The Anatomy of the Corrugator Supercilii Muscle: Part II. Supraorbital Nerve Branching Patterns:

Effect of Sub-Eyebrow Small Incision Dissection of the Corrugator Supercilii Muscle Combined with Autologous Block Fat Transplantation for the Treatment of Severe Frown Lines

Objective

To explore the clinical efficacy of small sub-eyebrow incision in severing the corrugator supercilii muscle combined with autologous block fat transplantation for treating severe frown lines.

Methodology

Sixteen patients with severe frown lines admitted to our hospital who refused to receive repeated injections of botulinum toxin were selected for treatment through corrugator dissection combined with fat transplantation.

Results

No patients had difficulty raising their eyebrows after surgery. They all had a smooth eyebrow shape, no abnormal movement of the eyebrows, and no tissue depression during relaxation or frowning. At 12 months after surgery, the overall patient satisfaction with the treatment was 100%, indicating satisfactory results.

Conclusion

Treating severe frown lines with a small incision of corrugator combined with autologous block fat transplantation is more effective than traditional treatment, maintains stable and long-term satisfaction, and is associated with less postoperative complications; therefore, this technique should be promoted for treating severe frown lines.

Simulating Upper Eyelid Ptosis During Neuromodulator Injections-An Exploratory Injection and Dissection Study

BACKGROUND

Aesthetic neuromodulator injections of the upper face are frequently performed to temporarily block muscular actions of the periorbital muscles to ultimately reduce skin rhytids. However, the adverse event rate in the literature for toxin-induced blepharoptosis ranges from 0.51% to 5.4%.

OBJECTIVE

To identify access pathways by which injected neuromodulator product can travel from extra- to intra-orbital and therefore affect the levator palpebrae superioris muscle.

METHODS

Nine non-embalmed human body donors were investigated in this study with a mean age at death of 72.8 (16.1) years. The 18 supraorbital regions were injected in 28 times (14 for supratrochlear and 14 for supraorbital) with 0.5 cc, whereas eight cases (four for supratrochlear and four supraorbital) were injected with 0.1 cc of colored product. Anatomic dissections were conducted to identify structures stained by the injected color.

RESULTS

The results of this injection- and dissection-based study revealed that both the supratrochlear and the supraorbital neurovascular bundles are access pathways for injected neuromodulator products to reach the intra-orbital space and affect the levator palpebrea superioris muscle. Out of 36 conducted injection passes, seven (19.44%) resulted in affection of the sole elevator of the eyelid of which 100% occurred only at an injection volume of 0.5 cc and not at 0.1 cc.

CONCLUSION

Clinically, the results indicate that a low injection volume, a superficial injection for the supraorbital location, and angling the needle tip away from the supratrochlear foramen (toward the contralateral temple) when targeting the corrugator supercilii muscles, can increase the safety profile of an aesthetic toxin glabellar treatment.

[Anatomy of the frontal region]

The forehead is an anatomic region located between the frontal hairline cranially, the eyebrow and the glabella caudally, and the anterior border of the temporal fossa laterally on both sides. Its vertical situation, due to the telencephalon growth, is specific of the human species. From surface to deep planes, the skin and sub-cutaneous fat pads are described first. The muscular plane is constituted of the frontal muscles elevators of the forehead and the eyebrow, and the depressors which are the procerus and orbicularis oculi muscles superficially, the depressor supercilii muscle, and the corrugator supercilii in a deep plane. The galea aponeurotica, located deep to the frontal muscles, is a fibrous lamina on which the muscles of the skull insert. There is a sexual dimorphism of the frontal bone. The male forehead has extensive supraorbital bossing, and above this there is often a flat area, in teh femalethe supraorbital bossing is often nonexistent and above, there is a continous mild curvature. Blood supply to the forehead is given by an anterior pedicle constituted by the supraorbital and supratrochlear vessels and a lateral pedicle made of the anterior branches from the superficial temporal vessels. The sensory innervation of the forehead is given by the ophtalmic nerve which divides in frontal, nasociliar and lacrymal nerves. The motor innervation is given by the temporal ramus of the facial nerve which passes laterally to the zygomatic arch, and gives the innervation of the frontal, corrugator supercilii and procerus muscles.

Safe Zones for Facial Fillers: Anatomical Study of SubSMAS Spaces in Asians

The study "Spaces of the Face for Filler Procedures: Identification of subSMAS Spaces Based on Anatomical Study" explores the anatomy of facial spaces crucial for safe and effective filler injections. By delineating the subSMAS (sub-superficial musculoaponeurotic system) spaces, this research highlights how these virtual compartments, bordered by fat, muscles, fascia, and ligaments, facilitate independent muscle movement and reduce the risk of damaging critical structures. The thicker and more robust skin of East Asians necessitates deeper filler injections, emphasizing the significance of accurately identifying these spaces. A cadaver study with dyed gelatin validated the existence and characteristics of these subSMAS spaces, confirming their safety for filler procedures. Key spaces, such as the subgalea-frontalis, interfascial and temporalis, and prezygomatic spaces, were examined, illustrating safe zones for injections. The findings underscore the importance of anatomical knowledge for enhancing facial aesthetics while minimizing complications. This study serves as a guide for clinicians to perform precise and safe filler injections, providing a foundation for further research on the dynamic interactions of these spaces and long-term outcomes.

The Positive and Negative Predictive Value of Targeted Diagnostic Botox Injection in Nerve Decompression Migraine Surgery

BACKGROUND

Nerve decompression surgery is an effective treatment modality for patients who experience migraines. Botulinum toxin type A (Botox) injections have been traditionally used as a method to identify trigger sites; however, there is a paucity in data regarding its diagnostic efficacy. The goal of this study was to assess the diagnostic capacity of Botox in successfully identifying migraine trigger sites and predicting surgical success.

METHODS

A sensitivity analysis was performed on all patients receiving Botox for migraine trigger site localization followed by a surgical decompression of affected peripheral nerves. Positive and negative predictive values were calculated.

RESULTS

A total of 40 patients met our inclusion criteria and underwent targeted diagnostic Botox injection followed by a peripheral nerve deactivation surgery with at least 3 months' follow-up. Patients with successful Botox injections (defined as at least 50% improvement in Migraine Headache Index scores after injection) had significantly higher average reduction in migraine intensity (56.7% versus 25.8%; P = 0.020), frequency (78.1% versus 46.8%; P = 0.018), and Migraine Headache Index (89.7% versus 49.2%; P = 0.016) postsurgical deactivation. Sensitivity analysis shows that the use of Botox injection as a diagnostic modality for migraine headaches has a sensitivity of 56.7% and a specificity of 80.0%. The positive predictive value is 89.5% and the negative predictive value is 38.1%.

