;
- with age, the cheeks sank, “jowls” formed and the nasolabial folds deepened;
- other aesthetically sound prerequisites for .
It is important to understand that by excision of lumps it is impossible to form a completely new oval of the face - however, you can significantly correct its lower part, visually rejuvenate and smooth it out.
The operation can be carried out either under local anesthesia, and under general anesthesia. The choice of pain relief method is at the discretion of the doctor. The surgeon makes a small (1-2 cm) incision on the inner surface of the cheeks, through which he gains access to excess fat. Exactly how many to remove is determined depending on the wishes of the patient and the characteristics of the face shape.
In some cases, fat is not extracted, but is moved to the cheekbone area to create additional volume. After completing all the planned actions, the incision on the inside of the cheek is closed with a cosmetic suture.
| How the operation is performed. Photo 1 - making an incision to access Bisha's lumps: | |
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| Photo 2 – removal of lumps and suturing: | |
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The rehabilitation period is quite short. Already on the day of the operation, having recovered from anesthesia, the patient can go home. Swelling of the tissues on the face persists for 2-3 days, which is why visually the cheeks may appear even wider than they were. Sutures (if self-absorbable material is not used) are removed after 5-8 days.
As after any other operation, patients will need to stop physical activity for 2-3 weeks, avoid visiting the sauna and prolonged swimming. Also, during this period, it is not recommended to put excessive stress directly on the facial muscles (writhing, laughing, screaming, etc.), and you will have to sleep on a high pillow to avoid swelling, and mainly in a position on your back, so as not to accidentally injure operated areas.
After removal of Bisha's lumps, special requirements are placed on the patient's diet: for the first 3 days a liquid diet is indicated, for the next 2-3 weeks it is necessary to avoid solid food, which must be chewed for a long time and with effort. All food should be at medium temperature - nothing hot or cold. After every meal oral cavity You need to rinse thoroughly and brush your teeth if possible. Additionally, the doctor will prescribe a course of antibiotics or alternative drugs to avoid inflammatory processes in the internal tissues of the face.
It will be possible to evaluate the results of the operation in a couple of weeks, when the swelling subsides, and the final appearance of the face will take place in 5-6 months, after complete healing and settling of the tissues.
| Photos before and after operations to remove Bisha's lumps: | |
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Contraindications and possible complications
Removal of fat from the cheeks is not recommended for patients whose body weight deviates significantly from the norm, up or down, or if a significant decrease or gain is planned. Like any other plastic surgery, removal of Bish's lumps must be carried out after weight stabilization. Besides, Other general surgical contraindications also apply: problems with blood clotting, infectious diseases, exacerbations of chronic diseases, etc.
Also, it is not recommended to perform plastic surgery before the age of 25, since until approximately this age the natural decrease in the thickness of the fat layer continues, and a previously operated person may end up looking thin or emaciated - and it will be very difficult to restore the lost fat volume.
The likelihood of complications developing is minimal. In rare cases, it is possible to develop an inflammatory process in the internal tissues of the cheeks - if the patient initially had foci of inflammation in the body or soft fabrics the mucous membranes were injured (for example, involuntarily during sleep, playing sports or chewing solid foods).
How much does it cost to remove Bisha's lumps? Current prices
Costs to the patient will depend on the amount of fat removed, the technique used by the surgeon, and the anesthesia method chosen. Average prices for removing Bisha lumps in Moscow are 25-50 thousand rubles. As with other operations, this figure may vary (mostly upward) depending on the status of the specialist and the clinic.
Despite the fact that the procedure is considered quite simple, it is not worth saving on it. The fact is that all manipulations are carried out in close proximity to the facial nerves and an inexperienced surgeon has a chance of damaging them. In addition, there are cases where fat from different cheeks was removed unevenly, and as a result the face looked asymmetrical.
If you are most unhappy with the weighted and massive lower part of the face, very plump cheeks and unsightly cheekbone contour, then removing or relocating bisha lumps can help make the face more refined and beautiful.
Bish's lumps are dense clusters of fatty lumps that form the fatty body of the cheek; it can also be called the body of Bish. They are located below the cheekbones, between the mucous membrane of the cheek and the skin. Thanks to these lumps on the face, additional volume is formed in the lower area of the face. The lumps received this name in honor of the outstanding French anatomist and physiologist Marie Francois Xavier Bichat. The scientist was the first to describe in detail the properties and characteristics of the lumps.
