Surgical Decompression of the Greater Auricular Nerve: A Therapeutic Option In Neurapraxia Following Rhytidectomy

Goal: Nerve injuries following rhytidectomy are uncommon and are rarely permanent.  The great auricular nerve (GAN) is rarely mentioned but recent clinical cases show that due to its anatomical location and superficial course that the incidence of these injuries may be higher than expected, especially in short scar facelift techniques which have become more popular.  Post-operative edema and traction neuropraxia may result in temporary tingling and numbness; however, the dilemma is differentiating a recoverable injury from a nerve which is severed or crushed.  In the event of a complete or persistent nerve injury, the proximal end of the irritated nerve may become attached to the scar or anterior skin flap.  Neuroma formation or stitch impingement will cause a trigger point on the lateral part of the neck, which may lead to migraine-like pain on the side of the face or ear. We present our recent experience of patients presenting with persistent nerve allodynia.  All patients underwent surgical exploration, nerve release and wide decompression, with significant improvement in sympotomatology.

Methods: Four patients with persistent dysfunction of the great auricular nerve were seen after rhytidectomy by outside surgeons. In each patient, a traditional open exploration was performed with careful identification of the GNA at its normal anatomical location. Diagnosis of compression and suture impingement was confirmed at operative exploration, and extensive decompression was performed with care to protect the nerve from post-operative scar formation.

Results: Four patients presented with suture impingement of the GAN and extensive peri-neural scarring. All patients were successfully treated with exploration and decompression (five total GAN). All patients exhibited improved sensibility and significantly less pain at six months post-operatively. All patients healed with minimal scarring of the incisions. 

Conclusion:  Re-exploration and surgical decompression of the greater auricular nerve may represent an excellent adjunct for sensory defects and severe pain following rhytidectomy. Neurolysis with repair of this nerve as indicated, either at the time of the operation or several years later, has a very favorable prognosis. Patients undergoing short scar or “lifestyle” facelifts may be more prone to this type of complication due to limited visualization, which may result in a higher incidence of symptomatic GAN injury. Knowledge of anatomical relationships, nerve decompression techniques, and close patient follow-up may allow for appropriate operative planning.