Dermatomes of the Face Image

Dermatome Image

 

Summary

• A dermatome represents the area of skin that provides cutaneous innervation by fibers of a specific nerve. Most of the skin on the body is innervated by spinal nerves, but the face receives cutaneous innervation from a cranial nerve (known as the trigeminal nerve). 
• The trigeminal nerve is known as the 5th cranial nerve (CN V) and is the largest cranial nerve in the body. It gives rise to 3 divisions or branches known as the ophthalmic division (V1), maxillary division (V2), and mandibular division (V3), which provide cutaneous (sensory) innervation to the skin on the face. 
• Only the mandibular division carries motor fibers, which innervate muscles of mastication.
• As it relates to skin innervation of the face and neck there is also contribution from the cervical spinal nerves (C2, C3, C4).  Note: The spinal nerve at C1 lacks any significant afferent input
  from the skin and thus is the only spinal nerve without any
  representation as a dermatome.

Ophthalmic Nerve (V1)

• Innervation of the skin includes: Forehead, scalp, upper eyelid, cornea, & dorsum of the nose.
• Cutaneous Branches of CN V1: Supraorbital n., supratrochlear n., lacrimal n., infratrochlear n., external nasal n.
• Clinical Pearls: 
• Corneal Reflex:  This nerve is tested during the “corneal reflex” which is an
  involuntary blinking of the eyes when the cornea receives either
  tactile, painful, or thermal input. The input travels down the afferent
  fibers, but it is the facial nerve (CN VII) that sends impulses down the
  efferent fibers to cause contraction of the orbicularis oculi muscle
  resulting in the blinking of the eye.
• Ophthalmic Herpes Zoster:  The V1 division is most commonly involved in a herpes virus infection involving the trigeminal nerve.  When an infection occurs along this division, vesicles can erupt along the branches of the nerve to also include involvement of the cornea of the eye. Recognizing this is clinically important as it can lead to painful corneal ulcerations and scarring. You should associate vesicles on the tip of the nose (Hutchinson’s Sign) with ophthalmic involvement due to their shared innervation.

Maxillary Nerve (V2)

The division that passes anteriorly from the trigeminal ganglion to pass through the foramen rotundum at the base of the greater wing of the sphenoid bone. 

• Innervation of the skin includes:  Lower eyelid & conjunctiva, lateral nose, anteroinferior nasal septum, cheeks, upper lip.  It also innervates the mucosa of the maxillary sinus, premolar, canine, and incisor of the maxillary teeth.
• Cutaneous branches of CN V2: Infraorbital, zygomaticofacial, zygomaticotemporal
• Clinical Pearls:
• Infraorbital Nerve Block: When repairing skin of the upper lip and/or cheek, infiltration of area around the infraorbital nerve with lidocaine can provide local anesthesia and pain relief to the patient. This is done by injecting the anesthetic in the area of the infraorbital foramen as a result of elevating the upper lip and passing the needle through the area where the gingiva and oral mucosa meet. Aspiration prior to injection at this area is necessary since blood vessels also exit the infraorbital foramen along with nerve.

Mandibular Nerve (V3)

The V3 division is the largest and exits the trigeminal ganglion inferiorly and passes through the foramen ovale. 

• Innervation of the skin includes: Lower lip, chin, anterior 2/3 of the tongue, anterior aspect of the external ear
• Motor innervation of muscles include: Of the three divisions, V3 is the only one with motor fibers.   It innervates
  the muscles of mastication (medial & lateral pyerygoid muscle, masseter muscle, temporalis muscle)
• Cutaneous branches of V3: Auriculotemporal n., buccal n., mental n.
• Clinical Pearl:
• Submental Nerve Block: Infiltration of the area of the submental foramen will provide local anesthesia to the lower lip and mucosal membrane of the lower lip when repairing lacerations to this area.  It is accomplished by injecting anesthetic in the area of the mental foramen, which can be reached by retracting the lower lip and passing a needle inferiorly between the gingiva and the oral mucosa between the premolars.

