2. CONTENTS
1. INTRODUCTION
2. SURGICAL ANATOMY
3. TYPES OF PAROTIDECTOMY
4. PREOPERATIVE EVALUATION
5. SUPERFICIAL PAROTIDECTOMY
6. TOTAL PAROTIDECTOMY
7. EXTENDED TOTAL PAROTIDECTOMY
8. COMPLICATIONS
9. REFERENCES
3. INTRODUCTION
A parotidectomy is the surgical excision (removal) of
the parotid gland, the major and largest of the salivary
glands.
The procedure is most typically performed due to benign
or malignant tumors.
The majority of parotid gland tumors are benign,
however 20% of parotid tumors are found to be
malignant.
4. Rule of 80’s:
-80% of parotid tumors are benign
-80% of parotid tumors are pleomorphic adenomas
-80% of salivary gland pleomorphic adenomas
occur in the parotid
-80% of parotid pleomorphic adenomas occur in the
superficial lobe
-80% of untreated pleomorphic adenomas remain
benign
5. SURGICAL ANATOMY
Parotid gland
The paired parotid glands
are the largest of the major
salivary glands
weigh, on average, 15–30
g.
Preauricular region
9. Superficial Muscular Aponeurotic
System (SMAS)
SMAS is a fibrous network that
invests the facial muscles, and
connects them with the dermis.
Platysma inferiorly;
Zygomatic arch superiorly
Facial nerve courses deep to the
SMAS and the platysma.
Parotid fascia
10. Facial nerve and
branches
Structures within the parotid gland
13. Lymphatics:
Superficial nodes drains
auricle, anterior part of
scalp, upper part of face
Deeper nodes receives
lymph from external
acoustic meatus, middle
ear, auditory tube, nose,
palate and deep parts of
cheek.
Cervical lymphnodes
15. TYPES OF PAROTIDECTOMY
Partial parotidectomy: Resection of parotid
pathology with a margin of normal parotid tissue.
This is the standard operation for benign pathology
and low grade malignancies
Superficial parotidectomy: Resection of the entire
superficial lobe of parotid and is generally used for
metastases to parotid lymph nodes e.g. from skin
cancers, and for high grade malignant parotid
tumors.
16. Total parotidectomy: This involves resection of the
entire parotid gland, usually with preservation of the
facial nerve
Extended Total Parotidectomy: Removal of the
superficial and deep parotid gland also may be
extended to involve adjacent structures.
17. PREOPERATIVE EVALUATION
A thorough history is obtained prior to consideration
for surgery.
Symptoms of sensory loss, trismus and facial
weakness are worrisome for local tumor invasion by
a malignant neoplasm.
The past medical history should include information
regarding any prior cutaneous lesions or
malignancies.
18. In addition, the patient should be queried about any
prior radiation exposure to the head and neck
including dental radiographs.
Smoking is associated with Warthin’s tumor and,
therefore, should be investigated.
This tumor can also occur bilaterally, thus any
history of a prior parotid tumor should be elicited.
19. Cranial nerve function should be examined and
facial nerve function should be evaluated carefully.
Facial nerve paralysis is usually an indication of
nerve invasion by a malignant tumor.
Fixation to the overlying skin, limited mobility of the
mass, and associated cervical lymphadenopathy
are other signs suggestive of malignancy.
20. FINE-NEEDLE ASPIRATION BIOPSY (FNAB)
It is an accurate and useful investigation for the
diagnosis of a parotid mass.
FNAB allows for improved patient selection for
surgery since it can identify conditions such as
reactive lymph nodes or cysts that might mimic
parotid neoplasms clinically.
The information gained by FNAB is useful for
patient counseling, surgical timing and planning,
and guiding the direction of preoperative
consultation
21. RADIOLOGY
Radiological investigation is not routinely required
with parotid tumors.
It is recommended for surgical planning with tumors
that are large, fixed, and are associated with facial
nerve involvement, trismus, and parapharyngeal
space involvement.
