Decompression-Avulsion of the Auriculotemporal Nerve for Treatment of Migraines and Chronic Headaches

The Positive and Negative Predictive Value of Targeted Diagnostic Botox Injection in Nerve Decompression Migraine Surgery

BACKGROUND

Nerve decompression surgery is an effective treatment modality for patients who experience migraines. Botulinum toxin type A (Botox) injections have been traditionally used as a method to identify trigger sites; however, there is a paucity in data regarding its diagnostic efficacy. The goal of this study was to assess the diagnostic capacity of Botox in successfully identifying migraine trigger sites and predicting surgical success.

METHODS

A sensitivity analysis was performed on all patients receiving Botox for migraine trigger site localization followed by a surgical decompression of affected peripheral nerves. Positive and negative predictive values were calculated.

RESULTS

A total of 40 patients met our inclusion criteria and underwent targeted diagnostic Botox injection followed by a peripheral nerve deactivation surgery with at least 3 months' follow-up. Patients with successful Botox injections (defined as at least 50% improvement in Migraine Headache Index scores after injection) had significantly higher average reduction in migraine intensity (56.7% versus 25.8%; P = 0.020), frequency (78.1% versus 46.8%; P = 0.018), and Migraine Headache Index (89.7% versus 49.2%; P = 0.016) postsurgical deactivation. Sensitivity analysis shows that the use of Botox injection as a diagnostic modality for migraine headaches has a sensitivity of 56.7% and a specificity of 80.0%. The positive predictive value is 89.5% and the negative predictive value is 38.1%.

CONCLUSIONS

Diagnostic targeted Botox injections have a very high positive predictive value. It is therefore a useful diagnostic modality that can help identify migraine trigger sites and improve preoperative patient selection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Temporal surgery for chronic migraine treatment: A minimally-invasive perspective

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In this paper, we describe our mini-invasive approach for the deactivation of the auriculotemporal nerve in migraine surgery.

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After a mean follow-up of 21 months (range, 3–67 months), patients complaining for temporal MH had 83% positive surgical outcome (50% complete MH elimination, 33% significant improvement).

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Only rare minor complications are usually reported (eg, oedema, paresthesia hematoma/ecchymosis, and numbness).

The Great Auricular Nerve Trigger Site: Anatomy, Compression Point Topography, and Treatment Options for Headache Pain

BACKGROUND

Peripheral nerve decompression surgery can effectively address headache pain caused by compression of peripheral nerves of the head and neck. Despite decompression of known trigger sites, there are a subset of patients with trigger sites centered over the postauricular area coursing. The authors hypothesize that these patients experience primary or residual pain caused by compression of the great auricular nerve.

METHODS

Anatomical dissections were carried out on 16 formalin-fixed cadaveric heads. Possible points of compression along fascia, muscle, and parotid gland were identified. Ultrasound technology was used to confirm these anatomical findings in a living volunteer.

RESULTS

The authors' findings demonstrate that the possible points of compression for the great auricular nerve are at Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle in the dense connective tissue before entry into the parotid gland (point 2), and within its intraparotid course (point 3). The mean topographic measurements were as follows: Erb's point to the mastoid process at 7.32 cm/7.35 (right/left), Erb's point to the angle of the mandible at 6.04 cm/5.89 cm (right/left), and the posterior aspect of the sternocleidomastoid muscle to the mastoid process at 3.88 cm/4.43 cm (right/left). All three possible points of compression could be identified using ultrasound.

CONCLUSIONS

This study identified three possible points of compression of the great auricular nerve that could be decompressed with peripheral nerve decompression surgery: Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle (point 2), and within its intraparotid course (point 3).

Clinical Effectiveness of Peripheral Nerve Blocks for Diagnosis of Migraine Trigger Points

BACKGROUND

With a 13 percent global prevalence, migraine headaches are the most commonly diagnosed neurologic disorder, and are a top five cause of visits to the emergency room. Surgical techniques, such as decompression and/or ablation of neurovasculature, have shown to provide relief. Popular diagnostic modalities to identify trigger loci include handheld Doppler examinations and botulinum toxin injection. This article aims to establish the positive predictive value of peripheral nerve blocks for identifying therapeutic surgical targets for migraine headache surgery.

