American Society of Regional Anesthesia and Pain Medicine November 2017 - 39

Figure 1: Sensory innervation of the head and neck.

Figure 2: Supraorbital and supratrochlear nerves.

involving the upper lip, nose, and maxillary teeth. Although there
are three approaches to block the infraorbital nerve (sublabial,
direct, or transnasal), we routinely use a transnasal approach,
which reduces the chance of a noticeable facial skin puncture
postoperatively.
First, the infraorbital foramen, where the infraorbital nerve is
located, is palpated by finding the groove located inferior to the
orbit rim, 3 cm from the midline of the face.4 This finger is left in
this notch both as a marker for the needle trajectory and also to
prevent the needle from entering the orbit. A 1.5-inch 25-gauge
needle is inserted through the nares and tunneled superficially
under the skin toward the infraorbital foramen, stopping at the

halfway point between the edge of the nose and the infraorbital
foramen (Figure 6). The needle is then aspirated, and 2 ml of 0.5%
bupivacaine is injected.5 The block is repeated contralaterally for
bilateral surgical procedures.
Contraindications to this procedure include neoplasms or
arteriovenous malformations involving the nasal cavity. If such
contraindications exist, we perform this block using a sublabial
approach. In this approach, the free finger is again left on the
infraorbital notch for reasons previously mentioned, and the needle
is passed starting between the gums and lips until the needle
is again positioned midway between the edge of the nose and
the infraorbital groove, where the needle is aspirated and 2 ml

American Society of Regional Anesthesia and Pain Medicine
2017

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