Video: three-dimensional model of the location of bisha lumps
IN human body Bish lumps perform 2 main functions:
- facilitate the process of sucking breast milk;
- thanks to them, a soft glide of the chewing muscles and cheek muscles is ensured during meals in the first years after birth. Also, dense fatty bodies protect the jaws from any external damage.
Such lumps in adulthood do not have any important function, they are needed only in infancy. Lumps of bisha of any shape and size are not pathological; they are removed only for aesthetic purposes.
With age (after about 25 or 30 years), the lumps become smaller because they do not grow along with other tissues. But they do not disappear completely, but leave fat reserves in the cheeks, but because of them the cheeks look plump, the volume of the lower facial part increases, and with age-related changes they droop and form jowls.
The lumps have a very high density, so in most cases, general weight loss of the body through sports activities or special diets does not make them smaller.
In children, bisha lumps are especially clearly visible, which explains why all babies have very chubby cheeks.
In the photo of the baby, the lumps are very clearly visible
Removal of bisha lumps is performed if a person has:
- round face with excess fat deposits;
- age-related changes: weakening of facial muscles, formation of deep nasolabial folds and jowls;
- excess fat deposits on the face and cheeks.
Before such an operation, medical and cosmetology centers are increasingly offering computer facial modeling services. The service is very useful and convenient, because the client will be able to look at a photo of his potentially changed face and decide whether he likes this face better and whether he needs such changes. These photos show an exact model of the face after removing lumps, which helps avoid an ineffective and ineffective operation.
You can eliminate aesthetic problems associated with bisha lumps using surgical removal, or, in other words, resections.
There are two methods for surgical removal of bisha lumps:
1. Removing bisha lumps through inner side cheeks This technique is the safest and least traumatic, since the lumps are located near the inner walls of the cheeks and are easy to remove.
An incision (approximately 1 or 2 centimeters in size) is made on the mucous tissue to remove the lumps. After the muscles are separated, the lumps are pulled up and peeled away from the tissues and thus removed.
Video procedure:
After suturing, all scars disappear without a trace due to the special properties of the mucous membrane. This technique also allows you to avoid long-term restoration of facial tissue.
Removal of bisha lumps can be carried out either under general anesthesia or under local anesthesia, depending on the client’s wishes and the doctor’s recommendations. But psychologically it is easier to undergo the operation under general anesthesia, so as not to feel psychological discomfort.
The entire operation lasts no more than thirty minutes.
Photos of women before and after the procedure.
2. Technique for removing lumps through incisions on the face. As a rule, this operation is not performed only to remove lumps, because this is impractical, but is performed as an addition to another main operation, which involves incisions or punctures on the face. The incisions that are made for any operation can be used to remove bisha lumps.
The 2nd technique is much more complex and more traumatic than the technique with incisions on the inner surface of the cheeks. This is explained by the fact that the surface facial muscles and lumps of bisha are separated by nerve endings and salivary glands. Therefore, the operation requires careful attention and caution.
There is an operation not to remove, but to move the lumps under the cheekbones to form additional volume.
The volume of lumps removed may vary, depending on the desired effect. But as a rule, lumps are removed in one piece. After which on postoperative suture A special disinfectant pad is applied.
If the removal of bisha lumps was carried out through the buccal mucosa, then the rehabilitation is very short. Immediately after the patient wakes up and recovers from anesthesia, he can immediately go home or run errands.
Swelling may remain on the face for two or three days. The sutures are removed after five or eight days, unless, of course, self-absorbable material was used.
After the procedure, the patient must abstain for two to three weeks from any physical activity, from visiting a bathhouse, sauna, from prolonged bathing in a bathtub, and also not swimming in open reservoirs and pools at all. You also need to keep your face calm, you should not strain your facial muscles, for example, laugh, grimace, scream and perform other actions, and it is also better not to talk for a long time.
The patient's diet in the first three days consists exclusively of liquid food, and in the next two to three weeks, solid foods that require diligent and prolonged chewing should not be consumed. Food should be exclusively at medium temperature, without dishes with high or low temperatures.
You will have to sleep on your back for some time, so as not to accidentally injure the areas where the operation was performed in your sleep. You also need to sleep only with a high pillow to avoid swelling.
It is very important to maintain oral hygiene; always brush your teeth or rinse your mouth after eating.
The doctor can make an appointment medicines to avoid inflammation on the internal tissues of the face.
