Tumors are the most common indication for surgical exploration of the parotid gland. Most are benign mixed tumors that arise in the lateral lobe and are treated with wide excision, including a margin of normal tissue to prevent local recurrence. Exploration of the parotid area must include careful identification of the facial nerve and its branches, which can have variable anatomy, thus avoiding the major complication of facial nerve palsy. Malignant tumors are also seen and require wide excision, which may include all or a portion of the facial nerve, if involved. Lesions of the medial lobe may necessitate a total parotidectomy; a superficial parotidectomy is carried out first to identify and preserve the facial nerve before the medial lobe is explored.
It is essential that all patients undergoing parotid surgery be made aware of the possible loss of facial nerve function, with its resulting functional and cosmetic consequences. Men should shave themselves early on the morning of surgery; the hair about the ear may be cleared by the surgeon before draping.
Oral endotracheal anesthesia with a flexible coupling is used so that the anesthesiologist may be located at the patient’s side, thus giving the surgeon adequate room. A short-acting muscle relaxant should be used for the endotracheal intubation. This allows the surgeon to identify motor nerves by neuromonitoring during the dissection.
Patients are positioned on their back, and the face is turned to the side opposite the lesion. The head and neck are placed in slight extension, and the head of the table is elevated to reduce venous pressure in the head and neck.
After appropriate skin preparation with detergents and antiseptic solutions, sterile towel drapes are positioned to allow visualization of the entire ipsilateral side of the face. Then a time-out is performed.
The incision is carried in the crease immediately in front of the ear, around the lobule, and up in the postauricular fold (FIGURE 1). It then curves posteriorly over the mastoid process and swings smoothly down into the superior cervical crease. The superior cervical crease is located approximately 2 cm below the angle of the mandible. It should be remembered that with the patient’s neck extended and head turned to the side, the facial skin is pulled down onto the neck, and the incision should be made low enough that when the patient’s head is returned to normal position, the incision does not lie along the body of the mandible. No incisions are made on the cheek itself.
The cervical facial skin flap is then elevated with sharp dissection to adequately expose the area of the tumor. This elevation takes place to ...