Jeffrey E. Janis

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

Background: This article focuses on delineation of supraorbital nerve branching patterns relative to the corrugator muscle fibers and identifies four branching patterns that help improve understanding of the local anatomy. Methods: Twenty-five fresh cadaver heads (50 corrugator supercilii muscles and 50 supraorbital nerves) were dissected and the corrugator supercilii muscles isolated. After corrugator supercilii muscle measurement points were recorded for part I of the study, the supraorbital nerve branches were then traced from their emergence points from the orbit and dissected out to the defined topographical boundaries of the muscle. Nerve branching patterns relative to the muscle fibers were analyzed, and a classification system for branching patterns relative to the muscle was created. Results: Four types of supraorbital nerve branching patterns were found. In type I (40 percent), only the deep supraorbital nerve division sent branches that coursed directly along the undersurface of the muscle. In type II (34 percent), branches emerging directly from the superficial supraorbital nerve were found in addition to the branches from the deep division. Type III (4 percent) included discrete branches from the superficial division, but none from the deep division. In type IV (22 percent), significant branching began more cephalad relative to the muscle and, therefore, displayed no specific relation to the muscle fibers. Conclusions: Contrary to previous reports, both the deep and superficial divisions of the supraorbital nerve are intimately associated with corrugator supercilii muscle fibers. Four supraorbital nerve branching patterns from these divisions were found. Potential sites of supraorbital nerve compression were identified. This more detailed anatomical information may improve the safety and accuracy of performing complete corrugator supercilii muscle resection.

Anatomy of the corrugator supercilii muscle: part I. Corrugator topography.

Background: Complete corrugator supercilii muscle resection is important for the surgical treatment of migraine headaches and may help prevent postoperative abnormalities in surgical forehead rejuvenation. Specific topographic analysis of corrugator supercilii muscle dimensions and its detailed association with the supraorbital nerve branching patterns has not been thoroughly delineated. Part I of this two-part study aims to define corrugator supercilii muscle topography with respect to external bony landmarks. Methods: Twenty-five fresh cadaver heads (50 corrugator supercilii muscles and 50 supraorbital nerves) were dissected to isolate the corrugator supercilii muscle from surrounding muscles. Standardized measurements of corrugator supercilii muscle dimensions were taken with respect to the nasion and lateral orbital rim. Results: Relative to the nasion, the most medial origin of the corrugator supercilii muscle was found at 2.9 ± 1.0 mm; the most lateral origin point, 14.0 ± 2.8 mm. The lateralmost insertion of the corrugator supercilii muscle measured 43.3 ± 2.9 mm from the nasion or 7.6 ± 2.7 mm medial to the lateral orbital rim. The most cephalic extent (apex) of the muscle was located 32.6 ± 3.1 mm cephalad to the nasion–lateral orbital rim plane and 18.0 ± 3.7 mm medial to the lateral orbital rim. There were no statistical differences noted between the right and left sides. Conclusions: The dimensions of the corrugator supercilii muscle are more extensive than previously described and can be easily delineated using fixed bony landmarks. These data may prove beneficial in performing safe, complete, and symmetric corrugator supercilii muscle resection for forehead rejuvenation and for effective decompression of the supraorbital nerve and supratrochlear nerve branches in the surgical treatment of migraine headaches.

Rhinoplasty with advancing age

Rhinoplasty in the aging patient poses a unique set of challenges to the plastic surgeon. Aging patients usually have different expectations and motivations than their younger counterparts; therefore, open communication and frank discussions are paramount to define realistic goals. Anatomically, changes in skin quality, cartilage characteristics, underlying bony framework, and the nasal airways mandate special considerations to optimize the functional and aesthetic results. This review will present a practical approach to the management of the nose in the aging patient.

The zygomaticotemporal branch of the trigeminal nerve: Part II. Anatomical variations.

Background: Musculofascial and vascular entrapments of peripheral branches of the trigeminal nerve have been thought to be trigger points for migraine headaches. Surgical decompression of these sites has led to complete resolution in some patients. The zygomaticotemporal branch of the trigeminal nerve has been shown clinically to have sites of entrapment within the temporalis. A cadaveric study was undertaken to elucidate and delineate the location of this nerves foramen and intramuscular course. Methods: The periorbital and temporal regions of 50 fresh cadaveric hemiheads were dissected. The deep temporal fascia and lateral orbital wall were exposed through open dissection. The zygomaticotemporal nerve was located and followed through the temporalis muscle to its exit from the zygomatic bone. The muscular course was documented, and the nerve foramen was measured from anatomical landmarks. Results: In exactly half of all specimens, the nerve had no intramuscular course (n = 25). In the other half, the nerve either had a brief intramuscular course (n = 11) or a long, tortuous route through the muscle (n = 14). The foramen was located at an average of 6.70 mm lateral to the lateral orbital rim and 7.88 mm cranial to the nasion-lateral orbital rim line, on the lateral wall of the zygomatic portion of the orbit. Two branches were sometimes seen. Conclusions: The zygomaticotemporal branch of the trigeminal nerve is a site for migraine genesis; surgical decompression or chemodenervation of the surrounding temporalis can aid in alleviating migraine headache symptoms. Advances in the understanding of the anatomy of this branch of the trigeminal nerve will aid in more effective surgical decompression.

