Superselective Craniofacial Nerve Decompression in a Pediatric Patient: A Case Report.

Peripheral nerve release has emerged as a viable treatment option for pharmacologically refractory migraines secondary to craniofacial compression neuropathies. Although occipital nerve decompression is well described, management of supraorbital and zygomaticotemporal nerve compression is less characterized despite its relevance in patients with multi-nerve compression. Conventional techniques rely on long, blepharoplasty-like incisions to address both supraorbital and temporal compression sites. However, extensive areas of dissection may increase complication rates and reduce aesthetic outcomes. We present a pediatric case in which a super-selective supraorbital and temporal nerve release was implemented as part of a staged surgical approach. The technique was applied in a 15-year-old girl with posttraumatic chronic occipital neuralgia refractory to medical management. Following conventional occipital nerve decompression, additional trigger points became apparent, warranting a minimally invasive supraorbital nerve decompression. Targeted release of the bilateral supraorbital nerve was performed using 1 cm incisions along the inferior border of the brow. Immediate and sustained resolution of frontal migraine was achieved, without sensorimotor dysfunction and with minimal scar burden. Residual temporal pain was later addressed with decompression of the zygomaticotemporal nerve, utilizing bilateral pretrichial 1 cm incisions, preserving muscle integrity and limiting iatrogenic facial nerve injury. One year postoperatively, the patient demonstrated complete resolution of occipital and frontal symptoms with marked improvement in temporal migraines. This case illustrates the application of a clinically guided, staged surgical approach for frontotemporal compression neuropathies in a pediatric patient, offering targeted neural release, concealed incisions, and minimal risk of iatrogenic nerve injury.