MRI is a valuable investigation with recurrence of
pleomorphic adenoma as it is often multifocal.
22. PREOPERATIVE CONSENT
Scar
Anesthesia in the greater auricular distribution
Facial nerve weakness
Facial contour
Prominence of auricle
Frey’s syndrome (gustatory sweating)
23. PREOPERATIVE CONSENT
Scar
Anesthesia in the greater auricular distribution
Facial nerve weakness
Facial contour
Prominence of auricle
Frey’s syndrome (gustatory sweating)
24. SUPERFICIAL PAROTIDECTOMY
Superficial lobe parotidectomy describes removal of all
or a portion of the parotid gland superficial to the facial
nerve.
The most common indications are:
1. Benign or low grade tumor of the superficial lobe of the
parotid gland
2. metastases to parotid lymph nodes from adjacent sites
of skin cancer or melanoma, or from cancer of the
external auditory meatus.
25. 3. Access to the deep lobe of the gland or other
structures deep to the facial nerve.
4. Chronic inflammation of parotid gland, resistant to
conservative treatment.
26. ANAESTHESIA
General anaesthesia
Short-acting muscle relaxation for intubation only,
so that facial nerve may be stimulated and/or
monitored
No perioperative antibiotics unless specifically
indicated
Hyperextend the head, and turn to opposite side
27. Infiltrate with vasoconstrictor along planned skin
incision,
Keep corner of eye and mouth exposed so as to be
able to see facial movement when facial nerve
mechanically or electrically stimulated.
28. TECHNIQUE
A modified Blair incision
An alternative incision is
a modified face-lift
incision.
29. The ipsilateral face is
prepared with an antiseptic
solution and the surgical
field is draped with a
transparent adhesive
sterile drape.
Nerve electrodes are
placed in the ipsilateral
facial muscles and tested
for electrical integrity.
30. The skin incision is
made through the
subcutaneous tissues
and platysma muscle.
Greater auricular
nerve.
31. An anterior flap is
elevated superficial to
the greater auricular
nerve and the parotid
fascia.
Anterior flap- the
peripheral branches of
the facial nerve.
A posterior, inferior flap-
expose the tail of the
32. The tail of the parotid gland is dissected
off of the sternocleidomastoid muscle
by dissecting deep to the posterior
branch of the greater auricular nerve.
Next, the posterior belly of the digastric
muscle is exposed with further
elevation of the tail of the parotid gland
The posterior belly of the digastric
muscle serves as a landmark for the
facial nerve.
During elevation of the tail of the
parotid, the integrity of the posterior
facial vein also is preserved if possible.
33. The preauricular space is
opened by division of the
attachments of the parotid
gland to the cartilaginous
external auditory canal
with blunt and sharp
dissection.
This plane of dissection
exposes the tragal
cartilage pointer which
serves as another
landmark for the facial
34. A wide plane of
dissection from the
zygoma to the digastric
muscle is created to
facilitate exposure of the
facial nerve.
The gland is carefully
retracted anteriorly.
This exposes the
operative field for
identification of the facial
35. The facial nerve is
identified using
anatomic landmarks:
1. Posterior belly of the
digastric muscle
2. Mastoid tip
3. Tragal cartilage pointer
4. Tympanomastoid
suture.
36. If the proximal segment
of the facial nerve is
obscured, retrograde
dissection of one or
more of the peripheral
facial nerve branches
may be necessary to
identify the main trunk.
37. When necessary, the
facial nerve can be
identified in the
mastoid bone by
mastoidectomy and
followed peripherally.
38. Once the facial nerve is
identified, the parotid
gland superficial to the
facial nerve is divided
carefully, preserving the
integrity of the nerve.
The exact location of the
facial nerve should
always be determined
prior to division of the
gland tissue.
39. The facial nerve is
followed peripherally,
the desired portion of
the gland is dissected
from facial nerve
branches and the
specimen removed.
