Needling Technique on Facial Points
Needling methods chiefly include proper insertion of filiform needles into points and various techniques and manipulations applied to the needles. Application of those methods plays an essential role in achieving the preventive and curative functions of points. In clinical practice, there are more than one distinctive needling method for most points corresponding to their locations, indications and regional anatomy. Reviewing all the relevant literature both in Chinese and in English, however, there is little article focusing on the different puncturing methods of each individual point. What most textbooks provide limits to the angle and depth of insertion of one kind of conventional method, which is far from satisfying the needs of clinical practice. To supply the gap, the diverse needling methods of several facial points that have been frequently used in clinic are discussed in this paper. Both more detailed information about conventional needling method and comparatively special manipulations suitable to each point are mentioned.
Xiaguan(ST7) is anterior to the ear, in the depression between the zygomatic arch and mandibular notch. Its indications include deafness, tinnitus, otitis media, toothache, facial paralysis, prosopalgia, temporomandibular joint disturbance syndrome(TMJDS), masseter spasm and so on.
The conventional needling method of Xiaguan(ST7) is puncturing perpendicularly 15-25 mm with the mouth close. Gentle manipulation of rotating, lifting and thrusting with small amplitude may be applied to the needle. Patients feel soreness and distension around the point. This method is effective for most ailments. However, to treat the refractory cases, special needling techniques may be employed with the precondition of mastering regional anatomy. Most special methods of this point involve in deep insertion and stimulation of corresponding nerve or ganglion.
Multidirectional insertion method: Insert the needle perpendicularly around 25mm. After the Qi sensation is obtained, lift, thrust and rotate the needle in small amplitude for about half a minute to strengthen the needling sensation. Pull the needle to the subcutaneous level. Thrust the needle about 30mm obliquely to the left or right. Lift, thrust and rotate the needle in small amplitude at required depth for about half a minute. Then change the direction and repeat the same operation. Patients may feel soreness and distension diffusing to the whole temporomandibular joint. This method has good effect in treating TMJDS.
Oblique insertion toward opposite mastoid process: Firstly, insert the needle 4-5cm vertically. When touch the bone(pterygoid process of sphenoid bone), pull the needle a little bit out and then continue the insertion in the backward and upward direction (toward mastoid process of opposite side). The needle is inserted obliquely 4-6cm to form an angle of approximately 40° with the skin surface. The tip of the needle may arrive at lateral portion of the foramen oval and touch the third branch of trigeminal nerve (mandibular nerve). Patients may feel electric shock spreading thourgh homolateral jaw, inferior gum and tongue. This method was often adopted to treat prosopalgia (third branch), inferior toothache, and facial paralysis.
Backward oblique insertion method: To treat otopathy such as otalgia, otitis and hypoacusis, insert the needle 4 cm obliquely backward to the internal ear. Patients may feel soreness and distension spreading through the ear area.
Oblique insertion toward opposite outer canthus: After inserting the needle to the subcutaneous level, thrust the needle obliquely upward and forward (toward opposite outer canthus) with an angle of around 30° between the skin and needle body. At the depth of 5-6 cm, the tip of the needle can reach foramen rotundum where the second branch of trigeminal nerve (maxillary nerve) comes out of the skull. Patients may feel local soreness and distention. If the needle touches the maxillary nerve, the feelings of numbness and electrical shock will occur at the homolateral face and upper gum. This method can be employed for prosopalgia (second branch), upper toothache, and rhinitis.
To guarantee the safety, it is applicable to insert the needle perpendicularly reaching the lateral side of the wing of sphenoidal bone firstly and note down the depth. Pull the needle to the subcutaneous level and then thrust it obliquely toward opposite outer canthus with the depth of 1cm more than that of perpendicular insertion. It is not advisable to insert the needle too deep even if no expected sensation occurs. The practitioner may change the direction of insertion slightly rather than thrust the needle deeper in searching needling sensation.
