Supraorbital Neurovascular Bundle Research Articles

Danger Zone for Paramedian Forehead Flap Elevation: Maximizing Flap Length and Viability

The supratrochlear artery (STA) demonstrates anatomical variability that impacts facial reconstruction with a paramedian forehead flap. STA branching patterns and the distance to the midline have been reported, but the STA pedicle has not been characterized. Our aim was to triangulate the STA pedicle relative to known anatomical landmarks and identify a danger zone to aid surgeons in creating viable tissue flaps. The upper facial region was dissected bilaterally on 38 cadaveric donors. Measurements from the supraorbital neurovascular bundle, orbital rim, and medial canthus to the STA pedicle were collected. Data were tallied and statistically analyzed. Measurement means, range, and standard deviations were calculated; no significant differences were found in the laterality of the measurements (p > 0.05). Statistically significant, sex-based differences were identified for all measurements collected among male and female donors. This study characterizes a surgical danger zone for the STA pedicle specific to a paramedian forehead flap and identifies important differences within this danger zone among male versus female donors that surgeons should consider to prevent pedicle violation and enhance surgical success while maximizing flap length and mobility.

Supraorbital Foramina and Supraorbital Notches in Unknown Dry Human Skulls- A Review of Literatures

In craniofacial surgery and supraorbital nerve block, the anatomy of the supraorbital region is crucial. Injury to the supraorbital neurovascular bundle is a frequent complication during the anterior orbital approach, blepharoplasty, fronto-glabellar reconstruction flap, and in the supraorbital nerve blocks during treatment of maxillofacial wounds and treatment of migraine. However, there are a lot of variations of supraorbital foramina and notches among different groups of populations of various races. Morphometric analysis of supraorbital foramina and notches have been carried out on unknown dry adult human skulls by authors. In these studies, two planes have been made use of, namely sagittal and transverse planes of the skulls along with vertical & horizontal dimensions. In addition, the positions of notches and foramina in relation to midline as well as frontozygomatic sutures were also measured. Various combinations of the presence or absence of supraorbital foramina and notches were also noted. The study on supraorbital foramina and notches has profound anthropological importance, anesthetics importance, and surgical importance. Various studies' findings and conclusions on notches and foramina are being considered for the study of review articles

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Quantifying Lateral Frontal Sinus Access: The Upper Blepharoplasty Approach.

Despite advances in technology and instrumentation, access to the lateral frontal sinus remains a challenge for surgeons. We sought to quantify the reach and applicability of the upper blepharoplasty approach (UBA) to the frontal sinus. Twelve cadaveric specimens were obtained for anatomic research and frontal sinuses divided into 3 zones. Zone 1 was defined as medial to the supraorbital neurovascular bundle (SON). The remaining orbit was then bisected to define zone 2 (centrally) and zone 3 (laterally). Twenty-four UBAs were performed followed by 12 modified endoscopic Lothrop procedures (MELP). The ability to instrument each wall of the frontal sinus was recorded for the MELP, UBA, and combined approach. The UBA provided excellent access to the lateral frontal sinus in zones 2 and 3 (89% and 100%). The MELP provided poorer access in zone 3 (67%) but improved access in zone 1 (83%-100%). Access for zone 1 through the UBA was limited. The combined approach yielded 100% access to each frontal sinus boundary. The MELP in combination with the UBA/lateral trephination provides excellent access to each frontal sinus boundary. The UBA provides excellent access to the lateral frontal sinus but is limited medially by the SON.