Removing bisha lumps has the following contraindications:
- age less than 25 years, since the lumps themselves may shrink before this age;
- inflammation in the face, neck, mouth;
- diabetes;
- blood clotting disorder;
- chronic diseases;
- Surgery should not be performed on patients whose weight is very unstable. Lumps can be removed only after weight has stabilized.
Face > Removal of Bisha's lumps - is the operation effective?
2. Cheek fat pad paired, located on the buccal muscle, anterior and partly deeper than the masticatory muscle (Fig. V). In 1801, the French anatomist and surgeon X. Bichat first described the fatty bodies of the cheeks, which before him were taken for the salivary glands ( Heister L., 1732; Winslow I.B., 1753). The laying of these anatomical formations occurs at the stage of 1 cm of the parietal-coccygeal size of the embryo. This is the first structure of the developing organism where adipose tissue appears ( Kahn I.L., 1987). Having reached the definitive state at the time of birth, the fatty bodies of the cheeks retain the stability of the cellular composition and components of the microvasculature until the age of 11-12 years, after which they undergo age-related involution.
These anatomical formations are a complex of adipocytes of both white and brown adipose tissue, cellular and non-cellular elements of loose connective tissue, cells of diffuse lymphoid tissue and components of the microvasculature.
Cold exposure to the maxillofacial area stimulates oxidation fatty acids in the adipocytes of brown adipose tissue, as a result of which a large amount of heat is released, surrounding areas are heated
DrawingV.
Fat body of the cheek (Bisha).
tissue and blood in blood vessels, passing through the fat pads of the cheeks. Throughout the entire postnatal period of ontogenesis, they perform the function of sealing the oral cavity and mechanically facilitate the act of sucking in newborns ( Gehewe I., 1853), are organs that take an active part in the formation of protective autoimmune mechanisms of the oral cavity (Borovsky E.V., 1989) and the most important damping formations maxillofacial area(participate in thermoregulation of this area and regulation of blood circulation in the system of external carotid arteries).
How the cheek fat pads function in all people age periods, while individual, gender and age characteristics of the size, weight and number of their processes are reliably determined. Markov A.I., 1994, considers the fatty bodies of the cheeks as endocrine glands that secrete specific factors that stimulate heat production.
Outside and in front of the cheek fat capsule forms a continuation of the parotid-masticatory fascia - buccal fascia , passing onto it from the anterior edge of the masticatory muscle. There are 1-2 spurs running into the thickness of Bish’s body, which do not completely divide it into lobes. The shape of the cheek fat pad is constantly changing due to the functioning of the masticatory muscles. The shifting muscles carry with them the walls of the fascial capsule of the fat body, change its shape, and in connection with this the mass is redistributed fat lump. The clinically described cases of “dislocation” of the fat pad of the cheek (A.I. Skarzova) can only occur when it leaves the fascial capsule, but not together with it.
Bisha's fat body consists of the main part and processes extending from it: masticatory, superficial temporal, deep temporal, pterygomandibular, pterygopalatine, inferior orbital - penetrating into the superficial and deep areas of the face. Above and anteriorly it passes into the fiber of the canine fossa.
Morphometric data reliably indicate the preservation of the weight mass of these anatomical formations in people of all age periods. The processes of the fat pads of the cheeks plug the cracks and openings of the base of the skull and include neurovascular bundles passing through them. Of all the processes of the cheek fat pads, the most variable is the masticatory process, which is absent in almost 42% of cases in mature, elderly and old age. It has been established that the lingual and lower alveolar nerves pass through the thickness of the pterygomandibular process, the maxillary nerve and pterygopalatine ganglia pass through the thickness of the pterygopalatine process, and the upper posterior alveolar nerves, emerging from the pterygopalatine process, enter the openings of the tubercle of the upper jaw . Thus, individual species conduction anesthesia used in dentistry (according to Bershe, Dubov, Uvarov, Weisblat) are actually based on the introduction of anesthetic substances into the fatty body of the cheek. In this case, the distribution of the anesthetic is limited to the capsule of the fatty body of the cheek, which achieves a high concentration of the anesthetic solution around the lingual, lower alveolar and buccal nerves. As the amount of injected solution increases, it fills not only the pterygomandibular, but also the interpterygoid dilatation and the pterygopalatine process, plugging the foramen ovale, the exit site of the second branch of the trigeminal nerve. For neuralgia of the second and third branches of the trigeminal nerve, when used novocaine blockade according to A.V. Vishnevsky, an anesthetic solution (30-50 ml) is injected to a depth of 4 cm at the level of the middle of the zygomatic arch. In this case, complete filling of the deep processes of the fatty body of the cheek with the solution is achieved and thereby switching off the second and third branches of the trigeminal nerve.
