A failsafe method to avoid injury to the great auricular nerve

Essential Surgical Anatomy for Facelift

It is crucial for a facelift surgeon to have a comprehensive understanding of ageing-related changes on the volume, elasticity, and relative position of various facial tissues and layers. These changes lead to an alteration in the surface topography, contour, and ultimately shape of the face. The depressions and sagging of tissues created as a result of ageing then has a bearing on one's perceived age. This article describes the various layers of the face and neck affected by ageing. The fat compartments, superficial musculoaponeurotic system (SMAS), potential facial spaces, facial ligaments, and facial nerve are discussed in detail. Safe and effective execution of facelift requires a thorough understanding of the intricate relationship between the various layers of face and neck, in particular the path of facial nerve, as it negotiates between these layers. The emphasis of this article is on integrating this knowledge to generate practical tips for safe dissection, effective tissue movement, and repositioning during various type of facelift procedures.

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).

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.

The Aging neck-A Case base treatment algorithm

BACKGROUND

Effective nonsurgical treatments for the aging face are widely accepted and utilized. Although changes in the aging neck, often patients to seek esthetic rejuvenation protocols are neither well defined nor well designed. Increasingly, patients desire less invasive cosmetic treatments with less morbidity and downtime. A significant challenge exists in managing expectations and educating patients about the pros and cons of a surgical approach compared to the plethora of nonsurgical options. When equipped with state of the art information and technique, using a multi-modality nonsurgical approach, surprisingly outstanding results may be obtained.

AIMS

In this paper, we aim to revisit the neck's anatomy and then demonstrate current nonsurgical techniques in managing actual cases.

METHODS

To achieve that, we have utilized an intuitive four-point grading scale to guide both physician and patient regarding appropriate treatment combinations.

RESULTS

The proposed four-point scale was applied to six patients and their treatment plan was described in detail.

CONCLUSIONS

Skin laxity is not the only factor that comes into play when assessing the neck. careful analysis of the neck and face hold the key for treatment choice and execution.

A comprehensive review of the great auricular nerve graft

The great auricular nerve (GAN) is a superficial branch of the cervical plexus that innervates parts of the mandible, auricle, and earlobe. Over the past 30 years, the GAN has become the nerve graft donor of choice for many surgeons for reconstructing injured facial nerves. In this review, we discuss the anatomy and function of the GAN, while focusing on surgical landmarks and the characteristics that make it a suitable nerve graft donor. In addition, we present and summarize published case reports on use of the GAN for grafting. We hope that this review will provide surgeons with an up-to-date and concise reference.

Facelift Part I: History, Anatomy, and Clinical Assessment

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Neck Rejuvenation: Anatomy and Technique

An aesthetically pleasing neck contour remains the cornerstone for facial rejuvenation. In this article a detailed description of the anatomy pertaining to the necklift surgery is provided, with supplemental cadaver video dissections going over the most common and novel necklift techniques.

Perioperative Management of the Facelift Patient

In this article, the authors set out to lay a foundation for successful perioperative management of the facelift patient. They describe the changes of normal facial aging in an attempt to help one recognize the universal way the face is affected by aging. Having a clear understanding of these factors may help to guide the physician with procedures necessary to offer the patient for a desired outcome. Also, the authors emphasize the preoperative assessment and postoperative care necessary to ensure a successful, low-risk operation with minimal downtime and beautiful results, meeting the patient's expectations.

The Extended Superficial Musculoaponeurotic System

The extended superficial musculoaponeurotic system (SMAS) facelift targets the 2 cardinal signs of facial aging: (1) descent of the malar fat resulting in deepening of the nasolabial folds as well as accentuation of the palpebral malar groove and tear trough deformity; (2) formation of jowls, which also obscure the definition of the lower mandibular border. In this article the authors describe the concepts behind the extended SMAS operation, importantly the extent of skin dissection and SMAS elevation. They present a brief history of the operation and landmark papers and supplement with fresh cadaver dissections.

Variation of the Great Auricular Nerve and Prediction of the Facial Nerve Trunk Size

Supplemental Digital Content is available in the text.