Forward oblique insertion method: With regard to rhinopathy, the needle may be punctured from the point 1-1.5cm anterior to the centre of the hollow which is under the mid-point of the zygomatic arch. Insert the needle obliquely forward into the gap between zygoma and mandible with the depth of 5-6cm. Sometimes the tip of the needle can touch the Sphenopalatine ganglion. Patients feel electric shock at the homolateral face or feel like water flowing in nasal cavity, provided the ganglion is stimulated. Nasal obstruction may disappear immediately. This method gets effect instantly in curing rhinallergosis. The key point of this method is passing the needle through the small space between the two bones to touch the sphenopalatine ganglion. However, this technique is inapplicable to about 30% of all population who have no gap between zygoma and mandible. The depth of this insertion should be no more than 6cm. Otherwise the tip of the needle may get into nasal cavity, giving rise to epistaxis.
Downward horizontal insertion method: the needle is inserted transversely toward Extra point ‘Qianzheng’ (0.5 cun anterior to the auricular lobe) to form an angle of approximately 20° with the skin. Thrust the needle horizontally 40-55mm where the tip of the needle may touch the branch of facial nerve. Needling sensation includes local soreness, distension and electric shock. There may be one time convulsion of homolateral facial muscles in some cases. This method is suitable for facial paralysis. When treating trismus due to masseter spasm, the direction of insertion may toward ‘Jiache(ST6)’ with proper depth of 4-6 cm.
Taiyang is an extra point in the depression about 1 cun posterior to the midpoint between the lateral end of the eyebrow and the outer canthus. Its indications include headache, migraine, dizziness, eye diseases, facial paralysis, prosopalgia, and so on.
The conventional needling method of Taiyang(Extra) is puncturing perpendicularly or obliquely 15-25 mm. There are plenty of blood vessels around the point Taiyang(Extra). So acupuncture is easy to cause bleeding and hematoma. To avoid injury of blood vessels, strong manipulation of rotating or lifting and thrusting the needle with large amplitude is not advisable at this point. Auxiliary manipulation of vibrating may be used to facilitate the arrival of qi and strengthen the needling sensation. Hold the needle with the thumb and index finger. Rotate the needle forward and backward and at the same time move the needle up and down gently and rapidly in a trembling way. Another auxiliary manipulation frequently used is flying. Hold the needle with the thumb and index finger. Twirl the handle of the needle gently for 1 to 3 times and then release it quickly. Separate the fingers just like a bird spreading its wings. The needle might be left slightly quivering on the point. Patients may feel soreness and distension at temple area.
Special techniques such as horizontal penetrating needling method and downward oblique insertion method may enlarge the range of indications and enhance the curative effects of this point.
Horizontal penetrating needling method: To treat migraine, horizontal penetrating needling technique may be applied to Taiyang(Extra). Pinch the skin up around the point with the thumb and index finger of the assistant hand. The needle is inserted horizontally to form an angle of approximately 15° with the skin surface. Puncture the needle along the skin 3-6cm with the tip directed toward the point Shuaigu(GB8). The tip of the needle may be felt at the subcutaneousness of point Shuaigu(GB8). The needling sensation of soreness and distension can diffuse along the needle throughout the whole temporal region of the head. Horizontal penetrating needling method from Taiyang(Extra) to Jiache(ST6) is applicable to facial paralysis. Puncture the needle 6cm subcutaneously with the tip of the needle directed toward the point Jiache(ST6). Needling sensation such as soreness or distension may diffuse to the tongue.
Downward oblique insertion method: To treat toothache, downward oblique deep insertion method needs to be employed. Insert the needle obliquely downward with an angle of 40-50° between the needle and the skin surface. Thrust the needle 6-7cm passing the media side of zygomatic arch. When patients feel strong soreness, distension, numbness or electric shock at upper gum, toothache will disappear at once or lighten markedly. This method has been employed in dental extraction. When insert the needle approximately 7cm, patients may have strong numb and distending sensation at the gum, and parotid area. Tooth extraction may be done at this time. Lift and thrust the needle in small amplitude continuously during the operation to keep the needling sensation. Clinical observation of 200 cases confirms the satisfactory anesthetic effects of this method.
To treat prosopalgia, facial paralysis or TMJDS, the direction of oblique insertion may toward Xiaguan(ST7) or Quanliao(SI18). Insert the needle obliquely downward with an angle of 40-50 degrees between the needle and the skin surface. Thrust the needle approximately 5cm passing the media side of zygomatic arch, with the tip directed toward homolateral Xiaguan(ST7) or Quanliao(SI18). Patients may feel strong local soreness, distension or electric shock.