METHODS

Electronic medical records of 36 patients were analyzed retrospectively. Patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified migraine headache trigger sites. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was performed using paired t tests, and positive-predictive value calculations were performed on subgroups.

RESULTS

The preoperative Migraine Headache Index of patients with positive blocks was 152.71, versus 34.26 postoperatively (p < 0.001). Each index component also decreased significantly: frequency (22.11 versus 15.06 migraine headaches per month; p < 0.001), intensity (7.43 versus 4.12; p < 0.001), and duration (0.93 versus 0.55 days; p < 0.001). The positive-predictive value of diagnostic peripheral nerve blocks in identifying a migraine headache trigger site responsive to surgical intervention was calculated to be 0.89 (95 percent CI, 1 to 0.74).

CONCLUSIONS

To the authors' knowledge, this is the first study to investigate the positive-predictive value of peripheral nerve blocks as used in the diagnostic workup of patients with chronic migraine headaches. Peripheral nerve blocks serve as a reliable clinical tool in mapping migraine trigger sites for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Associations between Zygoma Fracture and Post-Traumatic Headache: A Study among Taiwanese Population

Few studies have discussed the development of post-traumatic headache (PTH) after zygoma fracture. This research aimed to examine the association between zygoma fracture and PTH and its other associated factors. A total of 3043 patients with zygoma fracture and 3043 patients with non-fracture were included in this analysis. They were matched to a non-fracture cohort from the National Health Insurance database according to age, sex, and index year. The incidence of PTH and its association with zygoma fracture were assessed. The zygoma fracture cohort had a significantly higher cumulative incidence of PTH than the non-fracture cohort in a 10-year follow-up. The confounding risk factors of PTH included zygoma fracture, female sex, and comorbidities, including obesity and depression. Female patients under 40 years old who had zygoma fractures had a higher incidence of PTH than the non-fracture group. Moreover, patients with zygoma fractures commonly developed PTH within three months after injury. Female patients under 40 years old with precedent zygoma fractures had a higher incidence rate of PTH than those without fractures. Moreover, patients with zygoma fractures commonly developed PTH within three months after injury. Nevertheless, before widely applying our results, a prospective study must be conducted to verify the risk factors found in this study.

Occipital Neuralgia: Advances in the Operative Management

Background

Occipital neuralgia (ON) is a primary headache disorder characterized by sharp, shooting, or electric shock-like pain in the distribution of the greater, lesser, or third occipital nerves.

Aim

To review the existing literature on the management of ON and to describe our technique of an endoscopic-assisted approach to decompress the GON proximally in areas of fibrous and muscular compression, as well as distally by thorough decompression of the occipital artery from the nerve.

Methods

Relevant literature on the medical and surgical management of ON was reviewed. Literature on the anatomical relationships of occipital nerves and their clinical relevance were also reviewed.

Results

While initial treatment of ON is conservative, peripheral nerve blocks and many surgical management approaches are available for patients with pain refractory to the medical treatment. These include greater occipital nerve blocks, occipital nerve stimulation, Botulinum toxin injections locally, pulsed radiofrequency ablation, cryoneuroablation, C-2 ganglionectomy, and endoscopic-assisted ON decompression.

Conclusion

Patients of ON refractory to medical management can be benefitted by surgical approaches and occipital nerve blocks. Endoscopic-assisted ON decompression provides one such approach for the patients with vascular, fibrous or muscular compressions of occipital nerves resulting in intractable ON.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes.

SUMMARY

Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

Trigger areas nerve decompression for refractory chronic migraine

BACKGROUND

Chronic migraine refractory to medical treatment represents a common debilitating primary neurovascular disorder associated with great disability, high financial costs, reduced rates of productivity and impaired health-related quality of life.