CONCLUSIONS

Diagnostic targeted Botox injections have a very high positive predictive value. It is therefore a useful diagnostic modality that can help identify migraine trigger sites and improve preoperative patient selection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Pearls for Starting a Headache Surgery Practice in Academic and Private Practice

There has been a growing body of evidence indicative of the effectiveness of headache surgery in treating patients with refractory headache disorders. The American Society of Plastic Surgeons issued a Policy Statement in 2018 stating that peripheral nerve decompression surgery for the treatment of refractory chronic headache disorders in select patients is considered a standard of care treatment. This endorsement sparked the interest of numerous plastic surgeons into initiating their own headache surgery practices. However, establishing a headache surgery clinic introduces challenges and considerations. This report outlines the key pillars for launching a successful headache surgery practice in academic and private practice environments.

Evaluation and Classification of Supraorbital Nerve Emerging Patterns

BACKGROUND

Numerous significant variations in the supraorbital nerve (SON) pass through the notches and foramina. During endoscopic forehead lifting, the passage and the location of the nerve against the frontal bone render it susceptible to injury, resulting in diminished or absent sensation in the corresponding location. We attempted to obtain accurate knowledge of the SON emergence routes.

METHODS

Data of patients who underwent an endoscopic forehead lift in a plastic surgery clinic between November 2015 and August 2021 were retrospectively analyzed. Deep and superficial branch pathways of SONs were identified and compared according to side and gender. We also classified the nerve patterns into six types.

RESULTS

Altogether, 942 patients (1884 SON cases) were evaluated. Out of the patients, 86 patients were male, and 856 were female. The overall mean age was 48.6 (± 13.1) years. In the deep branches, 49% came from the notch, and 51% came from the foramen. In the superficial branches, 67% came from the notch, and 33% of superficial branches came from the foramen. Unlike the deep branch, superficial branches from the notch were significant. Deep and superficial branches of male patients were much more notched than those of female patients. Branches emerged together in 56% and separately in 44% of the cases.

CONCLUSION

The absolute number of SON notches was higher than that of SON foramina. This study with the largest number of SON cases will help surgeons understand the variation and course of SON.

LEVEL OF EVIDENCE IV

This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

Functional outcomes between headache surgery and targeted botox injections: A prospective multicenter pilot study

Introduction

Chronic migraine headaches (MH) are a principal cause of disability worldwide. This study evaluated and compared functional outcomes after peripheral trigger point deactivation surgery or botulinum neurotoxin A (BTA) treatment in patients with MH.

Methods

A long-term, multicenter, and prospective study was performed. Patients with chronic migraine were recruited at the Ohio State University and Massachusetts General Hospital and included in each treatment group according to their preference (BTA or surgery). Assessment tools including the Migraine Headache Index (MHI), Migraine Disability Assessment Questionnaire (MIDAS) total, MIDAS A, MIDAS B, Migraine Work and Productivity Loss Questionnaire-question 7 (MWPLQ7), and Migraine-Specific Quality of Life Questionnaire (MSQ) version 2.1 were used to evaluate functional outcomes. Patients were evaluated prior to treatment and at 1, 2, and 2.5 years after treatment.

Results

A total of 44 patients were included in the study (surgery=33, BTA=11). Patients treated surgically showed statistically significant improvement in headache intensity as measured on MIDAS B (p = 0.0464) and reduced disability as measured on MWPLQ7 (p = 0.0120) compared to those treated with BTA injection. No statistical difference between groups was found for the remaining functional outcomes. Mean scores significantly improved over time independently of treatment for MHI, MIDAS total, MIDAS A, MIDAS B, and MWPLQ 7 (p<0.05). However, no difference in mean scores over time was observed for MSQ.

Conclusions

Headache surgery and targeted BTA injections are both effective means of addressing peripheral trigger sites causing headache pain. However, lower pain intensity and work-related disabilities were found in the surgical group.

Anatomic Anomalies of the Nerves Treated during Headache Surgery

Background

Headache surgery is a well-established, viable option for patients with chronic head pain/migraines refractory to conventional treatment modalities. These operations involve any number of seven primary nerves. In the occipital region, the surgical targets are the greater, lesser, and third occipital nerves. In the temporal region, they are the auriculotemporal and zygomaticotemporal nerves. In the forehead, the supraorbital and supratrochlear are targeted. The typical anatomic courses of these nerves are well established and documented in clinical and cadaveric studies. However, variations of this "typical" anatomy are quite common and relatively poorly understood. Headache surgeons should be aware of these common anomalies, as they may alter treatment in several meaningful ways.

Methods

In this article, we describe the experience of five established headache surgeons encompassing over 4000 cases with respect to the most common anomalies of the nerves typically addressed during headache surgery. Descriptions of anomalous nerve courses and suggestions for management are offered.

Results

Anomalies of all seven nerves addressed during headache operations occur with a frequency ranging from 2% to 50%, depending on anomaly type and nerve location. Variations of the temporal and occipital nerves are most common, whereas anomalies of the frontal nerves are relatively less common. Management includes broader dissection and/or transection of accessory injured nerves combined with strategies to reduce neuroma formation such as targeted reinnervation or regenerative peripheral nerve interfaces.

Conclusions

Understanding these myriad nerve anomalies is essential to any headache surgeon. Implications are relevant to preoperative planning, intraoperative dissection, and postoperative management.

Feasibility of Ultrasound Measurements of Peripheral Sensory Nerves in Head and Neck Area in Healthy Subjects

Background

Current diagnostic methods for nerve compression headaches consist of diagnostic nerve blocks. A less-invasive method that can possibly aid in the diagnosis is ultrasound, by measuring the cross-sectional area (CSA) of the affected nerve. However, this technique has not been validated, and articles evaluating CSA measurements in the asymptomatic population are missing in the current literature. Therefore, the aim of this study was to determine the feasibility of ultrasound measurements of peripheral extracranial nerves in the head and neck area in asymptomatic individuals.

Methods

The sensory nerves of the head and neck in healthy individuals were imaged by ultrasound. The CSA was measured at anatomical determined measurement sites for each nerve. To determine the feasibility of ultrasound measurements, the interrater reliability and the intrarater reliability were determined.

Results

In total, 60 healthy volunteers were included. We were able to image the nerves at nine of 11 measurement sites. The mean CSA of the frontal nerves ranged between 0.80 ± 0.42 mm2 and 1.20 ± 0.43 mm2, the mean CSA of the occipital nerves ranged between 2.90 ± 2.73 mm2 and 3.40 ± 1.91 mm2, and the mean CSA of the temporal nerves ranged between 0.92 ± 0.26 mm2 and 1.40 ± 1.11 mm2. The intrarater and interrater reliability of the CSA measurements was good (ICC: 0.75-0.78).

Conclusions

Ultrasound is a feasible method to evaluate CSA measurements of peripheral extracranial nerves in the head and neck area. Further research should be done to evaluate the use of ultrasound as a diagnostic tool for nerve compression headache.

