The impact of GAN sacrifice morbidity on the patient’s quality of life is tolerable and improves during the first postoperative year. However, GAN morbidity may be bothersome enough to warrant efforts to preserve the branch of the GAN when possible.38,39 In our study, the location where the GAN emerged from the posterior border of the sternocleidomastoid muscle (Erb’s point)5,6 was 87.61 ± 12.13 mm below the Frankfort horizontal plane, the most consistent reference. In contrast to other studies, the GAN was found approximately 1 cm posterior to the external jugular vein7,40 and was reported to emerge from under the sternocleidomastoid muscle, as measured from the bony external auditory canal at either 6.5 ± 0.9 cm or 9.8 ± 1.2 cm.7,11 Due to the delicate GAN branching pattern, 5 sides (16.1%) were accidentally cut while elevating the skin flap and so were excluded from the analysis. We feel that this unintentional cut is inevitable, but note that its incidence (16.1%) is less than that for the postoperative hypesthesia of the ear from parotid gland surgery, which has an estimated incidence of from 26% to 59%.41–44 The patterns of branching of the GAN was previously described by Ozturk et al.,11 where 4 types of branching patterns of the nerve were identified: branching at the superior third of the SCM (type 1), branching at the mid-third of the SCM (type 2), branching at the inferior third of the SCM (type 3), and no branching (type 4). The most common branching pattern was type 1(53.8%), followed by type 3 (26.9%), type 4 (15.4%), and type 2 (3.8%). However, this was based upon only the anterior and posterior branches. In contrast, in this study, we included the superficial and deep branches as well and so could classify 5 types of branching pattern. The most common branching pattern was type 3 (30.77%), where the deep branch originated from the posterior branch of the GAN and the anterior branch ran superficial distributed to the skin and surface of the parotid gland. This is similar to that previously reported,45 where the most frequently observed pattern (28%) was where the deep branch originated from the posterior branch of the GAN. These confirm the difference to Gray’s Anatomy9 that described the GAN as being divided into the anterior and posterior branches, and then the anterior branch bifurcated into the superficial and deep branches, which matches our type 1 branching pattern and accounts for only 19.23% of the patterns seen. The least common patterns were the trifurcation (type 2; 11.54%) and the bifurcation before emerging on to the sternocleidomastoid muscle (type 5; 11.54%).
From individual clinical experiences, a small and delicate GAN corresponds to subsequently finding a small and delicate FN. It would appear the converse also holds true in that a robust GAN is correlated with a similarly robust FNT.34–36 To the best of our knowledge, this study is the first attempt to confirm the initial pilot study37 by using a very delicate measurement capable of measuring to 0.01 mm (Figs. 2, 3). The results confirmed that the width of the FNT can be predicted from the width of the GAN before its bifurcation.
However, this study has some possible limitations. In addition to limited ethnical divergence, we studied cadavers, which can be associated with the shrinkage of soft tissue.46,47
1. Montgomery WW. Montgomery. Surgery of the Upper Respiratory System. 1989.2nd ed. Philadelphia, Pa.: Lea & Febiger.
2. Wormald R, Donnelly M, Timon C. ‘Minor’ morbidity after parotid surgery via the modified Blair incision. J Plast Reconstr Aesthet Surg. 2009;62:1008–1011.
3. Beahrs OH. The surgical anatomy and technique of parotidectomy. Surg Clin North Am. 1977;57:477–493.
4. Lohuis PJ, Tan ML, Bonte K, et al. Superficial parotidectomy via facelift incision. Ann Otol Rhinol Laryngol. 2009;118:276–280.
5. Ginsberg LE, Eicher SA. Great auricular nerve: anatomy and imaging in a case of perineural tumor spread. AJNR Am J Neuroradiol. 2000;21:568–571.
6. Leung MK, Dieu T, Cleland H. Surgical approach to the accessory nerve in the posterior triangle of the neck. Plast Reconstr Surg. 2004;113:2067–2070.
7. Lefkowitz T, Hazani R, Chowdhry S, et al. Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthet Surg J. 2013;33:19–23.
8. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. 1980;66:675–679.
9. Standring S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 2015:29: 41st ed. Edinburgh, Scotland: Churchill Livingstone; 442–474.e1.
10. Peuker ET, Filler TJ. The nerve supply of the human auricle. Clin Anat. 2002;15:35–37.
11. Ozturk CN, Ozturk C, Huettner F, et al. A failsafe method to avoid injury to the great auricular nerve. Aesthet Surg J. 2014;34:16–21.
12. Rees TD, Aston SJ. Complications of rhytidectomy. Clin Plast Surg. 1978;5:109–119.
13. Waterhouse N, Vesely M, Bulstrode NW. Modified lateral SMASectomy. Plast Reconstr Surg. 2007;119:1021–1028.
14. Hopping SB, Joshi AS, Tanna N, et al. Volumetric facelift: evaluation of rhytidectomy with alloplastic augmentation. Ann Otol Rhinol Laryngol. 2010;119:174–180.
15. Matarasso A, Elkwood A, Rankin M, et al. National plastic surgery survey: face lift techniques and complications. Plast Reconstr Surg. 2000;106:1185–1196.
16. Berry MG, Davies D. Platysma-SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010;63:793–800.
17. Marchac D, Sándor G. Face lifts and sprayed fibrin glue: an outcome analysis of 200 patients. Br J Plast Surg. 1994;47:306–309.
