. 5
( 13)


level is diluted by the combined effects of aggressive IV Any surgeon, on any given day, can inadvertently place
¬‚uids and the reabsorption of nonaspirated tumescent or a liposuction aspiration probe in the wrong place (e.g.,
“wetting” solution. intestines, intrapleural, liver, kidney, major blood vessel).
Dorin was medical director of a high-volume, predomi- Any anesthesiologist or nurse anesthetist, on any given
nantly cosmetic surgery practice (about seventy-¬ve plas- day, can commit the error of inappropriate patient dosing,
tic surgeons) in an upscale metropolitan area. Most of inappropriate ¬‚uid replacement, lack of vigilance in mon-
the surgeons were conscientious. Aside from general tech- itoring, poor airway management or planning, and poor
nique and bedside manners, there were simply some doc- patient selection. A patient™s choice of medical provider,
tors who regularly exercised profoundly poor judgment in based on experience and judgment, is invaluable in pre-
their surgical practices. Dorin™s facility had a center-based venting iatrogenic injury. Despite the marvels of modern
policy based on the 1998 American Society of Plastic and medicine, improved surgical techniques, and the comput-
Reconstructive Surgeons (ASPRS) Liposuction guidelines erized advancements in anesthesia monitors, there is no
that limited the total volume of injectate and subsequent substitute for good judgment and unwavering vigilance
aspirate to 5,000 ccs. Nevertheless, there were a few cav- (see Chapter 18) in the delivery of patient care.
alier surgeons who continually ¬‚outed the guidelines by Iatrogenic error can also be more insidious, taking the
aspirating as much as 14,000 ml in a given surgical setting! form of multiple, overlapping therapies and risks. For
Dorin™s ability to insist on compliance with the ASPRS example, patients undergoing general anesthesia for SAL
guidelines was compromised in that he was not physically or liposuction will need, and possibly receive, a lower dose
present in those ORs when the guidelines were being vio- of tumescent lidocaine. Fodor states in his 1999 editorial,
lated. Two of these cavalier surgeons eventually had their “General or epidural anesthesia is used routinely for any-
surgery center privileges terminated by the medical exec- thing but small extractions, and local anesthetics can be
avoided entirely from the infusate.”24 These same patients
utive committee. One of these surgeons also had several
patients admitted to the local hospital emergency room by may be concurrently exposed to increased risks due to the
ambulance. Patients experienced symptoms ranging from aspiration of greater total volumes. General anesthesia also
severe dizziness (and an inability to get out of the PACU predisposes patients to venous stasis in the legs and pelvic
veins.16 Stasis may contribute to clot formation and sub-
gurney) to signi¬cant postoperative anemia.
sequent, sometimes fatal, pulmonary emboli.16 Utilizing
Third-space ¬‚uid shifts a lower dose of tumescent ¬‚uid may translate into greater
Many surgical insults result in the third-space ¬‚uid shifts. postoperative patient discomfort. Patients in discomfort
The degree of the “shift” depends on the degree of tissue tend to limit their activity that exacerbates the tendency
damage and the site of the surgery. In SAL or liposuction, for venous stasis and potential clot formation.
80 Adam Frederic Dorin

Pulmonary edema in the perioperative setting due to the administration
of epinephrine-containing local anesthetics. In patients
Any large volume of tumescent ¬‚uid administration, espe-
suffering from hypertension and/or pulmonary disease,
cially in the setting of undiagnosed heart disease/failure,
intravascular epinephrine can be problematic. As Grazer
can result in intravascular ¬‚uid overload and pulmonary
and de Jong have reported,14 serum epinephrine levels dur-
edema. A seasoned anesthesia provider will be attuned not
ing lipoplasty surgery peaked to 133 ug · ml’1 (upwards
only to the pulse oximeter reading but also to a patient™s
of ¬ve times the normal level) at three hours and returned
lung sounds and ease of breathing in the perioperative
to normal at a twelve-hour sampling. With each liter of
setting. In an otherwise hemodynamically stable patient,
a typical tumescent ¬‚uid solution containing 1 mg of
without a history of electrolyte disturbance, a suspicion
epinephrine, the sheer number of annual SAL or liposuc-
of intravascular ¬‚uid overload may be appropriately mit-
tion procedures performed is a testament that short-lived
igated with observation and a small dose of diuretic (e.g.,
supranormal levels of epinephrine are well tolerated by the
furosemide). Most practitioners would give a dose of 5“
40 mg furosemide to start and repeat as necessary over
the course of observation. For patients who regularly take
Lidocaine toxicity
furosemide, it would be prudent to use the patient™s base-
line dose as a starting point for treatment. Lidocaine toxicity can result in CNS symptoms and toxi-
city, followed by cardiovascular toxicity. Because of direct
Pulmonary embolism effects on the nervous system, and hepatic enzyme over-
Fat embolism and thomboembolism can be complications saturation, lidocaine toxicity causes depression of the
of any surgery but should be of special concern in liposuc- conduction mechanisms of nerve and muscle function.
tion patients. Lengthy procedures that involve prolonged The force of cardiac contraction may also be depressed.
periods of patient immobilization should be approached Although the absorption of lidocaine following tumes-
with the placement preoperatively of lower extremity com- cent injection is slow, the potential for drug interaction
pression devices (or, if necessary due to surgical site, rotat- and overdosage is a real possibility in the perioperative
ing compression stockings) to lessen the likelihood of deep setting.
venous thromboses. By treating the degree of venous stasis,
minimizing caval compression, and applying good surgi-
cal fat-aspiration technique, the potential of pulmonary A variety of sources (e.g., FDA, PDA, anesthesia text-
embolism can be minimized. Anesthetic techniques that books, surgical textbooks) describe a recommended upper
limit adult lidocaine dose of 7 mg · kg’1 not to exceed
preserve lower extremity muscle tone (i.e., IV sedation in
general and the MIA„ technique in particular; see Chap- 500 mg with epinephrine. Neither the manufacturer of
ter 1) may be inherently more advantageous in patients lidocaine nor the U.S. Food and Drug Administration
predisposed to the development of deep-vein thromboses (FDA) have data to support this recommendation. In its
(vide supra).16 1948 application to the FDA, Astra Pharmaceutical Prod-
ucts, Inc., simply stated that the maximum safe dose of
lidocaine is probably the same as for procaine!22 Of fur-
Epinephrine toxicity
Anesthesia providers often ¬nd it amusing when patients ther note is that neither the 2005, 2006, nor 2007 PDR
present in the preoperative holding area with a report of (print or electronic version) has any listing for injectabele
“epinephrine allergy.” These patients are invariably the lidocaine. In stark contrast, studies and common clinical
victim of some prior dental procedure during which the practice have repeatedly demonstrated that doses of highly
local anesthetic mixture containing epinephrine resulted diluted lidocaine epinephrine or tumescent or wetting
in a rather unsettling tachycardia and, possibly, related in¬ltration are considered to be safe to levels as high as
55 mg · kg’1 .25
shortness of breath. Although one may be hard-pressed
to ¬nd documentation that the body™s primary in-situ In preparation for the writing of this chapter, several
survival drug is inherently “allergenic,” experience will highly regarded anesthesiologists, with many years and
yield countless stories of tachycardia and hypertension thousands of cases of experience with megadose lidocaine
Lidocaine Use and Toxicity in Cosmetic Surgery 81

in SAL or liposuction, were consulted. All of them con¬- sive, prolonged SAL or liposuction. Surveyors for JCAHO,
dently reported having no hesitation (nor personal history AAAHC, and AAAASF often offer the insight that free-
of complications) in recommending highly diluted lido- standing facilities (especially single-specialty, of¬ce-based
caine doses even in excess of 55 mg · kg’1 for SAL or operating room suites) are notoriously underequipped for
liposuction. emergency contingencies.
There are several caveats to the recommended use of From supplies for malignant hyperthermia to dif¬cult
megadose lidocaine administration. First and foremost is airway carts (adult and pediatric) and code crash carts,
that a dose of 55 mg · kg’1 lidocaine is exclusively limited to anesthesiologists, surgeons, and administrators would
dilute lidocaine (i.e., 500“1,000 mg lidocaine in 1,000 ccs be well served in seeking and maintaining the stan-
NSS [Klein] or LR [Hunstad]) that is administered with dards required for facility accreditation. It takes only
epinephrine. Second, a dose of 55 mg · kg’1 lidocaine is one emergency to reveal the deadly vulnerability of a
only acceptable within the context of tumescent or “wet- poorly equipped facility. Freestanding operating rooms
ting” injections for SAL or liposuction. Third, a dose of must be even more prepared and inclusively self-suf¬cient
55 mg · kg’1 lidocaine applies only to surgeries that adhere than hospital-based operating suites. Greater strides in
to prudent guidelines regarding the appropriate total vol- anesthesia-surgeon cooperation, and the more frequent
ume of fat aspirate (i.e., 4,000“5,000 ccs), under conditions use of local/MAC, regional block, and BIS-monitored PK
of adequate anesthesia, monitoring, and limited IV ¬‚uid (propofol-ketamine) MAC anesthetics, have signi¬cantly
management. Sometimes a Foley catheter is used to mon- reduced the need to open the crash cart in the ¬rst place!
itor urine output for large volume SAL or liposuction. Luck always favors the prepared.
Last to consider are “combined” cosmetic surgical inter-
Suggestions for Clinical Practice
ventions, wherein SAL or liposuction is performed with
other procedures in the same setting. In cases involving the Lidocaine toxicity in the context of megadose lidocaine
administration of normal lidocaine “out-of-the-bottle” tumescent solution injection poses far more unique and
concentrations for subcutaneous in¬ltration (e.g., rhino- interesting questions than is observed with simple sub-
plasty, face/neck lift, breast augmentation), all bets are off. cutaneous in¬ltration of this drug. Tumescent or wetting
REPEAT: ALL BETS ARE OFF! In the scenarios where injection should not be restricted by the overly conserva-
tive formerly published PDR guidelines of 7 mg · kg’1 or
nondiluted concentrations of lidocaine are injected, the
injection of 35 mg · kg’1 could easily prove lethal. In addi- 500 mg total (with epinephrine) maximum dosing.
tion, be mindful that normal lidocaine pharmacokinetics
Preoperative assessment
of absorption and elimination will be at play.
It is essential that patients undergo a thorough preoper-
Anesthetic implications ative medical history (see Chapter 14 and Appendix A).
Most of the discussions heretofore address the issue of All medications used and discontinued within two weeks
toxic consequences to lidocaine overdosing. Intraoper- prior to surgery should be noted in the patient record.
atively, prudent anesthetic management should include Consideration should be taken for these drugs to have
good intravenous access and standard monitors (EKG, a potential effect on the liver cytochrome P450 enzyme
pulse oximetry, blood pressure, temperature monitoring). system. In addition to the in¬‚uence these medications
End tidal CO2 is a standard of care for general anesthetics may have on lidocaine metabolism and blood levels, a
and strongly recommended for opioid-based IV sedation close eye should be trained on all medications given in the
techniques. Fluid-in/urine-out assessment and aspirate immediate preoperative, intraoperative, and postoperative
volume tracking are also important. In addition, experi- period.
enced practitioners will anecdotally report an added value Sound clinical, perioperative management of patients
to BIS monitoring under anesthesia. Because CNS toxicity receiving lidocaine, especially in the context of SAL or
symptoms typically occur prior to end-stage cardiac toxi- liposuction, should incorporate careful patient selection
city in lidocaine overdosing, there may be a potential value criteria. This is an area of anesthesia and surgical care that
to monitoring the brain while under anesthesia for exten- is often lost in the various discussions and articles on this
82 Adam Frederic Dorin