Anatomic Variations of the Lateral Branch of the Supraorbital Nerve Observed in Endoscopic Forehead Surgery

Surgeons dissect carefully in the medial third of the supraorbital rim to preserve the supraorbital nerve (SON) during surgical forehead rejuvenation. However, the anatomic variations of SON exit from the frontal bone have been researched in cadaver or imaging studies. In this study, we report a variation in the lateral branch of SON observed in an endoscopic view during forehead lifts. A retrospective review of 462 patients who underwent endoscopy-assisted forehead lifts between January 2013 and April 2020 was performed. Data, including the location, number, and form of the exit point and thickness of SON and its lateral branch variant, were recorded and reviewed intraoperatively, utilizing high-definition endoscopic assistance. Thirty-nine patients and 51 sides were included, and all patients were female, with a mean age of 44.53 (18-75) years. This nerve exited a foramen in the frontal bone ~8.82 ± 2.79 mm lateral to SON and ~1.89 ± 1.34 mm from the supraorbital margin vertically. Observed thickness variations of the lateral branch of SON included 20 small, 25 medium, and 6 large nerves. This study revealed various positional and morphologic variations of the lateral branch of SON in an endoscopic view. Thus, surgeons can be alerted of the anatomic variations of SON and establish careful dissection during procedures. In addition, the findings of this study will be useful in planning nerve blocks, filler injections, and migraine treatments in the supraorbital region.

Measuring Success in Headache Surgery: A Comparison of Different Outcomes Measures

BACKGROUND

Studies of migraine surgery have relied on quantitative, patient-reported measures like the Migraine Headache Index (MHI) and validated surveys to study the outcomes and impact of headache surgery. It is unclear whether a single metric or a combination of outcomes assessments is best suited to do so.

METHODS

All patients who underwent headache surgery had an MHI calculated and completed the Headache Impact Test, the Migraine Disability Assessment Test, the Migraine-Specific Quality-of-Life Questionnaire, and an institutional ad hoc survey preoperatively and postoperatively.

RESULTS

Twenty-seven patients (79%) experienced greater than or equal to 50% MHI reduction. MHI decreased significantly from a median of 210 preoperatively to 12.5 postoperatively (85%; P < 0.0001). Headache Impact Test scores improved from 67 to 61 (14%; P < 0.0001). Migraine Disability Assessment Test scores improved from 57 to 20 (67%; P = 0.0022). The Migraine-Specific Quality-of-Life Questionnaire demonstrated improvement in quality-of-life scores within all three of its domains ( P < 0.0001). The authors' ad hoc survey demonstrated that participants "strongly agreed" that (1) surgery helped their symptoms, (2) they would choose surgery again, and (3) they would recommend headache surgery to others.

CONCLUSIONS

Regardless of how one measures it, headache surgery is effective. The authors demonstrate that surgery significantly improves patients' quality of life and decreases the effect of headaches on patients' functioning, but headaches can still be present to a substantial degree. The extent of improvement in migraine burden and quality of life in these patients may exceed the amount of improvement demonstrated by current measures.

Artificial Intelligence-Enabled Evaluation of Pain Sketches to Predict Outcomes in Headache Surgery

BACKGROUND

Recent evidence has shown that patient drawings of pain can predict poor outcomes in headache surgery. Given that interpretation of pain drawings requires some clinical experience, the authors developed a machine learning framework capable of automatically interpreting pain drawings to predict surgical outcomes. This platform will allow surgeons with less clinical experience, neurologists, primary care practitioners, and even patients to better understand candidacy for headache surgery.

METHODS

A random forest machine learning algorithm was trained on 131 pain drawings provided prospectively by headache surgery patients before undergoing trigger-site deactivation surgery. Twenty-four features were used to describe the anatomical distribution of pain on each drawing for interpretation by the machine learning algorithm. Surgical outcome was measured by calculating percentage improvement in Migraine Headache Index at least 3 months after surgery. Artificial intelligence predictions were compared with clinician predictions of surgical outcome to determine artificial intelligence performance.

RESULTS

Evaluation of the data test set demonstrated that the algorithm was consistently more accurate (94%) than trained clinical evaluators. Artificial intelligence weighted diffuse pain, facial pain, and pain at the vertex as strong predictors of poor surgical outcome.

CONCLUSIONS

This study indicates that structured algorithmic analysis is able to correlate pain patterns drawn by patients to Migraine Headache Index percentage improvement with good accuracy (94%). Further studies on larger data sets and inclusion of other significant clinical screening variables are required to improve outcome predictions in headache surgery and apply this tool to clinical practice.

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

Objective

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.

Materials and Methods

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.

Results

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.

Conclusion

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.

Effect of osteopathic techniques on human resting muscle tone in healthy subjects using myotonometry: a factorial randomized trial

Musculoskeletal disorders (MSDs) are highly prevalent, burdensome, and putatively associated with an altered human resting muscle tone (HRMT). Osteopathic manipulative treatment (OMT) is commonly and effectively applied to treat MSDs and reputedly influences the HRMT. Arguably, OMT may modulate alterations in HRMT underlying MSDs. However, there is sparse evidence even for the effect of OMT on HRMT in healthy subjects. A 3 × 3 factorial randomised trial was performed to investigate the effect of myofascial release (MRT), muscle energy (MET), and soft tissue techniques (STT) on the HRMT of the corrugator supercilii (CS), superficial masseter (SM), and upper trapezius muscles (UT) in healthy subjects in Hamburg, Germany. Participants were randomised into three groups (1:1:1 allocation ratio) receiving treatment, according to different muscle-technique pairings, over the course of three sessions with one-week washout periods. We assessed the effect of osteopathic techniques on muscle tone (F), biomechanical (S, D), and viscoelastic properties (R, C) from baseline to follow-up (primary objective) and tested if specific muscle-technique pairs modulate the effect pre- to post-intervention (secondary objective) using the MyotonPRO (at rest). Ancillary, we investigate if these putative effects may differ between the sexes. Data were analysed using descriptive (mean, standard deviation, and quantiles) and inductive statistics (Bayesian ANOVA). 59 healthy participants were randomised into three groups and two subjects dropped out from one group (n = 20; n = 20; n = 19-2). The CS produced frequent measurement errors and was excluded from analysis. OMT significantly changed F (-0.163 [0.060]; p = 0.008), S (-3.060 [1.563]; p = 0.048), R (0.594 [0.141]; p < 0.001), and C (0.038 [0.017]; p = 0.028) but not D (0.011 [0.017]; p = 0.527). The effect was not significantly modulated by muscle-technique pairings (p > 0.05). Subgroup analysis revealed a significant sex-specific difference for F from baseline to follow-up. No adverse events were reported. OMT modified the HRMT in healthy subjects which may inform future research on MSDs. In detail, MRT, MET, and STT reduced the muscle tone (F), decreased biomechanical (S not D), and increased viscoelastic properties (R and C) of the SM and UT (CS was not measurable). However, the effect on HRMT was not modulated by muscle-technique interaction and showed sex-specific differences only for F.Trial registration German Clinical Trial Register (DRKS00020393).