OBJECTIVE

To demonstrate the feasibility of scalp (trigger areas) nerve decompression as a treatment alternative in the management of refractory CM patients METHODS: From January 2005 to January 2020, we retrospectively collected data of 154 patients diagnosed with chronic migraine that underwent trigger site nerve decompression. These trigger areas were divided according the nerve compromise as frontal (supraorbital nerve), temporal (auriculotemporal nerve), occipital (greater occipital nerve). Following extensive clinical evaluation, the surgical treatment was performed after under local anesthesia and required the release of the affected nerve from surrounding connective tissue adhesions, and vascular conflicts.

RESULTS

Of the total amount of patients, 91 (59.09%) patients underwent auriculotemporal nerve decompression, 27 (13.63%) cases supraorbital nerve decompression, 15 (9.74%) patients greater occipital nerve decompression, and the remaining 21 (13.63%) patients had more than one procedure of nerve decompression. At 1-year follow or latest follow-up, 96 (62.2%) patients were considered as cured, 29 cases (18.83%) reported improvement of their symptoms, 21 (13.64%) patients considered only a partial symptomatic remission and 5 (3.25%) patients reported no change or failed surgical treatment.

CONCLUSION

Nerve decompression of trigger site areas (frontal, temporal, occipital) by removal of tissue, muscles and vessels in patients with medically refractory CM is a feasible alternative treatment modality with a high success of up to 80.5.

Risk of Subsequent Migraines in Facial Fracture Patients: A Population-Based Cohort Study

Background: Limited studies have discussed the association between facial fractures and subsequent migraines. In this study, we examined this association and the effect of facial fracture and surgery on the development of migraines. Methods: We selected 5034 patients with facial fractures and a matched cohort of 20,136 patients without facial fractures or facial-associated surgery with a history of migraine from the National Health Insurance database. Risk factors included age, gender, occupation (white-collar, blue-collar, and others), and comorbidities. Patients were frequency matched by age, gender, and index year. The incidence of migraine and the association between migraine development and facial surgery were identified by facial fracture location stratification. Results: The incidence of migraines in the facial fracture cohort was 1.37-fold higher when compared with the comparison cohort (6.47 vs. 4.73 per 1000 person-years). There was a 1.31-fold risk of migraines in the adjusted hazard model and a 1.30-fold risk of migraines in the subdistribution hazard model (95% confidence interval [CI], 1.12-1.52 and 1.12-1.51, respectively). Malar/maxillary and nasal fractures showed 1.48- and 1.29-fold risks of migraines in the adjusted hazard model and subdistribution hazard model (95% CI, 1.16-1.89 and 1.05-1.59, respectively). There were no significant differences in migraine occurrence among patients who underwent surgery. Conclusions: Our findings indicated that malar/maxillary and nasal fractures were associated with a subsequent risk of migraines. There were no significant differences in migraine occurrence among patients who underwent surgery. Because of the retrospective nature of this study, further studies are warranted.

Patient Pain Sketches Can Predict Surgical Outcomes in Trigger-Site Deactivation Surgery for Headaches

BACKGROUND

Patient selection for headache surgery is an important variable to ensure successful outcomes. In the authors' experience, a valuable method to visualize pain/trigger sites is to ask patients to draw their pain. The authors have found that there are pathognomonic pain patterns for each site, and typically do not operate on patients with atypical pain sketches, as they believe such patients are poor surgical candidates. However, a small subset of these atypical patients undergo surgery based on other strong clinical findings. In this study, the authors attempt to quantify this clinical experience.

METHODS

Patients were prospectively enrolled and completed pain sketches at screening. One hundred six diagrams were analyzed/categorized by two independent, blinded reviewers as follows: (1) typical (pain over nerve distribution, expected radiation); (2) intermediate (pain over nerve distribution, atypical radiation); or (3) atypical (pain outside of normal nerve distribution, atypical radiation). Preoperative and postoperative Migraine Headache Index was compared between subgroups using unpaired t tests.

