Supratrochlear Research Articles

Arterial Vascularization of the Forehead in Aesthetic Dermatology Procedures: A Review.

Background: The growing popularity of aesthetic procedures on the face raises the question of their safety. The forehead region is crucial aesthetically, but due to its abundant vascularization, it is also one of the most dangerous areas for dermatologic procedures, especially in the glabella area. The purpose of this article is to review the literature on the arterial vascularization of the forehead to identify potential high-risk zones for aesthetic dermatology procedures. Methods: A database search (PubMed, Web of Science, Scopus, and Embase) was conducted, and the titles and abstracts of all identified studies were screened, followed by full-text evaluation. Results: We identified 714 articles during the database search, and 25 articles were included in the review. The included studies used cadaveric dissection and computed tomography applied to cadavers as well as Doppler ultrasonography on volunteers to evaluate the forehead arteries (supratrochlear (STrA), supraorbital (SOA), central (CA), paracentral artery (PCA), and frontal branch of superficial temporal artery(FBSTA)). A total of 1714 cases involving the forehead arteries were analyzed. The included arteries were observed over a relatively large area, and their locations varied. The CA and PCA in cadaver studies were observed in an area of 0.2 to 10.8 mm and 0.8 to 16.2 mm, respectively, on the entire path from the glabellar point to the frontal prominence point. The distances from the midline in cadaveric studies at various measurement points ranged from 0.6 to 28.0 mm for the superficial branch of the STrA and 13.6 to 40.7 mm for the deep branch of STrA. In case of SOA, the distance from the midline ranged from 23 to 32 mm. Measurements from the midline in Doppler studies ranged from 0 to 23 mm for STrA and from 10 to 50 mm for the SOA. In studies using computed tomography, STrA was observed at a distance of 11 to 21 mm and the SOA at a distance of 21 to 32 mm, both lateral to the midline. Conclusions: Medical professionals should be aware of zones where frontal arteries are more likely to be encountered. The glabella region appears to be one of the most dangerous areas for dermatologic procedures. It is believed that the supratrochlear, supraorbital, and the paracentral arteries may cause ophthalmic complications due to occlusion of the ophthalmic artery, while this risk for the frontal branch of the superficial temporal artery seems to be low but cannot be completely excluded.

Comparison of the Efficacy of Two Different Local Anesthesia Techniques for Mesotherapy in Temporal Region Alopecia.

Introduction Mesotherapy is a wide range of minimally invasive injections. In mesotherapy, a mixture of various tonics is injected into the skin. These include plant extracts, various medications, vitamins, enzymes, hormones, growth factors, and other factors that will help treat alopecia. Most commonly, a mixture of platelet-rich plasma (PRP) and vitamins is used. In mesotherapy treatment for hair regrowth in the temporal region, zygomaticotemporal nerve blocks, supratrochlear nerve blocks, and supraorbital nerve blocks are given. The zygomaticotemporal nerve, supraorbital nerve, and supratrochlear nerve are the branches of the trigeminal nerve. They provide sensation on the lateral side of the forehead, which is the temple region. Methods A sample size of 100 people was taken for the study who were undergoing mesotherapy in the bilateral temporal region for alopecia. Each group had 50 subjects: group I was given supratrochlear, supraorbital, and zygomaticotemporal nerve blocks as local anesthesia techniques, and group II was given supratrochlear and supraorbital nerve blocks. PRP was injected using an insulin syringe. Pain was assessed using a visual analog scale (VAS). Results During the procedure, a mean VASof 1 and 3 wasobserved in groups I and II, respectively, during the procedure (p-value0.023). A mean VASof 3 and 5 was observed in groups I and II, respectively, after three hours (p-value 0.000). This shows a significant difference in the pain experienced by the subjects between the groups. Conclusion This study proves that the zygomaticotemporal nerve, used along with supratrochlear and supraorbital nerve blocks, is better at producing analgesia and reducing pain.

Corneal Neurotization: Essentials for The Facial Paralysis Surgeon.

