I compliment Pascal and colleagues  for an excellent use of the block of the peripheral branches of the trigeminal nerve. However, their failure rate with regard to the block of infraorbital nerve surprises me. Their technique involves percutaneously feeling the depression of the foramen and inserting the needle 1 cm inferior to the foramen and tangentially advancing it upwards to the estimated location of the foramen. I feel it is the direction of the needle that may be responsible for the lower success rate. The infraorbital nerve is directed downwards, forwards and medially as it comes out of the foramen, the needle inserted in the opposite direction (i.e. upwardly, backwardly and laterally) is more likely to meet the nerve and is often manifested by paraesthesia in the distribution of the nerve. For the needle to be directed in this manner, the skin puncture should be about ½–1 cm below and medial to the depression felt percutaneously at the site of the foramen. It is a very simple block to perform and in our centre we have a high incidence of success. Besides the use for surgery, I have used the block for providing postoperative pain relief after cleft lip surgery in paediatric patients and for injection of neurolytic drugs to treat pain of trigeminal neuralgia involving the maxillary nerve. The higher incidence of success in the block of this nerve reported with the intraoral technique [2,3] may be due to the difference in the direction of the needle.
Peripheral nerve blocks provide safe and effective regional anaesthesia not only for soft tissue surgery but for other procedures like fixation of the fractured mandible and procedures on the maxilla. For that, however, I suggest block of the trunk of the appropriate nerve as it emerges from the skull using the lateral extraoral approach. Continuous mandibular nerve block has also been described for providing pain relief in the postoperative period . The nerve blocks are a boon to many patients suffering from trigeminal neuralgia who do not have access to the advanced techniques like radiofrequency ablation or microvascular decompression and the difference in the quality of life that the neurolytic blocks make is great. I strongly suggest that these blocks should be practised for anaesthesia and analgesia more often as these are simple and safe with a very high degree of success.
1. Pascal J, Charter D, Perret D, Navez M, Auboyer C, Molliex S. Peripheral blocks of trigeminal nerve for facial soft-tissue surgery: learning from failures. Eur J Anesthesiol
2. Lynch MT, Syverud SA, Schwab RA, Jenkins JM, Edlich R. Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med
3. Hanke CW. The tumescent facial block: tumescent local anaesthesia and nerve block anaesthesia for full-face laser resurfacing. Dermatol Surg
4. Singh B, Bhardwaj V. Continuous mandibular nerve block for pain relief. A report of two cases. Can J Anesth