ABSCESS OF THE BUCHAL FAT BODY often develops secondarily, as a complication of purulent inflammation of other cellular spaces of the face. Less commonly, it occurs with purulent inflammation of the lymph nodes located in this area.
DISTRIBUTION WAYS. In the upward direction, the purulent process can move to the tissue of the infraorbital region and the canine fossa, posteriorly - to the tissue under the masticatory muscle, posteriorly and upwardly - to the upper part of the maxillopterygoid fissure, to the subfascial and deep cellular fissures of the temporal region (anterior sections), to the tissue pterygopalatine fossa, inward - into the tissue of the deep region of the face (corresponding to the location of the branches of the Bisha fatty body).
OPERATIONAL TECHNIQUE. The patient's head is turned to the healthy side. A skin incision 3-5 cm long is made from the anterior edge of the masticatory muscle along the line connecting the outer ear canal with the wing of the nose (Fig. VIII - 1) or the corner of the mouth. The anterior edge of the masticatory muscle is determined and the closed jaws of the hemostatic clamp are passed into the cavity of the pus. Carefully open the jaws of the instrument. The purulent cavity is washed and drained.
POSSIBLE COMPLICATIONS. When opening an abscess of the buccal fat body, there is a risk of damage to the facial vessels, branches of the facial nerve and the excretory (Stenon) duct of the parotid salivary gland. Therefore, manipulations in the wound with an instrument or finger should be carried out carefully.
3. Fat bodies of the eye sockets, retrobulbar tissue (Margorin E.I. et al., 1977) acts as a kind of articular cavities in which movements occur eyeballs similar to what happens in ball-and-socket joints. Lipolysis in the fat bodies of the orbits, as well as in the fat bodies of the cheeks, is observed only with cachexia, which is evidence in favor of their common origin.
4. Fiber of the canine fossa region located between the periosteum of the body of the upper jaw and facial muscles, spreading along the tubercle of the upper jaw, communicates with the fiber of the pterygomaxillary fissure, infratemporal and pterygopalatine fossae.
Phlegmon in the canine fossa area occurs, as a rule, with diseases of the lateral teeth of the upper jaw. Pus spreads upward along the alveolar process and the lateral surface of the upper jaw, involving in the process the fiber located under and between the facial muscles of the canine fossa area.
DISTRIBUTION WAYS. The inflammatory process can spread outward and downward to the buccal area, to the tissue of the buccal fat body. Along the tubercle of the upper jaw, it can spread posteriorly and upward into the infratemporal fossa (Fig. VII - 6).
OPERATIONAL TECHNIQUE. Pull upward and laterally upper lip and cheek. A 3-4 cm long mucosal incision is made along the upper transitional fold mucous membrane of the oral vestibule. A closed instrument is inserted upward into the incision along the bone to the point where pus accumulates. The instrument is pulled apart, the pus is evacuated and the purulent cavity is drained.
In the fiber located near the pharynx, it is customary to secrete retropharyngeal And lateral parapharyngeal cellular spaces. The latter is divided by the awl-diaphragm into anterior and posterior sections.
5. Retropharyngeal cellular space(Fig. II) is located behind the pharynx. It is limited posteriorly by the prevertebral fascia (II - E), in front by the peripharyngeal fascia (II - E), and laterally by the pharyngeal-vertebral fascial spurs (II - F). At the top it starts from the base of the skull, at the bottom it passes into the tissue located behind the esophagus (the posterior organ tissue space of the neck). The latter passes into the tissue of the posterior mediastinum. There are non-permanent fascial spurs located horizontally, which to a certain extent separate the retropharyngeal tissue from the tissue located in the neck. In addition to fiber, the retropharyngeal cellular space contains single lymph nodes. The sagittal connective tissue septum fixes the suture of the pharynx to the base of the skull and spine (A.V. Chugai), dividing the upper part of the retropharyngeal space into the right and left halves, which explains the left- or right-sided localization of the retropharyngeal abscess.