Deficits in corneal innervation lead to neurotrophic keratopathy (NK). NK is frequently associated with facial palsy, and corneal damage can be accelerated by facial palsy deficits. Corneal nerves are important regulators of limbal stem cells, which play a critical role in epithelial maintenance and healing. Nonsurgical treatments of NK have undergone recent innovation, and growth factors implicated in corneal epithelial renewal are a promising therapeutic avenue. However, surgical intervention with corneal neurotization (CN) remains the only definitive treatment of NK. CN involves the transfer of unaffected sensory donor nerve branches to the affected cornea, and a variety of donor nerves and approaches have been described. CN can be performed in a direct or indirect manner; employ the supraorbital, supratrochlear, infraorbital, or great auricular nerves; and utilize autograft, allograft, or nerve transfer alone. Unfortunately, comparative studies of these factors are limited due to the procedure's novelty and varied recovery timelines after CN. Regardless of the chosen approach, CN has been shown to be a safe and effective procedure to restore corneal sensation and improve visual acuity in patients with NK.

Optimizing Botulinum Toxin A Administration for Forehead Wrinkles: Introducing the Lines and Dots (LADs) Technique and a Predictive Dosage Model.

This study introduces the Lines and Dots (LADs) technique, a new approach for administering botulinum toxin type A (BoNT-A) in treating forehead wrinkles. (1) Background: BoNT-A application patterns in the forehead often rely solely on the anatomy of the frontalis muscle. The LADs technique proposes a combination of anatomical features with nerve pathways. (2) Methods: The technique employed a grid system aligned with the supraorbital and supratrochlear nerve pathways and used an electronic acupuncture pen for validation. This study analyzed treatment outcomes for efficacy and safety and proposed a predictive model for BoNT-A dosage. (3) Results: LADs was associated with a high satisfaction rate and low side effect incidence. The predictive model followed BoNT-A Units=0.322×Muscle Pattern Code+1.282×Line Type Code+2.905×Severity Pre-Treatment+3.947. (4) Conclusions: The LADs technique offers an alternative approach to treating forehead wrinkles, optimizing efficacy while minimizing the BoNT-A dose required.

Comparison of the Efficacy Between Regional Nerve Block and Ring Block as Local Anesthetic Techniques for Platelet-Rich Plasma Treatment.

Introduction Platelet-rich plasma (PRP), a solution of concentrated platelets, has been widely used to promote wound repair and tissue regeneration. In the treatment of pattern hair loss, platelets in PRP secrete an abundance of growth factors, including platelet-derived growth factor (PDGF), fibroblast growth factor(FGF), and many more, which stimulate and increase signaling molecules and accelerate cell proliferation. In the PRP treatment for hair regrowth, the supratrochlear nerve (STN) block and supraorbital nerve (SON) block are given to anesthetize the scalp up to the vertex except for the temporal region. The ring block is the common local anesthetic technique usedby infiltrating local anesthetic agents around the target area. The primary objectives were to compare the pain and anesthetic success rates produced by regional nerve blocks and ring blocks. Materials and methods A sample size of 100 patients undergoing PRP treatment for hair regrowth were taken as the subjects for the study. Patients were allotted into two groups by randomization. Group 1 was given regional nerve blocks as the anesthetic technique used for local anesthesia, and group 2 was given ring blocks. In the study group, STN and SON blocks as the regional nerve blocks were given 2% lignocaine with 1:80000 adrenaline to anesthetize the area, and the PRP was injected from the anterior hairline up to the vertex of the scalp, not involving the occipital and temporal regions. In the control group, a ring block was given for the same procedure. Participants from both groups were assessed for the pain and analgesia caused by ring block and regional nerve blocks using the visual analog scale (VAS). Results A mean rank of 30.28 was observed for the regional nerve block technique, and a mean rank of 70.72 was observed for the ring block technique. A p-value of 0.00 that is <0.05 was observed, which shows there is a significant difference in the pain and the analgesia experienced by the subjects between the two groups, during and three hours after the procedure. Conclusion PRP is one of the most commonly used treatments for hair regrowth. The ring block is the common local anesthetic technique used for producing anesthesia, while regional nerve blocks are more effective in producing local anesthesia. This study proves that STN and SON blocks are better anesthetic techniques than the ring block technique for PRP treatment in hair growth.

