Craniomaxillofacial surgeons must be prepared to diagnose and treat acute and chronic facial pain. Fortunately for both the patient and the surgeon, post-operative pain following extensive cosmetic or craniofacial surgery, for congenital, trauma, or tumor extirpation, is often modest in degree, and readily treated by traditional pain medication approaches. By definition, if pain persists for six months, then the problem of chronic facial pain arises. This pain must be distinguished from non-traumatic atypical facial pain and traditional trigeminal neuralgia “tic-doloreaux.” (see section on Trigeminal Neuralgia) The cause of the pain can be from injuries to various branches of the sensory nerves of the face, resulting in scarring around the nerve (entrapment) or scarring of the internal nerve itself (neuroma).
How can neuromas of the trigeminal nerve occur?
Surgery to remove tumors of the face or jaw
Cosmetic surgery, such as a face lift
Dental extractions or orthognathic jaw surgery
Trauma such as automobile accidents
Which specific nerves can be involved?
The specific trigeminal branch nerve injuries we treat include the supra-orbital, supra-trochlear, zygomaticofrontal, zygomaticofacial, infraorbital, posterior superior alveolar, and inferior alveolar. Other nerves which can be injured and lead to pain in face and scalp include the greater auricular and occipital, which are not technically branches of the trigeminal nerve.
How is the diagnosis made?
For patients who fail extensive non-operative management, surgery may be indicated. Patients are selected for surgery based on history of trauma to regional nerve sites, physical exam, CT scan review, computer-aided neurosensory testing, and diagnostic nerve blocks.
What types of surgeries can be done if non-operative pain management is not successful?
We find that the patient with post-operative chronic facial pain refractory to extensive non-operative management can achieve relief through hardware removal, neurolysis (decompression) and/or neuroma resection, with nerve grafting if needed. Nerve stimulators may be considered as well.
Patients benefit from a multidisciplinary pain team approach to ensure optimal care. Surgeons must be selective in recommending surgical treatment to patients with persistent oral and facial pain, i.e. due to specific trigeminal nerve injuries. However, when surgery is indicated, patients have a very good chance of improvement.