The key point of downward oblique insertion method is the angle of insertion. If the angle between skin surface and the body of the needle is less than 40°, it is easy to touch the zygomatic arch. If the angle of insertion is above 50°, the needle may encounter the resistance of temporal bone. Therefore, the desired depth requires the appropriate angle of insertion. Pressing the hole with sterilized dry cotton ball soon after withdrawing the needle is necessary for all above methods to avoid bleeding and hematoma.
The location of Dicang(ST4) is lateral to the corner of the mouth, directly below the pupil. It is an effective point in treating mouth deviation of facial paralysis, salivation and twitching of eyelids.
This point may be punctured perpendicularly or obliquely outward 10-15 mm to treat salivation or twitching of eyelids. The needling sensation is often described as tingling or dull ache. Referring to facial paralysis, penetrating needling technique may be employed to this point. Puncture subcutaneously 30-40 mm with the tip of the needle directed toward Jiache(ST6). To avoid pain, the needle need not get out of skin at Jiache(ST6), but the tip of the needle may be felt at subcutaneousness when place the tip of the finger at Jiache(ST6). Patients may have strong needling sensation of soreness or distension when the needle goes deep. It is comparatively easy to cause stuck needle by the tension of the muscle, so twirling with large amplitude is not encouraged under this method.
The location of this point is one finger-breadth (middle finger) anterior and superior to the lower angle of the mandible where masseter is prominent when the teeth are clenched. Indications of this point include facial paralysis, toothache, swelling of the cheek and face, mumps, trismus due to masseter spasm, and so on.
This point could be punctured perpendicularly 10-20 mm. The fundamental manipulation technique of rotating the needle is applicable to facilitate the arrival of qi and strengthen the needling sensation. Patients may feel local soreness and distension.
If Qi fails to arrive, auxiliary technique such as vibrating could be applied to this point. Hold the needle with the thumb and index finger. Vibrate the needle by rotating, lifting and thrusting it very quickly and gently with small amplitude. Trembling of the needle functions to excite the muscle, which is particularly effective in treating masseter atonicity of facial paralysis. Patients may feel soreness and distension at the parotid, cheek and gum. Sometimes electric shock may also occur provided that the tip of the needle touches the nerve innervating this area.
Penetrating needling technique may be employed to this point as well. Puncture subcutaneously 30-40 mm with the tip of the needle directed towards Dichang(ST4). Twirl the needle only in one direction, causing muscle fibers to wind around the needle. Pull the needle backward 3-5 times. The masseter was drawn backward with the needle. Patients feel strong soreness, distension and dragging pain during the operation. The practitioner feels stuck sensation under the needle. This technique is applicable to wry mouth arising from facial paralysis.
Yingxiang(LI20) is located in the nasolabial groove, at the level of the midpoint of the lateral border of ala nasi. Indications of this point include nasal diseases such as nasal obstruction, hyposmia, epistaxis, rhinorrhea, deviation of the mouth due to facial paralysis, itching and swelling of the face.
Generally, this point may be punctured obliquely upward or perpendicularly 10-20 mm. Fundamental manipulation technique of rotating is often used. Ache and soreness are the commonest needling sensation.
To strengthen the stimulation, the needle may goes deeper with the tip reaching the bone. Sparrow pecking technique may be applied to Yingxiang(LI20) for sinusitis or rhinitis. Lift and thrust the needle continuously for one to two minutes with small amplitude and high frequency like a sparrow pecking at the corn. Patients may have strong soreness, distention and itching sensation around the nose. Nasal obstruction could be cleared immediately. Patients feel much easier to do nasal respiration.
Another needling method is puncturing subcutaneously 20-35 mm with the tip of the needle toward the root of the nose. In order to fix the depth of the needle absolutely and to be easy to twist the needle, hold the needle handle with the palmar surface of the thumb and radial surface of the index or middle finger. Twist the needle with the help of the bending and stretching movement of the metacarpophalangeal joint of the index or middle finger. Rotate the needle handle rapidly with the twisting speed reaching 200 times per minute or so. Twist the needle continuously for 2-3 minutes per time and repeat this manipulation 2-3 times during retaining period. Patients may also have strong soreness, distention and itching sensation around the nose. Nasal obstruction could be largely mitigated after withdraw the needle.