40. The facial nerve is preserved except in cases when
confirmed malignancy is found invading the nerve.
In instances of facial nerve invasion by carcinoma,
facial nerve resection is performed.
Proximal and distal margins of the resected nerve are
examined histologically by frozen section to ensure
clear surgical margins.
41. If the tumor involves the stylomastoid foramen,
mastoidectomy is performed to identify the proximal
facial nerve in the fallopian canal to achieve a clear
margin.
Immediate nerve reconstruction by a nerve
interposition graft is usually indicated if facial nerve
resection is performed.
42. After the superficial
portion of the gland is
removed.
The wound is carefully
inspected and bleeding
sites are controlled with
bipolar electrocautery
or ligatures
43. The integrity of the
facial nerve is
confirmed visually and
by electrical stimulation
of the main trunk of the
facial nerve and all the
peripheral branches.
44. A neck dissection is performed for clinically positive
nodes.
For the clinically negative neck, the first echelon
nodes are inspected.
Enlarged or suspicious nodes are examined and a
neck dissection is performed if metastatic disease
is confirmed by frozen section.
45. The wound is irrigated,
realigned, and closed in
layers over a closed-
suction drain.
The drain is usually
removed on the first
postoperative day and
the skin sutures are
removed within one
week.
46. Adjuvant radiation therapy is recommended for
select malignancies including
i. metastatic cutaneous squamous cell carcinoma
ii. high-grade and advanced parotid malignancies
47. TOTAL PAROTIDECTOMY
Total parotidectomy is the total removal of the
superficial and deep parotid gland.
The operation may involve sparing or sacrifice of
the facial nerve branches or trunk depending on
tumor extent to the nerve.
48. INDICATIONS:
1. Metastasis to a superficial parotid node from a
primary parotid tumor or an extraparotid
malignancy
2. Parotid malignancy that indicates metastasis by
involvement of cervical lymph nodes
3. High-grade parotid malignancy with a high risk of
metastasis.
49. 4. Primary parotid malignancies originating in the
deep lobe and for primary malignancies that
extend outside the parotid gland.
5. Multifocal tumors, such as oncocytomas, to
ensure complete removal
50. EXTENDED TOTAL PAROTIDECTOMY
Removal of the superficial and deep parotid gland
also may be extended to involve adjacent
structures such as the overlying skin, the underlying
mandible, the temporal bone and external auditory
canal, or the deep musculature of the
parapharyngeal space.
These extensions are dictated by tumor growth and
behavior.
52. 5. Removal of superficial gland
6. Deep parotidectomy
7. Total Parotidectomy with Facial Nerve Sacrifice
8. Resection of Adjacent Structures and
Reconstruction
53. PREPARATION
The operation is performed with the patient under
general endotracheal anesthesia.
Endotracheal tube is positioned and taped to the
oral commissure and cheek opposite to the lesion.
The patient is placed in a 45° reverse-
trendelenburg position or lounge-chair position with
the head higher than the heart.
54. The head is turned to the opposite side of the
lesion, and the neck is extended by placement of a
rolled sheet under the shoulders.
The patient is prepared by sterile scrub and draped
so that the ear, lateral corner of the ipsilateral eye,
ipsilateral oral commissure, and entire ipsilateral
neck are visible in the field.
55. If facial nerve monitoring is to be used, the nerve
monitor is placed in the orbicularis oris and
orbicularis oculi muscles to ensure upper and lower
division monitoring.
The surgeon stands on the side of the patient
ipsilateral to the gland to be dissected, the assistant
stands at the head and opposite the surgeon, and
the scrub technician stands on the side of the
surgeon.
66. A small curved clamp is oriented perpendicular to
the anticipated direction of the facial trunk to
elevate tissues layer by layer.
Scissors are never used for dissection down to the
nerve, and no tissue is cut in this area until the
nerve is seen.
Blunt dissection proceeds posterior to anterior until
the surgeon identifies the nerve as a white cord 2–3
mm wide.
67.