Related Content

• Anatomy: Dermatomes of the Full Body
• Anatomy: Dermatomes of the Hands
• Anatomy: Brachial Plexus

 

Editors & Reviewers

Editors:

• Anthony J. Busti, MD, PharmD, MSc, FNLA, FAHA 
• Dylan Kellogg, MD

Last Updated: January 2023

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Development of a skin temperature map for dermatomes in individuals with spinal cord injury: a cross-sectional study

Introduction

In individuals with spinal cord injury (SCI), autonomic regulation of body temperature could be impaired below the injury level, and the hypothalamus is unable to control the cutaneous blood flow. A loss of sweating capacity and vasomotor control has also been reported [1]. The skin temperature (Tsk) varies with the ambient temperature and is influenced by skin blood flow and microcirculation, presenting different temperatures in the tendons, ligaments, muscles, adipose tissue, and bones [2,3,4]. Individuals with SCI often show vascular changes such as decreased arterial diameter, capillarization, changes in the resistance of vessels, and impaired microcirculation and, consequently, blood flow [2, 3, 5,6,7,8,9,10].

One instrument that could be used to measure the Tsk is the infrared thermometer (IRT). It detects the radiation emitted by a hot surface and provides an estimate of the surface temperature [4]. Currently, it is widely used as it offers considerable advantages such as hygiene, rapid measurement, noninvasiveness, and comfort compared with other thermometers [3, 11,12,13,14].

As the Tsk of individuals with SCI is subject to change with the changes in blood flow and microcirculation, the aim of this study was to map the Tsk of individuals with SCI and compare it with that of able-bodied controls. We hypothesized that the Tsk of individuals with SCI is lower below the lesion level than individuals in the control group. The various changes that occur in blood flow in individuals with SCI, especially in the microcirculation of lower limbs, may be one of the factors that lead to decreases in Tsk in these individuals. Furthermore, clinical rehabilitation protocols might lead to increases in Tsk below the injury level due to improvements such as muscle contraction, which could increase the individual’s metabolism and quality of life.

Methods

Study design

Cross-sectional study.

Participants and setting

Forty-one male individuals with SCI were enrolled and were divided into two groups: 21 individuals with paraplegia and 20 individuals with tetraplegia; and 11 able-bodied controls were recruited. According to the International Standards for Neurological Classification of Spinal Cord Injury, the level of injury (neurological level) was classified by using ASIA impairment scale [15]; the score ranged from C4 to T12, where C4 [A (n = 7), B (n = 1)], C5 [A (n = 3), B (n = 2)], C6 [A (n = 2), B (n = 4)], C7 [A (n = 1)], T3 [A (n = 5)], T4 [A (n = 3), B (n = 3)], T5 [A (n = 1), B (n = 1)], T6 [A (n = 1)], T7 [A (n = 2), B (n = 1)] T8 [A (n = 3)], and T12 [B (n = 1)]. In addition, individuals with SCI were further subdivided into paraplegia: high (T1–T6) and low (T7–T12) injuries, and for tetraplegia: high (C1–C4) and low (C5–C8) injuries. The inclusion criteria were individuals with SCI for more than a year and hemodynamically stable. The following individuals were excluded, based on restrictions in the measurements of Tsk: those with fever or ingestion of antipyretics up to 2 h before the test; those exposed to sun before the test; those who consumed alcohol, who performed strenuous activity on the previous day, who smoked, who consumed caffeine or chocolate up to 1 h before the test; those who presented with autonomic dysreflexia during the test or any type of infection including active urinary tract infection, skin disease, inflammation, or skin lesions; in pain, especially severe neuropathic pain, and with fractures of the lower limb.

The study was approved by the local ethics committee (CCAE: 19458313.1.0000.54.04). Prior to the test, all individuals provided written informed consent. In Individuals who could not write due to the involvement in the lesion, fingerprints were used or a family member signed the informed consent, being similarly aware. We certify that all applicable institutional and government regulations concerning the ethical use of human volunteers were followed during the course of this research. All evaluations were performed in the same room by the same researcher, in the Spinal Cord Injury Rehabilitation Outpatient Clinic of the Department of Orthopedics and Traumatology. This paper has included all parameters included in the STROBE guidelines [16].