Creating Harmonious Arcs: The Importance of Brow Shape in Determining Upper Lid Aesthetics

Brow lifting, when indicated, can significantly improve upper eyelid aesthetics. Brow lifting is a powerful maneuver to shape and lateralize the curvature of the brow arc and directly influences the upper eyelid fold height and the curvature of the upper eyelid crease. This article reviews the importance of upper periorbital aesthetic assessment because it lays the foundation to tailor the appropriate operative intervention. Highlighted are the authors' preferred approach to aesthetically shape the brow along with other complimentary upper eyelid aesthetic procedures including upper blepharoplasty, blepharoptosis repair, fat grafting, and upper periorbital fat shifting to optimize brow lifting outcomes.

Brow Anatomy and Aesthetics of the Upper Face

The surgical approach to the brow has changed perhaps more than any other facial esthetic procedure in the past 20 years. Understanding the functional anatomy of the upper face is the best means of maximizing results and minimizing untoward events in this region. The surgical and clinical correlation is addressed in detail in this article. Cadaver and intraoperative photographs are used to illustrate critical points. Armed with the details of this anatomy, the reader will best be able to best individualize surgical treatment.

Efficacy and Safety of Migraine Surgery: A Systematic Review and Meta-analysis of Outcomes and Complication Rates

OBJECTIVE

The objectives of this study are to assess the efficacy and safety of peripheral nerve surgery for migraine headaches and to bibliometrically analyze all anatomical studies relevant to migraine surgery.

SUMMARY BACKGROUND DATA

Migraines rank as the second leading cause of disability worldwide. Despite the availability of conservative management options, individuals suffer from refractive migraines which are associated with poor quality of life. Migraine surgery, defined as the peripheral nerve decompression/trigger site deactivation, is a relatively novel treatment strategy for refractory migraines.

METHODS

EMBASE and the National Library of Medicine (PubMed) were systematically searched for relevant articles according to the PRISMA guidelines. Data was extracted from studies which met the inclusion criteria. Pooled analyses were performed to assess complication rates. Meta-analyses were run using the random effects model for overall effects and within subgroup fixed-effect models were used.

RESULTS

A total of 68 studies (38 clinical, 30 anatomical) were included in this review. There was a significant overall reduction in migraine intensity (P < 0.001, SE = 0.22, I2 = 97.9), frequency (P < 0.001, SE = 0.17, I2 = 97.7), duration (P < 0.001, SE = 0.15, I2 = 97), and migraine headache index (MHI, P < 0.001, SE = 0.19, I2 = 97.2) at follow-up. A total of 35 studies reported on migraine improvement (range: 68.3%-100% of participants) and migraine elimination (range: 8.3%-86.5% of participants). 32.1% of participants in the clinical studies reported complications for which the most commonly reported complications being paresthesia and numbness, which was mostly transient, (12.11%) and itching (4.89%).

CONCLUSION

This study demonstrates improved migraine outcomes and an overall decrease in MHI as well as strong evidence for the safety profile and complication rate of migraine surgery.

The Great Auricular Nerve Trigger Site: Anatomy, Compression Point Topography, and Treatment Options for Headache Pain

BACKGROUND

Peripheral nerve decompression surgery can effectively address headache pain caused by compression of peripheral nerves of the head and neck. Despite decompression of known trigger sites, there are a subset of patients with trigger sites centered over the postauricular area coursing. The authors hypothesize that these patients experience primary or residual pain caused by compression of the great auricular nerve.

METHODS

Anatomical dissections were carried out on 16 formalin-fixed cadaveric heads. Possible points of compression along fascia, muscle, and parotid gland were identified. Ultrasound technology was used to confirm these anatomical findings in a living volunteer.

RESULTS

The authors' findings demonstrate that the possible points of compression for the great auricular nerve are at Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle in the dense connective tissue before entry into the parotid gland (point 2), and within its intraparotid course (point 3). The mean topographic measurements were as follows: Erb's point to the mastoid process at 7.32 cm/7.35 (right/left), Erb's point to the angle of the mandible at 6.04 cm/5.89 cm (right/left), and the posterior aspect of the sternocleidomastoid muscle to the mastoid process at 3.88 cm/4.43 cm (right/left). All three possible points of compression could be identified using ultrasound.

CONCLUSIONS

This study identified three possible points of compression of the great auricular nerve that could be decompressed with peripheral nerve decompression surgery: Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle (point 2), and within its intraparotid course (point 3).

Clinical Effectiveness of Peripheral Nerve Blocks for Diagnosis of Migraine Trigger Points

BACKGROUND

With a 13 percent global prevalence, migraine headaches are the most commonly diagnosed neurologic disorder, and are a top five cause of visits to the emergency room. Surgical techniques, such as decompression and/or ablation of neurovasculature, have shown to provide relief. Popular diagnostic modalities to identify trigger loci include handheld Doppler examinations and botulinum toxin injection. This article aims to establish the positive predictive value of peripheral nerve blocks for identifying therapeutic surgical targets for migraine headache surgery.

METHODS

Electronic medical records of 36 patients were analyzed retrospectively. Patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified migraine headache trigger sites. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was performed using paired t tests, and positive-predictive value calculations were performed on subgroups.

RESULTS

The preoperative Migraine Headache Index of patients with positive blocks was 152.71, versus 34.26 postoperatively (p < 0.001). Each index component also decreased significantly: frequency (22.11 versus 15.06 migraine headaches per month; p < 0.001), intensity (7.43 versus 4.12; p < 0.001), and duration (0.93 versus 0.55 days; p < 0.001). The positive-predictive value of diagnostic peripheral nerve blocks in identifying a migraine headache trigger site responsive to surgical intervention was calculated to be 0.89 (95 percent CI, 1 to 0.74).

CONCLUSIONS

To the authors' knowledge, this is the first study to investigate the positive-predictive value of peripheral nerve blocks as used in the diagnostic workup of patients with chronic migraine headaches. Peripheral nerve blocks serve as a reliable clinical tool in mapping migraine trigger sites for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache

BACKGROUND

Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies.

METHODS

One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data.

RESULTS

The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups.

CONCLUSIONS

The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.

The anatomical variations of the emergence routes of supraorbital nerve cadaveric study and systematic review

BACKGROUND

Knowledge of the location of supraorbital nerve is essential to perform supraorbital endoscopic surgery, regional nerve block, and nerve decompression in the treatment of migraine. This study discusses the emergence routes of supraorbital nerve as well as a systematic literature review on previous anatomical studies. This comparative analysis will be beneficial for surgeons worldwide.

METHODS

The study sample consisted of 19 cadavers with bilateral supraorbital nerve dissections. The emergence route of the nerve through either a notch or foramen was recorded. Additionally, the distance from midline, nerve branching patterns, and diameter of emergence routes were measured.