Результаты хирургического лечения нейротрофической кератопатии методом прямой невротизации роговицы

Relevance. Trigeminal nerve defeat can lead to the development of neurotrophic keratopathy. The only pathogenetically justified method of treating this pathology is corneal neurotization. Purpose. To develop rehabilitation tactic for the patients with neurotrophic keratopathy based on the analysis of the results of operations performed according to the author's technique of direct corneal neurotization. Material and methods. 10 direct corneal neurotizations: with initial manifestations – in 2 cases and in the advanced stage of neurotrophic keratopathy – in 8 cases. Results and discussion. Postoperative period proceeded without complications. Corneal sensitivity was restored in 60%. In all cases, corneal transparency improved, the density of the eyesore and the depth of the invasion of opacities decreased, subbasal nerve fibers began to be visualized, positive dynamic in the state of tear production were observed. Perforation defects of the cornea was closed. In initial stage of the disease corneal opacity has almost completely regressed. Conclusion. Direct corneal neurotization provides restoration of its sensitivity, prevention of neurotrophic keratopathy, which provides medical and social rehabilitation. Key words: facial nerve, paralytic lagophthalmos, abductive nerve, convergent paralytic strabismus, trigeminal nerve, corneal innervation, corneal opacity, corneal sensitivity, esthesiometry, supraorbital nerve, supratrochlear nerve

Clinical outcomes of corneal neurotization using sural nerve graft in neurotrophic keratopathy.

To evaluate the efficacy of corneal neurotisation using sural nerve graft coaptation of the contralateral supratrochlear nerve in unilateral neurotrophic keratopathy and corneal anesthesia. Corneal neuralization has emerged as a potential option in the treatment of neurotropic keratopathy, however not free from the predicament. We evaluated the long-term outcome of corneal neurotisation in the treatment of unresponsive unilateral neurotropic keratopathy using surgical variations to mimic and expedient the surgical procedure. A Prospective interventional study involving patients with unilateral neurotrophic keratopathy (NK) who did not respond to medical measures was conducted. The study parameters evaluated were best-corrected visual acuity improvement, ocular surface evaluation parameters [tear break-up time (TBUT), Schirmer's 1, and ocular surface staining scores (corneal and conjunctival staining)], central corneal sensation (Cochet Bonnet esthesiometer), sub-basal nerve fiber length (SBNFL), and sub-basal nerve fiber density (SBNFD) determined by central confocal microscopy at recruitment and during follow-up at 1-month, 3-month, 6-month, 9-month and 12-month respectively, following corneal neurotization. Eleven eyes of 11 patients with unilateral neurotrophic keratopathy (NK) who underwent corneal neurotisation were studied. The mean follow-up was 10.09±2.31months (range, 6-12). Mean best corrected visual acuity in log MAR at baseline, 1.35±0.52 improved significantly to 1.06±0.76 (P = 0.012) at 3 months and continued to 0.55±0.60 (P = 0.027) at 12 months. There was a significant reduction in NK grade severity and improvement in the ocular surface as early as 1 month, and central corneal sensations (P = 0.024) as soon as 3 months. Mean corneal SBNF improved from 3.12±1.84 mm/mm2 to 4.49±1.88 at 1 month (P = 0.008), 13.31±3.61 mm/mm2 (P = 0.028) at 12 months. Mean central corneal SBNFD evident at 6 months was 1.83±2.54no/mm2 (P = 0.018) and 4.90±3.12no/mm2 (P = 0.028) at 12 months. This study substantiates the routine practice of corneal neurotisation by simplifying the intricacies observed during the procedure.

Quantitative Assessment of Subjective Symptoms and Corneal Sensitivity in Chronic Orbital Pain Patients.

