Topography of the supraorbital nerve with reference to the lacrimal caruncle: danger zone for direct browplasty.

PURPOSE: To elucidate the course of the supraorbital nerve (SON) with reference to the lacrimal caruncle in order to facilitate safer direct browplasty by preventing nerve injury.

METHODS: Thirty-four hemifaces from 18 embalmed Korean cadavers were dissected. A vertical line through the upmost point of the lacrimal caruncle and a horizontal line through the supraorbital margin were used as the horizontal and vertical reference positions, respectively. The course of the SON in the frontal view and the point at which it pierced the overlaying musculature were examined.

RESULTS: The SON divides into a superficial branch and a deep branch just after exiting the orbit. In all cases, the deep SON remains in the subgaleal plane deep to the corrugator and frontalis muscles. The superficial SON travels under the corrugator muscle dividing into three branches (medial, intermediate and lateral) and pierced the frontalis muscle at 19-32 mm above the supraorbital margin. However, in 11 cases (32%) the medial branch of the superficial SON pierced the lower portion of the corrugator muscle at 3.6 mm above the supraorbital margin and ran in front of the muscle along with the vertical line through the upmost point of the lacrimal caruncle.

CONCLUSIONS: One-third of the medial branch of the superficial SON without corrugator muscle protection is vulnerable to iatrogenic injury during direct browplasty. Therefore, the oculofacial surgeon must bring the dissection plane of the forehead tissue more superficially around the vertical line through the upmost point of the lacrimal caruncle in order to avoid nerve injury.