RESULTS

Our findings showed an equal number of supraorbital emergence route between notch and foramen (42%) and demonstrated average distance from emergence route and facial midline 22.34 (3.05) mm in male and 23.58 ± 2.42 mm in female. Diameter of notch type is 3.97 (0.99) mm and 3.39 (1.09) mm in foramen type. Data from systematic review showed range of distance from emergence route to facial midline from 22.2 to 33.7 mm. East Asia population had significant shorter distance of supraorbital emergence route to facial midline than Middle Asia and Caucasian population.

CONCLUSION

This study provides greater insight into the anatomic variations and supraorbital never course in an understudied minority population. Surgeons should be aware of this critical area and strive to minimize dissection to prevent iatrogenic nerve injury.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes.

SUMMARY

Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

Cost-effectiveness of Erenumab Versus Surgical Trigger Site Deactivation for the Treatment of Migraine Headaches: A Systematic Review

BACKGROUND

Migraine headache is a common, debilitating condition responsible for astronomical societal burden. The chronicity of migraine headaches necessitates the use of many healthcare services. Preventative treatment remains the desirable option for this patient population. Pharmacologic advances have led to the development of erenumab, a monoclonal antibody calcitonin gene-related peptide receptor antagonist that directly interferes with the known biochemical pathway of migraine initiation. Alternatively, surgical decompression of migraine trigger sites is a historically effective preventative option for certain patients experiencing migraine headaches. As new treatments emerge, the large economic burden of migraine headaches requires cost evaluation against already available preventative modalities.

METHODS

Studies evaluating the cost-effectiveness of both erenumab and surgical trigger site deactivation were found using EMBASE and MedLine. Relevant economic data was extracted from this literature and the cost of treatment with erenumab was compared with surgical decompression.

RESULTS

The market price of erenumab is $6900/yr. Speculative models predicted a direct annual healthcare cost ranging from $11,404 to $12,988 for patients experiencing episodic migraine. For chronic migraine patients, this range extended to $25,604. Annual indirect costs ranged from $7601 to $19,377. Prospective and model-based studies evaluating surgical trigger site deactivation reported an average 1 time surgical cost between $6956 and $10,303. In episodic migraine, subsequent annual healthcare costs were $900.

CONCLUSIONS

Erenumab has potential to be a revolutionary noninvasive preventative treatment for migraine headache. With that said, the cost-conscious option for patients receiving more than 1 year of treatment remains surgical trigger site deactivation.

Selective denervation of the corrugator supercilii muscle for the treatment of idiopatic trigeminal neuralgia purely paroxysmal distributed in the supraorbital and suprathrochlear dermatomes

Introduction

Idiopatic trigeminal neuralgia purely paroxysmal (ITNp) distributed in the supraorbital and suprathrochlear dermatomes (SSd), refractory to conventional treatments have been linked to the hyperactivity of the corrugator supercilii muscle (CSM). In these patients, the inactivation of the CSM via botulinum toxin type A (BTA) injections has been proven to be safe and effective in reducing migraine burden. The main limitation of BTA is the need of repetitive injections and relative high costs. Based on the study of the motor innervation of the CSM, we describe here an alternative approach to improve these type of migraines, based on a minimally invasive denervation of the CSM.

Materials and methods

Motor innervation and feasibility of selective CSM denervation was first studied on fresh frozen cadavers. Once the technique was safely established, 15 patients were enrolled. To be considered eligible, patients had to meet the following criteria: positive response to BTA treatment, migraine disability assessment score > 24, > 15 migraine days/month, no occipital/temporal trigger points and plausible reasons to discontinue BTA treatment. Pre- and post- operative migraine headache index (MHI) were compared, and complications were classified following the Clavien-Dindo classification (CDC).

Results

Fifteen patients (9 females and 6 males) underwent the described surgical procedure. The mean age was 41 ± 10 years. Migraine headache episodes decreased from 24 ± 4 day/month to 2 ± 2 (p < 0.001) The MHI decreased from 208 ± 35 to 10 ± 11 (p < 0.001). One patient (7%) had a grade I complication according to the CDC. No patient needed a second operative procedure.

Conclusions

Our findings suggest that the selective CSM denervation represents a safe and minimally invasive approach to improve ITNp distributed in the SSd associated with CSM hyperactivation.

Trial registration

The data collection was conducted as a retrospective quality assessment study and all procedures were performed in accordance with the ethical standards of the national research committee and the 1964 Helsinki Declaration and its later amendments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01218-6.

Upper Blepharoplasty with Endoscopically Assisted Brow Lift to Restore Harmonious Upper Lid Arc Curvatures

BACKGROUND

Achieving excellent results in upper lid rejuvenation requires a balanced approach to address skin, muscle, fat, upper lid margin position, and brow aging changes. In the appropriately selected patient, brow lifting plays an essential complement to upper blepharoplasty to restore more youthful upper lid fold-to-pretarsal ratios. The goal of this study is to describe a safe and reproducible method to perform brow lifting and upper blepharoplasty.

METHODS

Medial to the temporal line of fusion, in-line with the brow peak, a 2-cm scalp incision is oriented parallel to the course of the deep branch of the supraorbital nerve to minimize the risk of nerve injury. The brow vector of pull is maximal in this location and secured to a monocortical bone channel with 3-0 polydioxanone. Lateral to the temporal line of fusion, an ellipse of scalp tissue is excised to gently elevate the brow tail. Upper blepharoplasty is performed in an individualized fashion to achieve a youthful contour of the upper lid fold.

RESULTS

The endoscopically assisted technique is designed to achieve tissue release under direct visualization. The brow-lift maximal vector of pull is centered over the brow peak and, to a lesser extent, at the brow tail to improve lateral upper lid fold height and a smooth contour of the pretarsal space. Muscle shaping sutures improve convexity of the lateral upper lid fold.

CONCLUSION

In the appropriately selected patient, combined brow lift and upper blepharoplasty with muscle contouring are safe and effective techniques that help improve aesthetic upper lid topographic proportions.

Decompression Surgery for Frontal Migraine Headache

INTRODUCTION

Migraine headache (MH) is one of the most common diseases worldwide and pharmaceutical treatment is considered the gold standard. Nevertheless, one-third of patients suffering from migraine headaches are unresponsive to medical management and meet the criteria for "refractory migraines" classification. Surgical treatment of MH might represent a supplementary alternative for this category of patients when pharmaceutical treatment does not allow for satisfactory results. The goal of this article is to provide a comprehensive review of the literature regarding surgical treatment for site I migraine management.

METHODS

A literature search using PubMed, Medline, Cochrane and Google Scholar database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted using the following MeSH terms: "frontal neuralgia," "frontal trigger site treatment," "frontal migraine surgery" and "frontal headache surgery" (period: 2000 -2020; last search on 12 March 2020).

RESULTS

Eighteen studies published between 2000 and 2019, with a total of 628 patients, were considered eligible. Between 68% and 93% of patients obtained satisfactory postoperative results. Complete migraine elimination rate ranged from 28.3% to 59%, and significant improvement (>50% reduction) rates varied from 26.5% to 60%.