Renzhong(GV26) is located at the junction of the upper third and middle third of the philtrum. This point is effective in treating mental disorders, epilepsy, hysteria, infantile convulsion, coma, apoplexy-faint, facial paralysis, puffiness of the face, acute lumbar sprain, and so on. Because most indications of Renzhong(GV26) are acute symptoms, strong stimulation is generally applied to this point.
The needling method of Renzhong(GV26) is puncturing perpendicularly or obliquely upward 10-20 mm. Insert the needle perpendicularly. Apply sparrow pecking technique at this point. The quick lift-thrust movement with small amplitude gives rise to strong stimulation to the buccal branch of facial nerve. Or insert the needle obliquely upward. Hold the needle handle with the palmar surface of the thumb and radial surface of the index or middle finger. Twist the needle with the help of the bending and stretching movement of the metacarpophalangeal joint of the index or middle finger. Rotate the needle handle rapidly with the twisting speed reaching 200 times per minute or so. Both methods are applicable in emergency treatment. Patients may feel strong soreness and ache with recovery of consciousness.
When treating pain and stiffness of the lower back due to acute sprain, active needling technique may be employed. On applying sparrow pecking technique or rotating the needle rapidly, ask the patient to move their lumbar part slowly. The lumber pain may be alleviated and the amplitude of movement may increase gradually with the manipulation on the needle.
Yangbai(GB14) is on the forehead, when the patient looks straight forward, the point is directly above the pupil, 1 cun superior to the eyebrow. This point is effective in treating headache, peripheral facial paralysis, twitching of the eyelids, ptosis of the eyelids, acute conjunctivitis, amblyopia, and so on.
Normally, Yangbai(GB14) is punctured subcutaneously downward. Referring to ptosis of the eyelids, the direction of insertion may be upward. Pinch the skin up around the point with the thumb and index finger of the auxiliary hand. Insert the needle horizontally 10-15 mm with the needling hand. Rotating technique may be applied to this point. Patients may feel slight ache.
To treat such symptoms of facial paralysis as lack of wrinkling on forehead of paralyzed side, inability to close eyes, abnormal blink and so on, penetrating needling technique could be employed. Insert the needle subcutaneously with the tip of needle directed toward Yuyao, an extra point at the midpoint of the eyebrow. Place the thumb or index finger of the auxiliary hand on the point Yuyao(Extra). The needle goes further until its tip can be felt at subcutaneousness of point Yuyao(Extra). The function of auxiliary hand is very important to control the depth of insertion and guarantee safety of the eye. To strengthen the stimulation and enhance the curative effect, triple needling method is applicable at this point. Insert one needle subcutaneously with the tip of needle directed toward Yuyao(Extra). The other two needles are inserted from the spots 15mm left and right to Yangbai(GB14) respectively with the tips toward Yuyao(Extra) as well. Most patients with inability to close eye are capable to close the eyes completely and feel very comfortable during retaining period.
2.8 Ermen(SJ21), Tinggong(SI19), Tinghui(GB2)
Those three points are all located in the groove behind the condyloid process of the mandible with the mouth open. Ermen(SJ21) is anterior to the supratragic notch. Tinggong(SI19) is anterior to the tragus and Tinggui(GB32) intertragic notch. All those three points can treat deafness, tinnitus, otorrhea, and motor impairment of the mandibular joint.
Based on the guideline set in most textbooks, those three points need to be punctured perpendicularly 10-30mm when the mouth is open. In clinical practice, the depth of insertion may up to 40 mm. But the insertion should be operated very slowly to avoid pain. Even light stimulation may cause tingling and distending sensation. Manipulation of lifting, thrusting and rotating in large amplitude is not suitable here. The advisable technique is Scraping the needle at those points. Place the thumb on the end of the needle to hold it steady. Scrape the handle with the nail of the index or middle finger of the same hand from the tail to the root of the needle or vice versa. Itching sensation in the interior of the ear is expected needling sensation in treating deafness and tinnitus.
Daying(ST5) is located anterior to the angle of mandible, on the anterior border of the attached portion of masseter where the pulsation of facial artery is palpable. Indications of this point include facial paralysis, trismus of masseter spasm, facial neuralgia, toothache and so on.