REPHARRYNGEAL ABSCESS is most often a consequence of purulent lymphadenitis as a complication of inflammation of the tonsils in children.
DISTRIBUTION WAYS. The purulent process can move from the tissue along the posterior wall of the pharynx down the posterior surface of the esophagus into the posterior organ tissue space of the neck and further into the posterior mediastinum. However, such complications are rare, since the retropharyngeal space is closed from below by fascial leaves.
OPERATIONAL TECHNIQUE. Intraoral access. The patient is in a sitting position, the head is fixed by an assistant. At the site of protrusion of the posterior wall of the pharynx, with the tip of a scalpel, previously wrapped with a tape of adhesive plaster to avoid injury to surrounding tissues, a vertical incision 1-1.5 cm long is made. In cases where the abscess cannot be examined, an autopsy is performed by passing the scalpel along index finger left hand, palpating the abscess. To avoid aspiration of pus, the patient's head is lowered down immediately after opening the abscess. The edges of the wound are spread apart with a clamp. The abscess cavity is washed with a stream of disinfectant solution.
6. Anterior section or anterior parapharyngeal cellular space limited: medially by the peripharyngeal fascia (Fig. II - D), anteriorly and laterally by the interpterygoid fascia (Fig. II - D), laterally by the capsule of the parotid gland and its pharyngeal spur (Fig. II - 7), posteriorly and laterally by the awl -diaphragm (Fig. II - 3), separating the transdiaphragmatic space from the anterior peripharyngeal space. In front, this space is closed due to the fusion of the pharyngobuccal fascia with the interpterygoid fascia at the level of the anterior edge of the ramus of the mandible. The peripharyngeal cellular space is filled with fiber. It contains the ascending pharyngeal vessels, lymphatic vessels and lymph nodes. It communicates with the bed of the parotid gland through a defect in the fascial capsule of the latter. Below, the peripharyngeal space freely passes into the tissue of the floor of the mouth.
Posterior lateral parapharyngeal space or transdiaphragmatic cellular space(Fig. II) paired, located on the sides of the retropharyngeal cellular space. Medially it reaches the peripharyngeal fascia (Fig. II - E) and is delimited from the retropharyngeal cellular space by the pharyngeal-vertebral fascial spur (Fig. II - G). Laterally it is limited by the capsule of the parotid gland (Fig. II - 7) and the beginning of the sternocleidomastoid muscle, behind - by the prevertebral fascia (Fig. II - E), in front - by the styloid diaphragm (Fig. II - 3). In the transphrenic tissue space there are: the internal carotid artery, the internal jugular vein, the vagus, glossopharyngeal, hypoglossal and accessory nerves, the superior node of the sympathetic trunk and lymph nodes. The fiber of the subdiaphragmatic space along the vessels and nerves passes into the fiber space of the main neurovascular bundle medial triangle of the neck, and then into the tissue of the anterior mediastinum.
Phlegmon of the anterior circumpharyngeal cellulose space (Fig. VII - 8) can be a complication of purulent lymphadenitis with inflammation of the tonsils or develop as a result of a peritonsillar abscess breaking into this space. Cellulitis can be secondary to the transition of inflammation from the maxillary-pterygoid fissure or the tissue of the floor of the mouth.
DISTRIBUTION WAYS. The purulent process can freely move down and anteriorly into the tissue of the floor of the mouth. In some cases, along the fiber of the lateral wall of the pharynx, phlegmon can spread down to the neck, to the fiber of the lateral surface of the laryngopharynx, and below - to the fiber located near the esophagus and trachea (anterior and posterior organ fiber spaces of the neck).
OPERATIONAL TECHNIQUE. The abscess of the anterior part of the lateral peripharyngeal cellular space can be opened (in the absence of trismus - spasm chewing muscles) with an intraoral incision of the mucous membrane medial to the pterygomandibular fold and parallel to it, 1.5-2 cm long and up to 0.75 cm deep. Next, they bluntly penetrate to the abscess, open it and drain it.
To create a good outflow of pus in case of phlegmon of the peripharyngeal space, many authors consider extraoral access more preferable - the only one possible in the case of trismus. The patient's head is turned in the opposite direction and slightly tilted back. The angle and lower edge of the lower jaw are probed and a 5-6 cm long incision is made in the skin and subcutaneous tissue 1-1.5 cm below (Fig. VIII - 5). They bluntly reach the inner surface of the angle of the lower jaw, feel the tense medial pterygoid muscle and bluntly along the inner surface of the muscle, carefully penetrate upward and medially to the place of accumulation of pus (it is dangerous to damage the ascending artery of the pharynx). The pus is evacuated, the cavity is washed and drained.