Background:

This study aimed to reveal the anatomical variation in the great auricular nerve (GAN) and the correlation between the size of the GAN and the facial nerve trunk (FNT), so as to aid surgeons to perform safe facelift surgery and parotidectomy.

Methods:

Sixteen human cadavers were studied on 16 left and 15 right facial sides. The GAN’s branching patterns, location, and the mean width of the GAN and FNT were measured.

Results:

The average distance where the nerve emerged from under the sternocleidomastoid muscle was 87.61 ± 12.13 mm when measured perpendicular to the Frankfort horizontal plane. The branching pattern of the GAN could be classified into 5 types of which the most common was type 3 (30.77%), where the GAN divided into the anterior (superficial) and posterior branches, and then the deep branch originated from the posterior branch of the GAN. The mean width of the GAN and FNT from all the dissections was 3.26 ± 0.67 mm and 3.36 ± 0.71 mm, respectively. There was a significant correlation between the width of the nerves on both facial sides (right: r =0.740, P =0.002; left: r = 0.839, P < 0.001).

Conclusions:

This study revealed the anatomical variation and the width of the GAN, which can strongly predict the width of the FNT. This should be taken into consideration during facelift surgery and parotidectomy, especially in patients with a small GAN to prevent iatrogenic injury to the small FNT.

Face and Neck Lifting After Weight Loss

After massive weight loss, deflation of the tissues and loss of skin elasticity in the face and neck can result in the appearance of accelerated facial aging. Surgical facial rejuvenation can be successfully performed with several modifications. Proper preoperative counseling and expectation management regarding staged or ancillary procedures is recommended. Wide undermining of the face and neck, and extended postauricular incisions are required to allow for mobilization of excess skin and access to the mobile superficial musculoaponeurotic system (SMAS). Fat transfer into the deep malar compartment for midface volumizing is helpful. Treatment of the SMAS and platysma are universally necessary.

Anterior Greater Auricular Point: Novel Anatomic Landmark to Facilitate Harvesting of the Greater Auricular Nerve

BACKGROUND

The greater auricular nerve (GAN) may be used as a nerve graft during neurosurgical procedures to repair damaged nerves. There is extensive literature on localization of the GAN at the posterior triangle of the neck, but objective information on localization of the GAN at the anterior triangle of the neck close to cranial neurosurgical fields is lacking. The aim of this study was to introduce simple and reliable landmarks to localize the GAN at the anterior triangle of the neck to facilitate its harvest during neurosurgical procedures.

METHODS

The GAN was exposed bilaterally in 11 cadaveric specimens at the point of crossing the anterior border of the sternocleidomastoid muscle (anterior greater auricular point [AGA]). Distances from the AGA point to the angle of the mandible and the tip of the mastoid process were measured. Additionally, the location of the crossing point between the GAN and an imaginary line passing through the mastoid tip and the angle of the mandible (M-A line) was found relative to these bony landmarks.

RESULTS

Mean (±SD) distances from the AGA point to the mastoid tip and the angle of the mandible were 29.1 ± 3.4 mm and 27.5 ± 4.5 mm, respectively. The GAN was always found to cross the M-A line in its middle third (mean 48.2% ± 6.9% from the mastoid tip).

CONCLUSIONS

The AGA point and the M-A line are reliable landmarks for locating the GAN at the anterior triangle of the neck and for helping neurosurgeons expose and harvest the GAN efficiently.