Place the tip of the thumb or the index finger of the auxiliary hand on the facial artery at acupuncture point to protect the vessel. Hold the needle with the other hand and keep the needle tip closely to the finger tip of the auxiliary hand. Insert the needle perpendicularly or obliquely toward the opposite side of the artery. The advisable depth of insertion is 10-20mm. The tip of the needle may get into oral cavity provided that too deep insertion is applied to Daying(ST5). The key of this puncturing method is accurate point location with avoidance of hurting the artery. Rotating manipulation with small amplitude may be applied to this point. No strong manipulation is encouraged to this point due to local vasculature. Daying(ST5) is a comparatively sensitive point. In most cases, patients feel soreness after the needle is inserted in the suitable depth. Slightly electric shock arising from stimulation of facial or masseteric nerve often occurs as well.
Yintang(Extra) is located at the midway between the medial ends of the two eyebrows. It is very commonly used in treating headache, dizziness, epistaxis, rhinitis, sinusitis, infantile convulsion and insomnia.
This point may be punctured subcutaneously upward or downward with the depth of 10-20mm. Pinch the skin up around the point with the thumb and index finger of the auxiliary hand. The needle is inserted transversely with the puncturing hand to form an angle of 20 degrees with the skin. Rapid rotating technique is often applied to this point to strengthen the stimulation. Hold the needle handle with the palmar surface of the thumb and radial surface of the index or middle finger. Twist the needle with the help of the bending and stretching movement of the metacarpophalangeal joint of the index or middle finger. Rotate the needle handle rapidly with the twisting speed reaching 200 times per minute or so. Patients feel strong heaviness at the forehead.
2.11 Juliao(ST3) and Quanliao(SI18)
The location of Juliao(ST3) is directly below the pupil, at the level of the lower border of ala nasi. The location of Quanliao(SI18) is directly below the outer canthus, in the depression on the lower border of zygoma. Both of those points have indications such as facial paralysis, twitching of eyelids, face spasm, facial neuralgia, toothache, swelling of lips and cheek, and so on.
Similar needling method can be used to the two points. Puncture perpendicularly 10-20 mm. lift and thrust or rotate the needle gently with small amplitude. Patients may feel local soreness and distension. Sometimes ecchymoma may occur due to loose subcutaneous tissue. Therefore, it is advisable to pressed the hole with dry sterilized cotton ball after withdraw the needle.
The location of Chengjiang(CV24) is in the depression in the centre of the mentolabial sulcus. Its indications include deviation of the mouth, swelling of the gums, salivation, mental disorders, facial puffiness and so on.
This point can be punctured obliquely upward 10-15 mm. To treat mental disorders such as hysteria, rapid rotating may be applied to the needle to cause strong stimulation. Patients may feel strong ache. To treat facial paralysis, the needle may be punctured obliquely toward the paralyzed side.
Facial points are sensitive to acupuncture stimulation due to rich regional vasculature and innervation. Therefore, it needs to be cautious to employ strong stimulation at facial points unless for some special purpose. Pressing the hole with sterilized dry cotton ball soon after withdrawing the needle is encouraged to avoid bleeding. Needles can be inserted perpendicularly, obliquely, or horizontally according to the convenience of manipulation. Shallow insertion between 15-25mm is applicable to most facial points. Deep insertion can be used at Xiaguan(ST7), Taiyang(Extra), Jiache(ST6), Dicang(ST4), etc. to broaden the indications and improve the curative effects. Regarding to the fundamental manipulation techniques, rotating is much more frequently used than lifting and thrusting. Other auxiliary methods such as scraping, sparrow pecking technique, vibrating, etc. are also valuable to promote the circulation of qi and strengthen the needling sensation.
At last, all the needling methods selected for patients serve to implement the therapeutic principle guided by the theory of Traditional Chinese Medicine. For example, at the initial stage of facial paralysis, exogenous pathogenic wind and cold invade the body at superficial level. Shallow insertion should be applied to facial points to disperse exterior evil qi. Around a week later, deep needling technique and strong stimulation can be used to treat stagnation of qi and blood in the meridians. If the disease can not be cured for long time, anti-pathogenic qi of patients is weak. The shallow insertion and gentle methods should be used again to inspire the meridian qi and expel remaining evils.