68. REMOVAL OF THE SUPERFICIAL GLAND
The gland is separated at its edge, the temporal or
marginal branches being followed to the periphery.
The thickest fascia is encountered
posterosuperiorly; this must be divided sharply or
the surgeon will make tunnels into the gland along
the nerve.
Posteriorly- branches of the superficial temporal
vein may be encountered.
69. Vessels directly adjacent to the nerve branches should
not be cauterized until the superficial lobe is completely
mobilized.
After following a nerve branch to its peripheral
emergence from the parotid gland, the surgeon returns
to a proximal position along that nerve and searches
for another branch to follow.
Dissection progresses from posterior to anterior and
either superiorly or inferiorly until the superficial gland
has been completely separated from the facial nerve
and the deep parotid gland.
70. At this point, the surgeon should have a clear
impression of the relationship of the tumor to the
facial nerve, superficial gland, deep gland, and
surrounding structures.
It may be necessary to dissect along the tumor
capsule to separate it from the deep gland and
facial nerve.
Careful retraction and meticulous dissection can
prevent rupture of the tumor capsule, which is often
71. The gland is now left attached to only the parotid
duct.
The surgeon inspects this area to ensure that no
buccal branches are adherent to the duct.
The duct is divided and ligated, and the specimen is
sent for examination by the pathologist.
The wound should now be irrigated and the field
inspected for bleeding vessels, which are ligated.
75. The gland is completely freed from attachment to any
adjacent structures and sent for frozen-section
pathologic examination.
Small vessels around the deep gland adjacent to the
mastoid and trunk can be cauterized using the bipolar
forceps.
The wound is irrigated, and meticulous hemostasis is
achieved.
If necessary, the incision can be extended for neck
dissection at this time.
76. At the conclusion of the operation, a suction drain is
placed in the wound through a separate stab
incision in the postauricular skin and sewn into
place.
The wound is closed with interrupted absorbable
sutures
Dressing or antibiotic ointment can be applied.
Patient is awakened and extubated.
77. TOTAL PAROTIDECTOMY
WITH FACIAL NERVE SACRIFICE
If facial nerve function is normal preoperatively,
even in patients with malignancy, then the nerve
can be preserved with careful dissection of the
tumor off the nerve sheath.
If the nerve is paretic or fully paralyzed
preoperatively, then it is involved with tumor and is
normally resected during tumor resection.
78. Nerve that is clearly invaded by high-grade
malignant tumor should be resected with the
specimen to negative proximal and distal margins.
This may necessitate sacrificing peripheral
branches, divisions, or even the main trunk of the
facial nerve.
Intraoperatively, a nerve that is infiltrated with tumor
will appear swollen and usually darker than the
normal glistening white appearance of normal facial
79. After negative proximal and distal facial nerve
margins are obtained, the nerve is reconstructed
with primary neurorraphy or grafting.
Mastoidectomy and nerve mobilization may be
necessary to attain proper length of the facial nerve
for tension-free anastomosis.
80. Appropriate grafts include:
i. ipsilateral greater auricular nerve if it is not
involved with tumor
ii. ipsilateral sural nerve graft.
Peripheral branches can be grafted
i. proximal facial nerve
ii. ipsilateral hypoglossal nerve
81. RESECTION OF ADJACENT STRUCTURES
AND RECONSTRUCTION
The operation may be extended to involve resection
of adjacent structures that are involved with tumor.
It may include
i. lateral or subtotal temporal bone resection,
ii. partial mandibular resection,
iii. resection of the overlying skin,
iv. resection of portions or all of the auditory canal,
and
v. resection of surrounding musculature.
82. Options for reconstruction include
i. primary closure,
ii. dermal fat grafting,
iii. muscle transposition with loco regional flaps of
the sternocleidomastoid or pectoralis muscles,
iv. micro vascular cutaneous, musculocutaneous,
and innervated muscular flaps.
Again, the reconstruction will be guided by the
functional and aesthetic goals of the surgeon and
patient.