subject. Once a patient has passed the basic preoperative tion anesthesia. The discussion of lidocaine toxicity and,
laboratory and history hurdles, a solid “laying of hands” more speci¬cally, an examination of megadose lidocaine
should establish the suitability of a patient™s cardiac, respi- in tumescent liposuction, covers the full gamut of ade-
ratory, and airway status for surgical clearance. Any signs quate patient evaluation and clinical management skills
of fever, productive cough, or labored breathing should necessary for the safe and vigilant practice of anesthesia in
be cause for concern. Similarly, wheezing, distended neck the outpatient perioperative setting. Although controversy
veins, or signi¬cant peripheral edema should raise red ¬‚ags exists around the safety of liposuction and lidocaine dos-
immediately. Defer and reschedule the case if and when ing, this most popular of cosmetic surgical procedures will
adequate clinical investigation can establish the patient™s continue to grow in numbers, as does experience, under-
acceptability for surgery and anesthesia. standing, and comfort level with tumescent technique.
SAL or liposuction is not equivalent to cataract extraction
or ganglion cyst surgery.
Foresight must be applied to the scheduled surgical pro-
cedure. The ambulatory setting does not allow the routine
application of invasive monitoring and thus demands a 1. Goodman, Gillman: The Pharmacologic Basis of Therapeu-
higher degree of scrutiny in choosing appropriate surgical tics. 10th ed. New York, McGraw-Hill, 2001, pp. 374, 961.
2. Ibid.
3. Boyes RN: The pharmacokinetics of lidocaine in man. Clin
A patient™s airway should be carefully assessed for ade-
Pharmacol Ther 12:105,1971.
quacy of mouth opening, presence of dentures, veneers 4. Narand PK: Lidocaine and its active metabolites. Clin Phar-
or teeth in poor condition, range of motion about the macol Ther 24:654,1978.
5. Melmon HK: Clinical Pharmacology: Basic Principles in
neck, and the ability to tolerate easily LMA or endotracheal
Therapeutics. 2nd ed. New York, Macmillan Ltd. 1978, p.
intubation. When in doubt of the potential intraoperative
patency of a patient™s airway, every effort should be made 6. Marriot HJ: Lidocaine toxicity. J Electrocardiology 7:70,
to obtain previous surgical records and/or speak with the
7. Smith, M, Wolfram W: Toxicity-seizures in an infant caused
anesthesiologist who was involved in the earlier cases.
by (or related to) oral viscous lidocaine use. J Emerg Med
8. Jonville AP, Barbier P: Accidental lidocaine overdose in an
CONCLUSION infant. J Toxicol Clinical Toxicol 28:101,1990.
9. Lie RL: Severe lidocaine intoxication by cutaneous absorp-
This chapter has touched not only on the basic pharma- tion. J Am Acad Derm 5:1026,1990.
cology and pharmacokinetics of lidocaine use and toxic- 10. Palmisano JM: Lidocaine toxicity after subcutaneous in¬l-
tration in children undergoing cardiac catheterization. Am J
ity but also on some of the peripheral issues surrounding
Cardiol 67:647,1991.
this important subject. The clinical techniques of tumes-
11. Coldiron B, Shreve BA, Balkrishnan R, et al.: Patient
cent or megadose lidocaine use, SAL- or liposuction- injuries from surgical procedures performed in medical
related complications, and some reported cases of lido- of¬ces: Three years of Florida data. Dermatol Surg 30:1435,
caine toxicity have been reviewed. Also discussed were
12. Williford P: Commentary on Coldiron B, Shreve E, Balkrish-
salient perioperative- and facility-related issues that may nan R: Patient injuries from surgical procedures performed
affect patient outcomes in the setting of SAL or liposuction. in medical of¬ces: Three years of Florida data. Dermatol Surg
These ¬ndings suggest that the continued quest for patient
13. Gorney M: Liability issues in aesthetic surgery. Aesth Surg J
safety should not ignore the progressive trends of of¬ce-
based dermatologists, plastic surgeons, and anesthesiolo- 14. Grazer FM, de Jong RH: Fatal outcomes from liposuction:
gists who have made signi¬cant contributions to patient Census survey of cosmetic surgeons. Plast Reconstr Surg
safety over the past two decades. With patient safety at the
15. Rao, RB, Ely, SF: Deaths related to liposuction. N Engl J Med
foremost, these pioneers have creatively pushed the enve-
lope of the lidocaine dosage and encouraged anesthesiol- 16. Lofsky AS: Deep venous thrombosis and pulmonary
ogy practices to avoid the use of traditional general inhala- embolism in plastic surgery of¬ce procedures. The Doctors™
Lidocaine Use and Toxicity in Cosmetic Surgery 83

Company Newsletter, Napa, CA,2005. www.thedoctors.com/ 21. Cosmetic Surgery National Data Bank 2003 Statistics. New
risk/specialty/anesthesiology/J4254.asp York, NY. Am Soc for Aesthetic Plastic Surgery, 2004.
17. Lillis PJ: Liposuction under local anesthesia: Limited blood 22. Klein JA: The tumescent technique for liposuction surgery.
loss and minimal lidocaine absorption. J Dermatol Oncol Am J Cosmet Surg 4:263,1987.
Surg 14:1145,1988. 23. Klein JA: Tumescent technique for regional anesthesia per-
18. Hildreth B: Large Volume Liposuction. Presented at the mits lidocaine doses of 35 mg/kg for liposuction. J Dermatol
World Congress of Liposuction, Pasadena, CA, October 9“ Surg Oncol 16:248,1990.
11, 1998. 24. Fodor PB: De¬ning wetting solutions in lipoplasty. Plast
19. Friedberg BL: Propofol ketamine anesthesia for cosmetic Reconstr Surg 103:1519,1999.
surgery in the of¬ce suite, chapter in Osborn I (ed.), Anes- 25. Ostad A, Kageyama N: Tumescent anesthesia with a lido-
thesia for Outside the Operating Room. International Anes- caine dose of 55 mg/kg is safe for liposuction. Dermatol Surg
thesiology Clinics. Baltimore, Lippincott, Williams & Wilkins 22:921,1996.
41(3):47,2003. 26. Laurito CE: Anesthesia provided at alternative sites, in
20. www.asds-net.org/liposafety (Am Soc for Dermatological Barasch PG, Cullen BF, Stoelting RK (eds.), Clincal Anesthe-
Surgeons); www.plasticsurgery.org/mediactr/natstats (Am sia, 4th ed., Philadelphia, Lippincott, Williams & Wilkins,
Soc of Plastic Surgeons). 2001, p. 1343.
9 Local Anesthetic Blocks in Head and Neck Surgery
Joseph Niamtu, III, D.M.D.

Sensory Anatomy of the Head and Neck
Sensory anatomy of the trigeminal nerve
Sensory anatomy of the ophthalmic nerve (V1)
Local Anesthetic Techniques for the Scalp and Forehead
Sensory anatomy of the maxillary nerve (V2)
Local Anesthetic Techniques for the Infraorbital Nerve Block
Total second division nerve block
Sensory anatomy of the mandibular nerve (V3)
Local Anesthetic Techniques for the Mental Nerve Block
Local Anesthetic Techniques for the Inferior Alveolar Nerve Block (Intraoral)
Local Anesthetic Techniques for the Mandibular Nerve (V3)
Block (Facial Approach)
Sensory anatomy of the scalp
Local Anesthetic Techniques to Block the Scalp
Greater Occipital Nerve Block Technique for Posterior Scalp Anesthesia
Sensory Anatomy of the Neck; Innervation of the Cervical Plexus
Local Anesthetic Techniques for the Cervical Plexus
Selected Area Blocks
Anesthesia for the ear
Anesthesia for the nose
Blocking the lips
Tumescent Anesthesia
Tumescent Local Anesthesia for Facial Procedures
Blocking the entire face

INTRODUCTION est patient cannot imagine having a tooth extracted or an
extremity amputated with no anesthesia. Prior to the late
One of the biggest advances in the last thousand years of 1800s, one could get drunk or literally bite the bullet, nei-
medical history has been the discovery of local anesthe- ther of which had any effect on pain. An interesting article
sia. Prior to this, patients had to endure excruciating pain appeared about a .50 caliber bullet found at the site of
with procedures taken for granted today. Even the tough- the Battle of Ox Hill. The 21st Massachusetts Regiment