7. Cellular space of the parotid gland paired (Fig. II), limited by a dense capsule formed by the parotid-masticatory fascia (Fig. II - B), which covers the gland on all sides. It contains the parotid gland, facial nerve, superficial temporal artery, primary departments deep vein face, lymph nodes and a small amount of fiber. The capsule has two weak spots in the following locations:
where it is adjacent to the cartilaginous part of the external auditory canal (the place of passage of blood vessels);
where the parotid gland approaches the lateral wall of the pharynx, forming the pharyngeal process of the gland (here the capsule is absent and the gland is directly adjacent to the anterior section of the lateral parapharyngeal cellular space).
DISTRIBUTION WAYS. A breakthrough of pus into the external auditory canal is possible. If the pharyngeal process of the gland is damaged, the process can spread inward to the peripharyngeal tissue. Along the vessels located in the bed of the parotid salivary gland, the process can spread into the temporal cellular space. If the inner layer of the parotid fascia is destroyed, the process will spread to the transdiaphragmatic tissue space, from where, along large vessels and nerves, the purulent process can spread upward to the base of the skull and even into its cavity, as well as downwards, reaching the tissue of the anterior mediastinum.
OPERATIONAL TECHNIQUE. The patient's head is turned in the opposite direction. When a purulent-inflammatory focus is localized in the superficial parts of the gland, the incision is made in the radial direction from the base of the earlobe, slightly retreating from it, 3-4 cm long (Fig. VIII - 3). The skin, subcutaneous tissue and gland capsule formed by the parotid-masticatory fascia are dissected. Then, to avoid damage to the branches of the facial nerve, the abscess is penetrated bluntly. The purulent cavity is washed antiseptic solution and drain.
When the purulent-inflammatory focus is localized deep in the parenchyma, for example, in the pharyngeal process of the parotid salivary gland, the incision is made 1 cm posterior to the branch of the lower jaw and 3-4 cm down from the earlobe (Fig. VIII - 4). The skin, subcutaneous tissue and parotid-masticatory fascia are dissected. They pass into the gland tissue with a finger, reaching the tip of the styloid process, and then anteriorly, into the parenchyma of the pharyngeal process of the gland. If necessary, penetrate the peripharyngeal cellular space with a finger. After opening the abscess, the wound is washed with an antiseptic solution and drained.
POSSIBLE COMPLICATIONS. In the fascial bed of the parotid salivary gland there are the trunk and branches of the facial nerve, the auriculotemporal nerve, the terminal branch of the external carotid artery, transverse facial artery and retromandibular vein. Therefore, manipulations in the wound with a finger or instrument should be carried out with caution to avoid damage to the above neurovascular formations.
8. Cellular space in the floor of the mouth(Fig. VI) is limited from above by the mucous membrane of the floor of the mouth, from below – by the mylohyoid muscles (oral diaphragm, m. mylohyoideus) (Fig. VI - 5), from the sides – by the inner surface of the lower jaw (Fig. VI - 4). There are five slits in it: the median, limited by the genioglossus muscles (m. genioglossus) (Fig. VI - 2); two medial ones, located between the genioglossus (m. genioglossus) and hyoglossus muscles (m. hyoglossus) (Fig. VI - 1); and two lateral fissures located between the hyoglossus muscles (Fig. VI - 1) and the inner surface of the body of the lower jaw (Fig. VI - 4). In the lateral cellular fissure are located: sublingual salivary gland, anterior process of the submandibular salivary gland and its duct, hypoglossal and lingual nerves, lingual artery and veins. In the medial cellular fissures there is fiber and the lingual artery, and in the median there is fiber and sometimes lymph nodes. The lateral fissure at the top is widely connected to the anterior section of the peripharyngeal cellular space, and at the bottom - along the duct of the submandibular gland (along the gap between the maxillary-hyoid and hyoid-lingual muscles) it is connected to the submandibular cellular space of the neck, located below the diaphragm of the mouth in the submandibular triangle, where the submandibular gland, facial artery and facial vein.