84. Inadequate hemostasis before
closure.
Suction drain reduces
possibility of postoperative
hematoma.
Treatment:
i. Evacuation of hematoma
ii. Control of bleeding points
iii. Reinsertion of suction drain
and closure.
HEMATOMA
85. Infection is rare
Some tumors presents with obstructive symptoms if
infected.
Prophylactic antibiotics are given if operating on an
infected gland.
INFECTION
86. Temporary or permanent
Partial or total
Neuropraxia- due to
stretching of the nerve.
If the nerve is intact at the
end of procedure-
recovery within few weeks.
FACIAL NERVE PALSY
87. If the palsy is severe and recovery is prolonged-
transcutaneous nerve stimulation of facial muscles.
Problems with eye closure-
i. protective glasses or tape the eyelid to prevent
exposure keratitis.
ii. Temporary tarsorrhaphy or paralysis of eyelid
elevator with botulinum toxin to allow closure of
upper eyelid.
88. When palsy is due to partial or total loss of facial
nerve:
i. reconstruction
ii. rehabilitation of face
89. Presents after suture
removal at the suture
line and posterior to
ear lobule.
Pressure dressing.
Drains
Anticholinergic drugs-
to reduce salivary
secretion
SALIVARY FISTULA
90.
91. Auriculotemporal
syndrome.
60% of all
parotidectomy cases.
Discomfort, localized
facial sweating and
flushing during
mastication.
FREY’S SYNDROME
92. Due to parasympathetic
and sympathetic
secretomotor stimuli
misdirected to
cholinergic receptors of
sweat glands during
healing after parotid
surgery.
93. The iodine test administered
by applying an alcohol–
iodine–oil solution (3 g
iodine, 20 mL castor oil, and
200 mL absolute alcohol)
described by Laage-Hellman
The solution was applied on
the lateral portion of the face
that had been surgically
treated and the upper region
of the neck.
94. The solution was allowed
to dry and was covered
lightly with starch
powder.
The patients received
lemon candy for a
gustatory stimuli for 10
minutes.
Discoloration of the
starch iodine mixture
was interpreted as a
95. There is no effective treatment, but various options
are described:
i. Injection of Botulinum Toxin
ii. Surgical transection of the nerve fibers
iii. Application of an ointment containing
an anticholinergic drug such as scopolamine
96. Incision mark
Sunken cheek due to
loss of parotid gland and
fat.
Rotation of
sternomastoid muscle
flap at the time of
surgery.
Free flaps.
COSMETIC DEFORMITY
97. REFERENCES
1. Salivary Gland Disorders: Eugene N. Myers, Robert
L. Ferris; Springer.
2. Parotidectomy : Johan Fagan : Open Access Atlas
Of Otolaryngology, Head & Neck Operative Surgery
3. Maxillofacial Surgery: Second Edition; Volume 1:
Peter Wardbooth.
4. Operative Maxillofacial Surgery; John D Langdon
and Mohan F Patel.
5. Internet
The paired parotid glands are the largest of the major salivary glands and weigh, on average, 15–30 g.
Located in preauricular region and along the posterior surface of the mandible
The parotid gland is bounded superiorly by the zygomatic arch.
Inferiorly, the tail of the parotid gland extends down and abuts the anteromedial margin of the sternocleidomastoid muscle.
This tail of the parotid gland extends posteriorly over the superior border of the sternocleidomastoid muscle toward the mastoid tip.
The deep lobe of the parotid lies within the parapharyngeal space
The parotid duct exits the gland anteriorly, crosses the masseter muscle, curves medially around its anterior margin, pierces the buccinator muscle, and enters the mouth opposite the 2nd upper molar tooth.
The superficial lobe, overlying the lateral surface of the masseter.
The deep lobe is medial to the facial nerve and located between the mastoid process of the temporal bone and the ramus of the mandible.
An accessory parotid gland may also be present lying anteriorly over the masseter muscle between the parotid duct and zygoma.