CONCLUSIONS

Our systematic review of the literature suggests that frontal trigger site nerve decompression could possibly be an effective strategy to treat migraine refractory patients, providing significant improvement of symptoms in a considerable percentage of patients.

Patient Pain Sketches Can Predict Surgical Outcomes in Trigger-Site Deactivation Surgery for Headaches

BACKGROUND

Patient selection for headache surgery is an important variable to ensure successful outcomes. In the authors' experience, a valuable method to visualize pain/trigger sites is to ask patients to draw their pain. The authors have found that there are pathognomonic pain patterns for each site, and typically do not operate on patients with atypical pain sketches, as they believe such patients are poor surgical candidates. However, a small subset of these atypical patients undergo surgery based on other strong clinical findings. In this study, the authors attempt to quantify this clinical experience.

METHODS

Patients were prospectively enrolled and completed pain sketches at screening. One hundred six diagrams were analyzed/categorized by two independent, blinded reviewers as follows: (1) typical (pain over nerve distribution, expected radiation); (2) intermediate (pain over nerve distribution, atypical radiation); or (3) atypical (pain outside of normal nerve distribution, atypical radiation). Preoperative and postoperative Migraine Headache Index was compared between subgroups using unpaired t tests.

RESULTS

Migraine Headache Index improvement was 73 ± 38 percent in the typical group, 78 ± 30 percent in the intermediate group, and 30 ± 40 percent in the atypical group. There was a significant difference in Migraine Headache Index between the typical and atypical groups (p = 0.03) and between the intermediate and atypical groups (p < 0.01). The chance of achieving Migraine Headache Index improvement greater than 30 percent in the atypical group was 20 percent.

CONCLUSIONS

Patient pain sketches classified as atypical (facial pain, atypical pain point origin, diffuse pain) can predict poor outcomes in headache surgery. As the authors continue to develop patient selection criteria for headache surgery, patient sketches should be considered as an effective, cheap, and simple-to-interpret tool for selecting candidates for surgery.

A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy

BACKGROUND

Recent clinical experience with migraine surgery has demonstrated both the safety and the efficacy of operative decompression of the peripheral nerves in the face, head, and neck for the alleviation of migraine symptoms. Because of the perceived novelty of these procedures, and the paranoia surrounding a theoretical loss of clinical territory, neurologists have condemned the field of migraine surgery. The Patient Safety Subcommittee of the American Society of Plastic Surgeons ventured to investigate the published safety track record of migraine surgery in the existing body of literature.

METHODS

A comprehensive review of the relevant published literature was performed. The relevant databases and literature libraries were reviewed from the date of their inception through early 2018. These articles were reviewed and their findings analyzed.

RESULTS

Thirty-nine published articles were found that demonstrated a substantial, extensively replicated body of data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger-site surgery.

CONCLUSIONS

Migraine surgery is a valid method of treatment for migraine sufferers when performed by experienced plastic surgeons following a methodical protocol. These operations are associated with a high level of safety. The safety and efficacy of migraine surgery should be recognized by plastic surgeons, insurance companies, and the neurology societies.

Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy

BACKGROUND

The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors' aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain.

METHODS

PATIENTS: scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed.

RESULTS

One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen.

CONCLUSIONS

The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.

A Surgical Approach to Treat Painful Neuromas of the Supraorbital and Supratrochlear Nerves with Implantation of the Proximal Stump into the Orbit

Frontal neuralgia causally related to trauma to the supraorbital and supratrochlear nerves remains a difficult problem to resolve. A peripheral nerve approach to this problem would involve neuroma resection and relocation of the proximal nerve stump to a location away from the vulnerable supraorbital ridge. A retrospective chart review was done to identify patients with frontal pain related to supraorbital trauma who underwent operative interventions to solve this problem by neuroma resection and relocation of the proximal stumps into the orbit. Eight patients were identified for inclusion in this study. At a mean of 16 months after surgery, there was a significant change in the visual analog score from a mean of 9.4 to 2.8 ( p  < 0.05), with 88% of the patients reporting a >50% reduction in pain postoperatively. There was one treatment failure. There were no postoperative complications. The strategy of relocating the proximal end of the supraorbital and supratrochlear nerves into the posterior orbit after resecting the painful neuromas can successfully manage posttraumatic craniofacial pain related to these injured nerves.

Radiologic Evaluation of Exiting Points of Supraorbital Region Neurovascular Bundles in Patients With Migraine

PURPOSE

To reveal the presence and nature of exiting points of supraorbital region neurovascular structures and determine the distances of those structures to midline with computed tomography images by taking into account gender and sides in patients with migraine.

METHODS

The study was conducted retrospectively on computed tomography images of 70 migraine and 70 control patients with a mean age of 39.5 ± 13.8 years (range: 18-80). Presence and nature (foramen or notch) of exiting points of neurovascular structures in terms of side and gender in both groups, and the distances of these structures to the midline of the face were evaluated.

RESULTS

In migraine and control groups, the most commonly seen structure was single notch. Coexistence of foramen and notch was statistically significant in migraine and female migraine groups than control and female control groups (P < 0.05). Bilateral presence of supraorbital structure was 51.4% in migraine group and 64.3% in control group patients. In all cases, foramen-midline distance was statistically significant longer than the notch-midline distance (P < 0.05). In migraine patients, no statistically significant difference was detected regarding distances of foramen and notch to midline in terms of side and gender.

CONCLUSION

Consideration of variable presence and location of the supraorbital notch and foramen, analysis of computed tomography scan might be beneficial in preoperative planning of foraminotomy and fascial band release in adult migraine patients to prevent intraoperative complications. Also, coexistence is more frequent on left side in migraine patients that might cause overlooking those structures during surgery.

Treatment of Frontal Secondary Headache Attributed to Supratrochlear and Supraorbital Nerve Entrapment With Oral Medication or Botulinum Toxin Type A vs Endoscopic Decompression Surgery

Importance

Endoscopic surgical decompression of the supratrochlear nerve (STN) and supraorbital nerve (SON) is a new treatment for patients with frontal chronic headache who are refractory to standard treatment options.

Objective

To evaluate and compare treatment outcomes of oral medication, botulinum toxin type A (BoNT/A) injections, and endoscopic decompression surgery in frontal secondary headache attributed to STN and supraorbital SON entrapment.

Design, Setting, and Participants

Prospective cohort study of 22 patients from a single institution (Diakonessen Hospital Utrecht) with frontal headache of moderate-to-severe intensity (visual analog scale [VAS] score, 7-10), frontally located, experienced more than 15 days per month, and described as pressure or tension that intensifies with pressure on the area of STN and SON. A screening algorithm was used that included examination, questionnaire, computed tomography of the sinus, injections of local anesthetic, and BoNT/A in the corrugator muscle.

Interventions

Different oral medication therapy for headache encountered in the study cohort, as well as BoNT/A injections (15 IU) into the corrugator muscle. Surgical procedures were performed by a single surgeon using an endoscopic surgical approach to release the supraorbital ridge periosteum and to bluntly dissect the glabellar muscle group.