RESULTS

Migraine Headache Index improvement was 73 ± 38 percent in the typical group, 78 ± 30 percent in the intermediate group, and 30 ± 40 percent in the atypical group. There was a significant difference in Migraine Headache Index between the typical and atypical groups (p = 0.03) and between the intermediate and atypical groups (p < 0.01). The chance of achieving Migraine Headache Index improvement greater than 30 percent in the atypical group was 20 percent.

CONCLUSIONS

Patient pain sketches classified as atypical (facial pain, atypical pain point origin, diffuse pain) can predict poor outcomes in headache surgery. As the authors continue to develop patient selection criteria for headache surgery, patient sketches should be considered as an effective, cheap, and simple-to-interpret tool for selecting candidates for surgery.

A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy

BACKGROUND

Recent clinical experience with migraine surgery has demonstrated both the safety and the efficacy of operative decompression of the peripheral nerves in the face, head, and neck for the alleviation of migraine symptoms. Because of the perceived novelty of these procedures, and the paranoia surrounding a theoretical loss of clinical territory, neurologists have condemned the field of migraine surgery. The Patient Safety Subcommittee of the American Society of Plastic Surgeons ventured to investigate the published safety track record of migraine surgery in the existing body of literature.

METHODS

A comprehensive review of the relevant published literature was performed. The relevant databases and literature libraries were reviewed from the date of their inception through early 2018. These articles were reviewed and their findings analyzed.

RESULTS

Thirty-nine published articles were found that demonstrated a substantial, extensively replicated body of data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger-site surgery.

CONCLUSIONS

Migraine surgery is a valid method of treatment for migraine sufferers when performed by experienced plastic surgeons following a methodical protocol. These operations are associated with a high level of safety. The safety and efficacy of migraine surgery should be recognized by plastic surgeons, insurance companies, and the neurology societies.

Site V Surgery for Temporal Migraine Headaches

Background:

Auriculotemporal nerve is demonstrated to contribute to migraine pain in temporal area. In particular, its relationship with the superficial temporal artery in the soft tissues superficial to the temporal parietal fascia has attracted researchers’ attention for many decades. The objective of this review was to explore whether site V nerve surgical decompression is effective for pain relief in temporal area.

Methods:

A literature search, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was conducted to evaluate the surgical treatment of auriculotemporal migraine. Inclusion was based on studies written in English, published between 2000 and February 2020, containing a diagnosis of migraine in compliance with the classification of the International Headache Society. The treatment must consist of surgical procedures involving the auriculotemporal nerve and/or arteries in site V, with outcome data available for at least 3 months.

Results:

Three hundred twenty-four records were identified after duplicates were removed, 31 full-text articles were assessed for eligibility, and 2 records were selected for inclusion. A total of 77 patients were included in the review. A direct approach at the anatomical site identified with careful physical examination and confirmed with a handheld Doppler probe is generally performed under local anesthesia. Blunt dissection to the superficial temporal fascia to expose the auriculotemporal nerve and the superficial temporal artery is followed by artery cauterization/ligament and eventual nerve transection/avulsion. Site V surgery results in a success rate from 79% to 97%.

Conclusions:

Despite the recent advances in extracranial trigger site surgery and a success rate (>50% improvement) from 79% to 97%, site V decompression is still poorly described. Elaborate randomized trials are needed with accurate reporting of patient selection, surgical procedure, adverse events, recurrencies or appearance of new trigger points, quality of life outcome, and longer follow-up times.

In-Depth Look at the Anatomical Relationship of the Lesser Occipital Nerve, Great Auricular Nerve, and Spinal Accessory Nerve and Their Implication in Safety of Operations in the Posterior Triangle of the Neck

BACKGROUND

Migraine surgery is an increasingly popular treatment option for migraine patients. The lesser occipital nerve is a common trigger point for headache abnormalities, but there is a paucity of research regarding the lesser occipital nerve and its intimate association with the spinal accessory nerve.

