Fig. 5.1 Branching pattern of the facial nerve and innervation of the brow and eyelids. Note that the temporal (frontal) branch innervates the brow and upper lid, while the zygomatic and buccal branches innervate the lower lid

and exposure. These blocks would also be useful when surgery is performed under local anesthesia or MAC in patients with facial dystonia (blepharospasm, hemifacial spasm, or synkinesis).

The most useful regional motor nerve block for eyelid surgery is the Van Lint block [12, 14, 15]. The needle is inserted at the point where a parallel line along the lateral and inferior orbital rims would meet. Approximately 2 cc of local anesthetic is injected along the superotemporal orbital rim. This blocks the temporal branches which supply the upper lids. Another 2 cc is injected along the temporal aspect of the inferior orbital rim. This blocks the zygomatic branches which innervate the lower lid. There may be buccal branches which innervate the medial lower lid which are missed with this block. The Van Lint block is easy to perform, selectively blocks branches of the facial nerve, and has a low risk of iatrogenic nerve damage (as bigger trunks of the nerve are avoided).

The Atkinson block is a more proximal block than the Van Lint, and is less predictable in producing eyelid akinesia, as there are numerous anastomoses between the branches

of the facial nerve. The needle is inserted at the inferior edge of the zygomatic arch with 2.5 cc injected superolaterally towards the top of the ear and also in the opposite direction in a linear tract over the zygomatic arch [12, 15].

The O’Brien block is the most proximal of the three blocks. Five cubic centimeter of local anesthetic is injected in front of the tragus of the ear to the condyloid process of the mandible [12, 15, 16].

Figure 5.2 depicts the injection patterns of all three regional motor nerve blocks.

5.11Sensory Blocks

Sensory blocks are the more useful regional blocks in eyelid and facial surgery. They do not provide the hemostasis (epinephrine effect) from diffuse local injections. These injections are helpful when tissue distortion from diffuse injection is not desired, as in Muellerectomy (posterior approach) ptosis surgery and periorbital laser skin resurfacing.

Sensory innervation of the eyelids and periorbital area is supplied by the ophthalmic (V1) and maxillary (V2) divisions of the trigeminal nerve [11]. The ophthalmic division enters the orbit through the superior orbital fissure and has three branches: lacrimal, frontal, and nasociliary. The maxillary division enters the orbit through the inferior orbital fissure and has two branches: infraorbital and zygomatic nerves. The lacrimal and frontal branches travel outside the muscle cone in the superior orbit, with the frontal branch further dividing into the supraorbital and supratrochlear nerves. The frontal nerve and its branches supply cutaneous innervation to the forehead, scalp medial upper eyelids, and side of the nose. The lacrimal branch innervates the skin overlying the lacrimal gland and temporal eyelid. The nasociliary nerve travels within the muscle cone and contributes sensation to the tip of the nose. The infraorbital branch of V2 travels in the inferior orbit in the infraorbital canal and exits the facial skeleton beneath the inferior orbital rim at the infraorbital foramen. It supplies the skin of the lower lid, cheek, upper lip, and side of the nose. The zygomatic nerve divides into a zygomaticotemporal and zygomaticofacial branch which supply innervation to the cheek and temple. Figure 5.3 demonstrates the sensory nerve branches of the eyelids and periorbital area.

There are various useful regional sensory blocks in the periorbital region. They are as follows:

•Frontal nerve block: The frontal nerve can be blocked by injecting 2 cc of local anesthetic at the level of the

supraorbital notch 2 cm into the superior orbit, hugging the orbital roof. A safer alternative is to inject the same anesthetic to the superior orbital rim at the level of the supraorbital notch (supraorbital nerve block) and advancing the needle nasally with a second injection to block the supratrochlear nerve.

•Infraorbital nerve block: The nerve is blocked by injecting 1–2 cc of local anesthetic 1.0 cm below the inferior orbital rim in line with the supraorbital notch (junction of

medial one third and lateral two third of orbital rim). Alternatively, the nerve can be blocked via an intraoral (gingivobuccal) approach.

•Zygomaticofacial nerve block: This nerve exits a foramen by the same name located in the inferolateral orbital rim just below the canthus. The nerve is blocked by a 1–2 cc direct injection of local anesthesia.

•Zygomaticotemporal nerve block: The nerve exits a foramen near the level of the lateral canthus behind the

Fig. 5.4 Frontal nerve block: a sagittal view of the orbit detailing the path of the needle along the roof of the orbit

orbital rim. A 1–2 cc injection of local anesthetic is given behind the lateral orbital rim. The injection must follow the posterior rim.

Figures 5.4 and 5.5 demonstrate the injection location for each regional sensory nerve block.

5.12Conclusion

Aesthetic surgery of the eyelids is both delicate and precise. It is obvious that a detailed knowledge of relevant anatomy, superior surgical skills, and experience are essential in order to attain appropriate surgical results. Often times, as surgeons are focused more on the technical aspects of the procedures, they have given less time and attention to the anesthesiarelated issues. When a basic understanding of topical, regional, oral, intravenous, and general anesthesia is attained, the surgery becomes easier and patient safety is significantly increased.

Fig. 5.5 The injection patterns for the remaining important regional sensory nerve blocks of the periorbital area are depicted

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