Facial Nerve Blocks Boost Comfort, Expectations

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN