Plastic and Reconstructive Surgery • November 2013 Moreover, an additional study analyzing the impact of adding prophylactic ondansetron (Zofran; Glasko Smith Kline, Philadelphia, Pa.) to our conscious sedation regimen revealed a 0 percent incidence of postoperative emesis in procedures lasting less than 90 minutes,4 which would include all procedures in the present study, which had an average operating time of approximately 76 minutes. The rate of recall of intraoperative events in that study was 16.9 percent; however, recall of intraoperative discomfort was very low, and more than 90 percent of patients in that study stated they would elect to undergo an additional procedure under conscious sedation. While we cannot provide quantitative data as a result of the current study design, we can state that patient satisfaction with this technique is very high, and our patients continue to refer friends and family, and choose conscious sedation at a high rate for repeated surgical procedures. DOI: 10.1097/01.prs.0000436782.70720.72
Michael S. Gart, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Northwestern Memorial Hospital Chicago, Ill. Jason H. Ko, M.D. Department of Surgery Division of Plastic Surgery University of Washington Seattle, Wash. Thomas A. Mustoe, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Northwestern Memorial Hospital Chicago, Ill. Correspondence to Dr. Mustoe Division of Plastic and Reconstructive Surgery Northwestern University Feinberg School of Medicine 675 North St. Clair Street Galter Suite 19-250 Chicago, Ill. 60611 [email protected]
DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication. This research received no specific grant from any funding agency in the public, private, or not-for-profit sectors. REFERENCES 1. Gart MS, Ko JH, Heyer KS, Mustoe TA. Breast implant procedures under conscious sedation: A 6-year experience in 461 consecutive patients. Plast Reconstr Surg. 2013;131:1169–1178. 2. Hasen KV, Samartzis D, Casas LA, Mustoe TA. An outcome study comparing intravenous sedation with midazolam/ fentanyl (conscious sedation) versus propofol infusion (deep sedation) for aesthetic surgery. Plast Reconstr Surg. 2003;112:1683–1689; discussion 1690.
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3. Byun MY, Fine NA, Lee JY, Mustoe TA. The clinical outcome of abdominoplasty performed under conscious sedation: Increased use of fentanyl correlated with longer stay in outpatient unit. Plast Reconstr Surg. 1999;103:1260–1266. 4. Marcus JR, Few JW, Chao JD, Fine NA, Mustoe TA. The prevention of emesis in plastic surgery: A randomized, prospective study. Plast Reconstr Surg. 2002;109:2487–2494.
Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches Sir: n their article “Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches,” Janis et al.1 dissected 50 fresh hemifaces and stated that the supratrochlear nerve generally bifurcates within the retro–orbicularis oculi fat pad. They classified the nerve into three types according to the relationship with the corrugator muscle: type I (24 hemifaces, 84 percent), where the nerve branches enter the muscle and wind their way more superficially through the muscle to exit into the plane of the frontalis at its cranial border; type II (two hemifaces, 4 percent), where one branch runs intramuscularly and the other branch runs deep to the muscle at all times; and type III (six hemifaces, 12 percent), where both branches remain deep into the corrugator at all times and then become more superficial at its cranial border. These findings seem to be very interesting and are useful information for clinical application. However, it is unclear what supratrochlear nerve “generally bifurcates” means within the retro–orbicularis oculi fat pad. Janis et al. classified the pattern of the supratrochlear nerve on the assumption that it has two branches. According to a previous article that Janis et al. did not cite, Andersen et al.2 dissected 20 hemifaces and found that in five (25 percent) of 20 cases, the supratrochlear nerve innervated the most medial part of the forehead by a single branch only, but consisted of two or three branches in the remaining 15 cases. In six cases (30 percen), the nerve had already split into branches at its exit from the orbit, while the remaining nine nerves entered the subcutaneous tissue as separate branches at different locations (45 percent). Although there were fewer dissected cadavers in Andersen et al.’s article, it is likely that the supratrochlear nerve can have a single branch or more than two branches. With regard to the presence of a supratrochlear foramen, Janis et al. state, “In nine facial halves (18.0 percent), there was a true bony foramen (for the supratrochlear nerve). When present, this foramen was found at 4 ± 0.4 mm cranial to the orbital rim.” In the Discussion, they cited Miller et al.’s study,3 stating, “the supraorbital foramen was found to be present only 2 percent of the time as a true foramen compared with 18 percent of the time in our study.” Miller et al. dissected 10 cadavers and observed an additional 50 skulls.3 They stated, “In none of our dissections did the supratrochlear nerve exit from a foramen,