Discussion: Plastic surgery chief resident clinics: The current state of affairs

I their report, “Plastic Surgery Chief Resident Clinics: The Current State of Affairs,” Neaman et al. present a summary of the survey responses from program directors and chief residents designed to characterize “chief clinics” and their importance and relevance to plastic surgery training. Chief clinics are an important aspect in addressing perceived deficiencies of plastic surgery training, especially cosmetic surgery, as shown by survey results in 2006 by Morrison et al.1 and in 2010 by Kenkel.2 These authors present some interesting data that, considered together with the prior surveys on resident cosmetic surgery education, raise several poignant topics for discussion. First, we commend the authors for obtaining representation from 85 percent of current programs—no small feat for a survey methodology that usually obtains far lower response rates than what was obtained in this study. Some of the surveys, though, were incomplete in that some questions were unanswered when returned to the authors. It would be interesting to know whether the incomplete surveys had similarities among the questions not answered. Unfortunately, the inclusion of these incomplete surveys in the study’s results somewhat confuses full reporting, potential accuracy, and completeness of the data set. It would be intriguing to see demographic data presented by geographic location of the programs. This may reveal associations or biases based on location, patient subpopulations, or even procedures performed. For instance, obesity is an epidemic across the country, but it is more prevalent in some areas of the country than in others. It is plausible that breast and body contouring, and body contouring after massive weight loss, may constitute a greater proportion of the surgical causes in some areas of the country compared with others. Furthermore, median income per capita can also influence the volume of patients seen in these clinics, particularly if they are predominantly cosmetic in nature. It would be interesting to see the survey data stratified by location and demographic factors to help define differences between different programs’ clinic experiences further, which may help explain disparities in responses reported by the survey. The authors state that they had similar response rates between cosmetic and reconstructive clinics. One important point that should be noted is that not all clinics are created equal. Specifically, the quality and quantity of cosmetic and reconstructive experiences can vary widely. This fact makes it difficult to compare these clinics against each other, especially with respect to referral patterns, fee-for-service, and procedures performed. Although the chief clinic experience, irrespective of cosmetic versus reconstructive emphasis, is still valuable, it is still difficult to interpret the data because of this fact. The reported data, although useful, could perhaps be even more beneficial if they were stratified by resident responses versus program director responses, giving more clarity in assessing results and comparing perceptions between residents and program directors. It has been shown that opinions between the two groups can vary significantly.1 For example, the impression of patient risk in this survey was reported using a combined perspective of both the residents and program directors. However, residents and program directors have very different experiences and access to objective data, and subsequently have unequal qualifications and/or perspectives to make such impressions. Perceived weaknesses in training, both from a resident perspective and a program director perspective, may also have been included in this survey, further legitimizing the need for such chief clinics. This is evident by the fact that other cos-

Hemicorporectomy: back to front

Hemicorporectomy involves amputation of the pelvis and lower extremities by disarticulation through the lumbar spine with concomitant transection of the aorta, inferior vena cava, and spinal cord, as well as creation of conduits for diversion of the urinary and fecal streams. A review of the literature reveals that the surgical technique has been relatively unchanged since 1960. The standard anterior to posterior approach is associated with significant blood loss and morbidity, likely contributing to lengthy hospital stay. Herein, we describe our back-to-front approach to hemicorporectomy, involving early division of the vertebral structures and spinal cord, pre-empting engorgement of Batsons plexus, thus minimizing blood loss. In addition, this approach greatly improves exposure of the pelvic vessels, allowing for a technically less challenging and safer procedure.

Book Review: General Reconstructive Surgery

Gregory R. D. Evans, MD Garrett A. Wirth, MD General Reconstructive Surgery. Procedures in Reconstructive Surgery Series. Philadelphia, PA: Saunders Ltd; 2008. Hardcover and DVD. ISBN-10: 0702029254 ISBN-13: 978-0702029257 ![][1] One of the most useful books on my shelf, especially as I prepared for cases in the operating room or studied for the oral American board exams, was Operative Plastic Surgery , published in 2000 by McGraw-Hill and edited by Dr. Greg Evans. That textbook was a commonsense, organized, relevant approach to many of the bread-and-butter procedures in plastic surgery. To this day, I cite it as a necessary volume to those who ask for recommendations. I recently read the follow-up text General Reconstructive Surgery , which was coedited by Drs. Evans and Wirth. This book is one of a four-volume set meant … [1]: /embed/graphic-1.gif