Local Anesthetic Blocks in Head and Neck Surgery 85

William Halsted was a prominent American surgeon
who investigated the principles of nerve block using
cocaine. In November 1884, Dr. Halsted performed
infraorbital and inferior alveolar (mandibular) dental
block. Halsted also demonstrated various other regional
anesthetic techniques. Halsted™s self-experimentation with
cocaine caused an addiction. After two years of effort to
resolve his addiction, he regained his eminent position in
surgery and teaching.
Early dentists dissolved cocaine hydrochloride pills in
water and drew this mixture up in a syringe to perform
nerve in¬ltrations and blocks. The extreme vasoconstric-
tive effects of cocaine often caused tissue necrosis but
nonetheless provided profound local anesthesia that rev-
Figure 9-1. Biting the bullet was apparently utilized as a means
olutionized dentistry and medicine forever. Many propri-
of pain control prior to the advent of anesthesia.
etary preparations of that time period contained cocaine.
By the early 1900s, cocaine™s adverse effects became well
recognized. These deleterious effects included profound
cardiac stimulation and vasoconstriction. Cocaine blocks
had fought at a local corn¬eld with extreme and horrify-
the neuronal reuptake of norepinephrine in the peripheral
ing injuries. Yet, they had no medical care. The bullet has
nervous system. Myocardial stimulation in combination
molar tooth cusp imprints, reportedly from a patient bit-
with coronary artery vasoconstriction has proven lethal in
ing during surgery without anesthesia. Figure 9-1 shows
sensitive individuals. Cocaine causes central nervous sys-
an artist™s rendition of the horror and panic of such a bat-
tem stimulation and mood-altering euphoric effect. These
tle¬eld amputation, complete with a bullet between the
effects coupled with the severe physical and psychological
patient™s teeth.
dependence proved to be signi¬cant drawbacks to cocaine
Cocaine was the ¬rst local anesthetic to be widely used in
use for local anesthesia.
surgical applications. In the 19th century, it was reported
In 1904, Alfred Einhorn, searching for a safer and less
that the Indians of the Peruvian highlands chewed the
toxic local anesthetic, synthesized procaine (Novocain).
leaves of the coca leaf (Erythroxylon coca) for its stimu-
lating and exhilatory effects.1’3 It was also observed that Novocain was the gold standard of topical anesthetics for
almost forty years when Nils Lofgren synthesized lido-
these Indians observed numbness in the areas around the
caine (Xylocaine), the ¬rst amide group of local anesthet-
lips. In 1859, Albert Niemann, a German chemist, was
ics. Lidocaine provided advantages over the ester group
given credit for being the ¬rst to extract the isolate cocaine
(procaine) in terms of greater potency, less allergic poten-
from the coca shrub in a puri¬ed form. When Niemann
tial, and a more rapid onset of anesthesia.1,2,5,6
tasted the substance, his tongue became numb. This prop-
erty led to one of the most humane discoveries in all of
medicine and surgery. Over two decades later, Sigmund
Freud began treating patients with cocaine for its physi-
ologic and psychologic effects. While treating a colleague
Local anesthetics block the sensation of pain by inter-
for morphine dependence, the patient developed cocaine
dependence.4 fering with the propagation of impulses along peripheral
nerve ¬bers without signi¬cantly altering normal resting
A resident at the University of Vienna Ophthalmologic
membrane potentials.7 Local anesthetics depolarize the
Clinic named Koller demonstrated the topical anesthetic
nerve membranes and prevent achievement of a threshold
activity of cocaine on the cornea in animal models and on
potential. A propagated action potential fails to develop
himself. In an operation for glaucoma, Koller used cocaine
and a conduction blockade is achieved. This occurs by the
for local anesthesia in 1894.
86 Joseph Niamtu

Figure 9-1A. Cover of out-of-print (1976) anesthesia text.
Local Anesthetic Blocks in Head and Neck Surgery 87

interference of nerve transmission by blocking the in¬‚ux the head and neck,” the trigeminal nerve is named for its
of sodium through the excitable nerve membrane.8 three major sensory branches. The ophthalmic nerve (V1),
maxillary nerve (V2), and mandibular nerve (V3) are liter-
ally “three twins” (trigeminal) carrying sensory informa-
tion of light touch, temperature, pain, and proprioception
from the face and scalp to the brainstem. The commonly
When reading the following section, some of the infor-
used terms V1, V2, and V3 are shorthand notation for
mation is clearly boring see Fig. 9-1A. Finite anatomy was
cranial nerve 5, branches 1, 2, and 3, respectively. In addi-
boring for most medical and dental students, but it is ulti-
tion to nerves carrying incoming sensory information, cer-
mately very important. In order to fully understand how
tain branches of the trigeminal nerve also contain nerves
and when to perform a local anesthetic block, one must
motor components. The ophthalmic and maxillary nerves
appreciate the anatomy.
consist exclusively of sensory ¬bers; the mandibular nerve is
joined outside the cranium by the motor root. These out-
Sensory Anatomy of the Head and Neck
going motor components include branchial motor nerves
The main sensory innervation of the face is derived from
(i.e., nerves innervating muscles derived embryologically
cranial nerve V (trigeminal nerve) and the upper cervical
from the branchial arches) as well as “hitchhiking” visceral
nerves. see Fig. 9-2.
motor nerves (i.e., nerves innervating viscera, including
smooth muscle and glands). The trigeminal nerve exits
Sensory anatomy of the trigeminal nerve
the trigeminal ganglion and courses “backward” to enter
The trigeminal nerve is the ¬fth of the twelve cranial nerves.
the midlateral aspect of the pons at the brainstem.9
Its branches originate at the semilunar ganglion (Gasse-
The ophthalmic nerve (V1) leaves the semilunar gan-
rian ganglion) located in a cavity (Meckel™s cave) near the
glion through the superior orbital ¬ssure. The maxillary
apex of the petrous part of the temporal bone. Three large
nerve (V2) leaves the semilunar ganglion through the fora-
nerves, the ophthalmic, maxillary, and mandibular, pro-
men rotundum at the skull base, and the mandibular nerve
ceed from the ganglion to supply sensory innervation to
(V3) leaves the semilunar ganglion through the foramen
the face. Often referred to as “the great sensory nerve of
ovale at the skull base (see Fig. 9-3 inset9 ). The remainder
of this chapter discusses only the sensory components of
this nerve system as they relate to local anesthetic blocking
techniques for cosmetic facial procedures.

Sensory anatomy of the ophthalmic nerve (V1)
The ophthalmic nerve, or ¬rst division of the trigeminal, is
a sensory nerve. It supplies branches to the cornea, ciliary
body, and iris; to the lacrimal gland and conjunctiva; to the
part of the mucous membrane of the nasal cavity; and to
the skin of the eyelids, eyebrow, forehead, and upper lateral
nose (see Fig. 9-3 V1). The smallest of the three divisions of
the trigeminal, it divides into three branches: the frontal,
the nasociliary, and the lacrimal.9 The frontal nerve divides
into the supraorbital and supratrochlear nerves providing
sensation to the forehead and anterior scalp.
The nasocillary nerve divides into four branches, two
of which supply sensory innervation to the face. These
two branches are the infratrochlear and the ethmoidal
nerves. The infratrochlear nerve supplies sensation to
Figure 9-2. Sensory innervation of the head and neck is derived
the skin of the medial eyelids and side of the nose. The
from the trigeminal and upper cervical nerves.
88 Joseph Niamtu

Figure 9-3. Main branches of the trigeminal nerve supplying sensation to the respective facial areas. The inset shows the trigeminal
ganglion with the three main nerve branches.

terminal branch of the ethmoidal nerve is called the exter- When injecting this area, it is prudent to always use
nal (or dorsal) nasal nerve. The ethmoidal nerve innervates the free hand to palpate the orbital rim to prevent inad-
the skin of the nasal dorsum and tip. The lacrimal nerve vertent injection into the globe! To anesthetize this area,
innervates the skin of the upper eyelid. the supratrochlear nerve is measured 17 mm from the
glabellar midline and 1“2 cc of 2% lidocaine 1:100,000
epinephrine are injected (see Fig. 9-5 left). The supraor-
bital nerve is blocked by palpating the notch (and or mea-
Local Anesthetic Techniques for the
suring 27 mm from the glabellar midline) and injecting
Scalp and Forehead
2 cc of local anesthetic solution (see Fig. 9-5 center). The
The frontal nerve exits through a notch (in some cases
infratrochlear nerve is blocked by injecting 1“2 cc of local
a foramen) on the superior orbital rim approximately
anesthetic solution at the junction of the orbit and the
27 mm lateral to the glabellar midline. This supraorbital
nasal bones (see Figure 9-5 right). In reality, one can block
notch is readily palpable in most patients. After exiting
all three of these nerves by simple injecting 2“4 cc of local
the notch or foramen, the nerve traverses the corruga-
anesthetic solution from the central brow proceeding to
tor supercilli muscles and branches into a medial and lat-
the medial brow Figure 9-6 shows the regions anesthetized
eral portion. The lateral branches supply the lateral fore-
from these blocks.
head and the medial branches supply the scalp. The supra-
trochlear nerve exits a foramen approximately 17 mm from
Sensory anatomy of the maxillary nerve (V2)
the glabellar midline (see Fig. 9-4) and supplies sensation
to the middle portion of the forehead. The infratrochlear The maxillary nerve or second division of the trigeminal
nerve exits a foramen below the trochlea and provides sen- is a sensory nerve that crosses the pterygopalatine fossa
sation to the medial upper eyelid, canthus, medial nasal before traversing the orbit in the infraorbital groove and
skin, conjunctiva, and lacrimal apparatus.10 canal in the ¬‚oor of the orbit. It appears on the face at
Local Anesthetic Blocks in Head and Neck Surgery 89