To objectively evaluate the subjective symptoms and characteristics of chronic orbital pain as well as to quantify sensitization of peripheral trigeminal nerves. In this prospective cohort study, patients who previously showed a response to peripheral trigeminal nerve blocks for unilateral, idiopathic chronic orbital pain and healthy subjects completed validated questionnaires assessing headaches, neuropathic signs and symptoms, photophobia, and pain qualities. Corneal sensitivity was measured in both eyes for all subjects with a Cochet-Bonnet aesthesiometer. For pain patients, the full assessment protocol was repeated 2-4 weeks after the study injection, and corneal sensitivity was also measured 30 minutes postinjection. Outcomes assessed were headache, neuropathic pain, and photophobia scores; pain qualities; and corneal sensitivity. Six female chronic orbital pain patients (mean age 48.2 years) and 11 female controls (mean age 47.5) were included. The mean headache, neuropathic pain, and photophobia questionnaire scores were significantly higher for pain patients than for controls (p < 0.001). On sensory testing, 5 pain patients (83.3%) endorsed allodynia, and all 6 (100%) had hyperalgesia in the ipsilateral frontal nerve dermatome. No controls had allodynia or hyperalgesia. Corneal sensitivity was similar between eyes in pain patients and between groups. Questionnaire scores and corneal sensitivity did not change significantly after the injection. Chronic orbital pain patients have a measurable reduction in quality of life due to headaches and photophobia. The supraorbital and supratrochlear nerves are sensitized, resulting in cutaneous hypersensitivity in the corresponding dermatome, but corneal nerves have normal sensitivity.

Evaluation of Clinical Efficacy of Scalp Block with 0.25% Injection Bupivacaine and 0.25% Injection Levobupivacaine to Blunt the Hemodynamic Response to Skull Pin Insertion during Supratentorial Craniotomies - A Prospective Study

BACKGROUND&#x0D; Head fixation is necessary to maintain the desired head position. Application of skull pins in neurosurgery leads to hemodynamic changes and this sudden change can be prevented by combining general anaesthesia with scalp block which blocks supraorbital nerve, supratrochlear nerve, zygomaticotemporal nerve, auriculotemporal nerve, lesser occipital nerve and greater occipital nerve which are present in superficial and deep layers of the scalp. Several studies have been done to study the efficacy of Injection levobupivacaine and injection bupivacaine in 0.5 % concentrations for scalp block. However, the comparative efficacy of 0.25% injection levobupivacaine and injection bupivacaine for scalp block has not been determined by any study previously. We wanted to compare the efficacy of 0.25% injection levobupivacaine and 0.25% injection bupivacaine in scalp block on the haemodynamic response to head pinning, incision and during craniotomy.&#x0D; METHODS&#x0D; This prospective randomised study included 60 patients of ASA status I or II between age 18–60 years and of either sex who underwent supratentorial craniotomy under general anaesthesia followed by scalp block. Patients were randomly allocated into two groups of 30 each and before application of the Mayfield skull pin head holder, scalp block was given as per group distribution (Group A: 20 ml 0.25% injection bupivacaine and Group B: 20 ml of 0.25% injection levobupivacaine). The hemodynamic responses were recorded at baseline, during scalp block and after head pin insertion, incision and at craniotomy. The total analgesic requirement during intraoperative and post operative period was noted.&#x0D; RESULTS&#x0D; There were no clinically and statistically significant differences in values of heart rate and blood pressure after head pin insertion, skin incision and craniotomy in both the groups.&#x0D; CONCLUSIONS&#x0D; The study revealed that 0.25% injection levobupivacaine when used for scalp block was as efficacious as 0.25% injection bupivacaine. Both the drugs in low concentration of 0.25% were effective in minimizing pressor response to skull pin insertion, incision and craniotomy with less incidence of complication and reduced intraoperative requirement of analgesia.

Literature Review: Pericranial Nerve Blocks for Chronic Migraines.

Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB). PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches. In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

Surgical therapy of migraine: a 12-year single-center experience

BackgroundIn recent years, surgical therapy has taken on an increasingly decisive role in the therapeutic armamentarium of migraine. All surgical techniques are aimed at the complete neurolysis of some extra-cranial nerves, of which the most involved (in our experience) are the greater and lesser occipital, auriculotemporal, supraorbital, and supratrochlear nerves. This paper describes our surgical approaches for the treatment of occipital, temporal, and frontal trigger sites. MethodsA single-center, retrospective study was conducted on all patients who underwent surgical treatment of migraine between 2011 and 2022. Patients were asked to fill out a headache diary and complete a migraine questionnaire assessing parameters before surgery, after 3 months, and 1 year after surgery. Data regarding age, sex, age at onset, migraines per month (in days), associated symptoms, severity (on a scale from 1 to 10), inability to work per month (in days), health status, history of neck trauma, and family history were collected. The Migraine Disability Assessment Scale (MIDAS) score was also used to evaluate the degree of disability for each patient.ResultsWe have operated on 612 patients: n.266 occipital, n.248 temporal, n.98 frontal. The surgical procedure elicited a positive response in 90% of the patients (69% complete recovery). Complications were mild and temporary: mainly, hypoesthesia and numbness of the undermined areas, lasting from 3 weeks to 6 months. We observed the onset of secondary trigger sites in 257 (42%) patients.DiscussionThe described procedure is minimally invasive and highly reproducible and allows to obtain a high degree of success with a negligible rate of complications. Nevertheless, given the high percentage of occurrence of secondary trigger points, it is particularly important to warn the patient of this possibility in pre-operative visits.Level of evidence:Level III, Therapeutic

The effectiveness and safety of cranial nerve block in migraine: a critical review

Cranial nerve blocks (CNBs) have been used for the acute and preventive treatment of a variety of headaches, including migraine. The effectiveness of CNBs in migraine is usually observed beyond the duration of the nerve block, possibly due to central pain modulation. The most used target is the greater occipital nerve. Other commonly targeted nerves are the lesser occipital nerve and various branches of the trigeminal nerve, including the supratrochlear, supraorbital, and auriculotemporal nerves. CNBs are generally safe and well-tolerated procedures that can be performed in either emergency or outpatient settings. There is currently no guideline standardizing CNBs in migraine. In clinical practice, as well as the few published studies, the results are encouraging, justifying further studies in the area. In the present study we critically review the literature about the safety and efficacy of CNBs in the treatment of migraine attacks and in the preventive treatment of migraine.

Sensory Innervation of the Upper Eyelid and Its Implication for Upper Eyelid Surgery.

Sensory alterations of the upper eyelid skin and eyelashes are frequently encountered after upper eyelid surgery. The objective of this study was to provide information on the exact course and distribution of sensory nerve fibers through the anatomic planes in the upper eyelid. Ten formalin-fixed hemifaces were dissected. The nerve branches of the ophthalmic nerve in the upper eyelid were traced in an anterograde fashion. A total of 151 nerve fibers were recorded during dissection. The infratrochlear, supratrochlear, supraorbital, and lacrimal nerve contributed each to both the upper eyelid skin innervation and the upper eyelid rim plexus in different distribution patterns. The mean distance from the eyelid margin at which nerve fibers pierced from preseptal into the orbicularis muscle was 14 ± 1.1 mm for nerve fibers targeting the eyelid dermis and 3.7 ± 1.2 mm for nerve fibers targeting the eyelid rim plexus ( p < 0.001). The mean intraorbicular course of nerve fibers was 3 mm (0-17; standard deviation 4.1). The mean distance from the eyelid margin at which nerve fibers pierced from the orbicularis muscle into the preorbicular plane was 10 ± 1 mm for nerve fibers innervating the eyelid dermis and 1.3 ± 0.8 mm for nerve fibers innervating the eyelid rim plexus ( p < 0.001). The mean distance of the preorbicular course of nerve fibers was 2 mm (0-15; standard deviation 3.6). Based on the findings, a certain degree of postoperative eyelid skin numbness is inevitable while eyelash innervation may be spared in upper blepharoplasty.

Anatomical considerations of cutaneous nerves of scalp for an effective anesthetic blockade for procedures on the scalp.