Its ducts empty directly into the parotid duct through one tributary
SMAS is a fibrous network that invests the facial muscles, and connects them with the dermis.
It is continuous with the platysma inferiorly; superiorly it attaches to the zygomatic arch.
In the lower face, the facial nerve courses deep to the SMAS and the platysma.
The parotid glands are contained within two layers of parotid fascia, which extend from the zygoma above and continue as cervical fascia below.
Enters through posteromedial surface and exits through anteromedial surface of the parotid gland
Main trunk divides into the upper temporofacial and lower cervicofacial divisions approximately 1.3 cm from the stylomastoid foramen.
The upper temporofacial division forms the frontal, temporal, zygomatic, and buccal branches.
The lower cervicofacial division forms the marginal mandibular and cervical branches.
It gives off the transverse facial artery inside the gland before dividing into the internal maxillary and the superficial temporal arteries
The maxillary and superficial temporal veins merge into the retro-mandibular vein within the parotid gland, but are not responsible for draining the gland.
Venous drainage of the parotid itself is to tributaries of external and internal jugular veins.
Parotid lymphnodes are embedded in the gland, especially near its superficial surface.
Both groups drain to cervical lymphnodes.
Scar: Usually very good healing ex-cept over the mastoid where some scarring may occur
Anaesthesia in the greater auricular distribution: Skin of inferior part of auricle, and overlying the angle of the mandible
Facial nerve weakness: Temporary weakness common (<50%); permanent weakness rare
Facial contour: loss of parotid tissue leads to a more defined angle of mandible, and deepening of retromandibular sulcus
Prominence of auricle: This is probably due to loss of innervation of the postauricular muscles and preauricular scarring
Frey’s syndrome (gustatory sweating): Although common, it only very rarely is bad enough to require treatment with Botox injection
A modified Blair incision is planned in a preauricular crease coursing around the ear lobule and then into an upper neck crease
Methylene blue can be used to mark points along the proposed incision, which facilitates proper wound alignment and closure.
The ipsilateral face is prepared with an antiseptic solution and the surgical field is draped with a transparent adhesive sterile drape to allow visualization of facial motion.
If electrophysiologic facial nerve monitoring is to be used intraoperatively, nerve electrodes are placed in the ipsilateral facial muscles and tested for electrical integrity.
The skin incision is made with a scalpel and carried down through the subcutaneous tissues and platysma muscle.
Care is taken to avoid division of the greater auricular nerve.
An anterior flap is elevated superficial to the greater auricular nerve and the parotid fascia (Fig. 14.4).
Elevation of a thick flap is desirable to reduce the occurrence of Frey’s syndrome while carefully avoiding violation of any neoplasm at the surface of the gland.
As the flap is elevated toward the anterior aspect of the gland, the peripheral branches of the facial nerve are carefully avoided.
A posterior, inferior flap is also elevated to expose the tail of the parotid gland.
After elevation, the flaps are retracted with silk sutures or selfretaining hooks.
The facial nerve usually courses superficial to this vessel and division of this structure can contribute to increased venous bleeding during dissection of the gland.
Occasionally some or all of the branches of the facial nerve will be found deep to the vein.
Care must be taken to avoid pressure or traction injury of the facial nerve during retraction of the gland.
Anatomic distortion by a neoplasm or operative manipulation must be considered.
In cases of previous parotid surgery or recurrent tumor, the usual dissection described above is not always possible.
If any injured facial nerve branches are identified, they are repaired immediately using a microscopic repair technique.
The incision site is marked with a surgical marker.
The incision begins in the preauricular crease at the superior root of the helix and curves gently below the lobule, and then turns anteriorly to run horizontally in a skin crease approximately two finger widths below the angle of the mandible
The surgeon may crosshatch the incision lines superficially with a no. 10 or 15 blade to assist in precise realignment during closure.
The incision is then made from superior to inferior through the skin into the subcutaneous tissue with the scalpel.