The supraorbital region revisited: An anatomic exploration of the neuro-vascular bundle with regard to frontal migraine headache

Recent findings on the pathogenesis of frontal migraine headache support, besides a central vasogenic cause, an alternative peripheral mechanism involving compressed craniofacial nerves. This is further supported by the efficiency of botulinum toxin injections as a new treatment option in frontal migraine headache patients. The supraorbital regions of 22 alcohol-glycerine-embalmed facial halves of both sexes were dissected. Both the supratrochlear and supraorbital nerves (STN and SON, respectively) were identified, and their relationship with the corrugator supercilii muscle (CSM) was investigated by dissection and ultrasound. The course of both nerves was defined, and the interaction between the supraorbital artery (SOA) and SON was determined. We discovered a new possible compression point of the STN passing through the orbital septum and verified previously described compression points of both STN and SON. Osteofibrous channels used by the STN and SON were found constantly. We described the varying topography of the STN and CSM, the SON and CSM, and the SON and SOA. Further, we provide an algorithm for the ultrasound visualization of the supraorbital neurovascular bundle. Our data support the hypothesis of a peripheral mechanism for frontal migraine headache because of following potential irritation points: first, the CSM is constantly perforated by the SON and frequently by the STN; second, the topographic proximity between SOA and SON and the osteofibrous channels is used by the SON and STN; and third, the STN passes through the orbital septum.

Supraorbital Notch and Foramen

Forehead paresthesia after brow lift is well-documented with rates as high as 40.7%. The authors describe an anatomical study to identify the variation in position of the supraorbital notch/foramen to define safe limits for deep dissection during this procedure. Sixty-six orbits from 23 dry skulls and 9 formalin-fixed cadavers were analyzed photographically using ImageJ software. The cadaveric specimens were dissected using a coronal incision, which allowed the inferior resection of the frontalis muscle and periosteum. The exit point of the supraorbital neurovascular bundle was noted as a foramen or notch. The position of the supraorbital notch or foramen was recorded in relation to the midline as defined by the sagittal suture at the level of the highest point of the supraorbital rim. The distance and angle for each foramen/notch were calculated. Thirty-three percent of orbits had a foramen. The average distance from the midpoint to the foramen was 25.24 mm (standard deviation 3.78 mm) and to the notch was 22.69 mm (22.69 mm). The range of distance between the midpoint and the foramen/notch was 17.62 to 32.35 mm. The average angle between the horizontal meridian and the foramen was 81/57° (standard deviation 4.69°). A wide variation in anatomy was seen. Greater caution is required when performing deep dissection around the supraorbital notch because of the variation in position of the supraorbital foramen.

Characterisation of the supraorbital foramen and notch as an exit route for the supraorbital nerve in populations from different climatic conditions

The aim of this study was to obtain morphological data on the supraorbital foramina and notches related to sex and side of the skull in populations from different climatic conditions. We assume that the type and frequency of these supraorbital structures may depend on the climatic conditions in which the population lived. Populations from colder regions should have a higher frequency of foramina and populations from warmer climates should have a higher frequency of supraorbital notches than other populations. This may be a result of adaptive changes and developmental responses to ambient temperatures, for prevention of heat loss in the supraorbital neurovascular bundle passing through these supraorbital structures. Localisation of the supraorbital neurovascular bundle is higher and deeper when it passes through the foramen than in the notch.A total of 1978 orbits from 989 skulls collected in three climatic regions: warm, temperate and cold, were analysed.The highest frequency of supraorbital foramina (35.4%) was in skulls from cold climatic conditions. In samples from warm climates, the frequency of supraorbital foramina was lowest (16.4%). In contrast, the frequency of supraorbital notches was highest in the sample from warm climates (54.5%), and lowest in the sample from cold climatic conditions (44.0%). Statistically significant differences in the frequency of supraorbital structures were found between cold climate sample and the other two samples (p<0.05).Our results suggest a relationship between the type of supraorbital structure and climatic conditions as an adaptation to cold climate and thermoregulatory processes concerning the human head. This research is of direct relevance to clinical practice, and drawing attention to the differences in the frequency of these supraorbital structures may help surgeons to avoid injuring the neurovascular bundles. These data and studies may also contribute to the understanding of the impact of climate on the morphology of modern European skulls.