The anatomy of the scalp nerves varies widely with age, race, and individuals of the same race and even within the same individual and hence need to be studied extensively to avoid complications and improve effectiveness during various surgical and anesthetic procedures of the scalp. Gross dissection was carried out on 11 cadavers (22 Hemifaces: 11 right and 11 left) with no obvious scalp deformities or surgeries. The distances of the supraorbital nerve (SON), supratrochlear nerve (STN), and greater occipital nerve (GON) from commonly used bony landmarks were measured. The branching pattern and presence of accessory notches/foramina were noted. SON and STN were found almost midway and at the junction between medial and middle one-third of the line joining midline and lateral orbital margin, respectively. The distances of STN and SON from the midline were about ½ and 3/4th of the transverse orbital diameters of the individual. GON was found at the medial 2/5 and lateral 3/5 of the line joining inion to the mastoid. In 40.9% cases, SON gave three branches while STN and GON remained as single trunks in 77.27% and 40.0% cases, respectively. Accessory foramina/notches for SON and STN were found in 36.36% and 4.54% of the specimen, respectively. SON and STN remained lateral in the majority while GON ran medially to corresponding vessels. These parameters on the Indian population would give a comprehensive idea of the distribution of these cutaneous scalp nerves and would be beneficial in the targeted and accurate deposition of local anesthetic.

Role of Supratrochlear and Supraorbital Nerve Block in Chronic Atypical Facial Pain Management: A Case Series

Chronic Atypical Facial Pain (CAFP) presents a daunting clinical challenge, characterised by persistent, unexplained facial pain that is resistant to conventional treatments. It poses a significant challenge to both patients and healthcare providers due to its poorly understood aetiologies and resistance to traditional analgesic therapies. As a result, novel approaches are sought to alleviate the suffering of affected individuals. Supratrochlear and supraorbital nerve blocks have emerged as promising interventions for CAFP. These nerve blocks target the supratrochlear and supraorbital nerves, which are branches of the ophthalmic division of the trigeminal nerve. These nerves are frequently implicated in the generation and propagation of facial pain. By interrupting the transmission of pain signals along these nerves, supratrochlear and supraorbital nerve blocks offer a targeted and minimally invasive approach to managing CAFP. Furthermore, their relatively low risk profile makes them an attractive option for individuals who have not responded well to other treatments or who wish to avoid more invasive interventions. The present case series (three males and one female) discusses the anatomical considerations, technique, and potential complications associated with supratrochlear and supraorbital nerve blocks. It also reviews the current body of evidence supporting their use in CAFP management, including outcomes such as pain reduction and improved quality of life. Supratrochlear and supraorbital nerve blocks represent a valuable addition to the armamentarium of therapies available for the management of CAFP.

Evaluation of Supratrochlear, Supraorbital and Angular Artery Course Variations and Depth by Doppler Ultrasound.

Supratrochlear (STA), supraorbital (SOA), and dorsal nasal artery (DNA) branches from the ophthalmic artery and angular artery (AA) from the facial artery are the primary suppliers of blood to the upper face. Filler injection without precise knowledge of its vascular topography poses a risk of severe complications. Seventy-four hemifaces from 37 subjects with a median age of 25.0 (21.0, 35.0) years and a median body mass index of 21.2 (20.0, 25.4) kg/m2 underwent high-frequency ultrasound tests between March 2022 and April 2022. The bilateral location, depth, peak systolic velocity (PSV), and inner diameter (ID) of the four periorbital arteries (STA, SOA, DNA, AA) were measured. The average ID ranges from 0.6~1.0 mm, and the average PSV ranges from 9.2~24.9 cm/s. All arteries detected passed through the superficial subcutaneous fascia. Most subjects' STAs traveled within 1.0 to 2.0 cm from the midline (left 96.8%, right 93.8%), while SOAs were mainly concentrated within 2.0 to 4.0 cm (left 83.9%, right 81.3%). STAs were more superficial and had a larger internal ID and PSV than SOAs (p<0.001). Except for the ID of the right SOA2 being significantly larger than that of the left SOA2 (p<0.05), no dominant side was found. The depth of STAs and SOAs was moderately correlated with BMI (p<0.05), except for STA1 on the left side. The course of AAs presented a high variability. These findings emphasize that the periorbital arteries carry with it a likelihood of ocular complication risks during injection. Targeting the supraperiosteal layer in the STA area and the supramuscular layer in the SOA area of the inferior forehead during injection seems reasonable, and an area within 1.0~2.0 cm from the midline should be avoided. Additionally, the high variability of AAs will enhance the understanding of the anatomy of the facial artery terminals. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ultrasound-Guided Scalp Blocks for an Awake Craniotomy: A Case Report

