Ultrasound-Guided Local Anesthetic Nerve Blocks in a Forehead Flap Reconstructive Maxillofacial Procedure
Head and neck reconstructive surgery involving tissue flaps is often complex requiring the development of an individualized anesthetic plan. The following case report describes the anesthetic management of an 87-year-old man considered at high risk for postoperative delirium due to advanced age and blindness undergoing general anesthesia for resection of squamous cell carcinoma of the right side of the nose and reconstructive surgery with a scalping forehead flap. Ultrasound-guided local anesthetic maxillary and supraorbital nerve blocks were successfully used perioperatively to reduce the need for alternative analgesics associated with higher risks of complications such as postoperative nausea, vomiting, and delirium.
Surgical defect and planned soft tissue flap. Perioperative view of the resected nasal lesion and planned reconstruction with a left forehead rotational soft tissue flap.
Completed soft tissue flap. Perioperative view of the completed reconstruction with the pedicle flap sutured in place.
Ultrasound-guided maxillary nerve block via a suprazygomatic approach. Ultrasound probe placed just caudal to the zygomatic arch and a 22-G block needle inserted at the angle formed by the superior edge of the zygomatic arch and the posterior orbital rim.
Ultrasound visualization of the temporal fossa. The maxillary artery was observed in the temporal fossa, allowing avoidance of arterial injury. C, coronoid; LP, lateral plate of the pterygoid process; MT, maxillary tuberosity; MA, maxillary artery.
Supraorbital nerve block approach. Needle insertion point was slightly cranial to the supraorbital notch, which was palpable as a bony landmark. Local anesthetic injected subcutaneously.
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