Material

Instrumentation

The noncontact IRT, FLIR TG 165 (FLIR Systems Inc., Orlando, FL, USA), was used for the Tsk measurements. The IRT, featuring a FLIR Lepton^® micro-thermal sensor, was imported by the FLIR Systems, Brazil. The measurement accuracy of the IRT is ±1.5 °C, with a measuring range of −25 to 380 °C. The emissivity of the apparatus was adjusted to that of the skin (0.98). This device has been approved by the United States Food and Drug Administration and is furnished with the appropriate certification document (Fig. 1a) [2, 17,18,19,20].

Fig. 1: Devices for the Tsk Measurements.

a Noncontact infrared thermometer FLIR TG 165, and b MT-240 hygrometer/thermometer.

Full size image

The room temperature and humidity were controlled using a thermo-hygrometer device (MT-240, Minipa Electronics Inc., Houston, TX, USA), imported by Minipa Ltd of Brazil. The device has an internal sensor (range 0 to +60 °C) and an accuracy of ±1 °C (range 0–40 °C), and it measures humidity (20–90%) with an accuracy of ±5% (Fig. 1b).

A reliability test was performed using the IRT and three digital thermometers, and the temperature was measured at the axilla of a staff member and/or of an individual in the study using three consecutive measurements. The digital thermometers were the MC-245 (Omron Healthcare Dalian, China), TH 400 (G-Tech, Hangzhou, China), and the mercury thermometer BR-P136 (Incoterms, Brazil).

Measurement points

The measurement points (baseline) for mapping of the Tsk were the center of the forehead and the dermatomes (C2 to S2) on the right side of the body. The parameters points used were the same used by ASIA level [15]. The core body temperature measurement was done at the axilla.

Experimental procedure

The room temperature was artificially adjusted with air conditioning to 24 °C. Data were collected from 10 a.m. to 4 p.m. On the day of data collection, the first step was the reliability of the IRT with three digital thermometers in the axilla. Then, the Tsk measurement was performed for each individual, with three measurements for each dermatome. The time for each test was 40 min.

All individuals were assessed in the same room in a sitting position. The control group individuals were seated in chairs with armrests, and the individuals with SCI were seated in their own wheelchairs. All individuals were asked to wear shorts to facilitate the exposure of the skin to the ambient temperature of the room. Prior to data collection, all individuals were asked to remain at rest for 20 min to accommodate to the room temperature. The distance between the thermometer and the skin was 60.9 cm. All measurements were performed three times under the same condition by the same researcher.

Data analysis

The mean and standard deviation for all measurements were calculated for further analysis. The Shapiro–Wilk test was used to verify normal distribution. The Student’s t test for independent samples was used to determine the influence of the level of SCI, such as for paraplegia: high (T1–T6) and low (T7–T12) injuries, and for tetraplegia: high (C1–C4) and low (C5–C8) injuries. Comparisons among groups (able-bodied controls, individuals with paraplegia, and individuals with tetraplegia) were performed using the analysis of variance tests (p value ≤ 0.05). If significant differences were detected, post hoc with the Tukey’s test were performed (three per variable) with corrected p of 0.01666 (0.05/3 = 0.01666). The data were analyzed using IBM SPSS software version 21 for Windows.

Results

Participants

In total, 52 males were evaluated. Table 1 shows the demographic variables for the individuals in the control, paraplegia, and tetraplegia groups.

Table 1 Characteristics of the individuals studied (n = 52).

Full size table

Instrumentation

The mean (SD) value of room temperature was 23.59 (0.22) °C and that of relative humidity was 60.27 (7.19)%. The IRT accuracy compared with the three conventional thermometers used was not statistically different (Table 2).

Table 2 Values of the three clinical thermometers and the IRT in all groups.

