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  • 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 the buccal mucosa, at the level ...

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