How We Do It: Prevention of Postoperative Scarring after Ner… : Plastic and Reconstructive Surgery

Surgery for sensory nerve decompression has been popularized in the management of intractable migraine headache.1,2 Among the sensory nerves decompressed, the greater, lesser, and third occipital nerves are the targets for nuchal pain radiating forward. We recently initiated these procedures in Israel.

Postoperative adhesions have been reported to be the major cause of persistent or recurrent nuchal pain after appropriate nerve decompression by experienced surgeons and tend to be attributable to excessive scar tissue around the nerve. Reoperation around this scar tissue is known to be more challenging.3 Many techniques have been proposed to prevent this recompression, including cushioning the nerve with a subcutaneous fat flap1,2,4,5 or intraoperative corticosteroid injection,3 with temporary results. In this article, we propose our innovation.

After induction of anesthesia, patients are placed in the prone position. A swath of hair is cut in the midline in the occipital region from the inion to the hairline and the area is injected with local anesthetic.

An incision is made in the midline just below the inion. After identifying the greater occipital nerve, it is followed in both directions and appropriate decompression of the pressure sites is completed.

After identification and isolation of the greater occipital nerve and its branches, our practice is to cut a ~4 cm sleeve of Gore-Tex (W. L. Gore & Associates, Newark, Del.) longitudinally and tailor it to shield the now released nerve along its length (Figs. 1 and 2). Gore-Tex is an inert, biocompatible, strong, conformable, and easy-to-handle grafting material used by vascular surgeons. Approximation of the edges of the Gore-Tex with Vicryl 5-0 (Ethicon, Somerville, N.J.) recloses the sleeve over the nerve. We believe this modification is an improvement over the classic surgery described by Guyuron1–3 because Gore-Tex provides a permanent barrier preventing recompression of the nerve. Its use has not retarded the recovery of the nerve, with normal scalp sensation attained after several months.

Fig. 1.:

Distant view after isolation of the greater occipital nerves (GON) and their branches with fenestrated Gore-Tex sleeves (blue arrows). The edges of the Gore-Tex are sutured.

Fig. 2.:

Closer view after isolation of the greater occipital nerves (GON) and their branches with fenestrated Gore-Tex sleeves (blue arrows). The edges of the Gore-Tex are sutured.

An important aspect that we have noted in the immediate postoperative period, not mentioned in the previous literature, is a common complaint of bilateral frontal pressure. We believe it is secondary to the prolonged operative prone position (despite judicious cushioning). Local anesthetic injection postoperatively at the supraorbital pressure points can often provide better relief than analgesics or nonsteroidal anti-inflammatory drugs.

Five patients have received the Gore-Tex sleeves, with a follow-up time ranging between 4 and 18 months, with the minimum follow-up time reported in the literature being 12 months.3 All report reduction of pain in the nuchal area without a foreign body sensation in the neck. There appears to be a tendency for other trigger points (temple or face) to awaken after the nuchal surgery, which will be a subject for further study after adequate follow-up.

We present the successful use of a Gore-Tex shield over the greater occipital nerve to prevent recompression with an insetting time of less than 5 minutes. We recommend the application of this modification.


The authors have no conflicts of interest or financial interests to declare. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.


1. Mosser SW, Guyuron B, Janis JE, Rohrich RJ. The anatomy of the greater occipital nerve: Implications for the etiology of migraine headaches. Plast Reconstr Surg. 2004;113:693–697.

2. Chmielewski L, Liu MT, Guyuron B. The role of occipital artery resection in the surgical treatment of occipital migraine headaches. Plast Reconstr Surg. 2013;131:351e–356e.

3. Lineberry K, Lee M, Monson A, Guyuron B. Intraoperative corticosteroid injections in migraine surgery. Plast Reconstr Surg. 2015;135:393e–396e.

4. Gfrerer L, Austen WG, Janis JE. Migraine surgery. Plast Reconstr Surg Glob Open 2019;7:e2291.

5. Janis JE, Hatef DA, Ducic I, et al. The anatomy of the greater occipital nerve: Part II: Compression point topography. Plast Reconstr Surg. 2010;126:1563–1572.


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