Ultrasound-guided scalp blocks may revolutionize regional anesthesia for neurosurgery. In this report, we demonstrate that ultrasound-guided scalp blocks can be used effectively for a craniotomy. A 48-year-old patient with a brain tumor at the motor cortex was scheduled for an awake craniotomy. Ultrasound-guided scalp blocks targeting the bilateral supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, greater auricular, lesser occipital, greater occipital, and third occipital nerves were performed. A total of 29 mL of levobupivacaine 0.3% was used. No additional local anesthetic agent was given for skull pinning, skin incision, or the craniotomy. Postoperatively, the patient remained pain-free, and she was discharged without complications.

Assessment of Postoperative Neurosensory Deficit Following Craniomaxillofacial Reconstruction Utilizing Bicoronal Flap

Objective: To assess post operative neurosensory deficit following craniomaxillofacial reconstruction using bicoronal flap. Subject and Methods: In altogether, 44 individuals between the ages of 18 and 60 were included in the research. All patients reported with primary complain of craniomaxillofacial trauma. Bicoronal flap was utilized in all patients. All patients were clinically examined for neurosensory deficits (supraorbital , supratrochlear region , zygomaticotempral and auriculotempral nerve). At least three intervals of one month, three months, and six months have been used to follow up on every case. Results: In 1st month evaluation, 14 patients were seen with neurosensory deficit with supraorbital nerve and 2 patients with supratrochlear nerve, while none of the patients were seen with disturbances in auriculotemporal and zygomaticotemporal nerve. At 6 month interval only 3 patients were remained with paresthesia of supraorbital nerve Conclusion: Using a bicoronal flap during craniomaxillofacial surgery is recommended, it provides excellent access and has reduced complications Keywords: Bicoronal Flap, Craniomaxillofacial Reconstruction, Neurosensory Deficit

Commentary: Corneal neurotization

Commentary: Corneal neurotization

Peripheral Neurectomy With Customized Nerve Reconstruction for Periorbital Neuropathic Pain: Initial Experience and Clinical Outcomes.

To describe a novel, minimally invasive surgical technique to treat severe, intractable periorbital neuropathic pain. A retrospective analysis of patients with severe, treatment-refractory periorbital pain who underwent transection of affected sensory trigeminal branches with nerve repair was performed. Collected data included etiology and duration of neuropathic pain, comorbidities, prior treatment history, surgical technique including site of transected sensory nerves and type of nerve repair, preoperative and postoperative pain scores as well as follow-up duration. Differences between preoperative and postoperative values were analyzed by the Wilcoxon signed-rank test. A total of 5 patients with severe periorbital neuropathic pain underwent transection of affected supraorbital, supratrochlear, infratrochlear, infraorbital, zygomaticotemporal, and zygomaticofacial nerves with customized nerve reconstruction. All 5 had improvement of periorbital pain after surgery, with 3 (60%) noting complete resolution of pain and 2 (40%) experiencing partial pain relief over a median follow-up period of 9 months (interquartile range [IQR], 6-19 months). Of the 3 patients who had complete resolution of pain, all reported continued pain relief. Median McGill pain scores significantly decreased from 8.4 (IQR, 8.2-10.0) preoperatively to 0.0 (IQR, 0.0-4.8; p < 0.001) postoperatively. All patients reported satisfaction with the surgical procedure and stated that they would undergo the procedure again if given the option. One patient with history of postherpetic neuralgia (PHN) had reactivation of herpes zoster at postoperative month 3, which was self-limited, without worsening of her neuropathic pain. Another patient with PHN required a staged procedure to achieve complete pain relief. Peripheral neurectomy with customized reconstruction of involved sensory nerves can successfully reduce and even eradicate periorbital neuropathic pain that was previously recalcitrant to combination pharmacotherapy and prior neurolysis procedures.