Great Auricular Nerve Anatomy and Post-Facelift Neuropathic Pain
The great auricular nerve originates from the C2-C3 cervical plexus, emerges from the posterior border of the sternocleidomastoid muscle approximately 8.96 cm above the clavicle, and ascends obliquely across the muscle to innervate the skin over the lower auricle, earlobe, and mandibular angle—making it highly vulnerable during facelift procedures and a likely cause of your patient's ear and mandibular-angle pain three weeks postoperatively. 1, 2
Anatomical Course and Surgical Relevance
The GAN is a purely sensory branch of the superficial cervical plexus formed by contributions from C2 and C3 nerve roots 3, 2
The nerve emerges from behind the posterior border of the sternocleidomastoid (SCM) muscle at an average distance of 8.96 ± 1.85 cm (range 6.4-12.0 cm) superior to the clavicle 4
After emerging, the GAN ascends at an initial angle of approximately 64.5° relative to the posterior SCM border, which then changes to approximately 39.5° as it crosses the middle portion of the SCM muscle 4
The nerve runs almost parallel to the external jugular vein (EJV), separated by only 2.24 ± 0.79 cm on average, and lies approximately 0.60 cm posterior to the free edge of the platysma muscle 4, 1
Sensory Distribution Territory
The GAN provides sensation to three distinct anatomical regions: the inferior and ventral portions of the auricle (pinna), the skin overlying the mandibular angle, and the mastoid region 5, 1
This sensory territory precisely matches the distribution of pain your patient is experiencing three weeks post-facelift 5
Clinical Presentation of GAN Neuropathy
Great auricular neuropathy presents as circumscribed shooting, lancinating, or constant abrasive-quality pain in the preauricular region, mandibular angle, and inferior ear, characteristically aggravated by head movements, cervical rotation, mandibular movement, and direct palpation over the affected area. 5
Pain quality is typically described as neuropathic—burning, shooting, or lancinating paroxysms—rather than dull or aching 5, 3
The pain is exacerbated by movements that stretch or compress the nerve, including neck turning, jaw opening, and direct pressure on the nerve's superficial course 5
Complete or near-complete pain relief following diagnostic nerve block with local anesthetic is pathognomonic for GAN neuropathy 5, 3
Why Facelift Surgery Injures the GAN
The GAN's superficial location—running just beneath the platysma and parallel to the EJV—places it directly in the surgical field during rhytidectomy procedures 1, 2
The nerve is most vulnerable where it crosses the SCM muscle and as it ascends toward the ear, areas routinely dissected during facelift surgery 1
Injury mechanisms include direct transection, stretching during tissue elevation, compression from hematoma or edema, entrapment in sutures, or ischemia from cautery 2
Diagnostic Approach for Your Patient
Perform targeted physical examination by palpating along the posterior border of the SCM muscle 6-12 cm above the clavicle, assessing for Tinel's sign (shooting pain with percussion), and testing whether cervical rotation or jaw movement reproduces the pain. 5, 3
Map the exact distribution of sensory changes (hypoesthesia, hyperesthesia, or allodynia) to confirm it matches GAN territory rather than trigeminal nerve branches 5
If clinical suspicion is high, proceed directly to diagnostic ultrasound-guided GAN block with local anesthetic; immediate complete pain relief confirms the diagnosis 3
Electrophysiologic studies (nerve conduction studies of the GAN) can definitively confirm the diagnosis when the clinical picture is unclear, though this is rarely necessary when history and examination are classic 3
Imaging (MRI of the neck) is not indicated for typical post-surgical GAN neuropathy unless you suspect hematoma, abscess, or other structural complication 3
Management Algorithm
Immediate (Weeks 1-4 Post-Injury)
Initiate neuropathic pain medications: gabapentin (starting 300 mg three times daily, titrating to 900-1800 mg daily) or pregabalin (75 mg twice daily, titrating to 150-300 mg twice daily) 5
Add topical lidocaine patches or compounded creams to the affected area for localized relief 5
Perform diagnostic and therapeutic GAN block with local anesthetic (lidocaine or bupivacaine) plus corticosteroid under ultrasound guidance 3
If Pain Persists Beyond 4-8 Weeks
Repeat ultrasound-guided GAN blocks with longer-acting local anesthetic and corticosteroid at 2-4 week intervals 3
Escalate systemic neuropathic medications if partial response: consider duloxetine (30-60 mg daily) or tricyclic antidepressants (amitriptyline 10-50 mg nightly) 5
Avoid relying solely on opioids or NSAIDs, as these are typically ineffective for neuropathic pain and carry significant risks 5
Refractory Cases (>3 Months)
Consider surgical exploration with neurolysis (freeing the nerve from scar tissue) or neurectomy (complete nerve division) if conservative measures fail 2
Refer to a peripheral nerve surgeon or pain management specialist experienced in nerve blocks and neuromodulation 3
Critical Pitfalls to Avoid
Do not dismiss this as "normal post-surgical pain"—GAN neuropathy causes severe, debilitating pain that significantly impacts quality of life and will not resolve with simple analgesics 5
Do not confuse GAN neuropathy with trigeminal neuralgia; the latter affects different facial territories (V2 affects the cheek and upper lip, V3 affects the chin and lower lip but not the ear or mandibular angle) and is not related to cervical movement 6, 5
Do not order extensive imaging (brain MRI, CT) unless other cranial nerves are involved or you suspect central pathology—this is a peripheral nerve injury with a clear surgical etiology 3
Recognize that standard analgesics (acetaminophen, NSAIDs) and even opioids are typically ineffective for neuropathic pain; you must use neuropathic-specific medications 5
Do not delay nerve blocks beyond 4-6 weeks if medications are ineffective; early intervention with blocks improves outcomes 3