18. Lawson W, Naidu RK. The male facelift: an analysis of 115 cases. Arch Otolaryngol Head Neck Surg. 1993;119:535–541.
19. Scarborough D, Bisaccia E. The Webster-type face and neck lift: an extensive cervico-facial rhytidectomy employing a minimally invasive technique. Dermatol Surg. 2001;27:747–755.
20. Matarasso A, Wallach SG, Difrancesco L, et al. Age-based comparisons of patients undergoing secondary rhytidectomy. Aesthetic Surg J. 2002;22:526–530.
21. Stuzin JM. MOC-PSSM CME article: face lifting. Plast Reconstr Surg. 2008;121:1–19.
22. Monkhouse S. Cranial Nerves: Functional Anatomy. 2005.New York, United States of America: Cambridge University Press.
23. Pather N, Osman M. Landmarks of the facial nerve: implications for parotidectomy. Surg Radiol Anat. 2006;28:170–175.
24. Nishida M, Matsuura H. A landmark for facial nerve identification during parotid surgery. J Oral Maxillofac Surg. 1993;51:451–453.
25. Janfaza P, Cheney ML. Janfaza P, Nadol JB, Galla R, Fabian RL, Montgomery WW. Superficial structures of the face, head, and parotid region. In Surgical Anatomy of the Head and Neck. 2001:Philadephia, Pa.: Lippincott William & Wilkins; 1–48.
26. Ji YD, Donoff RB, Peacock ZS, et al. Surgical landmarks to locating the main trunk of the facial nerve in parotid surgery: a systematic review. J Oral Maxillofac Surg. 2018;76(2):438–443.
27. Kwak HH, Park HD, Youn KH, et al. Branching patterns of the facial nerve and its communication with the auriculotemporal nerve. Surg Radiol Anat. 2004;26:494–500.
28. Bernstein L, Nelson RH. Surgical anatomy of the extraparotid distribution of the facial nerve. Arch Otolaryngol. 1984;110:177–183.
29. Katz AD, Catalano P. The clinical significance of the various anastomotic branches of the facial nerve. Report of 100 patients. Arch Otolaryngol Head Neck Surg. 1987;113:959–962.
30. Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg. 2015;135:1318–1327.
31. Dulguerov P, Marchal F, Lehmann W. Postparotidectomy facial nerve paralysis: possible etiologic factors and results with routine facial nerve monitoring. Laryngoscope. 1999;109:754–762.
32. Witt RL. Facial nerve monitoring in parotid surgery: the standard of care? Otolaryngol Head Neck Surg. 1998;119:468–470.
33. Terrell JE, Kileny PR, Yian C, et al. Clinical outcome of continuous facial nerve monitoring during primary parotidectomy. Arch Otolaryngol Head Neck Surg. 1997;123:1081–1087.
34. Whear NM, Lopes V. The great auricular and the facial nerve: is there a correlation between the diameter of these nerves? Br J Oral Maxillofac Surg. 2001;39:162–163.
35. Rayatt S. Re: Whear NM, and Lopes V. The great auricular nerve and the facial nerve. Br J Oral Maxillofac Surg
2001; 39: 162-163. Br J Oral Maxillofac Surg. 2001;39:486.
36. Ezsias A. The great auricular and the facial nerve: is there a correlation between the diameter of these nerves?—observations. Br J Oral Maxillofac Surg. 2002;40:348.
37. Colbert S, Parry DA, Hale B, et al. Does the great auricular nerve predict the size of the main trunk of the facial nerve? A clinical and cadaveric study. Br J Oral Maxillofac Surg. 2014;52:230–235.
38. Ryan WR, Fee WE Jr.. Great auricular nerve morbidity after nerve sacrifice during parotidectomy. Arch Otolaryngol Head Neck Surg. 2006;132:642–649.
39. Brown JS, Ord RA. Preserving the great auricular nerve in parotid surgery. Br J Oral Maxillofac Surg. 1989;27:459–466.
40. Murphy R, Dziegielewski P, O’Connell D, et al. The great auricular nerve: an anatomic and surgical study. J Otolaryngol Head Neck Surg. 2012;41:S75–S77.
41. Biswas AK, Akhtar N, Debnath TK, et al. Complications of parotid Surgery – A study of 30 cases. Bangladesh J Otorhinolaryngol. 2015 Apr;21(1):23–27.
42. Linder TE, Huber A, Schmid S. Frey’s syndrome after parotidectomy: A retrospective and prospective analysis. Laryngoscope. 1997 Nov;107(11):1496–1501.
43. Koch M, Zenk J, Iro H. Long-term results of morbidity after parotid gland surgery in benign disease. Laryngoscope. 2010 Apr;120(4):724–730.
44. Correia M, Noronha FP, Audi P. Superficial parotidectomy an excellent procedure in the management of benign parotid tumors – outcome of various complications and tumor recurrence. Med J DY Patil Univ. 2016 Sep;9(5):600–604.
45. Yang HM, Kim HJ, Hu KS. Anatomic and histological study of great auricular nerve and its clinical implication. J Plast Reconstr Aesthet Surg. 2015 Feb 28;68(2):230–236.
46. Chen CH, Hsu MY, Jiang RS, et al. Shrinkage of head and neck cancer specimens after formalin fixation. J Chin Med Assoc. 2012;75:109–113.
47. Kerns MJ, Darst MA, Oslen TG, et al. Shrinkage of cutaneous specimens: formalin or other factors involved? J Cutan Pathol. 2008;35:1093–1096.