The blocks of the face remained the poor relations of the peripheral locoregional anaesthesia. Except some pilot centers, the disaffection of these blocks is due to a group of factors: knowledge necessary of the complexes anatomy of facial innervation, the technicality of realisation, the frequency of bilateral blocks, the fear of incidents on a very vascularised zone like the face. However with the evolution these last years of the locoregional anaesthesia, the creation of practice formative centers, these blocks start to diffuse itself. The contribution of new molecules of anaesthetic less toxic buildings, the neurostimulation which found its place, even on the level of the face, made grow the benefice risks ratio. The rise of the ambulatory practices, to which the blocks of face are adapted perfectly, gave an impulse to these practices, in spite of very interesting at fragile or old patients and in urgency. Finally a good collaboration with the surgical operator will allow a better precision in the indication of these blocks thus reducing the risks of incidents. |
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performing |
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| Supraorbital nerve block | |
At its exit of the supraorbital foramen or channel, the nerve is generally made up in two groups, a medial and lateral [1] accompanied by its artery. It hangs an ascending frontal direction for supply the forehead zone (except the median zone above the root of the nose). The material for performing this block is an intradermal needle (26 G 5/8, 16 mm) connected to a syringe luer lock by an extension cable; or a needle with court bevel of 25 mm (24 G), standard neurostimulation needle. A cutaneous pen marker. |
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The puncture procedure is very simple. The operator places himself vis-a-vis the patient. The supraorbital foramen is located with the pulp of the finger (marked with the pen), the point of puncture is done on the level of the orbital edge, classically with the balance of the centered pupil [7]. The needle will seek the bone contact (with less than 10 mm generally) at the edge of the foramen, with a medial direction [18]; to avoid the penetration of the foramen at all costs causes nervous traumatism [6, 7,19]. |
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The injection will be very slow (and thus less sensitive) with 2 to 2,5 ml of anaesthetic solution, in a medial direction. After the shrinking of the needle, a discrete massage supports the diffusion of the product. The territory supply by this block is all teguments, skin to bone (external table). The supraorbital nerve supplies the superior eyelid especially in its central part, and the forehead until the coronal linea. The supraorbital block remains simple, easy [7], with a very high success and very fast training for this superficial block. They are many indications for the supraorbital block. In surgery, all acts on the superior eyelid (in association with the supratrochlear nerve) and on the forehead. In emergency, all multiple skin lesion the forehead zone, and the superior eyelid. The surgery under block can be very fast, with very good postoperative analgesia. The other indications are especially a postoperative analgesia (out of relay of a general anaesthesia); treatment of certain supraorbital neuralgias. With the supraorbital block the complications are very rare. The cutaneous puncture and the bone contact are sensitive, a sedation can be necessary. The puncture of the supraorbital artery is exceptional and would mean quasi-nervous puncture. A transitory palpebral ptose can be seen, by diffusion of the product towards the elevator muscle of the eyelid; this transitory paresis can be awkward (especially if bilateral block) for an ambulatory patient. Paraesthesias sequels in the territory of the nerve can be seen, because of an oedema of the nerve, strangled in its foramen, and whose origin is especially traumatic. To reject the foramen injection, origin of complications [1,7]. |
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| Supratrochlear nerve block | |
The supratrochlear nerve leaves by the identical foramen, and takes a superior and medial direction for supply the forehead above the nose. The material for
performing this block is an intradermal needle (26 G 5/8, 16 mm)
connected to a syringe luer lock by an extension cable; or a needle
with court bevel of 25 mm (24 G), standard neurostimulation needle.