Main Outcomes and Measures

Headache VAS intensity after oral medication and BoNT/A injections. Additionally, early postoperative follow-up consisted of a daily headache questionnaire that was evaluated after 1 year.

Results

In total, 22 patients (mean [SD] age, 42.0 [15.3] years; 7 men and 15 women) were included in this cohort study. Oral medication therapy reduced the headache intensity significantly (mean [standard error of the mean {SEM}] VAS score, 6.45 [0.20] [95% CI, 0.34-3.02; P < .001] compared with mean [SEM] pretreatment VAS score, 8.13 [0.22]). Botulinum toxin type A decreased the mean (SEM) headache intensity VAS scores significantly as well (pretreatment, 8.1 [0.22] vs posttreatment, 2.9 [0.42]; 95% CI, 3.89-6.56; P < .001). The mean (SEM) pretreatment headache intensity VAS score (8.10 [0.22]) decreased significantly after surgery at 3 months (1.30 [0.55]; 95% CI, 5.48-8.16; P < .001) and 12 months (1.09 [0.50]; 95% CI, 5.71-8.38; P < .001). There was a significant decrease of headache intensity VAS score in the surgical group over the BoNT/A group (mean [SEM] VAS score, 2.90 [0.42]) after 3 months (mean [SEM] VAS score, 1.30 [0.55]; 95% CI, 0.25-2.93; P < .001) and 12 months (mean [SEM] VAS score, 1.09 [0.50]; 95% CI, 0.48-3.16; P < .001) after surgery.

Conclusions and Relevance

Endoscopic decompression surgery had a long-lasting successful outcome in this type of frontal secondary headache. Even though BoNT/A had a positive effect, the effect of surgery was significantly higher.

Level of Evidence

3.

Migraine Surgery

Supplemental Digital Content is available in the text.

This article is a practical and technical guide for plastic surgeons interested in or practicing migraine surgery. It discusses the goals of migraine surgery including selection of appropriate candidates (screening form contained), pertinent anatomy, and surgical techniques with text summary, intraoperative photographs, and videos. In addition, pearls and pitfalls, the most common complications, and current procedural terminology (CPT) coding are detailed.

Efficacy of Local Anesthesia in the Face and Scalp: A Prospective Trial

Background

The use of local anesthesia has allowed for the excision and repair of lesions of the head and neck to be done in an office-based setting. There is a gap of knowledge on how surgeons can improve operative flow related to the onset of action. A prospective trial was undertaken to determine the length of time for full anesthesia effect in the head and neck regions.

Methods

Consecutive patients undergoing head and neck cutaneous cancer resection over a 3-month period were enrolled in the study. Local anesthesia injection and lesion excision were all done by a single surgeon. All patients received the standard of care of local anesthesia injection.

Results

Overall, 102 patients were included in the prospective trial. The upper face took significantly longer (153.54 seconds) compared with the lower face and ears (69.37 and 60.2 seconds, respectively) (P < 0.001) to become fully anesthetized. In addition, there was no significant difference found when adjusting for the amount of local anesthesia used, type, and size of lesion (P > 0.05). Using the time to full anesthesia effect for each local injection, a heat map was generated to show the relative times of the face and scalp to achieve full effect.

Conclusions

This prospective trial demonstrated that for the same local anesthetic and concentration, upper forehead and scalp lesions take significantly longer to anesthetize than other lesions in the lower face and ear. This can help surgeons tailor all aspects of their practice, which utilizes local anesthesia to help with patient satisfaction and operative flow.

Anatomical Variations of the Supraorbital and Supratrochlear Nerves: Their Intraorbital Course and Relation to the Supraorbital Margin

Background

This study aimed to describe the topographical anatomy of the supraorbital and supratrochlear nerves. Anatomical variations of both the intraorbital course of the 2 nerves and their relation to the supraorbital margin were analyzed.

Material/Methods

The research material involved 50 isolated adult cadaveric hemi-heads and 25 macerated adult skulls. All studied specimens were of Caucasian origin.

Results

Taking into account the location of the frontal nerve division, 2 main variants of the intraorbital course of the supraorbital and supratrochlear nerves were distinguished. The first variant (variant I, 42%) involved cases in which the supraorbital and supratrochlear nerves branched off from the frontal nerve in the distal half of the length of the orbit. In the second variant (variant II, 58%), the frontal nerve branched into the supraorbital and supratrochlear nerves in the proximal half of the orbit. Variant II was characterized by the presence of a thick supraorbital nerve and a long, tiny supratrochlear nerve. For variant I, 27.8% of the supraorbital nerves were divided into the medial and lateral branch within the orbit, whereas, for variant II, 75% of nerves were divided into the medial and lateral branch within the orbit (before crossing the supraorbital margin). Single passage was observed on the supraorbital margin in 80% of wet specimens and in 78% of orbits examined on the macerated skulls.

Conclusions

Both the intraorbital and extraorbital course of the branches of the supraorbital and supratrochlear nerves were highly diverse. These variations should be taken into account during medical procedures performed within the orbital and frontal regions.

Entrapment Neuropathy: A Concept for Pathogenesis and Treatment of Headaches-A Narrative Review

Entrapment neuropathy is a known cause of neurological disorders. In the head and neck area, this pathophysiological mechanism could be a trigger for headache. Over the last few decades, injection of botulinum toxin type A in the muscles that are causing the compression as well as surgical decompression have proved to be effective treatment methods worldwide for large numbers of patients with daily headaches. In particular the entrapment of the supraorbital nerves in the glabellar musculature and the occipital nerves in the neck musculature are triggers for headache disorders for which many patients are still seeking an effective treatment. This article reviews the literature and aims to bring the concept of neural entrapment to the attention of a wider audience. By doing so, we hope to give more exposure to an effective and relatively safe headache treatment.

Surgical Treatment of Migraine Headache: Back to the Future

Understanding the history and evolution of ideas is key to developing an understanding of complex phenomena and is the foundation for surgical innovation. This historical review on migraine surgery takes us back to the beginnings of interventional management for migraine centuries ago, and reflects on present practices to highlight how far we have come. From Al-Zahrawi and Ambroise Paré to Bahman Guyuron, two common themes of the past and present have emerged in the treatment of migraine headache. Extracranial treatment of both nerves and vessels is being performed and analyzed, with no consensus among current practitioners as to which structure is involved. Knowledge of past theories and new insights will help guide our efforts in the future. One thing is clear: Where we are going, there are no roads. At least not yet.