Anatomy of the Supraorbital Region and the Evaluation of it for the Reconstruction of Facial Defects

Damaged supraorbital neurovascular bundle during anterior orbital approach, fronto-glabellar reconstruction flap, supraorbital injection, blepharospasm, and Graves disease surgery is an important complication reported with varying frequency. The origin, calibration, and branches of the supraorbital artery and its topographical relations were investigated by injection of the arterial bed with red-dyed latex in 38 forehead regions. The supraorbital artery with the supratrochlear artery arose from the orbit as two separate vessels in 33 out of 38 forehead sides (87%). The supraorbital artery entered the frontalis muscle between 20 and 30 mm in 20 cases (52.6%), and between 30 and 40 mm in 16 cases (42.1%). This artery was located approximately the subcutaneous tissues between 40 and 50 mm in 17 cases (44.7%), between 50 and 60 mm in 18 cases (47.4%). The transverse supraorbital vein coursed at the level of the orbital rim on 22 sides (58%) and between 6.1 and 11.2 mm (mean: 9.4 mm) above the supraorbital rim on 16 sides (42%). All branches of supraorbital nerve were located between 2.0 and 3.2 cm from the midline at the level of the orbital rim. In 23 cases (60%), the lateral branch of the supraorbital nerve exited the bone as two branches, usually one large and one much smaller, which can together run into the scalp without further branching. In the present anatomical study, special attention was paid to morphological details concerning the neurovascular relationship of the supraorbital region. A better understanding of the midline forehead neurovascularity should allow modification of reconstructive techniques, afford better localization of the supraorbital nerve during blepharoplasty and ptosis surgery, and reduce the incidence of postoperative hematomas and nerve injuries.

Update on brow and forehead lifting

The purpose of this review is to provide the latest findings in the constantly changing field of brow and forehead lifting. Significant articles published in the last 24 months are reviewed and discussed based on the personal experience of the senior author (F.P.). Important anatomical findings have been made over the last few years which will have an impact on plastic surgery of the upper third of the face, with new ligamentous structures of the forehead and more precise landmarks of the supraorbital neurovascular bundle being described. The short-term efficacy of a new device for periosteal fixation has been evaluated and new data have been collated about the time required for forehead periosteal readhesion. In the last few years there have been important anatomical findings which will allow the development of more detailed and safe techniques for forehead lift surgery. New absorbable materials are available that allow efficient mechanical fixation of the soft tissues. The senior author of this review has extensive personal experience involving more than 400 cases. In addition to commenting on recent articles, we detail the methods we have used over the last 8 years, especially regarding the fixation technique.

Characterization and Localization of the Supraorbital and Frontal Exits of the Supraorbital Nerve in Chinese: An Anatomic Study

To elucidate the characteristics and location of the supraorbital and frontal exits of the supraorbital nerve in Chinese skulls and to compare these findings with other ethnic populations. The anatomy of the supraorbital nerve exits was studied in 97 adult Chinese skulls (194 orbits). The characteristics and location of the supraorbital nerve exits were determined. Analyses were performed to compare differences between sexes and sides. Data were then compared with those of the other populations. Supraorbital exits were found in all 194 orbits. Among these, 89 (45.9%) were foramina. Frontal exits were found in 69 of the 194 (35.6%) orbits in which 18 were foramina (9.3%). The location of the supraorbital exits showed a skewed distribution toward the medial aspect of the superior orbital rim. The median distance between the supraorbital exits and the facial midline was 24.56 mm. Eighty percent of the supraorbital exits lay between 20.77 mm and 30.52 mm from the facial midline. The mean frontal exit was 7.02 mm medial to the supraorbital exits. Compared with other populations, a higher proportion of Chinese have foramina above the superior orbital rim as the exits for the supraorbital neurovascular bundle. The location of the supraorbital nerve exit is highly variable in all studied populations. In a significant proportion of Chinese, the supraorbital nerve exits are located toward the medial aspect of and above the superior orbital rim. Extra care should be taken during dissection around this region to avoid damage to the supraorbital nerve.