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Volume 132, Number 5 • Letters as is commonly represented. In only one of the skulls of the 50 examined could a foramen of any size be identified in the general vicinity, and this was less than 0.5 mm in diameter.” For the supraorbital nerve, Miller et al. described, “The supraorbital nerve was found to exit the orbit through a supraorbital notch in 59 of 100 skull sides and via a foramen in 41 of 100 sides.” I am afraid that Janis et al. may have confused the supraorbital foramen and the supratrochlear foramen. Andersen et al. noted that the supratrochlear nerve usually entered the subcutaneous tissue by exiting the orbit at its upper medial corner, and no foramen or notch was found at the exit site.2 If Janis et al. can provide a picture of the supratrochlear foramen containing a supratrochlear nerve in dissection, which I believe they have, it will be very valuable to anatomists. Janis et al. mentioned that the nerve entrance into the corrugator was found to be at a mean distance of 18.76 ± 2.94 mm lateral to the midline. The location of the exit of the supratrochlear nerve from the corrugator/entrance into the superficial plane was seen to be at a mean distance of 19.62 ± 2.94 mm lateral to the midline.1 Janis et al., in the conclusion, insisted that extension of this myotomy to within 1.8 cm of the midline would likely ensure complete decompression.1 For the location of the supratrochlear nerve, however, Andersen et al.2 already measured the most medial branch of the supratrochlear nerve, which was located between 8 and 30 mm from the midline along the supraorbital margin, and the most lateral branch, located between 6 and 38 mm from the supraorbital notch. If Janis et al. can provide the distance from the midline to the supratrochlear nerve, it will be very valuable to compare their data with the data from Andersen et al. DOI: 10.1097/PRS.0b013e3182a4c42f
Kun Hwang, M.D., Ph.D. Department of Plastic Surgery Inha University School of Medicine 7-206 Sinheung-dong Jung-gu, 400–711, Incheon, Korea [email protected]
Reply: Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches Sir:
We thank Dr. Hwang for his attentiveness to our article, “Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches.”1 We also confess a mild degree of envy at his deep knowledge of supraorbital anatomy and obvious familiarity with the relevant literature. His letter makes a number of good points which we will discuss further. We appreciate Dr. Hwang’s referencing the article by Andersen et al.,2 which we had overlooked. Andersen appears to have been a very early arriver to the theory of tight connective tissue bands in this region being contributors to pain in this region, and his study needs the attentive discussion that it did not receive in our article. Dr. Hwang points out that our classification is based on the assumption that there are always two branches of the supratrochlear nerve, and that this branching point is always within the retro–orbicularis oculi fat substance. Stating that there are always two branches may be oversimplifying the anatomy for the sake of creating a classification to guide clinical understanding; however, there were only a couple of instances seen where the nerve was three branches within the deep tissues along the supraorbital rim. We never saw a single branch, as Andersen et al. did. In most instances, supratrochlear nerve branches diminished into smaller and smaller branches within the muscle substances or cranial to it. In the forehead, superficial to frontalis, the nerve is often multiple branches, the lateral ones of which often connect with branches from the supraorbital nerve. As pointed out by Hwang, Andersen et al. found that the most medial supratrochlear nerve branch seen was just 8 mm from the midline. This was at the level of the supraorbital rim; at its entrance to the corrugator, we found that it entered at a mean distance of 18 mm from the midline, with a range of 11.5
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES 1. Janis JE, Hatef DA, Hagan R, et al. Anatomy of the supratrochlear nerve: Implications for the surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;131:743–750. 2. Andersen NB, Bovim G, Sjaastad O. The frontotemporal peripheral nerves: Topographic variations of the supraorbital, supratrochlear and auriculotemporal nerves and their possible clinical significance. Surg Radiol Anat. 2001;23:97–104. 3. Miller TA, Rudkin G, Honig M, Elahi M, Adams J. Lateral subcutaneous brow lift and interbrow muscle resection: Clinical experience and anatomic studies. Plast Reconstr Surg. 2000;105:1120–1127; discussion 1128.