PHLEGMON OF THE FIBER OF THE BOTTOM OF THE ORAL CAVITY develops as a result of a disease of the teeth of the lower jaw or, less commonly, an infection penetrates into the fiber of this area when the mucous membrane of the floor of the oral cavity is damaged. With dental disease, pus spreads along the inner surface of the alveolar process of the lower jaw under the mucous membrane of the floor of the mouth. Most often, the cause of these phlegmons is disease of the molars. In this case, the pus is localized in the lateral fissure of the cellular tissue
Figure VI. Cellular spaces in the floor of the mouth. Frontal cut made near the angle of the lower jaw through the root of the tongue (according to N.I. Pirogov).
1 – mylohyoid muscle, 2 – genioglossus muscle, 3 – stylohyoid muscle, 4 – body of the mandible, 5 – mylohyoid muscle, 6 – digastric muscle, 7 – geniohyoid muscle, 8 – salivary hypoglossus gland, 9 – hypoglossal artery, 10 – hypoglossal nerve, 11 – deep artery of the tongue.
the space of the floor of the mouth (Fig. VII - 7), corresponding to the maxillo-lingual groove.
DISTRIBUTION WAYS. When the abscess is initially localized in one of the fissures in the cellular space of the floor of the oral cavity, the inflammatory process can develop into a diffuse phlegmon, capturing all the cellular tissue in this area. From the lateral fissure, pus can freely spread down into the submandibular cellular space of the neck along the spur and duct of the submandibular salivary gland, between the posterior edge of the mylohyoid muscle and the hyoid muscle (Fig. VII - 9). From the same gap, pus can also freely spread backwards and upwards, into the peripharyngeal cellular space (Fig. VII - 8).
OPERATIONAL TECHNIQUE. In the oral cavity, the place of greatest fluctuation is determined, the mucous membrane is dissected longitudinally over it for 1.5-2 cm and the abscess is emptied. A strip of gauze or thin rubber is inserted into the cavity. When the process is localized in the maxillo-lingual groove, the incision is made parallel and closer to the inner surface of the lower jaw, directing the tip of the scalpel towards the bone to avoid damage to the lingual nerve and vein (the artery is located more medially). After dissecting the mucosa, the deeper layers are penetrated carefully with a blunt instrument. When phlegmon is localized in the median fissure of the cellular space of the floor of the mouth, a sagittal section of the mucous membrane of the floor of the mouth may be insufficient. In this case, the incision is made from below, from the skin side. Throwing the patient's head back, determine the inner surface of the lower jaw in the chin area and from this point cut the skin, subcutaneous tissue and fascia downwards, strictly along the midline towards the hyoid bone. The mylohyoid muscles are dissected along the midline and between the geniohyoid muscles penetrate into the tissue of the floor of the mouth.
Putrid-necrotic phlegmon of the floor of the oral cavity or Ludwig's sore throat is a special type of diffuse phlegmon of the floor of the mouth, submandibular and submental areas, in which there is a sharp swelling and necrosis of tissues without purulent melting. Instead of pus, there is a small amount of ichorous, foul-smelling liquid the color of meat slop. Most often, the process begins with a focal lesion of the mylohyoid muscle. The lymph nodes and the salivary glands are swollen in the first days, but without any significant changes. The muscles of the floor of the mouth thicken and in some places contain lesions with gas bubbles and a pungent ichorous odor. Treatment consists of early wide opening of the lesions.
THE WAYS OF DISTRIBUTION OF PUTTERNIC-NECROTIC PHLEGMON OF THE BOTTOM OF THE ORAL CAVITY cannot be traced, since without surgical intervention death quickly occurs with a picture of general sepsis and an increasing decline in cardiac activity.
OPERATIONAL TECHNIQUE. The patient's head is slightly tilted back. The corners and edge of the lower jaw are probed, stepping back from which by 1-1.5 cm, a collar-shaped incision is made from one corner of the lower jaw to the other. The skin, subcutaneous tissue, superficial fascia with the subcutaneous muscle of the neck are dissected. Then the underlying tissues are bluntly pushed apart at the point of greatest tension. Dead tissue and a small amount of ichorous fluid are evacuated. The wound is drained.