Full size table

The results for Tsk mapping and for the comparison of Tsk values in the paraplegia group—high and low injuries and in the tetraplegia group—high and low injuries are presented in Tables 3 and 4. In the paraplegia group, statistically significant differences were observed between high and low injuries at L5 (p < 0.01) and S1 (p = 0.03). In the tetraplegia group, no significant differences were observed in any dermatome, regardless of the level of injury.

Table 3 Comparison of Tsk in dermatomes between high (T1–T6) and low (T7–T12) injury in the group—individuals with paraplegia.

Full size table

Table 4 Tsk value according to dermatomes and comparison between high (C1–C4) and low (C5–C8) injury in the group—individuals with tetraplegia.

Full size table

The values of Tsk mapping and the comparisons among the three groups are shown in Table 5 (Supplementary information). Significant differences between the control and the SCI groups and between the SCI groups were found in many dermatomes. Significant differences were observed between the tetraplegia and the control groups at C5 (p < 0.01), C6 (p < 0.01), T1 (p < 0.01), T10 (p = 0.01), L3 (p < 0.01), and S1 (p = 0.01) dermatomes. The dermatomes that showed significant differences between the SCI groups were: C5–C7 (p < 0.01) and T5 (p < 0. 01).

Discussion

Despite not finding statistical differences in all dermatomes between individuals with SCI and able-bodied individuals, Tsk is lower in SCI, especially in individuals with tetraplegics. The principal objective of this study was the development of a Tsk map to compare the differences in Tsk between individuals with SCI and able-bodied individuals. Our study aimed to fill this gap in knowledge about the difference in Tsk between able-bodied and SCI individuals and to provide a new tool to use in clinical and research practice, which can be used in the analysis of care and/or treatment of SCI individuals, comparing the values with the values found in our study.

SCI has numerous deleterious effects on the human body, such as respiratory complications, pressure sores, heterotopic ossification, bladder dysfunction, spasticity, pain, musculoskeletal and metabolic complications, including dysfunction of thermoregulation and cardiovascular changes, such as increased risk of atherosclerosis [21, 22]. In addition, remodeling of the peripheral arteries in the paralyzed limbs, which could lead to a decrease in the systemic blood flow in as little as a few weeks after acute SCI. Therefore, the results suggest that there may be some change in blood flow, such as a decrease in blood flow in both upper and lower limbs after SCI.

Heat production from organ function or muscular work is transferred from the central compartment (core) to the skin (periphery) through the bloodstream in order to dissipate heat. This compartmental transfer is controlled by vasoconstriction and vasodilatation of the arteriovenous arterioles and anastomoses. This mechanism is under the control of the hypothalamic modulation of the sympathetic nervous system [23]. Therefore, individuals with SCI show a decrease in blood circulation (in the lower limbs, blood flow decreases by 50–67%) and, consequently, an increase in atherosclerotic risk factors due to inactivity, decreased insulin sensitivity, and body composition [24]. In this study, we found that Tsk has a variation of value depending on the characteristics of the measured area, for example, the temperature is higher in a more vascularized area. Individuals with paraplegia suffer from vasomotor disorders and show reduced venous distensibility [25, 26].

Krassioukov et al. [27] reported that body temperature and Tsk could be used to evaluate autonomic function above or below the injury and concluded that in the acute phase of injury, temperature is a valid parameter to determine the autonomic function in such individuals.

The values found in this study showed that individuals with SCI have lower Tsk in most dermatomes than individuals in the control group. Significant differences were found in dermatomes L5 and S1 for individuals with paraplegia between high injury (T1–T6) and low injury (T7–T12). Being regions of extremities, there is generally oscillation of Tsk values between individuals. This could be attributed to the small sample size of our study. Therefore, it would be interesting and necessary in the future, a study with a larger sample, as well as a more detailed investigation of each dermatome, to perhaps explain this behavior.

Another important observation was that dermatomes L3 and S1 presented with lower temperatures compared with the most dermatomes (Tables 3 and 4, Table 5 (Supplementary information)). This showed that location and anatomy could influence Tsk. Dermatome L3, due to its location (anterior part of the middle part of the knee joint), does not have much musculature, as it is located primarily in a bony area. The values for L3 in all groups were determined to be low. The dermatome S1 (lateral part of the calcaneus), being a part of the extremity (peripheral), favors greater temperature fluctuations and temperature exchange between individuals. Considering these observations pertaining to changes in Tsk in some body dermatomes, a detailed investigation analyzing a larger sample would be interesting in the future.