METHODS

Six cadaver necks were dissected. The lesser occipital, great auricular, and spinal accessory nerves were identified and systematically measured and recorded. These landmarks included the longitudinal axis (vertical line drawn in the posterior), the horizontal axis (defined as a line between the most anterosuperior points of the external auditory canals) and the earlobe. Mean distances and standard deviations were calculated to delineate the relationship between the spinal accessory, lesser occipital, and great auricular nerves.

RESULTS

The point of emergence of the spinal accessory nerve was determined to be 7.17 ± 1.15 cm lateral to the y axis and 7.77 ± 1.10 caudal to the x axis. The lesser occipital nerve emerges 7.5 ± 1.31 cm lateral to the y axis and 8.47 ± 1.11 cm caudal to the x axis. The great auricular nerve emerges 8.33 ± 1.31 cm lateral to the y axis and 9.4 ±1.07 cm caudal to the x axis. The decussation of the spinal accessory and the lesser occipital nerves was found to be 7.70 ± 1.16 cm caudal to the x axis and 7.17 ± 1.15 lateral to the y axis.

CONCLUSION

Understanding the close relationship between the lesser occipital nerve and spinal accessory nerve in the posterior, lateral neck area is crucial for a safer approach to occipital migraine headaches, occipital neuralgia, and new daily persistent headaches and other reconstructive or cosmetic operations.

Migraine Surgery

Supplemental Digital Content is available in the text.

This article is a practical and technical guide for plastic surgeons interested in or practicing migraine surgery. It discusses the goals of migraine surgery including selection of appropriate candidates (screening form contained), pertinent anatomy, and surgical techniques with text summary, intraoperative photographs, and videos. In addition, pearls and pitfalls, the most common complications, and current procedural terminology (CPT) coding are detailed.

Surgical Treatment of Migraine Headache: Back to the Future

Understanding the history and evolution of ideas is key to developing an understanding of complex phenomena and is the foundation for surgical innovation. This historical review on migraine surgery takes us back to the beginnings of interventional management for migraine centuries ago, and reflects on present practices to highlight how far we have come. From Al-Zahrawi and Ambroise Paré to Bahman Guyuron, two common themes of the past and present have emerged in the treatment of migraine headache. Extracranial treatment of both nerves and vessels is being performed and analyzed, with no consensus among current practitioners as to which structure is involved. Knowledge of past theories and new insights will help guide our efforts in the future. One thing is clear: Where we are going, there are no roads. At least not yet.

Surgical Therapy of Temporal Triggered Migraine Headache

Background

The auriculotemporal and zygomaticotemporal nerves are the 2 primary trigger points in the temporal area of migraine headache. Different surgical approaches are described in literature, either open or endoscopic ones.

Methods

We described and delineated the currently adopted strategies to treat temporal trigger points in migraine headache. Furthermore, we reported our personal experience in the field.

Results

Regardless of the type of approach, outcomes observed were similar and ranged from 89% to 67% elimination / >50% reduction rates. All procedures are minimally invasive and only minor complications are reported, with an incidence ranging from 1% to 5%.

Conclusions

Just like upper limb compressive neuropathies, migraine headache is believed to be caused by chronic compression of peripheral nerves (ie, the terminal branches of trigeminal nerve) caused by surrounding structures (eg, muscles, vessels, and fascial bands) the removal of which eventually results in improvement or elimination of migraine attacks. Particular attention should be paid to the close nerve/artery relationship often described in anatomical studies and clinical reports.

MR Neurography of Greater Occipital Nerve Neuropathy: Initial Experience in Patients with Migraine

BACKGROUND AND PURPOSE

MR imaging of peripheral nerves (MR neurography) allows improved assessment of nerve anatomy and pathology. The objective of this study was to evaluate patients with unilateral occipital neuralgia using MR neurography and to assess the differences in greater occipital nerve signal and size between the symptomatic and asymptomatic sides.