A Simplified Method for Management of Platysmal Bands: Platysmotomy as an Office Procedure

Restoration of the esthetic neck contour is an integral component of facial rejuvenation. Characters of the aging neck include lipodystrophy, platysmal bands and jowls that extend into the neck, reducing the esthetic characters of the lower face. The authors present a new, simplified and economic method to manage platysmal bands as an office procedure under local anesthesia using a standard 18-gauge syringe needle as a cutting tool. The new technique was used on a selected group of female patients classified as non-surgical cases according to Rorich classification. Twenty-five female patients shared in this study, with a follow-up period standardized to 1 year; one patient showed up after 1.5 years with preserved esthetic outcome. One patient showed residual band managed by recutting immediately after bruising and edema resolved. The technique was proven safe regarding important neurovascular structures of the neck. Patients gave no negative comments regarding results of surgery. Kappa statistical analysis showed perfect interobserver agreement between patients and an independent assessor. The authors concluded that the studied new technique is safe, effective, and valuable for management of platysmal bands in a selected group of patients. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

What Is the Lobular Branch of the Great Auricular Nerve? Anatomical Description and Significance in Rhytidectomy

BACKGROUND

Current literature suggests that preserving the lobular branch of the great auricular nerve has greater impact on sensory function of the auricle than preservation of the posterior branch during rhytidectomy. However, no methodology exists to efficiently and accurately determine the topographic location of the lobular branch. This study describes the branching characteristics of the lobular branch and algorithmic surface markings to assist surgeons in preservation of the great auricular nerve during rhytidectomy flap elevation.

METHODS

The lobular branch was dissected in 50 cadaveric necks. Measurements were taken from the lobular branch to conchal cartilage, tragus, and antitragus. The anterior branch was measured to its superficial musculoaponeurotic system insertion, and the posterior branch was measured to the mastoid process. The McKinney point was marked and the great auricular nerve diameter was recorded. Branching pattern and location of branches within the Ozturk 30-degree angle were documented. Basic statistics were performed.

RESULTS

The lobular branch was present in all specimens and distributed to three regions. In 85 percent of specimens, the lobular branch resided directly inferior to the antitragus; in the remaining specimens, it was located directly inferior to the tragus. Preoperative markings consisting of two vertical lines from the tragus and antitragus to the McKinney point can be used to outline the predicted location of the lobular branch.

CONCLUSIONS

This study delineates the location of the lobular branch of the great auricular nerve. The authors translate these findings into a quick and simple intraoperative marking, which can assist surgeons in avoiding lobular branch injury during rhytidectomy dissection.

Topographic anatomy of the great auricular point: landmarks for its localization and classification

PURPOSE

The great auricular point (GAP) marks the exit of the great auricular nerve at the posterior border of the sternocleidomastoid muscle (SCM). It is a key landmark for the identification of the spinal accessory nerve, and its intraoperative localization is vital to avoid neurological sequelae. This study delineates the topography and surface anatomy landmarks that used to localize the GAP.

METHODS

Thirty cadaveric heminecks were dissected on a layer-by-layer approach. The topography of the GAP was examined relative to the insertion point of the SCM at the clavicle, tip of the mastoid process, and angle of the mandible. The GAP and its relation to the SCM were determined as a ratio of the total length of the SCM.

RESULTS

The GAP was demonstrated to be in a predictable location. The mean length of the SCM was 131.4 ± 22 mm, and the mean distance between the GAP and the mastoid process was found to be 60.4 ± 13.76 mm. The ratio of the GAP location to the total SCM length ranged between 0.33-0.57. The mean distance between the angle of the mandible and the GAP was determined to be 57 ± 22.2 mm. Based on the midpoint of the SCM, the GAP was above it in 66.7 % of subjects and classified to Type A, and below it in 33.3 % of subjects appointed to Type B.

CONCLUSIONS

The anatomical landmarks utilized in this study are helpful in predicting the location of the GAP relative to the midpoint of the SCM and can reduce neural injuries within the posterior triangle of the neck.

Neurovascular structures of the mandibular angle and condyle: a comprehensive anatomical review

BACKGROUND

Various surgical interventions including esthetic surgery, salivary gland excision, and open reduction of fracture have been performed in the area around the mandibular angle and condyle. This study aimed to comprehensively review the anatomy of the neurovascular structures on the angle and condyle with recent anatomic and clinical research.