Therefore, we conclude that there is a difference observed in Tsk between individuals with SCI and the able-bodied controls. However, significant differences were observed only in certain dermatomes while comparing individuals with tetraplegia and paraplegia. We speculate that these findings are probably the result of changes in blood flow and the tendency for cardiovascular changes common in individuals with SCI. An important benefit of our study by mapping Tsk in individuals with SCI and able-bodied individuals is that changes in Tsk in some body dermatomes would imply further investigation, assisting in the diagnosis, clinical rehabilitation protocols, and/or prevention complications such as hyperthermia, hypothermia, injuries, and clinical rehabilitation protocols that might yield increase in Tsk below the injury.

A limitation of this study was that it was performed in a hospital with few female individuals with SCI. Hence, the study was performed only in men. Another limitation was the difficulty in recruiting a large and homogeneous sample. Further studies, including males and females with SCI, performed at the same time of the day and to determine if rehabilitation protocols can increase Tsk, thus improving the metabolism of such individuals.

In conclusion, we showed a significant difference in Tsk in some dermatomes between individuals with SCI and able-bodied individuals. The Tsk map proposed in this study is a new and interesting tool that could help future rehabilitation research such as clinical practice daily assessments in clinics or hospitals, and could analyze autonomic function in different protocols used in rehabilitation. It could serve as a simple and quick method for analyzing a specific dermatome above or below the level of injury in individuals with SCI in any clinical setting.

Data availability

The support to this study is available from the corresponding author upon reasonable request.

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Acknowledgements

The authors thank the CNPq—National Council for Science and Technological Development #140215/2014–0 and FAPESP #2016/50253-0—São Paulo Research Foundation.

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Authors and Affiliations

1. Biomechanics and Rehabilitation Laboratory, Department of Orthopedics and Traumatology, Faculty of Medical Sciences, University of Campinas—Unicamp, Campinas, Brazil

   Janaina R. Tancredo, Rafael A. Tambascia, Claudiane A. Fukuchi & Alberto Cliquet Junior

2. Center for Studies and Research, Instituto Wilson Mello, Campinas, São Carlos, Brazil

   Rafael A. Tambascia

3. School of Physical Education, University of Campinas, Campinas, SP, Brazil

   Mariane Borges

4. Biocybernetics and Rehabilitation Engineering Laboratory, Department of Electrical Engineering, University of São Paulo, São Carlos, Brazil

   Alberto Cliquet Junior

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Contributions

JRT was the principal researcher of this research, who performed data collection, analyzed the results and discussion of the data. RAT was the co-author and assistant researcher, who assisted in the elaboration of the proposed method, in the interpretation and discussion of the data, and in data collection. MB performed the statistical analyses. CAF was the co-author, who assisted in the preparation of the manuscript, statistical analyses, discussion of data, and proofreading of the manuscript. ACJ was the academic advisor, who proposed the initial concept of this paper and provided guidance and assistance in the development and execution of the research. Each author has contributed substantially to the research, preparation, and production of the paper and approves of its submission to the Journal.

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Correspondence to
Janaina R. Tancredo.

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The authors declare that they have no conflict of interest

Ethics statement

We certify that all applicable institutional and government regulations concerning the ethical use of human volunteers were followed during the course of this research. This work has been approved by the Ethics Committee and consent forms have been signed by all participants.

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Electric dermatome and dermatoplasty St. Petersburg

A dermatome is a compact medical instrument that is used to remove a small amount of skin from a donor site for further transplantation. They have found wide application in burn medicine. The equipment is used for plastic surgery of the skin of various degrees of burns.

Dermatome classification

According to the type of drive, manual, electric and pneumatic dermatomes are distinguished. Depending on the mechanism of operation, 2 groups of devices are distinguished: reciprocating and disk.