Figure 9-4. The supraorbital nerve (SO) exits about 27 mm Figure 9-6. The shaded areas indicate the anesthetized areas
from the glabellar midline, and the supratrochlear nerve (ST) is from supraorbital nerve (SO), supratrochlear nerve (ST), and
located approximately 17 mm from the glabellar midline. The infratrochlear nerve (IT) blocks.
infratrochlear nerve (IT) exits below the trochlea.

the infraorbital foramen as the infraorbital nerve.9 At its at the back of that cavity into two terminal branches, the
termination, the nerve divides into branches that spread zygomaticotemporal and zygomaticofacial nerves.
out on the side of the nose, the lower eyelid, and the upper The zygomaticotemporal branch runs along the lateral
lip, joining with ¬laments of the facial nerve.9 Terminal wall of the orbit in a groove in the zygomatic bone before
branches include the following. passing through a foramen in the zygomatic bone and
The zygomatic nerve arises in the pterygopalatine fossa, entering the temporal fossa. It ascends between the bone
enters the orbit by the inferior orbital ¬ssure, and divides and substance of the temporalis muscle and pierces the

Figure 9-5. The forehead and scalp are blocked by a series of injections from the central to the medial brow.
90 Joseph Niamtu

temporal fascia about 2.5 cm above the zygomatic arch thus some patients will manifest anesthesia of the ante-
where it is distributed to the skin of the side of the forehead rior teeth and gingiva if the branching is close to the fora-
(see Fig. 9-3 V2). men. Areas anesthetized include the lateral nose, anterior
The zygomaticofacial branch passes along the infero- cheek, lower eyelid, and upper lip on the injected side. This
lateral angle of the orbit, emerges on the face through a nerve can be blocked either by the intraoral or extraoral
foramen in the zygomatic bone, and perforates the orbic- route.
ularis oculi and supplies the skin on the prominence of the To perform an infraorbital nerve block from an intraoral
cheek (see Fig. 9-3 V2). approach, topical anesthesia is placed on the oral mucosa at
As the maxillary nerve traverses the orbital ¬‚oor and the vestibular sulcus just under the canine fossa (between
exits the infraorbital foramen, it branches into a plexus of the canine and ¬rst premolar tooth) and left for several
nerves that has the following terminal branches. minutes. The lip is then elevated and a 1.5-inch 27 gauge
The inferior palpebral branches ascend behind the needle is inserted in the sulcus and directed superiorly
orbicularis oculi muscle and supply the skin and conjunc- toward the infraorbital foramen (see Fig. 9-7). The nee-
tiva of the lower eyelid (see Fig. 9-3 V2). dle does not need to enter the foramen for a successful
The lateral nasal branches (rami nasales externi) supply block. The anesthetic solution needs only to contact the
the skin of the side of the nose (see Fig. 9-3 V2). vast branching around the foramen to be effective. It is
The superior labial branches are distributed to the skin imperative to use the other hand to palpate the inferior
of the upper lip, the mucous membrane of the mouth, and orbital rim to avoid injecting the orbit. Two to four cc of
labial glands (see Fig. 9-3 V2). 2% lidocaine with 1:100,000 epinephrine is injected in this
area for the infraorbital block.
Local Anesthetic Techniques for The infraorbital nerve can also be very easily blocked
the Infraorbital Nerve Block by a facial approach. This is the preferred route of the
author. This may also be the preferred route in dental-
The infraorbital nerve exits the infraorbital foramen 4“7
phobic patients. A 27 ga 0.5-inch needle is used and is
mm below the orbital rim in an imaginary line dropped
placed through the skin and aimed at the foramen in
from the medial limbus of the iris or the pupillary mid-
a perpendicular direction. Two to four cc of local anes-
line. The anterior superior alveolar nerve branches from
thetic solution is injected at or close to the foramen (see
the infraorbital nerve before it exits the foramen, and

Figure 9-7. The intraoral approach for local anesthetic block of the infraorbital nerve.
Local Anesthetic Blocks in Head and Neck Surgery 91

Figure 9-9. Area of anesthesia from unilateral infraorbital nerve

The aforementioned techniques provide anesthesia to
the lateral nasal skin but does not provide anesthesia to
the central portion of the nose. A dorsal (external) nasal
nerve block will supplement nasal anesthesia by providing
anesthesia over the area of the cartilaginous nasal dorsum
and tip. This supplementary nasal block is accomplished
by palpating the inferior rim of the nasal bones at the
osseous cartilaginous junction. The dorsal nerve (anterior
ethmoid branch of the nasocillary nerve) emerges 5“10
mm from the nasal midline at the osseous junction of the
inferior portion of the nasal bones (the distal edge of the
nasal bones) (see Fig. 9-10). The dotted line in Figure 9-14
Figure 9-8. The facial approach for local anesthetic block of the shows the course of this nerve under the nasal bones before
infraorbital nerve.
Two often-overlooked nerves in facial local anesthetic
Fig. 9-8). Again, the other hand must constantly palpate blocks are the zygomaticotemporal and zygomaticofacial
the inferior orbital rim to prevent inadvertent injection nerves. These nerves represent terminal branches of the
into the orbit. zygomatic nerve. The zygomaticotemporal nerve emerges
A successful infraorbital nerve block will anesthetize through a foramen located on the anterior wall of the
the infraorbital cheek, the lower palpebral area, the lateral temporal fossa. This foramen is actually behind the lateral
nasal area, and superior labial regions, as shown in Fig- orbital rim posterior to the zygoma at the approximate
ure 9-9. level of the lateral canthus (see Fig. 9-11).
Figure 9-10. The dorsal (external) nasal nerve is blocked subcutaneously at the osseous-cartilaginous junction of the distal nasal bones.

Figure 9-11. The zygomaticotemporal nerve is blocked by placing the needle on the concave surface of the posterior lateral orbital

Local Anesthetic Blocks in Head and Neck Surgery 93

Injection technique involves sliding a 1.5-inch nee-
dle behind the concave portion of the lateral orbital rim.
It is suggested that one closely examine this area on a
model skull prior to attempting this injection, as it will
make the technique simpler.
To orient for this injection, the doctor needs to palpate
the lateral orbital rim at the level of the frontozygomatic
suture (which is frequently palpable). With the index ¬n-
ger in the depression of the posterior lateral aspect of the
lateral orbital rim (inferior and posterior to the frontozy-
gomatic suture), the operator places the needle just behind
the palpating ¬nger (which is about 1 centimeter posterior
to the frontozygomatic suture) (see Fig. 9-11). The needle
is then “walked” down the concave posterior wall of the
lateral orbital rim to the approximate level of the lateral
canthus. After aspirating, 1“2 cc of 2% lidocaine 1:100,000
epinephrine is injected in this area with a slight pumping
action to ensure deposition of the local anesthetic solution
at or about the foramen. Again, it is important to hug the
back concave wall of the lateral orbital rim with the needle
when injecting.
Figure 9-12. The anesthetized areas from the zygomaticotempo-
Blocking the zygomaticotemporal nerve causes anesthe-
ral (ZT) and the zygomaticofacial nerve (ZF).
sia in the area superior to the nerve including the lateral
orbital rim and the skin of the temple from above the zygo-
of the right orbit, if you will) portion of the lateral orbital
matic arch to the temporal fusion line (see Fig. 9-12 ZT).
rim, the nerve emerges several millimeters lateral to this
The zygomaticofacial nerve exits through a foramen (or
point. By palpating this area and injecting just lateral to
foramina in some patients) in the inferior lateral portion
the ¬nger, this nerve is successfully blocked with 1“2 cc
of the orbital rim at the zygoma. If the surgeon palpates the
of local anesthesia (see Fig. 9-13). Blocking this nerve will
junction of the inferior lateral (the most southwest portion

Figure 9-13. The zygomaticofacial nerve(s) is blocked by injecting the inferior lateral portion of the orbital rim.
94 Joseph Niamtu

result in anesthesia of a triangular area from the lateral the pterygopalatine canal, thereby placing the local anes-
canthus and the malar region along the zygomatic arch thetic solution into the pterygopalatine fossa. The course
and some skin inferior to this area10 (see Fig. 9-12). of the maxillary division of the trigeminal nerve (V2) is as
follows. The second division of the trigeminal nerve arises
Total second division nerve block from the gasserian ganglion in the medial cranial fossa
and exits the skull via the foramen rotundum (see Fig.
An ef¬cient and simple technique to obtain hemi midfa-
9-14 right). The nerve then traverses the superior aspect
cial local anesthesia is to block the entire second division
of the pterygopalatine fossa, where it divides into three
or maxillary nerve. This will anesthetize the entire hemi-
major branches: the pterygopalatine nerve, the infraor-
maxilla and the unilateral maxillary sinus by blocking the
bital nerve, and the zygomatic nerve.12 These nerves are
pterygopalatine, infraorbital, and zygomatic nerves and
targeted in this block.
their terminal branches. This is an easily learned tech-
When the foramen is located, the needle should be
nique involving an intraoral approach at the posterior lat-
gently advanced. If signi¬cant resistance is encountered,
eral palate (see Fig. 9-14). The maxillary nerve block via
the needle should be withdrawn and redirected. Approx-
the greater palatine canal was ¬rst described in 1917 by
Mendel.11 The greater palatine foramen is located ante- imately 5 percent of the population has been shown to
have tortuous canals that impede the needle tip and
rior to the junction of the hard and soft palate medial to
in some patients this technique is not possible. It is
the second molar tooth (see Fig. 9-14 center). The fora-
also important to aspirate before injecting to prevent
men is usually found about 7 mm anterior to the hard and
intravascular injection. When the needle is properly posi-
soft palate junction. This junction is seen as a color change
tioned (usually at a depth of 25“30 mm), the injection
such that the tissue overlying the soft palate is darker pink
(2“4 ml) should proceed over thirty to forty-¬ve sec-
than the tissue overlying the hard palate. The key to this
onds. Transient diplopia of the ipsilateral eye may occur.
block is to place a 1.5-inch needle through the greater pala-
This results from the local anesthetic diffusing superi-
tine foramen. It sometimes takes multiple needle sticks to
orly and medially to anesthetize the orbital nerves. The
localize the foramen. Due to the need for multiple sticks,
patient must be assured that if this phenomenon occurs,
the palatal mucosa in this area is ¬rst in¬ltrated with
it is transient. Again, this technique will anesthetize all
0.5 cc of lidocaine to facilitate painless location of the
the terminal branches of the maxillary nerve with a single
greater palatine foramen. A 1.5-inch 25 or 27 ga needle is
bent to a 45 degree angle and will usually easily negotiate

Figure 9-14. The maxillary nerve block is performed by locating the greater palatine foramen (left), inserting a bent needle up the
pterygopalatine canal (center) to inject local anesthetic into the ptergopalatine fossa (right). Notice the needle tip in the pterygopalatine
fossa on the far right image. As the second division traverses this area, it is blocked at the main trunk.
Local Anesthetic Blocks in Head and Neck Surgery 95

Figure 9-15. The mental foramen is approached intraorally below the root tip of the lower second premolar (left) or from a facial
approach (right).