Flap should be raised immediately over the parotid fascia, which is recognizable as a white fibrous layer deep to the subcutaneous fat and superficial musculoaponeurotic system layer.
Care should be taken not to enter a superficial tumor or the substance of the gland during flap elevation.
Flap elevation continues with Jones scissors spread open perpendicularly along the parotid
fascia; the scissors opens tunnels along the parotid gland
which are then connected with blunt and sharp dissection
over the parotid fascia
The anterior edge of the sternocleidomastoid muscle is identified, and the greater auricular nerve and external jugular vein, located just anterior to the nerve, are identi-
The parotid gland is next separated from the anterior sternocleidomastoid muscle by sharp dissection.
The gland is secured with Kocher clamps along its inferior border away from any tumor and retracted superomedially to assist in dissection.
The gland also is separated bluntly from the tragal cartilage by spreading with Jones scissors parallel to the plane of the cartilage down to the level of the tragal cartilaginous pointer.
After the parotid gland has been completely separated from the sternocleidomastoid muscle and the tragus, the posterior belly of the digastric muscle should be identified.
The search for this muscle should not be too low in the surgical field, thereby putting the internal jugular vein or accessory nerve at unnecessary risk.
too anterior in the field, puts the marginal branch of the facial nerve at risk.
The mastoid tip and the posterior border of the angle of the mandible serve as landmarks for the posterior digastric muscle.
Once the muscle belly is identified immediately deep to the angle of the mandible, the remainder of the parotid gland is freed with blunt dissection.
At this point, entire inferior surface of the parotid gland, the posterior belly of the digastric muscle, mastoid tip and tragal cartilage is exposed.
The main trunk of the facial nerve exits the stylomastoid foramen immediately posterior to the styloid process.
The nerve gives off branches to the posterior belly of the digastric muscle and postauricular muscles before it turns anterolaterally and enters the parotid gland just anterior to the border where the digastric muscle inserts into the mastoid.
Tumors may thin the nerve or displace the trunk, but the position where the nerve enters the gland is constant.
Placing a finger on the mastoid tip, the surgeon uses the position of the cartilaginous tragal pointer and superior edge of the digastric muscle to identify the position of the facial nerve.
It may be helpful to identify deeper structures such as the styloid process or tympanomastoid suture line to aid in nerve identification.
Further mobilization is performed by separating gland from the nerve, proceeding anteriorly; often the assistant will notice some twitching of the face during this separation
The surgeon should dissect distally along the nerve to identify the pes and confirm that the main trunk has been identified proximal to any significant branches.
these veins can be cauterized with bipolar cautery or ligated depending on their size.
The essence of deep parotidectomy is vascular control.
Once the surgeon has made the decision to perform deep parotid gland removal, the intraglandular segments of the external carotid artery and deep veins are ligated and divided.
The superficial temporal artery and vein are ligated at the superior periphery of the gland.
The posterior facial vein is divided and ligated.
The transverse facial artery is divided at the superior anterior periphery of the gland.
The only vascular structures remaining at this point are the internal maxillary artery and venous tributaries to the pterygoid musculature located at the posterior border of the masseter muscle and mandibular ramus.
After control of the intraglandular vessels is obtained, the facial nerve trunk and branches are mobilized off of the underlying tumor.
After complete mobilization of the nerve, the gland can be bluntly dissected from the deep bed with retraction and separation of the fascial attachments with a small curved clamp.
The gland is separated from the temporomandibular joint, bony ear canal, condyle of the mandible, and styloglossus and stylopharyngeus muscles.
The graft should be harvested with meticulous technique, freshened, and approximated without tension or redundancy with minimal use of well-placed 9-0 nylon sutures.
ipsilateral hypoglossal nerve by placement of an interpositional jump graft to preserve facial tone.
Infection is rare if the gland is not chronically infected
placement of an angiocatheter from behind the ear into the pocket of saliva. A scopolamine patch is also placed to decrease salivary gland flow.