The Client

Our client Arthur Formanek, MD was from Harvard University, Cambridge, Massachusetts, USA. Arthur Formanek was authoring a text book chapter on scalp block regional anaesthetic technique.

The Brief

Arthur Formanek, MD was interested in commissioning diagrams to illustrate a scalp block regional anaesthetic technique for a textbook chapter, The illustration, or series of illustrations, would depict the head in three profiles: front, side, and rear. We were sent the text and from this we designed illustrations to accompany the text. The text accompanying the illustration was a variation of:

“The greater occipital nerve is located by palpating the occipital artery in the midpoint between the mastoid process and occipital protuberance, and an ultrasound may be used to aid in locating the occipital artery, especially if it cannot be easily palpated. Since this location also establishes once of the landmarks for identifying the lesser occipital nerve, good localization is important. Inject 4-5 mL of local anesthetic medial to the artery.

The lesser occipital nerve is blocked by injecting 4-5mL of local anesthetic approximately 2.5 cm lateral to the greater occipital block along the nuchal line. To block the auriculotemporal nerve, insert the needle behind the superior temporal artery 1 cm cephalad to the level of the tragus of the ear. Advance the needle through the temporalis fascia and inject 2-3mL of local anesthetic above and below the fascia as you withdraw the needle.

For the zygomaticotemporal nerve block, find the groove along the zygomatic arch lateral to the lateral canthus of the eye. Advance the needle until a pop or resistance change is noted as the temporalis fascia is pierced. The zygomaticotemporal nerve ramifies as it pierces temporalis fascia, so local anesthetic should be injected above and below the fascia. Inject 1 to 2 mL as you withdraw the needle through the fascia. Palpate the supraorbital notch in the medial third of the supraorbital ridge. Advance the needle until bone is contacted, approximately 0.5 to 1 cm. Withdraw slightly and inject 2-3 mL of local anesthetic.

The supratrochlear nerve emerges from the supramedial angle of orbit and can be blocked by either by injecting above the eyebrow 1 cm medial to supraorbital or using the same injection site as supraorbital nerve and directing the needle medially and advancing 1 cm. Inject 2 to 3 mL of local anesthetic. The six nerves with relevant landmarks would need to be depicted with marks for the injection points.”