Sensory anatomy of the mandibular nerve (V3) lar (many patients may be missing a premolar due to
orthodontic extractions). The mental foramen is on the
The mandibular nerve supplies the teeth and gums of the
average 11 mm inferior to the gum line (see Fig. 9-15).
mandible, the skin of the temporal region, part of the auri-
There is variability with this foramen, like all foramina.
cle, the lower lip, and the lower part of the face (see Fig.
However, by injecting 2 to 4 cc of local anesthetic solution
9-3 V3). The mandibular nerve also supplies the muscles
about 10 mm inferior to the gum line or 15 mm inferior
of mastication and the mucous membrane of the anterior
to the top of the crown of the second premolar tooth, the
two thirds of the tongue. It is the largest of the three divi-
block is usually successful. In a patient without teeth, the
sions of the ¬fth cranial nerve and is made up of a motor
and sensory root.9 foramen is oftentimes located much higher on the jaw and
can sometimes be palpated. This block is performed more
Sensory branches of the mandibular nerve include the
superiorly in the denture-wearing patient. As stated earlier,
auriculotemporal nerve, which supplies sensation to the
the foramen does not need to be entered because a suf¬-
skin covering the front of the helix and tragus (see Fig. 9-3).
cient volume of local anesthetic solution in the general area
The inferior alveolar nerve is the largest branch of the
will be effective. By placing traction on the lip and pulling
mandibular nerve. It descends with the inferior alveolar
it away from the jaw, the labial branches of the mental
artery and exits the ramus of the mandible to the mandibu-
nerve can sometimes be seen traversing through the thin
lar foramen. It then passes forward in the mandibular
mucosa. The mental nerve gives off labial branches to the
canal, beneath the teeth, as far as the mental foramen,
lip and chin.
where it divides into two terminal branches, incisive and
When anesthetized, the distribution of numbness will
mental nerves. The mental nerve emerges at the men-
be the unilateral lip down to the mentolabial fold, but
tal foramen and divides into three branches. One branch
many times to the anterior chin and cheek, depending on
descends to the skin of the chin, and two branches ascend
the individual furcating anatomy of that patient™s nerve
to the skin and mucous membrane of the lower lip. The
(see Fig. 9-16). The inferior alveolar nerve also supplies
buccal nerve supplies sensation to the skin over the bucci-
nator muscle.9 sensory innervation to the chin pad. The mylohyoid nerve
may also innervate this area. To augment or extend the
Local Anesthetic Techniques area of local anesthesia on the chin, an inferior alveolar
for the Mental Nerve Block nerve (mandibular dental block) block can be performed
instead of or with the mental nerve block. Additionally,
The mental nerve exits the mental foramen on the hemi
local skin in¬ltration in that area may assist.
mandible at the base of the root of the second premo-
96 Joseph Niamtu

Local Anesthetic Techniques for the Inferior
Alveolar Nerve Block (Intraoral)
Almost every person who has ever been to a dentist has
had this block and is aware of its effects, distribution, and
duration. This block is technically more dif¬cult to master
but is easily learned. The basis of this technique involves
the deposition of local anesthetic solution at or about the
mandibular foramen on the medial mandibular ramus
where the inferior alveolar nerve enters the mandible (see
Fig. 9-17).
Detailed description of this technique is beyond the
scope of this review article but will be outlined as fol-
lows. The patient is seated upright and the surgeon places
the index ¬nger on the posterior ramus and the thumb
in the coronoid notch on the anterior mandibular ramus
(see Fig. 9-17).
A 1.5-inch 27 ga needle is then directed to the medial
mandibular ramus at the level of the cusps of the upper sec-
ond molar and the needle is advanced halfway between the
thumb and index ¬nger of the other hand that is grasping
the mandible.
Two cc of 2% lidocaine, 1:100,000 epinephrine is then
Figure 9-16. This shows the anesthetized areas from a unilateral
injected in a pumping motion to better the chances of
mental nerve block. Because of various anatomic factors, the area
below the mentolabial fold or at the midline may share other anesthetic solution contacting the nerve and foramen.
The needle can be slightly bent as shown in Figure 9-18
to negotiate the sometimes outward curvature of the

Figure 9-17. The target of the needle in the intraoral inferior alveolar nerve block is at the entrance of the nerve in the mandibular
foramen on the medial ramus. The needle can be slightly bent with a medial angle to negotiate the ¬‚aring anatomy of the ramus. The
mylohyoid nerve (inferior to needle) may or may not be blocked by this technique depending on its level of branching.
Local Anesthetic Blocks in Head and Neck Surgery 97

cess. This notch is located about 25 mm anterior to the
tragus. If one places their ¬nger 25 mm anterior to the tra-
gus and opens and closes the jaw, the mandibular condyle
can be palpated with the jaw open. When the jaw is closed,
the ¬nger will be over the sigmoid notch. A 22 ga, 8-cm
needle is inserted in the midpoint of the notch and directed
at a slightly cephalic and medial to angle through the notch
until the lateral pterygoid plate is contacted (number 1 in
Fig. 9-18). This is usually at a depth of approximately 4.5“
5.0 cm. Spinal needles frequently have measuring stops
that can be adjusted to the position of original contact
of the pterygoid plate. The needle is then withdrawn to
a subcutaneous position and carefully “walked off” the
Figure 9-18. The mandibular nerve (V3) block places the local
posterior border of the pterygoid plate (arrows in Fig. 9-
anesthetic just posterior to the lateral pterygoid plate, where the
18) in a horizontal plane until the needle no longer tou-
third division of the trigeminal nerve exits the foramen ovale.
The needle is walked off the pterygoid plate (1), and the local
ches the plate and is posterior to it. The needle depth
anesthetic solution is deposited in the region of the third division
should be the same as the distance on the needle stop
of the trigeminal nerve (2).
marker when the pterygoid plate was originally contacted.
The needle should not be advanced more than 0.5 cm
mandibular ramus. The surgeon should ¬rst aspirate to past the depth of the pterygoid plate because the supe-
avoid intravascular injection. Anesthesia from this block rior constrictor muscle of the pharynx can be pierced eas-
ily.13 When the needle is in appropriate position, 5 cc of
sometimes takes ¬ve to ten minutes to take effect. Pro-
¬ciency in this blocking technique requires practice but local anesthetic solution can be administered. The area
is very useful in cosmetic facial procedures. In addition, anesthetized is shown as V3 in Figure 9-3. Complications
the ispilateral tongue is usually anesthetized with this include hematoma formation and subarachnoid injection.
block. The area anesthetized includes the lower teeth and Again, this block should be learned in a proctored situation
gums, the chin, and skin on the lateral chin. The inferior and not be attempted by novice injectors.
alveolar nerve block frequently includes the mylohyoid
nerve. In some patients, the mylohyoid nerve branches
Sensory anatomy of the scalp
above the area of inferior alveolar injection and in this
The anterior scalp is anesthetized by injecting the branches
case needs a speci¬c mylohyoid nerve block, as outlined
of V1 (supraorbital and supratrochlear nerves) and V2
(the zygomaticotemporal nerve). The greater and lesser
occipital nerves innervate the posterior scalp. The greater
Local Anesthetic Techniques for the Mandibular
auricular nerve supplies the lateral scalp (see Fig. 9-19).
Nerve (V3) Block (Facial Approach)
The greater occipital nerve arises from the dorsal rami
The mandibular nerve can also be blocked from a deep
of the second cervical nerve and travels deep to the cer-
injection as the nerve exits the foramen ovale, posterior
vical musculature until it becomes subcutaneous slightly
to the pterygoid plate13 (see number 2 in Fig. 9-18). This
inferior to the superior nuchal line.14 It emerges on this
technique requires more experience and has more poten-
line in association with the occipital artery. The artery is
tial complications than the intraoral approach.
the most useful landmark for locating the greater occipital
The technique for performing this block begins with the
patient in supine position with the head and neck turned
away from the side to be blocked. The patient is asked to
Local Anesthetic Techniques to Block the Scalp
open and close the mouth gently so that the operator can
identify and palpate the sigmoid notch. This is the area By performing the brow blocks (see Fig. 9-5), the cervical
between the mandibular condyle and the coronoid pro- plexus block (see Fig. 9-20), and the zygomaticotemporal
98 Joseph Niamtu

block (see Fig. 9-11), most of the scalp is anesthetized,
except the posterior area. This is anesthetized by blocking
the greater occipital nerve. One can also perform a ring
block where wheals of local anesthetic are injected every
several centimeters around the entire scalp at about the
level of the eyebrows. About 30 cc of local is required to
perform a scalp-ring block.