A cutaneous pen marker. |
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The puncture procedure is very simple. The operator is vis-a-vis a the patient. The point of puncture is at the junction of two axial lines: superior palpebral linea, horizontal axe and nasal linea, vertical axe; needle will seek the bone contact, with a medial direction [1, 7, 18]; then injection. It will be necessary to be compelled at a surface point of puncture close to the root of the nose to avoid the risk of ponction of the angular vein. The injection will be very slow with 1 to 1,5 ml of anaesthetic solution, with a medial direction. After the shrinking of the needle, a discrete massage supports the diffusion of the product. The territory supplies by the supratrochlear block is all teguments, skin to bone, in medial forehead zone with the top of the root of the nose. The supratrochlear block remains simple, and very easy success. The indications of this block, in surgery is, acts on the upper eyelid (in association with the supraorbital block); the forehead above the root of the nose. In emergency, the fracture nose (in association with the nasal block). Few incidents with the supratrochlear block: the cutaneous puncture and the bone contact are sensitive: sedation can be necessary. The only incident is the puncture of the angular vein involving a haematoma obstructing the surgery zone [18]. |
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| Nasal or anterior ethmoidal nerve | |
After its orbital exit, the nerve gives the infratrochlear nerve, and the anterior ethmoidal nerve that one will improperly call “nasal” with his internal nasal branches very close with the root of the nose, and the external nasal branch. |
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The material for performing this block
is an intradermal needle (26 G 5/8, 16 mm) connected to a syringe luer
lock by an extension cable; or a needle with court bevel of 25 mm (24
G), standard neurostimulation needle. A cutaneous pen marker. |
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Two puncture procedures are possible: intraorbital technique it will be voluntarily isolated for several reasons [7, 20]:
However in professionals hands, the quality of the anaesthesia is correct and the complications rare for simple acts [20]. Nevertheless this technique remains very difficult in training. extraorbital technique It is the good technique; it is essential
by its obvious simplicity [18],
its harmlessness, and its effectiveness [19], with a maximal ratio
benefit risks. The operator is vis-a-vis the patient.
The injection must be particularly slow because very sensitive: 1 ml on the first site and 1,5 ml of anaesthetic solution, on the second site. After the shrinking of the needle a discrete massage supports the diffusion of the product. The territory supplies by the nasal nerve, is the nasal bone, edge of the nose; supply also the anterior part of the lateral wall and upper parts of the septum; the skin of the external nose to the nasal tip. The root of the nose requires in more the supratrochlear nerve. The nasal block remains simple, and very easy success, compared to the intraorbital technique. The indications of the nasal block are in surgery: all acts of tegumental surgery of the nose (in association with the infraorbital and supratrochlear nerves); the rhinoplasty (in association with a general anaesthesia). In emergency: nose fracture, nasal skin traumatism. Another indication
is postoperative analgesia of the nasal surgery under general anaesthesia. |
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| Indications With surgery type Tegumental surgery The explosion of the indications of the surgery of facial surface made strongly develop the requests for facial blocks. Practically all the teguments are accessible to these techniques. The carcinologic surgery of face (basocellular tumour and spinocellular tumour) with or without local scrap of rebuilding is integrated perfectly in this diagram [7, 18, 19], the more so as it is often practised at subjects at the risks (old patient, or at the patient risk) and more and more, into ambulatory surgery. Plastic surgery and cosmetic like face lipostructure, localised repair of scars, face lifting and especially, upper and lower blepharoplasty, surgery of the lips, the chin, and the "separated" ears. In emergency the wounds of the face also profit from these techniques [7]: indeed the interest of small volume of local anaesthetic, not deforming the banks of the wound, will facilitate repair [7]. The anaesthesia for the scalp is included in the same category that it is in emergency, or to ensure a good postoperative analgesia in neurosurgery. Thus the face and the upper eyelids will be accessible with supraorbital block and supratrochlear block; the cheek and the lips with an infraorbital block or maxillary block; for the nose one will need bilateral infraorbital and nasal blocks; finally for the chin and the inferior lips a mental block is enough. However for broad acts covering several territories it is to better extend nervous blocking; thus for a lipostructure of the face interesting the maxillary territory and the mandibular territory in their totality. It is advised to make maxillary and mandibular blocks at their origin, if one chooses a regional anaesthesia. Maxillofacial surgery In this indication the alone regional anaesthesia is exceptionally used [7]. Nevertheless simple gestures as the mandibular osteotomy can be carried out under blocks [21]. Generally these techniques accompany a traditional general anaesthesia to carry out an operational analgesia and especially great quality postoperative analgesia. Practically all the facial bone surgery can be performed with complementary block of the trigeminal branches; it is then preferable to perform these blocks at a waked up patient, especially if one chooses a neurostimulation. Nasal surgery The rhinoplasty, associating blocks of face and general anaesthesia optimizes comfort, and the hemodynamics effects and gets a great quality postoperative analgesia. With the operational circumstances and patient It is an indication of choice at the subjects at the risks:
Interesting indication also in emergency, at the patient not with jeun, with an often surface surgery. Within the framework of ambulatory surgery the these blocks have a dominating place, allowing, acts in full safety with a remarkable residual analgesia facilitating the return with the social life in the day surgery. Contraindications The general counter-indications are those of any regional anaesthesia,
in particular [27]: The counter-indications due to the patient are especially:
The reserves due to the operator must be taken into account. The variable level of difficulty of these blocks is solved only by one anatomical knowledge and a hands-on training preliminary [7, 27]. A few blocks are of easy and durable acquisition: supraorbital, infraorbital, mental, nasal, ear block, very safe from serious complications. On the other hand the blocks carried out in the "plexus" beginning, like the maxillary nerve and the mandibular nerve, are more delicate, with a rate of less raised success, even for accustomed, and with risks of complications raised in the literature. Only the neurostimulation although not evaluated, seems in this case to facilitate the access to these blocks. Blocks for analgesia Postoperative analgesia The tegumental surgery can be controlled in postoperative analgesia plan by prolonged facial blocks. A local anaesthetic of long duration, with an additive drug, allows a very good quality of postoperative analgesia (EVA < III), during at least ten hours. In certain cases, a postoperative analgesic block could be performed after the end of surgery. Catheters Some rare indications of prolonged analgesia by perineural catheter are described [28, 29, 30]; primarily within the framework of a major carcinologic surgery (postoperative analgesia) or of a complementary treatment to an algic pathology rebel with the traditional treatments, like an in eradicable orofacial cancer [28]. They will get a good quality and stable analgesia. The sites of realisation are the nerves located in a fossa: maxillary nerve in rotundum foramen (suprazygomatic way) or by infrazygomatic way [30]; mandibular nerve near the oval foramen. The technique of realisation of these catheters is same with that of the simple block except that the perform is optimized by the use of motor stimulation for the mandibular nerve. The catheters will be introduced only one centimetre beyond the nozzle and will be fixed with a wire (the head being very mobile). Currently the choice rather goes worms of the discontinuous injections with a local anaesthetic to low concentration (ropivacaine 0,2%). On a short series as a double blind study (8 patients) a team showed that the postoperative analgesics consumption over 4 postoperative days was very low in the catheter group, and very significant compared to the group without regional anaesthesia [30]. Medical indication For a long time the nerves of the face and especially the trigeminal nerve, were targeted for the treatment of the pains on the level of the face [1, 31]. Some indications with diagnostic and therapeutic aiming exist on the level of the face. All the neuralgias of the maxillary nerve (superior alveolar nerve), and the mandibular nerve (inferior alveolar nerve), can be relieved by blocks. Nervous alcoholisations can use the same procedures as those, which are employed for the anaesthetic blocks. Rare but effective indications exist like the treatment with mandibular block, of a trismus associated a hypoxic encephalopathy [32]. COMPLICATIONS Vascular complication The facial vascular richness is the essential cause of the major risk,
which is the vascular breach [7, 18, 21]
with on the pharmacological plan an intense and fast resorption of
the anaesthetic solution and the possibility of an intravascular injection.
All the nerves are accompanied by an artery (supra and infraorbital)
or close to a significant arterial axis (mandibular nerve and maxillary
artery); only the maxillary nerve with the foramen rotundum is above
the vessels. Neurological complication The only notorious accidents are the extension of the anaesthesia to the motor nerves: facial paralysis, ptose of superior eyelid; all these incidents are regressive spontaneously. The specific accident is the risk of paraesthesias due to the wound of one nerve at the exit of its foramen with oedema and suffering: the injection in the foramen is to be rejected formally. Articular complication A characteristic: the intramuscular injection in the pterygoid muscles can involve a blocking of the temporomandibular articulation with limited oral opening and trismus [33]. Toxic complication They are due either to the vascular passage, or with a fast resorption of the anaesthetic solution. They do not present characteristics and are superposable with those of the other peripheral blocks (arm or leg). CONCLUSION The regional anaesthesia of the face is accessible by two types of blocks; deep blocks supplies a large territory, specialised perform and not easy realisation; and the superficial blocks of very easy access and simple to realise, but with more reduced territories where they could be associated. |
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Movie of supraorbital block 