9. Odontogenic mediastinitis is a complication of odontogenic phlegmon, initially localized most often in the tissue of the floor of the mouth. As stated above, these phlegmons easily spread into the submandibular cellular space. From the latter, having destroyed the capsule of the submandibular salivary gland, pus can pass into the subcutaneous tissue of the neck and spread above and under the subcutaneous muscle of the neck along its entire length. Phlegmon from the tissue of the floor of the mouth can move into the tissue space of the main neurovascular bundle of the medial triangle of the neck along the tissue surrounding the lingual vein and artery, as well as from the submandibular region along the facial vein and artery. Along the tissue space of the neurovascular bundle of the neck, mainly along the tissue surrounding the internal jugular vein, the infection descends into the tissue of the anterior mediastinum surrounding the brachiocephalic veins, brachiocephalic trunk, the beginning of the left common carotid artery and the aortic arch. Odontogenic phlegmon, descending along the retropharyngeal tissue, can spread to the posterior organ tissue space of the neck. Through this fiber space they can also reach the upper sections of the tissue of the posterior mediastinum, located between the trachea and the esophagus.
OPERATIONAL TECHNIQUE. With this formidable complication of odontogenic phlegmon, it is necessary to widely open and drain the place of initial localization of phlegmon - the tissue of the floor of the oral cavity. According to indications, multiple incisions are made in the subcutaneous tissue and subcutaneous muscle of the neck. To open the deep cellular spaces of the neck and access the mediastinum, a wide incision is made along the anterior edge of the sternocleidomastoid muscle (Fig. VIII - 7). After dissecting the skin, subcutaneous tissue and subcutaneous muscle, the second fascia of the neck is dissected, the muscle is retracted to the lateral side, the sheath of the neurovascular bundle of the neck is dissected and drained. The fingers penetrate down the vessels into the mediastinum. From the same incision, moving the neurovascular bundle to the side, they reach the cervical trachea. Along the lateral and anterior surface of the trachea the finger reaches the mediastinum. The tissue of the upper mediastinum is widely drained between the vessels and the chest wall, the vessels and the trachea, the trachea and the esophagus. If this incision is not enough, make a horizontal incision above the jugular notch of the sternum, penetrate behind the sternum along the anterior surface of the trachea with a finger and drain the anterior mediastinum from this incision.
POSSIBLE COMPLICATIONS. When making incisions in the subcutaneous tissue of the neck, damage to the superficial veins of the neck is very dangerous, as this can lead to air embolism. Veins must first be captured
Figure VII. Facial phlegmon.
1 – phlegmon of the masticatory-maxillary fissure, 2 – phlegmon of the subfascial fissure of the temporal cellular space, 3 – phlegmon of the maxillary-pterygoid fissure, 4 – phlegmon of the interpterygoid fissure, 5 – phlegmon of the deep fissure of the temporal cellular space, 6 – phlegmon of the infratemporal fossa, 7 – phlegmon of the lateral cracks in the cellular space of the floor of the mouth, 8 – peripharyngeal phlegmon, 9 – submandibular phlegmon of the neck area.
tighten with clamps, then cut and bandage between the clamps (Hemostatic clamps go in front of the scalpel). Damage to cutaneous nerves is less important. When dissecting the vagina of the neurovascular bundle and draining the surrounding tissue, damage to the thin-walled internal jugular vein, since its dressing leads to severe complications. When manipulating the mediastinal tissue with a finger, one must not damage the brachiocephalic veins and the veins that form them.
Figure VIII. Incisions for phlegmon of the face and neck:
1 - buccal fat body, 2 - temporal region; 3, 4 – with purulent mumps, 5 – maxillary-pterygoid fissure, peripharyngeal cellular space; 6, 7 - previsceral and retrovisceral cellular spaces of the neck, 8 - submandibular region.
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Preface………………………………………………………………………………4
Fascia of the head……………………………………………………………...6
The concept of fascial nodes, types of fascial and
interfascial receptacles…………………………………………...11
Abscesses and phlegmons of the face. Basic principles
surgical interventions…….…………………………………….13
Cellular spaces, abscesses and phlegmons of the brain
head section…………………..………………………………………….15
Fiber of the frontal-parietal-occipital region….…………………15
Trepanation triangle Shipo..……………………………18
Temporal cellular space……………………………...23
Cellular spaces, abscesses and facial phlegmons
head section………………………………………………………26
Chewing fiber space………………………26
Cheek fat pad……….……………………………………..30
Fat bodies of the orbits…………………………………………….34
Fiber of the canine fossa area……………………………….34
Retropharyngeal cellular space……………………….35
Lateral parapharyngeal cellular space………...36Cellular space of the parotid gland……………..38
Cellular space of the floor of the mouth…………………..40