Greater Occipital Nerve Block Technique
for Posterior Scalp Anesthesia
The most ef¬cient patient position is sitting upright with
the chin ¬‚exed to the sternum.15 The nerve is identi-
¬ed at its point of entry to the scalp, along the superior
nuchal line one third to one half the distance between
the mastoid process and the occipital protuberance in the
midline14 (see Fig. 9-21). Another measurement for locat-
ing the artery is 2.5“3.0 cm lateral to the occipital pro-
trubence.16 The patient will report pain upon compres-
sion of the nerve: the point at which maximal tenderness
is elicited can be used as the injection site. A 25 ga 5/8-
Figure 9-19. Innervation of the scalp where 1 = supratrochlear
inch needle is used for the block. The occipital artery is
nerve, 2 = supraorbital nerve(s), 3 = zygomaticotemporal nerve,
4 = greater auricular nerve, 5 = lesser occipital nerve, 6 = greater just lateral to the greater occipital nerve and can be used
occipital nerve.
as a pulsatile landmark. Two to four cc of local anesthetic
solution can be in¬ltrated on either side of the artery to
ensure proximity to the nerve. Figure 9-22 shows the der-
matomes anesthetized by blocking the greater occipital

Sensory Anatomy of the Neck; Innervation
of the Cervical Plexus
The cervical plexus is formed from the ventral rami of
the upper four cervical nerves (see Fig. 9-21 center). The
dorsal and ventral roots combine to form spinal nerves as
they exit through the intervertebral foramen. The ante-
rior rami of C2 through C4 form the cervical plexus. The
cervical plexus lies just behind the posterior border of
the sternocleido-mastoid muscle, giving off both super¬-
cial (super¬cial cervical plexus) and deep branches (deep
cervical plexus). The branches of the super¬cial cervical
plexus supply the skin and super¬cial structures of the
Figure 9-20. The cervical plexus block is performed by making a
head, neck, and shoulder. The deep branches of the cervical
line from the mastoid process (1) to the level of the transverse
plexus innervate the deeper structures of the neck, includ-
process of C6 (2), then ¬nding the point halfway between these
two marks (X) just posterior to the sternocleidomastiod (dotted ing the muscles of the anterior neck and the diaphragm
line). Local anesthetic is then injected perpendicularly, superiorly,
(phrenic nerve) and are not blocked for local anesthetic
and inferiorly in this region (the middle picture also shows the
greater occipital nerve, which is not part of the cervical plexus.)
Local Anesthetic Blocks in Head and Neck Surgery 99

Figure 9-21. The greater occipital nerve is in close approximation to the artery of the same name (1). The nerve can be located by
palpating the artery and injecting just medial to it (2). Another landmark is injecting on the nuchal line, one third to one half the distance
between the mastoid prominence and occipital protrubence (3 and 5). Number 4 in the diagram shows the lesser occipital nerve.

Super¬cial branches of the cervical plexus include
the following.
The lesser occipital nerve arises from the second (and
sometimes third) cervical nerve and emerges from the deep
fascia on the posterior lateral portion of the head behind
the auricle, supplying the skin and communicating with
the greater occipital, the great auricular, and the posterior
auricular branch of the facial.
The greater auricular nerve arises from the second and
third cervical nerves and divides into an anterior and a
posterior branch. The anterior branch is distributed to the
skin of the face over the parotid gland and communicates
in the substance of the gland with the facial nerve.
The posterior branch supplies the skin over the mastoid
process and on the back of the auricle, except at its upper
part; a ¬lament pierces the auricle to reach its lateral sur-
face, where it is distributed to the lobule and lower part of
the concha. The posterior branch communicates with the
lesser occipital nerve, the auricular branch of the vagus,
and the posterior auricular branch of the facial nerve.
The cutaneous cervical nerve (cutaneus colli nerve, ante-
rior cervical nerve) arises from the second and third cervical
Figure 9-22. Blocking the entire ear (with the exception of the nerves and provides sensation to the antero-lateral parts
area supplied by the vagus nerve) can be performed by insert-
of the neck (see Fig. 9-21 center).
ing the needle at the black dots and in¬ltrating along the dotted
lines. This will anesthetize the terminal branches of the auricu-
lotemporal nerve, the lesser occipital nerve, and the anterior and Local Anesthetic Techniques for the Cervical Plexus
posterior branches of the greater auricular nerve. The main trunks
This technique is used in cosmetic facial surgery to
of these nerves could be blocked as detailed earlier in this article,
block the super¬cial branches of the cervical plexus to
but this terminal in¬ltration technique may be more convenient.
100 Joseph Niamtu

anesthetize skin of the lateral or anterior neck, the pos- thetize the entire ear, except the concha and the external
terior lateral scalp, and portions of the periauricular area auditory canal, which are innervated by the Vagus nerve
(see Fig. 9-2). (CN X). The needle is inserted into the skin at the junc-
The technique involves lying the patient back with the tion where the earlobe attaches to the head. The anesthetic
sternocleidomastiod ¬‚exed, exposing the mastoid process should be in¬ltrated while the needle is advanced to the
and the transverse process of C6 (Chassaignac™s Tubercle) subcutaneous plane. In¬ltration is made in a hexagonal
(approximate level of the cricoid cartilage) (see Fig. 9-21 pattern around the entire periphery of the ear (see Fig. 9-
left). This line is divided in half at the posterior border of 22). The chonal bowl and external auditory canal will need
the sternocleidomastoid to determine the injection point. separate in¬ltration. One should aspirate (as with all injec-
Another technique is to simply bisect the distance from the tions) prior to injection to prevent intravascular injection.
origin and insertion of the sternocleidomastoid without
Anesthesia for the nose
osseous landmarks. The success of this block involves a
larger volume of local anesthesia diffusing and spreading The nose receives innervation from multiple nerves. The
out over a larger area rather than absolute accuracy of supratrochlear and infratrochlear nerves innervate the
the nerve position. 3 to 5 cc of local anesthetic solution root, bridge, and upper portion of the side of the nose.
is injected subcutaneously with the needle perpendicular The infraorbital nerve supplies the skin on the side of
to the skin. The needle is then redirected superiorly and almost half of the lower nose. The external nasal branch
another 3 to 5 cc are injected. Finally, the needle is then of the anterior ethmoidal nerve (dorsal nasal nerve) exits
directed inferiorly and another 3 to 5 cc is injected. Figure between the nasal bone and the lateral nasal cartilage to
9-21 (center) shows the areas anesthetized by a cervical supply the skin over the dorsum of this part of the nose
plexus block. to the tip.
Phrenic nerve involvement is rare with super¬cial cervi- Anesthetic techniques for blocking the nose vary with
cal plexus block (more common with deep cervical blocks) the type of procedure being performed. To block the exter-
but technically possible as C3, 4, and 5 innervate the nal nasal structures (the bridge and tip), bilateral blocks
diaphragm. Healthy patients can tolerate a hemi paral- of the following nerves are performed: infraorbital, supra-
ysis of the diaphragm. However, caution must be used in trochlear, infratrochlear, and the dorsal nasal nerves.
patients with cardiopulmonary problems because assisted For internal nasal surgery such as rhinoplasty or nasal
ventilation may be required. It must be kept in mind that trauma, the aforementioned blocks are performed in con-
a bilateral block could potentially de-innervate the entire junction with the following. The second division max-
diaphragm. To prevent unwanted spread of local anesthetic illary block is valuable in providing supplemental anes-
solution, this injection is just subcutaneous in placement thesia. This is shown in Figure 9-14. For septal anesthe-
and never done bilaterally. sia, local anesthetic solution is deposited 1 cm in front
of the sphenoid rostrum to block the posterior and supe-
Selected Area Blocks rior branches of the sphenoplatine nerve (see Fig. 9-23).
Anesthesia for the ear Bending a 1.5-inch needle will improve visualization while
injecting. The in¬ltrations are performed from posterior
Four nerve branches supply sensory innervation to the ear.
to anterior to prevent needle puncture bleeding from
The anterior half of the ear is supplied by the auriculotem-
obscuring the ¬eld. In¬ltration can also be made into the
poral nerve, which is a branch of the mandibular portion
inferior turbinates.
of the trigeminal nerve. The posterior half of the ear is
innervated by two nerve branches derived from the cervi-
Blocking the lips
cal plexus: the great auricular nerve and the lesser occipital
nerve (see Fig. 9-22 center). The auditory branch of the Minimally invasive cosmetic surgery techniques such as
vagus nerve innervates the concha and external auditory ¬ller injections may require local anesthesia of the lips.
canal. Although the doctor could perform bilateral infraorbital
Although these nerves can be individually targeted with and mental nerve blocks, they present disadvantages.
blocks, a circumferential in¬ltration (ring block) will anes- Many practitioners are uncomfortable with these blocks,
Local Anesthetic Blocks in Head and Neck Surgery 101

Figure 9-23. Septal anesthesia is performed to block branches of Figure 9-25. This rendition shows the approximate area anes-
the sphenopalatine nerve and constrict the vascular supply. thetized with the vestibular anesthesia technique.

