Chapter 155

• Currently underused because the technique is not widely known and taught
• Ultrasound may make these blocks easier and more effective

• The sensory nerve of the face, part of the ear, the orbit, nasal fossae, and oral cavity is the trigeminal nerve (fifth cranial pair)
• It has three branches: the ophthalmic (V1), the maxillary (V2), and the mandibular (V3)
• It is also the motor nerve of mastication
• Each branch divides in terminal branches, which emerge with a small artery from their respective foramina:
• The frontal and supratrochlear nerves (branches of V1) emerge from the supraorbital foramen
• The infraorbital nerve (branch of V2) emerges from the infraorbital foramen
• The mental nerve (branch of V3) emerges from the mental foramen
• The three foramina are (theoretically) in line with the pupil, at 2.5 cm from the midline in most patients
• For the blocks, the patient is in supine position with the head on a pillow

###### Figure 155-1. Skin Innervation, Landmarks, and Ultrasound Probe Position for Superficial Blocks of the Face

• Frontal and supratrochlear nerves supply cutaneous sensation to the forehead from the upper eyelid up to the coronal suture of the skull
• Indications are upper blepharoplasty or surgery performed on the scalp, including craniotomies and anterior dermoid cyst excisions
• The main landmark is the supraorbital foramen, usually easy to find by palpating the roof of the orbital rim, in line with the pupil
• Keep the finger above the foramen. Insert a 25G needle under the finger and, after aspiration, inject 3 mL of local anesthetic toward the foramen, without entering it
• The needle is then redirected toward the angle of the upper nasal bone and the orbit, to block the supratrochlear nerve with 1 mL of local anesthetic
• Very rare complications have been described, such as hematoma, intravascular or intraneural injection, or transient eyelid paresis

###### Figure 155-2. Supraorbital Foramen and Technique for Frontal Nerve Block

• The infraorbital nerve exits through the infraorbital foramen, with the infraorbital artery and vein
• It supplies sensation to the lower eyelid, the skin of the nose, the cheek, and the upper lip
• Block indications are lower blepharoplasty, dermoid cyst excisions, or wounds of the cheek or the upper lip, and, especially in children, cleft lip surgery or transsphenoidal pituitary surgery
• The landmark is the infraorbital foramen. It is palpated at 8 mm from the floor of the orbital rim, approximately 3.4 cm from the midline (not really in line with the pupil)
• Transcutaneous approach: with a finger on the foramen, a 25G needle is inserted below the foramen and directed toward it; avoid intraneural injection or penetration in the orbit
• Oral approach especially used for children: the needle is inserted through ...

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