Fig. 1. The supratrochlear nerve is shown exiting through a true foramen.
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Michael S. Gart, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Northwestern Memorial Hospital Chicago, Ill. Jason H. Ko, M.D. Department of Surgery Division of Plastic Surgery University of Washington Seattle, Wash. Thomas A. Mustoe, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Northwestern Memorial Hospital Chicago, Ill. Correspondence to Dr. Mustoe Division of Plastic and Reconstructive Surgery Northwestern University Feinberg School of Medicine 675 North St. Clair Street Galter Suite 19-250 Chicago, Ill. 60611 [email protected]
DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication. This research received no specific grant from any funding agency in the public, private, or not-for-profit sectors. REFERENCES 1. Gart MS, Ko JH, Heyer KS, Mustoe TA. Breast implant procedures under conscious sedation: A 6-year experience in 461 consecutive patients. Plast Reconstr Surg. 2013;131:1169–1178. 2. Hasen KV, Samartzis D, Casas LA, Mustoe TA. An outcome study comparing intravenous sedation with midazolam/ fentanyl (conscious sedation) versus propofol infusion (deep sedation) for aesthetic surgery. Plast Reconstr Surg. 2003;112:1683–1689; discussion 1690.
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3. Byun MY, Fine NA, Lee JY, Mustoe TA. The clinical outcome of abdominoplasty performed under conscious sedation: Increased use of fentanyl correlated with longer stay in outpatient unit. Plast Reconstr Surg. 1999;103:1260–1266. 4. Marcus JR, Few JW, Chao JD, Fine NA, Mustoe TA. The prevention of emesis in plastic surgery: A randomized, prospective study. Plast Reconstr Surg. 2002;109:2487–2494.
Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches Sir: n their article “Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches,” Janis et al.1 dissected 50 fresh hemifaces and stated that the supratrochlear nerve generally bifurcates within the retro–orbicularis oculi fat pad. They classified the nerve into three types according to the relationship with the corrugator muscle: type I (24 hemifaces, 84 percent), where the nerve branches enter the muscle and wind their way more superficially through the muscle to exit into the plane of the frontalis at its cranial border; type II (two hemifaces, 4 percent), where one branch runs intramuscularly and the other branch runs deep to the muscle at all times; and type III (six hemifaces, 12 percent), where both branches remain deep into the corrugator at all times and then become more superficial at its cranial border. These findings seem to be very interesting and are useful information for clinical application. However, it is unclear what supratrochlear nerve “generally bifurcates” means within the retro–orbicularis oculi fat pad. Janis et al. classified the pattern of the supratrochlear nerve on the assumption that it has two branches. According to a previous article that Janis et al. did not cite, Andersen et al.2 dissected 20 hemifaces and found that in five (25 percent) of 20 cases, the supratrochlear nerve innervated the most medial part of the forehead by a single branch only, but consisted of two or three branches in the remaining 15 cases. In six cases (30 percen), the nerve had already split into branches at its exit from the orbit, while the remaining nine nerves entered the subcutaneous tissue as separate branches at different locations (45 percent). Although there were fewer dissected cadavers in Andersen et al.’s article, it is likely that the supratrochlear nerve can have a single branch or more than two branches. With regard to the presence of a supratrochlear foramen, Janis et al. state, “In nine facial halves (18.0 percent), there was a true bony foramen (for the supratrochlear nerve). When present, this foramen was found at 4 ± 0.4 mm cranial to the orbital rim.” In the Discussion, they cited Miller et al.’s study,3 stating, “the supraorbital foramen was found to be present only 2 percent of the time as a true foramen compared with 18 percent of the time in our study.” Miller et al. dissected 10 cadavers and observed an additional 50 skulls.3 They stated, “In none of our dissections did the supratrochlear nerve exit from a foramen,
I