A simple and reliable landmark for identification of the supraorbital nerve in surgery of the forehead: An in vivo anatomical study

In this in vivo study, we set out to determine the reliability of the medial margin of the iris as a landmark for the course of the supraorbital neurovascular bundle at the supraorbital rim. Seventy-five patients (73 women and 2 men) undergoing endoscopic brow lift procedures were enrolled, for a total of 150 sides. With the patient focused on a distant point, a line was constructed preoperatively along the mid-sagittal plane, tangential to the medial iris. After general anesthesia and initial dissection, a 27-gauge needle was placed (without the aid of the endoscope) through this line, parallel to the mid-sagittal plane at the orbital rim. Measurements were then taken following creation of the optical cavity. Measurements were taken from the course of the deep (lateral) branch of the supraorbital nerve to the needle. In addition, measurements were taken from the course of the supraorbital nerve to the course of the supratrochlear nerve. In 84 sides, the needle was at the nerve; in 48 sides, the needle was less than 1 mm to the nerve; and in 18 sides, the needle was 2 mm from the edge of the nerve. Overall, the nerve was an average of 0.56 +/- 0.7 mm from the needle, and in no case was the nerve course greater than 3 mm from the landmark. The supratrochlear nerve was located medial to the supraorbital nerve an average of 9.0 +/- 1.0 mm. Based on our findings, the medial iris, as opposed to the mid-pupil line, serves as a reliable topographical landmark for the course of the supraorbital nerve at the supraorbital rim.

Surgical pearl: temporary suspension suture (Frost suture) to help prevent ectropion after infraorbital reconstruction

An ectropion is a complication that can arise from reconstruction in the infraorbital region (Fig 1). Often, this complication occurs despite proper positioning of the lower lid at the time of closure. Edema and bleeding postoperatively can cause the lower lid to pull away from the globe. Fibrosis and subsequent contracture in this position can lead to an ectropion. To help prevent this we have incorporated the use of a temporary suspension suture, known in oculoplastics as a Frost suture, 1 for selected closures in the infraorbital area. After an appropriate closure has been executed (Fig 2), a 4-0 nylon suture is passed through the tarsus or just inferior to it. Both ends of the suture are then attached to the skin above the eyebrow (Fig 3). This serves as a sling as the tension of the suture is directed in a manner that most closely approximates the normal anatomic location of the lower lid. The suture may be attached either by sewing it to the skin or by use of adhesive strips. When passing the suture through the lower lid margin, the surgeon should avoid placing the lower end of the suture through the puncta or canaliculus. Likewise, the surgeon should be aware of the supratrochlear or supraorbital neurovascular bundle if sewing the upper end of the suture. Adhesive strips may be preferable because they allow the tension to be easily adjusted, if necessary, in the postoperative period. One should use large strips and a liquid adhesive when attaching the suture by this method. The suture remains in place for approximately 3 days, depending on the clinical appearance and the amount

Transconjunctival Frontalis Suspension (TCFS)

We have devised a frontalis suspension technique originally described in an article entitled, "Transconjunctival frontalis suspension for blepharoptosis" (Trans Am Acad Ophthal Otolaryngol 83:684-92), by Swan and Tongue in 1977. This modified transconjunctival frontalis suspension (TCFS) procedure is described. It has been used at the Oregon Health Sciences University in its original or modified form since 1970. To better understand how this procedure successfully corrects blepharoptosis in patients with poor levator function, a study was undertaken to discern the anatomic relationship of the suspension material to important ocular adnexal structures. The findings are based on gross anatomic dissection and histologic examination of a cadaver eyelid after postmortem transconjunctival fascia lata frontalis suspension. The distal, horizontal limb of the fascia suspends the central portion of the levator aponeurosis in a hammock-type fashion. The two vertical limbs pierce the aponeurosis at the level of Whitnall's ligament and incorporate this ligament. The fascia then exits the orbit through the orbital septum near the arcus marginalis and is incorporated into the frontalis muscle near the junction of the medial one-third and lateral two-thirds of the brow, temporal to the supraorbital neurovascular bundle. This anatomic location is not only relatively easily and safely attained, but also maximizes the principles of more traditional frontalis suspensions while minimizing the effort and surgical manipulation.