Figure 9-25 shows the area anesthetized by using the
and they can be unpleasant for the patient. In addition,
in¬ltration technique in both lips. Obviously, only the
this combination of blocks will render a large area of the
upper or lower lip can be anesthetized, respectively.
face insensate for several hours, which is disconcerting to
Although profound anesthesia may extend from the nasal
patients. A simple technique for obtaining anesthesia of the
tip to the chin, some patients can still feel pain at the lateral
upper and lower lips is to inject 0.5 cc increments of 2%
portions of the lips but usually tolerate injection.
lidocaine with 1:100,000 epinephrine across the vestibule
of the anterior maxilla and mandible (see Fig. 9-24). This
Tumescent Anesthesia
simple technique is performed as follows. First, topical
anesthesia is applied to the anterior and mandibular sul- Dermatologist Jeffery A. Klein, M.D., popularized the
cus for several minutes. Next, a 0.5-inch 30 ga needle is concept of tumescent local anesthesia and thereby rev-
used to deposit 0.5 cc increments of anesthesia in four to olutionized outpatient liposuction as well as enhanced
¬ve areas between the canine teeth. This technique will other cosmetic procedures. The word “tumescent” means
provide profound anesthesia in the perioral area, which is swollen and ¬rm. By injecting a large volume of very dilute
usually suf¬cient for ¬ller injection. lidocaine (local anesthetic) and epinephrine (capillary

Figure 9-24. A simple vestibular in¬ltration technique can assist cosmetic techniques such as the injection of ¬llers.
102 Joseph Niamtu

constrictor) into subcutaneous fat, the targeted tissue large volume of dilute epinephrine into subcutaneous fat.
becomes swollen and ¬rm, or tumescent. The tumescent Tumescent vasoconstriction is so complete that liposuc-
technique is a method that provides local anesthesia to tion can be done with virtually no blood loss. In contrast,
large volumes of subcutaneous fat and thus permits lipo- the older forms of liposuction used before the invention of
suction totally by local anesthesia. The tumescent tech- the tumescent technique were associated with so much sur-
nique may eliminate the need for both general anesthesia gical blood loss that autologous blood transfusions were
and IV narcotics and sedatives. often routine.
The tumescent technique for liposuction (1) provides Because the vasoconstriction delays lidocaine absorp-
local anesthesia, (2) constricts capillaries and prevents sur- tion, the local anesthetic remains in place in the fat
gical blood loss, and (3) provides ¬‚uid to the body by sub- for many hours. This prolonged anesthesia may permit
cutaneous injection so that no IV ¬‚uids are needed.18 surgery for up to ten hours after in¬ltration and can pro-
Depending on the clinical requirements, a tumescent vide twenty-four to thirty-six hours of signi¬cant postop-
anesthetic solution may contain a ¬ve- to fortyfold dilu- erative analgesia in some patients.
Maximum recommended lidocaine dosage is 40 mg ·
tion of lidocaine found in commercially available for-
kg’1 to 50 mg · kg’1 for tumescent liposuction when lido-
mulations of local anesthesia. Commercial solutions of
lidocaine used by dentists and anesthesiologists typically caine is greatly diluted. This is a relatively large dosage com-
pared to the 7 mg · kg’1 that is widely accepted as the “safe
contain 1 gm (1,000 mg) of lidocaine and 1 mg of
epinephrine per 50 ml (2% lidocaine with 1:200,000 maximum dose for lidocaine with epinephrine.” Anesthe-
epinephrine) of saline. In contrast, tumescent solutions of siologists use nondiluted lidocaine for nerve blocks such
as epidural blocks.18
local anesthesia contain approximately 0.5“1 gm of lido-
caine and 1 mg of epinephrine in 1,000 ml of NSS. This is a Because tumescent local anesthesia lasts so long, tumes-
twentyfold dilution of the commercial version of lidocaine cent liposuction is less painful and more pleasant than
and epinephrine.18 liposuction under general anesthesia or IV sedation. With
Tumescent liposuction totally by local anesthesia has tumescent local anesthesia, patients are able to avoid the
proven to be extremely safe despite the use of unprece- postoperative nausea and vomiting associated with gen-
dented large doses of lidocaine and epinephrine. One eral anesthesia or IV opioids. Tumescent anesthesia is so
explanation for this remarkable safety is the extreme dilu- ef¬cient at providing ¬‚uid to the body that it is unneces-
tion of the tumescent local anesthetic solution. Large vol- sary to administer IV ¬‚uids. There is a risk of dangerous
umes of dilute epinephrine produce intense constriction ¬‚uid overload if excessive IV ¬‚uids are given to a tumescent
liposuction patient.18
of capillaries in the targeted fat, which in turn greatly
delays the rate of absorption of lidocaine and epinephrine.
Tumescent Local Anesthesia for Facial Procedures
Undiluted lidocaine and epinephrine are absorbed into
the bloodstream in less than an hour. Tumescent dilu- Although any part of the head or neck can, in theory, be
tion causes widespread capillary constriction that causes blocked, sometimes it is easier or advantageous to utilize
the absorption process to be spread over twenty-four to tumescent anesthesia instead of blocks. One big advantage
thirty-six hours. This reduces peak concentration of lido- is the simultaneous hemostasis that accompanies the pain
caine in the blood, which in turn reduces the poten- control. Head and neck procedures that lend themselves to
tial toxicity of a given dose of lidocaine (see Chap- tumescent local anesthesia include platysmaplasty (“neck-
ter 8). Dentists typically use concentrated epinephrine, lift”), rhytidectomy (facelift), brow and forehead lift, and
which may cause a tachycardia, or rapid heart rate, if the resurfacing procedures. This author utilizes tumescent
epinephrine is rapidly absorbed. When very dilute tumes- anesthesia for all of these except skin resurfacing. IV seda-
cent epinephrine is used, the widespread vasoconstriction tion with reliance on the potency of ketamine will obtund
slows the rate of epinephrine absorption, which in turn these patients. Niamtu ¬nds that tumescent local anes-
prevents an increase in heart rate.18 thesia distorts the anatomy too much for his preferences.
Profound vasoconstriction (shrinkage of capillary Many practitioners favor this technique with laser resur-
blood vessels) results from the tumescent in¬ltration of a facing or chemical peel. Generally, tumescent anesthesia
Local Anesthetic Blocks in Head and Neck Surgery 103

would be combined with selected local anesthetic blocks.
This adds extra time, material, and equipment to resur-
facing, so Niamtu has not embraced it.
For rhytidectomy, there exist numerous advantages
for the use of tumescent local anesthesia. The effects of
pain control and hemostasis are obvious. The ability of
the engorged tumescent anesthetic solution to hydrodis-
sect the subcutaneous plane is, in Niamtu™s opinion,
paramount. The ef¬cacy of rhytidectomy hinges on the
correct tissue planes being dissected and manipulated.
Novice surgeons frequently become confused when spe-
ci¬c tissue planes are required. By engorging the subcu-
taneous plane with 50“100 cc of tumescent anesthesia in
Figure 9-27. The preauricular and jowl tissues are engorged with
each pre- and postauricular areas as well as the 100“200 tumescent in preparation for facelift.
cc in the submental and cervical regions, the facelift can
be performed solely with local anesthesia (see Figs. 9-26
provides superior postoperative pain control. Figure 9-30
to 9-29).
shows the various dermatomes providing sensation to the
head and neck. By realizing the nerves that supply these
Blocking the entire face
areas, a customized “anesthetic map” may be made by the
Although many cosmetic facial procedures are performed
surgeon applicable to the operated areas.
with IV sedation or general anesthesia, many can be per-
formed with only local anesthetic techniques if one mas-
ters the blocks described in this chapter. Although this
author usually uses IV sedation for facelift, chemical peel,
and laser resurfacing, he has performed these procedures
with only local anesthesia. Even when using IV sedation
or general anesthesia, a prudent surgeon will utilize local
anesthetic techniques. This allows the anesthesia provider
to maintain the patient with less IV medication or gas and

Figure 9-26. Tumescent local anesthesia is in¬ltrated in the pre- Figure 9-28. The submental area is engorged with 100 cc of
and postauricular areas prior to facelift. tumescent anesthesia in preparation for platysmaplasty.
104 Joseph Niamtu

Figure 9-29. The facelift ¬‚ap is dissected ¬fteen minutes after
tumescent injection to the pre- and postauricular regions. Notice
the bloodless ¬eld, which speaks for the effectiveness of the
tumescent technique.

Using the picture in Figure 9-30, the surgeon can cre-
ate a formula for which blocks are required for what
procedure. An example would be to select a procedure, say
Figure 9-30. The major sensory dermatomes of the head and
endoscopic brow and forehead lift. Look at Figure 9-30 and neck. AC = anterior cervical cutaneous colli; AT = auriculotempo-
ral, B = buccal, EN = external (dorsal) nasal, GA = greater auric-
see what blocks correspond with which dermatomes. For
ular, GO = greater occipital, IO = infraorbital, IT = infratroch-
the endoscopic brow, one would need to block bilaterally
lear, LO = lesser occipital, M = mental, SO = supraorbital,
ST, SO, GO, LO, AT, and ZT. Because of anatomic vari- ST = supratrochlear, ZF = zygomaticofacial, ZT = zygomatico-
ables, crossover may be needed with adjacent dermatomes,
but Figure 9-30 should be a good map and starting

1. Hersh EV, Condouis GA: Local anesthetics: A review of their
pharmacology and clinical use. Compend Contin Educ Dent
A ¬rm knowledge of the sensory neuroanatomy of the
2. Jastak JT, Yagiela JA, Donaldson D: Local anesthesia of the
head and neck can bene¬t the practice of cosmetic facial oral cavity. Philadelphia, WB Saunders, 1995.
surgery for both the surgeon and the patient. Although the 3. Covino BG, Vassalo HG: Chemical aspects of local anesthetic
agents. In Kitz RJ, Laver MB (eds.), Local Anesthetics: Mecha-
pathways of sensation for the head and neck are complex,
nism of Action and Clinical Use. New York, Grune & Stratton,
they can be easily and safely blocked by reviewing the basic 1976; p1.
innervation patterns shown in Figure 9-30. 4. Hersh EV: Local Anesthetics. In Fonseca RJ (ed.), Oral
and Maxillofacial Surgery. Philadelphia, WB Saunders, 2000;
The entire sensory apparatus of the face is supplied
p. 58.
by the trigeminal nerve and several cervical branches.
5. Yagiela JA. Local Anesthetics. In Dionne RA, Phero JC (eds.),
There exist many patterns of nerve distribution anomaly, Management of Pain and Anxiety in Dental Practice. New
cross innervation, and individual patient variation; how- York, Elservier, 1991; p. 109.
6. Malamed SF: Handbook of Local Anesthesia, 4th ed. St. Louis,
ever, by following the basic techniques outlined in this
chapter, the cosmetic surgeon should be able to achieve
7. Aceves J, Machne X: The action of calcium and of local anes-
pain control of the major dermatomes of the head and thetics on nerve cells and their interaction during excitation.
neck.19’22 J Pharmacol Exp Ther 140:138,1963.
Local Anesthetic Blocks in Head and Neck Surgery 105

8. Stricharatz D: Molecular mechanisms of nerve block by local 16. Gmyrek R: Local Anesthesia and Regional Nerve Block Anes-
anesthetics. Anesthesiol 45:421,1976. thesia. 2002 www.emedicine.com/derm/topic824.htm.
9. Gray H: Anatomy of the Human Body, 13th ed. Lea & Febiger, 17. Larrabee W, Msakielski KH: Surgical anatomy of the face.
Philadelphia. 1918; p. 1158. New York, Raven Press, Ltd., 1993; p. 83.
10. Zide BM, Swift R: How to block and tackle the face. Plast 18. http//www.liposuction.com. Accessed 2“8“05.
Reconst Surg 101:840,1998. 19. Niamtu J: Local anesthetic blocks of the head and neck for
11. Mendel N, Puterbaugh, PG: Conduction, In¬ltration and cosmetic facial surgery, Part I: A review of basic sensory neu-
General Anesthesia in Dentistry, 4th ed. Dental Items of Inter- roanatomy. Cosmet Dermatol 17:515,2004.
est Publishing Co. 1938; p. 140. 20. Niamtu J: Local Anesthetic blocks of the head and neck for
12. Mercuri LG: Intraoral second division nerve block. Oral Surg cosmetic facial surgery, Part II: Techniques for the upper and
47:9,1979. midface. Cosmet Dermatol 17:583,2004.
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Saunders, 1999; p. 170. cosmetic facial surgery, Part III: Techniques for the maxillary
14. Bonica TT, Buckley FO: Regional anesthesia with local anes- nerve. Cosmet Dermatol 17:645,2004.
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2001 www.emedicine.com/neuro/topic514.htm#target10. face.Cosmet Dermatol 17:714,2004.
10 Local Anesthetics and Surgical Considerations
for Body Contouring
Rodger Wade Pielet, M.D.


INTRODUCTION glandular or submuscular augmentation mammoplasty
with or without mastopexy.
A signi¬cant number of techniques for proper in¬ltration
The glandular tissue receives its sensory innervation
of local anesthetic for body contouring procedures can
from the lateral mammary rami of the third through sixth
be summarized on three levels. First, establish preemp-
intercostal nerves and medial mammary rami of the sec-
tive analgesia and adequate vasoconstriction at all incision
ond through sixth intercostal nerves (Fig. 10-2). A very
sites. Second, provide both anesthesia and vasoconstric-
separate anterior branch of the fourth intercostal nerve
tion in all planes of dissection and manipulation. Third,
supplies sensation to the nipple. The nipple and areolar
facilitate vasoconstriction to all vascular beds supplying
complex are always supplied by sensory nerves were seen
the surgical planes of dissection. The third objective is
through the depths the glandular tissue and not by super-
best accomplished by having an understanding of the mus-
¬cial nerves (Fig. 10-3).
culocutaneous and fasciocutaneous vascular anatomy. In
many cases, these vascular pedicles are in close proximity
to the sensory nerves; but often, they need to be addressed
as distinct anatomic areas. A signi¬cant amount of local For proper analgesia as well as vasoconstriction at the
in¬ltration occurs prior to the surgical scrub and prepa- incision sites, Pielet prefers the use of 1% lidocaine with
ration. This allows for an appropriate amount of time to epinephrine (1:100,000). This is preferable to the use
elapse for adequate analgesia and vasoconstriction. of bupivicaine with epinephrine because the potent and
Breast augmentation, for example, is the second most prolonged vasodilitation of bupivicaine seems to out-
requested surgical procedure in many aesthetic surgery last the effects of the epinephrine and there is a slightly
practices. Although there is no dominant vascular sup- higher increase of delayed postoperative bleeding Edi-
ply to the breast (Maliniak, 1943), the main contributors tor™s note: Bupivicaine does not have vasodilating prop-
are perforators from the internal mammary artery, the erties. Bupivicaine for postoperative pain management
lateral thoracic artery, and intercostal vessels (Fig. 10-1). is discussed later in this chapter. Either 0.5% or 1%
There are also perforators from the thoracoacromial and lidoocaine with epinephrine is injected to in¬ltrate the
thoracodorsal vessels to the pectoralis major muscle. This areas of vascular perforators or planes of dissection when
understanding is important when performing either sub- necessary.

Local Anesthetics and Surgical Considerations for Body Contouring 107

Figure 10-3. Local anesthetic injection to the incisional area for
periareolar breast augmentation.

When considering liposuction, for example, it is impor-
Figure 10-1. Dominant vascular supply to the breast.
tant to have continuous communication with one™s anes-
thesiologist. Factors that must be monitored during these
Numerous authors have written about the use of tumes- procedures include the starting hematocrit of the patient,
cent ¬‚uids to in¬ltrate the super¬cial and deep layers of the volume of tumescent ¬‚uid in¬ltrated, volume of fat
fat when performing liposuction. Tumescent in¬ltration aspirated, volume of crystalloid administered through the
is also useful in other procedures, such as breast reduc- IV, and the amount of lidocaine used.
tion and abdominoplasty. The typical tumescent solution A useful rule of thumb predicts that if a lidocaine-
consists of 50 cc of 1% lidocaine plus 1 mg of epinephrine epinephrine solution is injected in the amount of 15“30 cc
per liter of normal saline or Lactated Ringers solution. per 100 cm2 of the area to be treated, the hematocrit will
Other surgeons may choose to add up to 12.5 cc of 8.4% fall approximately 1% for every 150 cc of fat aspirated. For
sodium bicarbonate as well as various concentrations of example, if 1,500 cc fat were removed by liposuction, the
hyaluronic acid. Pielet has not found either bicarbonate hematocrit would be expected to fall by approximately
or hyaluronic acid to be necessary. 10% (Hetter, 1989). A one-to-one volume of ¬‚uid is
injected equal to the amount of lipo-aspirate from any
given area. Depending on the size of liposuction, this
often involves amounts of lidocaine that far exceed the
limits thought to be toxic (see Chapter 8). Because there
is delay in the peak levels for several hours after injection,
lidocaine doses as high as 35 mg · kg’1 have been found to
be completely safe in an outpatient setting (Klein, 1990)
(see Chapter 8).


The three most common incision sites for breast augmen-
tation include the inframammary fold, the peri-areola,
and the axilla. Pielet prefers to perform pectoral aug-
mentation entirely through an axillary incision. Pielet
does not perform the transumbilical approach (TUBA),
Figure 10-2. Nerve supply to the breast.
108 Rodger Wade Pielet

Figure 10-6. Accufusor R pain pump.

Following dissection of the pocket and assurance of
Figure 10-4. Parasternal injection of local anesthesia for breast
augmentation. meticulous hemostasis, a small catheter is placed in the
pocket. The catheter is later connected to a postopera-
tive pain pump delivering a constant infusion of 0.25%
as this offers no real advantage over other incision sites.
bupivicaine to each side. Some devices include an addi-
Following in¬ltration of the incision areas, the medial
tional patient-controlled bolus (Fig. 10-6). It is also effec-
parenchymal breast tissue is in¬ltrated to block the neu-
tive to place approximately 5“10 cc of 0.25% bupivicaine
rovascular perforators arising from the internal mammary
in the pocket if the patient does not wish to have catheters
artery above the ribs (Fig. 10-5). This seems to be equally
emerging from the skin for a few days after she goes home.
effective as distinct, individual intercostal blocks and does
Editor™s note: Up to 50 cc of 0.25% bupivicaine (125 mg) is
not carry the added minimal risk of pneumothorax, which
considered a safe dose more effective analgesia will result from
is slightly more common in very thin individuals. All injec-
using 20“25 cc per breast pocket. Bupivicaine used in these
tions can be accomplished with approximately 10“15 cc of
applications has not demonstrated an increased risk of
1% lidoocaine with epinephrine per side. Editor™s note: At
postepinephrine, rebound vasodilatation, or hematoma.
least 50“70 cc of 0.5% lidocaine with epinephrine is more
effective. Dr. Pielet is a plastic surgeon and client of Dr. Bar-
inholtz (Chapter 11). Inadequate local analgesia is a rea- REDUCTION MAMMAPLASTY AND MASTOPEXY
sonable explanation for Barinholtz inability to avoid opioids
These two operations are performed in a very similar
with the MIA„ technique. Some surgeons may wish to use
manner. If one considers the breast simplistically, it is com-
a dilute tumescent solution in the subglandular or subpec-
prised of an “outer skin envelope” and “inner stuf¬ng.”
toral spaces.
The stuf¬ng is basically made up of parenchyma, fat,
and sometimes an alloplastic implant above or below
the pectoralis major muscle. There are several different
procedures, techniques, and potential scar con¬gurations
based on the patient™s needs and surgeon preference. In
general, a breast reduction involves the removal of both
components, skin and stuf¬ng, whereas a breast lift is
usually the removal of skin only.
Most procedures require some degree of skin-¬‚ap
elevation above the parenchyma. The nipple/areolar
complex remains attached to the underlying parenchyma
in order to preserve neurovascular continuity. The excep-
tions to this principle are extremely severe cases of symp-
tomatic macromastia. In this instance, the resultant pedicle
Figure 10-5. Marking for lateral intercostals injections in the ante-
would be insuf¬cient to maintain the blood supply to the
rior axillary line for breast augmentation.
Local Anesthetics and Surgical Considerations for Body Contouring 109

nipple/areola. The second exception would be for patients in¬ltration. The VAL has revolutionized the practice of
whose medical or social (i.e., smoking) history precludes liposuction. VAL has signi¬cantly reduced the use of intra-
adequate vascularity and/or safety. In these situations, an operative opioids as compared to other methods of tumes-
en-bloc amputation of the skin, breast tissue, and fat with cent liposuction, including other applications of ultrasonic
replacement of the nipple/areolar complex is performed technology. Decreased opioid requirement is likely related
as a free graft. to lesser tissue trauma and increased precision. More harsh
Regardless of the procedure, all incision sites are in¬l- techniques require more vigorous action in both tunnel-
trated with 0.5% or 1% lidocaine with epinephrine. If ing with the cannula as well as application of ultrasonic
any area is to be de-epithelialized, intradermal placement energy. This decreased precision often results in placement


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