MATERIALS AND METHODS

In this case-control evaluation using MR neurography, bilateral greater occipital nerve caliber, signal intensity, signal-to-noise ratios, and contrast-to-noise ratios were determined by 2 observers.

RESULTS

Among 18 subjects with unilateral occipital migraines, the average greater occipital nerve diameter for the symptomatic side was significantly greater at 1.77 ± 0.4 mm than for the asymptomatic side at 1.29 ± 0.25 mm (P = .001). The difference in nerve signal intensity between the symptomatic and asymptomatic sides was statistically significant at 269.06 ± 170.93 and 222.44 ± 170.46, respectively (P = .043). The signal-to-noise ratios on the symptomatic side were higher at 15.79 ± 4.59 compared with the asymptomatic nerve at 14.02 ± 5.23 (P = .009). Contrast-to-noise ratios were significantly higher on the symptomatic side than on the asymptomatic side at 2.57 ± 4.89 and -1.26 ± 5.02, respectively (P = .004). Intraobserver performance was good to excellent (intraclass coefficient correlation, 0.68-0.93), and interobserver performance was fair to excellent (intraclass coefficient correlation, 0.54-0.81).

CONCLUSIONS

MR neurography can be reliably used for the diagnosis of greater occipital nerve neuropathy in patients with unilateral occipital migraines with a good correlation of imaging findings to the clinical presentation.

Anatomical Regional Targeted (ART) BOTOX Injection Technique: A Novel Paradigm for Migraines and Chronic Headaches

Supplemental Digital Content is available in the text.

Migraine headaches are a debilitating disease that causes significant socioeconomic problems. One of the speculated etiologies of the generation of migraines is peripheral nerve irritation at different trigger points. The use of Onabotulinum toxin A (BOTOX), although initially a novel approach, has now been determined to be a valid treatment for chronic headaches and migraines as described in the Phase III Research Evaluating Migraine Prophylaxis Therapy trials that prompted the approval by the Food and Drug Administration for treatment of chronic migraines. The injection paradigm established by this trial was one of a broad injection pattern across large muscle groups that did not always correspond to the anatomical locations of nerves. The senior author developed the Anatomical Regional Targeted BOTOX injection paradigm as an alternative to the current injection model. This technique targets both the anatomical location of nerves known to have causal effects with migraines and the region where the pain localizes, to provide relief across a wide distribution of the peripheral nerve. This article serves as a guide to the Anatomical Regional Targeted injection technique, which, to our knowledge, is the first comprehensive BOTOX injection paradigm described in the literature for treatment of migraines that targets nerves and nerve areas rather than purely muscle groups. This technique is based on the most up-to-date anatomical and scientific studies and large-volume migraine surgery experience.

Anatomical study of the superficial temporal branches of the auriculotemporal nerve: Application to surgery and other invasive treatments to the temporal region

BACKGROUND AND AIM

The auriculotemporal nerve (ATN) is one of the branches of the mandibular division of the trigeminal nerve, which gives rise to many branches to the retromandibular and temporal regions. Of these, the superficial temporal branch can occasionally be the cause of migraine headaches and auriculotemporal neuralgia. The purpose of this study was to elucidate the anatomy of the superficial temporal branch, which has never been described in detail.

METHODS

A total of 14 sides of cadaveric heads were used for this study. The number of superficial temporal branch was counted, and the horizontal and vertical distances from the middle of the tragus to the branching point were measured.

RESULTS

Three of 14 sides had two main trunks, and 11 sides had one main trunk. Each of the duplicated ATN had already branches into two main trunks as they left the retromandibular space. The number of superficial temporal branches ranged from two to seven. The vertical and horizontal distances from the middle of the tragus to the branching point of the superficial temporal branch ranged from 6.19 to 25.65 mm and from 3.45 to 11.88 mm, respectively. The communicating branches occasionally formed a loop or so-called "ansa," and a double ansa was identified in one case.

CONCLUSIONS

These data can provide surgeons a better view of the course of these distant branches, so that skin incisions can be better planned.