Positional Patterns Among the Auriculotemporal Nerve, Superficial Temporal Artery, and Superficial Temporal Vein for use in Decompression Treatments for Migraine

This study aimed to clarify intersection patterns and points among the superficial temporal artery (STA), superficial temporal vein (STV), and auriculotemporal nerve (ATN) based on surface anatomical landmarks to provide useful anatomical information for surgical decompression treatments of migraine headaches in Asians. Thirty-eight hemifaces were dissected. The positional patterns among the ATN, STA, and STV were divided into three morphological types. In type I, the ATN ran toward the temporal region and superficially intersected the STA and STV (n = 32, 84.2%). In type II, the ATN ran toward the temporal region and deeply intersected the STA and STV (n = 4, 10.5%). In type III, the ATN ran toward the temporal region and deeply intersected the STV alone (n = 2, 5.3%). The intersection points of types II and III were 10.3 ± 5.6 mm (mean ± SD) and 10.4 ± 6.1 mm anterior and 42.1 ± 21.6 mm and 41.4 ± 18.7 mm superior to the tragus, respectively. The ATN superficially intersected the STA and STV in all the Korean cadaver, while the ATN deeply intersected the STA and STV in 15% of the Thai cadavers. The pattern of the ATN deeply intersecting the STA and STV was less common in present Asian populations than in previously-reported Caucasian populations, implying that migraine headaches (resulting from the STA and STV compressing the ATN) are less common in Asians.

Anatomic characteristics of supraorbital and supratrochlear nerves relevant to their use in corneal neurotization

BACKGROUND

Corneal denervation can lead to opacification and blindness. A new treatment technique, surgical corneal neurotization, transfers healthy donor nerve, (most commonly contralateral supratrochlear or supraorbital) to the affected limbus to prevent corneal destruction and improve healing potential of the cornea following insult. We examine gross and histomorphometric anatomy of the supratrochlear and supraorbital nerves relevant to their use in corneal neurotization.

METHODS

For each of nine adult cadaver heads, bilateral supraorbital and supratrochlear nerves were dissected from the supraorbital rim to the anterior hairline. The following data were recorded for each nerve: exit from the orbit through a notch versus foramen; horizontal distance from midline at the supraorbital rim; and distance from orbital exit to first branching point. Samples of all left supraorbital and supratrochlear nerves were obtained at the level of the supraorbital rim and at points 3 cm and 6 cm distally for histomorphometric analysis. Myelinated axon counts were determined for each sample.

RESULTS

Four supraorbital foramina, 14 supraorbital notches, two supratrochlear foramina, and 15 supratrochlear notches were identified. Average supraorbital and supratrochlear distances to midline were 26.5 mm and 21 mm respectively. Average myelinated axon counts for both nerves were greater at the orbital rim (supraorbital: 6018, supratrochlear: 2533) than at 6 cm distally (supraorbital: 1621, supratrochlear: 1112).

CONCLUSIONS

Anatomic dissection shows relative close approximation of the supraorbital and supratrochlear nerves, with a high proportion of both nerves exiting the orbit through foramina. The supraorbital nerve at the orbital rim contains the greatest number of myelinated axons.

Glabellar Rejuvenation in Forehead Lift: Reversed Periosteum or Dermal Fat Graft to Cover Pedicled Glabellar Flap

Forehead aging is characterized by wrinkles, loss of skin elasticity, brow ptosis, and soft-tissue atrophy. For patients with prominent rhytids and marked brow ptosis, forehead lift is still the most effective treatment with a persisting result. In order to eliminate the glabellar wrinkles, forehead lift usually requires the removal of the corrugator supercilii muscle and procerus, which can lead to glabellar flattening or depression. Instead of muscle removal, the corrugator supercilii muscle, procerus, and the underlying galea were dissected as a pedicled glabellar flap. Then reversed periosteum or dermal fat graft was used to cover the glabellar flap to restore the glabellar volume. From January 2005 to November 2014, a total of 164 coronal and 42 trichophytic forehead lifts were performed. Reversed periosteum was used to cover the glabellar flap in 191 patients while dermal fat graft was applied in 15 patients with a follow-up period ranging from 6 months to 10 years. There was no irregularity or depression in the glabellar region in the group of reversed periosteal flap. The take of dermal fat graft placed over the glabellar flap was minimal. Complications from surgical procedures occurred in 2.91% of the patients. There was 1 asymmetry, 4 patients with higher than desired frontal hairline for implantation of autologous follicular units, and 1 patient with scar hyperplasia. There was no hematoma or nerve injury, no permanent numbness, and no alopecia. The techniques are simple and effective to eliminate the glabellar wrinkles and maintain or restore the glabellar volume.

Reduction of Closed Frontal Sinus Fractures through Suprabrow Approach

Background

The traditional approach for reduction of frontal sinus fractures is coronal incision. Inherent complications of the coronal approach include long scar, hair loss, and long operation time. We describe a simple approach for the reduction of frontal sinus anterior wall fractures using a suprabrow incision that is commonly used for brow lift.

Methods

From March 2007 to October 2016, the authors identified patients with anterior wall frontal sinus fractures treated by open reduction through a suprabrow incision. Only cases with photographic/radiographic documentation and a minimum follow-up of 6 months were included. The incision line was designed to be at the upper margin of the eyebrow. Medical records and radiographic data were retrospectively reviewed. Surgical outcomes, cosmetic results, and complication were assessed. The patient scale of the patient and observer scar assessment scale was used to assess patient satisfaction for incisional scar at the 6-month follow-up.

Results

Thirty-one patients underwent fracture reduction through a suprabrow approach during the study period, with a mean follow-up of 41 months. No patients showed any recurrent displacement, eyebrow asymmetry, or infection during follow-up. Thirteen patients reported their forehead paresthesia postoperatively, and 12 of them had preoperative symptom. One patient complained of incisional scar and underwent scar revision. All patients were satisfied with their eyebrow and forehead contour.

Conclusion

The suprabrow approach allowed for an accurate reduction of the fractures in the anterior wall frontal sinus by providing direct visualization of the fracture. This transcutaneous approach can effectively restore forehead contour with acceptable postoperative complications and patient satisfaction.

Interface Between Cosmetic and Migraine Surgery

This article describes connections between migraine surgery and cosmetic surgery including technical overlap, benefits for patients, and why every plastic surgeon may consider screening cosmetic surgery patients for migraine headache (MH). Contemporary migraine surgery began by an observation made following forehead rejuvenation, and the connection has continued. The prevalence of MH among females in the USA is 26%, and females account for 91% of cosmetic surgery procedures and 81-91% of migraine surgery procedures, which suggests substantial overlap between both patient populations. At the same time, recent reports show an overall increase in cosmetic facial procedures. Surgical techniques between some of the most commonly performed facial surgeries and migraine surgery overlap, creating opportunity for consolidation. In particular, forehead lift, blepharoplasty, septo-rhinoplasty, and rhytidectomy can easily be part of the migraine surgery, depending on the migraine trigger sites. Patients could benefit from simultaneous improvement in MH symptoms and rejuvenation of the face. Simple tools such as the Migraine Headache Index could be used to screen cosmetic surgery patients for MH. Similarity between patient populations, demand for both facial and MH procedures, and technical overlap suggest great incentive for plastic surgeons to combine both. Level of Evidence V 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 .