METHODS AND RESULTS

We provide detailed information about the branching and distributing patterns of the neurovascular structures at the mandibular angle and condyle, with reported data of measurements and proportions from previous anatomical and clinical research. Our report should serve to help practitioners gain a better understanding of the area in order or reduce potential complications during local procedures. Reckless manipulation during mandibular angle reduction could mutilate arterial branches, not only from the facial artery, but also from the external carotid artery. The transverse facial artery and superficial temporal artery could be damaged during approach and incision in the condylar area. The marginal mandibular branch of the facial nerve can be easily damaged during submandibular gland excision or facial rejuvenation treatment. The main trunk of the facial nerve and its upper and lower distinct divisions have been damaged during parotidectomy, rhytidectomy, and open reductions of condylar fractures.

CONCLUSION

By revisiting the information in the present study, surgeons will be able to more accurately prevent procedure-related complications, such as iatrogenic vascular accidents on the mandibular angle and condyle, complete and partial facial palsy, gustatory sweating (Frey syndrome), and traumatic neuroma after parotidectomy.

Great auricular nerve preservation in parotid gland surgery: Long-term outcomes

OBJECTIVES/HYPOTHESIS

To assess sensory outcomes and quality of life (QoL) in two groups of patients with and without great auricular nerve (GAN) preservation during parotidectomy.

STUDY DESIGN

Retrospective chart review.

METHODS

The posterior branch of the GAN was preserved in 42 patients (group A) and sacrificed in 13 (group B). Tactile, heat, and cold sensitivities were investigated by dividing GAN territory into seven areas. Comparisons between operated (OS) and nonoperated sides (NS) within each group, and between the OS of the two groups were made. The QoL questionnaire was administered.

RESULTS

In group A, normal tactile, heat, and cold sensitivities ranged from 16.7% to 66.7%, 11.9% to 73.8%, and 21.4% to 81%, respectively, in different OS areas. Significant differences between OS and NS were found, except for the preauricular superior area. In group B, normal tactile, heat, and cold sensitivities ranged from 0% to 61.5%, 0% to 53.8%, and 7.7% to 76.9%, respectively, in different OS areas. Significant differences between OS and NS were found except for the preauricular superior (tactile sensitivity), and preauricular superior and helix/concha areas (cold sensitivity). Comparing the OS tactile and thermic sensitivities between the two groups, only the lobule area showed differences. The preauricular inferior area was different only for heat. The QoL questionnaire showed different hypoesthesia extension between the two groups. All other items were comparable.

CONCLUSIONS

Sensory deficits are commonly reported despite GAN preservation. Lobule and preauricular inferior areas showed differences in terms of tactile and thermic sensitivities, with better outcomes in group A. QoL seems tolerable despite GAN sacrifice.

LEVEL OF EVIDENCE

4

Anatomic and histological study of great auricular nerve and its clinical implication

BACKGROUND

The great auricular nerve (GAN) is often sacrificed during parotidectomy, rhytidectomy, and platysma flap operation. Transection of the nerve results in a wooden numbness of preauricular region, pain, and neuroma. The aim of this study was to describe the branching patterns and distribution area of the GAN.

METHODS

Twenty-five embalmed, adult hemifacial Korean cadavers (16 males, nine females; mean age 62.5 years) were used in this study. The branching of the GAN was determined through careful dissection. The histological structure of the GAN was also examined by harvesting and sectioning specimens, and then viewing them with the aid of a light microscope.

RESULTS

The branching pattern of the anterior, posterior, deep, and superficial branches of the GAN could be classified into five types: type I (20%), where the deep branches arose from the anterior branch; type II (24%), where all branches originated at the same point; type III (28%), where the deep branch arose from the posterior branch; type IV (8%), where the superficial branches arose from the posterior branch; and type V (20%), where the anterior and posterior branches ran independently. A connection between the GAN and the facial nerve trunk was observed in all specimens, and a connection with the auriculotemporal nerve was observed in a few specimens. The total fascicular area of both regions decreased from proximal (1.42 mm2) to distal (0.60 mm2). There were 2.5 and 5 fascicles in the proximal and distal regions, respectively.

CONCLUSION

The results reported herein will help toward preservation of the GAN during surgery in the region of the parotid gland. Furthermore, the histologic findings suggest that the GAN would be a good donor site for nerve grafting.