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Figure.
Photograph of Transcutaneous Pin Piercing the Glabellar Skin Crease in Close Approximation of the Supratrochlear Nerve
Photograph of Transcutaneous Pin Piercing the Glabellar Skin Crease in Close Approximation of the Supratrochlear Nerve

The asterisk indicates the transcutaneous pin marking the glabellar crease. CSM indicates corrugator supercilii muscle; STN, supratrochlear nerve.

Table.  
Relationship of the Supratrochlear Nerve to the Glabellar Crease and Corrugator Supercilii
Relationship of the Supratrochlear Nerve to the Glabellar Crease and Corrugator Supercilii
1.
Langsdon  PR, Velargo  PA, Rodwell  DW  III.  Surgical manipulation of the periorbital musculature.  Clin Plast Surg. 2013;40(1):125-131.PubMedGoogle ScholarCrossref
2.
Sykes  JM.  Applied anatomy of the temporal region and forehead for injectable fillers.  J Drugs Dermatol. 2009;8(10)(suppl):s24-s27.PubMedGoogle Scholar
3.
Guyuron  B.  Endoscopic forehead rejuvenation: I. limitations, flaws, and rewards.  Plast Reconstr Surg. 2006;117(4):1121-1133.PubMedGoogle ScholarCrossref
4.
Knize  DM.  Transpalpebral approach to the corrugator supercilii and procerus muscles.  Plast Reconstr Surg. 1995;95(1):52-60.PubMedGoogle ScholarCrossref
5.
Knize  DM.  An anatomically based study of the mechanism of eyebrow ptosis.  Plast Reconstr Surg. 1996;97(7):1321-1333.PubMedGoogle ScholarCrossref
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Research Letter
Jul/Aug 2017

Cutaneous Landmarks of the Supratrochlear Nerve in Forehead Rejuvenation Surgery

Author Affiliations
  • 1Department of Otolaryngology, University at Buffalo, Buffalo, New York
JAMA Facial Plast Surg. 2017;19(4):337-338. doi:10.1001/jamafacial.2016.2258

Complete resection of the corrugator supercilii and procerus muscles has previously been advocated for forehead rejuvenation surgery.1 These procedures are complicated due to the supratrochlear nerve, which commonly runs near the fibers of the corrugator supercilii muscle (Figure). Damage to the supratrochlear nerve after forehead rejuvenation can lead to undesirable sequelae such as paresthesia and dyesthesia. The incidence of these complications may be related to the surgical approach, specific technical execution, and/or the surgeon’s experience with the technique. Familiarity with the location of the supratrochlear nerve in relation to the corrugator supercilii and procerus muscles can minimize unpredictability and allow for a more systematic approach to precise muscle removal.

The senior author postulates that the supratrochlear nerve branches demonstrate a significant investment pattern in relation to the corrugator supercilii muscle fibers and a close approximation to the overlying glabellar crease. The glabellar crease is the typical vertically oriented skin wrinkle located just medial to the brows. Although the investing topography of other peripheral points has been described, the supratrochlear nerve and its close relationship to the corrugator supercilii muscle fibers and cutaneous glabellar frown line requires further inspection.2 A comprehensive understanding of these anatomical relationships may assist surgeons of all levels of experience in obtaining successful outcomes when performing any of the surgical approaches for forehead rejuvenation.

Methods

Fifteen fresh cadaver heads (30 corrugator muscles and 30 supratrochlear nerves) were labeled at the lines corresponding to the glabellar crease. They were then dissected using a cross-shaped incision centered over the radix, with the transverse component following the eyebrow arches (Figure). The frontalis and depressor supercilii muscles were dissected off the corrugator supercilii muscle and elevated along with the skin flaps. Once the full extent of the supratrochlear nerve and the corrugator supercilii muscle were well delineated, transcutaneous pins were placed through the glabellar crease at a position approximately 1 cm superior to the superior orbital rim, and standardized measurements of nerve relationships to the glabellar crease were taken.

Results

The mean distance from the supratrochlear nerve to the glabellar crease was 0.6 mm (range, 0-3 mm). The supratrochlear nerve ran within the corrugator supercilii muscle in all 15 (100%) of specimens. There was no statistical difference seen between the right and left supratrochlear nerve relationships to the glabellar crease. All measurements were obtained using millimeters as the unit of measurement (Table).

Discussion

A lack of familiarity with the relationship of the corrugator supercilii and the supratrochlear nerve in brow lift surgery can have deleterious consequences, such as paresthesias, forehead and/or brow asymmetries, skin dimpling (particularly with animation), and recurrence of glabellar furrows and frown lines.3-5 To our knowledge, this is the largest cadaveric study looking at supratrochlear nerve anatomy and relationships. This study found the supratrochlear nerve to be consistently near the glabellar crease and symmetric bilaterally. The nerve also always ran within the fibers of the corrugator supercilii muscle, never along the superficial or deep surface. While palpation of a contracted corrugator supercilii muscle on forehead animation may provide approximate muscle dimensions in the clinical setting and should be a part of the preoperative examination, objective topographic points based on clear cutaneous landmarks may assist in identifying the location of the supratrochlear nerve. The improved understanding of this ambiguous path of the supratrochlear nerve allows for a more precise and tailored approach to corrugator supercilii muscle removal. This information can be used to implement a more systematic approach to complete corrugator supercilii muscle removal by providing a “surgical roadmap” to the surrounding structures, allowing for precise surgical identification of the supratrochlear nerve, regardless of technique used.

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Article Information

Corresponding Author: David A. Sherris, MD, Department of Otolaryngology, University at Buffalo, 1237 Delaware Ave, Buffalo, NY 14209 (dsherris@buffalo.edu).

Published Online: March 16, 2017. doi:10.1001/jamafacial.2016.2258

Author Contributions: Dr Sherris had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of data analysis. Dr Sherris was the senior author of this study.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Starkman.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Starkman.

Administrative, technical, or material support: Sherris.

Supervision: Sherris.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery Annual Meeting; October 6, 2016; Nashville, Tennessee.

References
1.
Langsdon  PR, Velargo  PA, Rodwell  DW  III.  Surgical manipulation of the periorbital musculature.  Clin Plast Surg. 2013;40(1):125-131.PubMedGoogle ScholarCrossref
2.
Sykes  JM.  Applied anatomy of the temporal region and forehead for injectable fillers.  J Drugs Dermatol. 2009;8(10)(suppl):s24-s27.PubMedGoogle Scholar
3.
Guyuron  B.  Endoscopic forehead rejuvenation: I. limitations, flaws, and rewards.  Plast Reconstr Surg. 2006;117(4):1121-1133.PubMedGoogle ScholarCrossref
4.
Knize  DM.  Transpalpebral approach to the corrugator supercilii and procerus muscles.  Plast Reconstr Surg. 1995;95(1):52-60.PubMedGoogle ScholarCrossref
5.
Knize  DM.  An anatomically based study of the mechanism of eyebrow ptosis.  Plast Reconstr Surg. 1996;97(7):1321-1333.PubMedGoogle ScholarCrossref
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