The most popular electric dermatome

Unlike mechanical devices with a manual drive, they do not require the use of adhesive material. By means of a special electric motor, the movements of the blade are used. Such devices are equipped with an ergonomic handle, which allows for convenient manipulations on different parts of the body. Thanks to the change of nozzles, it is possible to easily use all the functionality of the equipment, to prepare grafts of any given size and thickness. The main advantage for engraftment of transplant material is the speed of cutting the skin.

Currently, ultra-precise devices are being produced that allow you not to leave scars on donor skin areas. Alfa Mobile offers various dermatomes and skin equipment. They are in great demand in medical institutions where they practice pediatric and general plastic surgery.

The company’s product range includes the following dermatomes:

• D42 Wireless Dermatome. Due to its small size, it is actively used in pediatric surgery. With it, you can easily take samples from uneven surfaces;
• Electric Dermatome D80. The device has a particularly powerful battery, which allows you to use the device in conditions of continuous operation (more than 60 minutes). Changing blades is quick and safe;
• Dermatome SOBER. It is equipped with double blades. When working with the device, no transverse movements are required; cutting a thin flap is not difficult;
• MEEK skin grafting machine. It is intended for the “brand” method of skin grafting. It is used even with 4 degree burns, the device provides a high cosmetic result;
• Skin perforator. The equipment is used to significantly increase the area of ​​the flap (through incisions are made in a checkerboard pattern).

You can buy dermatomes and equipment for the skin at Alfa Mobile in St. Petersburg

If you doubt the choice and do not know which model of equipment is more suitable for your medical institution, you can seek help from consultants. Managers of Alfa Mobili have the necessary qualifications to inform the client in detail, to select the most suitable option, taking into account the wishes of the client. Delivery of the selected dermatome is carried out to all cities of Russia. Warranty service is provided for the period of operation of the equipment.

Drawing up an individual map of skin neoplasms

New electronic system in the EMC Clinic of Dermatovenereology and Allergology-Immunology.

Dear patients, partners and colleagues of EMC.

Dermatologists of the Clinic of Dermatovenereology and Allergology – Immunology have begun the procedure for compiling an individual map of the patient’s skin neoplasms using a new computer system.

The skin is the largest organ of the human body with a huge number of functions, which is the boundary of the interaction between the environment and the body. Everyday life can have a detrimental effect on skin health: daily exposure to solar radiation, poor ecology, nutrition, solarium, travel to countries with high solar activity, etc. The factor of genetic predisposition to a particular skin disease is of great importance, and in some cases plays a leading role.

Neoplasms may appear on the skin of each person, but not everyone is aware that some of them can be malignant.

According to the World Health Organization (WHO), with melanoma, the neoplasm develops rapidly, grows deep into the skin and metastasizes to distant organs and tissues. The disease is extremely difficult to treat. Deaths are reported in half of all cases of the disease.

The main means of combating this formidable disease is its early diagnosis.

Diagnosis in the early stages is very difficult. Education when viewed with the naked eye looks quite benign, and only a special study can reveal signs of malignancy of the tumor. That is why modern dermatology uses the method of dermatoscopy to draw up an individual map of skin neoplasms.

A modern dermatoscope is an optical device that allows obtaining high-precision macro images of formations and their structures with a 20-fold increase in polarized light or immersion oil. With dermatoscopy, the rays penetrate into the upper layers of the skin, where the primary accumulation of malignant cells occurs. Based on this information, the dermatologist determines the current state of the neoplasms and makes a prognosis.

The mapping procedure involves observing changes over any period of time. To do this, all images, doctor’s description and conclusions are uploaded to the medical database. After the required amount of time has elapsed, the procedure for dermatoscopy of skin neoplasms is repeated the required number of times; the results are compared, allowing the dermatologist to timely and correctly diagnose the disease at the very beginning of its development, which ensures high treatment efficiency.

EMC dermatologists use their own development. The new information system evaluates neoplasms based on a wide range of modern technologies, which allows you to get the most complete and reliable picture of the processes in the affected areas of the skin.