Volume 132, Number 5 • Letters as is commonly represented. In only one of the skulls of the 50 examined could a foramen of any size be identified in the general vicinity, and this was less than 0.5 mm in diameter.” For the supraorbital nerve, Miller et al. described, “The supraorbital nerve was found to exit the orbit through a supraorbital notch in 59 of 100 skull sides and via a foramen in 41 of 100 sides.” I am afraid that Janis et al. may have confused the supraorbital foramen and the supratrochlear foramen. Andersen et al. noted that the supratrochlear nerve usually entered the subcutaneous tissue by exiting the orbit at its upper medial corner, and no foramen or notch was found at the exit site.2 If Janis et al. can provide a picture of the supratrochlear foramen containing a supratrochlear nerve in dissection, which I believe they have, it will be very valuable to anatomists. Janis et al. mentioned that the nerve entrance into the corrugator was found to be at a mean distance of 18.76 ± 2.94 mm lateral to the midline. The location of the exit of the supratrochlear nerve from the corrugator/entrance into the superficial plane was seen to be at a mean distance of 19.62 ± 2.94 mm lateral to the midline.1 Janis et al., in the conclusion, insisted that extension of this myotomy to within 1.8 cm of the midline would likely ensure complete decompression.1 For the location of the supratrochlear nerve, however, Andersen et al.2 already measured the most medial branch of the supratrochlear nerve, which was located between 8 and 30 mm from the midline along the supraorbital margin, and the most lateral branch, located between 6 and 38 mm from the supraorbital notch. If Janis et al. can provide the distance from the midline to the supratrochlear nerve, it will be very valuable to compare their data with the data from Andersen et al. DOI: 10.1097/PRS.0b013e3182a4c42f
Kun Hwang, M.D., Ph.D. Department of Plastic Surgery Inha University School of Medicine 7-206 Sinheung-dong Jung-gu, 400–711, Incheon, Korea [email protected]
Reply: Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches Sir:
We thank Dr. Hwang for his attentiveness to our article, “Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches.”1 We also confess a mild degree of envy at his deep knowledge of supraorbital anatomy and obvious familiarity with the relevant literature. His letter makes a number of good points which we will discuss further. We appreciate Dr. Hwang’s referencing the article by Andersen et al.,2 which we had overlooked. Andersen appears to have been a very early arriver to the theory of tight connective tissue bands in this region being contributors to pain in this region, and his study needs the attentive discussion that it did not receive in our article. Dr. Hwang points out that our classification is based on the assumption that there are always two branches of the supratrochlear nerve, and that this branching point is always within the retro–orbicularis oculi fat substance. Stating that there are always two branches may be oversimplifying the anatomy for the sake of creating a classification to guide clinical understanding; however, there were only a couple of instances seen where the nerve was three branches within the deep tissues along the supraorbital rim. We never saw a single branch, as Andersen et al. did. In most instances, supratrochlear nerve branches diminished into smaller and smaller branches within the muscle substances or cranial to it. In the forehead, superficial to frontalis, the nerve is often multiple branches, the lateral ones of which often connect with branches from the supraorbital nerve. As pointed out by Hwang, Andersen et al. found that the most medial supratrochlear nerve branch seen was just 8 mm from the midline. This was at the level of the supraorbital rim; at its entrance to the corrugator, we found that it entered at a mean distance of 18 mm from the midline, with a range of 11.5
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES 1. Janis JE, Hatef DA, Hagan R, et al. Anatomy of the supratrochlear nerve: Implications for the surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;131:743–750. 2. Andersen NB, Bovim G, Sjaastad O. The frontotemporal peripheral nerves: Topographic variations of the supraorbital, supratrochlear and auriculotemporal nerves and their possible clinical significance. Surg Radiol Anat. 2001;23:97–104. 3. Miller TA, Rudkin G, Honig M, Elahi M, Adams J. Lateral subcutaneous brow lift and interbrow muscle resection: Clinical experience and anatomic studies. Plast Reconstr Surg. 2000;105:1120–1127; discussion 1128.
Fig. 1. The supratrochlear nerve is shown exiting through a true foramen.
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