a

Total Parotidectomy

this video demonstrates the technique of

total parotid ectomy I'm Eric Moorhead

neck surgeon at the Mayo Clinic total

parotid ectomy is typically performed

for either aggressive parotid

malignancies or metastatic tumor - the

parotid gland the incision is typical to

superficial parotid ectomy as well with

a pre regular crease incision that's

brought down behind the angle of the

earlobe and behind the angle of the

mandible and potentially continued on

into the neck

if neck dissection is going to be

performed after the skin incision is

performed in a flap is elevated and the

subcutaneous plane above the parotid

fashio the flap has several sticking

points particularly around the auricular

cutaneous and mandibular cutaneous

ligaments that have to be divided

sharply and the flap is elevated beyond

the confines of the parotid gland so

over the parotid fashio and then out

over the masseteric fasciae at the

anterior edge of the parotid gland into

the mid-face the portion of the flap

overlying the parotid gland is typically

elevated with a 15 blade in sharp

dissection the portion that gets to the

periphery of the parotid gland has been

typically elevated bluntly with

spreading this protects the branches of

the facial nerve as they emanate from

the parotid gland this is demonstrating

the parotid duct and the masseteric

branches over the mid-face once the flap

is elevated it is secured with skin

hooks and then dissection of the parotid

gland ensues I typically first begin the

parotid gland dissection by separating

the parotid from the tragus and the

traigo perichondrium this is an a

vascular plane that separates usually

bluntly if it's not been infiltrated by

tumor I then elevate the parotid gland

away from the superficial temporal

faction superiorly once the tragus is

outlined in skeletonized then i elevate

the parotid gland in fearly away from

the sternocleidomastoid muscle at this

point the greater regular nerve can be

identified in either the posterior

branch to the lobule can be preserved or

the greater auricular nerve can be

severed

but then reflect to post yearly for a

potential nerve graph if necessary

continuing on with the separation of the

parotid gland away from the sternal

mastoid fascia that allows us to outline

the confines the greater ocular nervous

branches here it's going to be severed

and reflected post dearly and then the

dissection will be carried down to the

posterior belly of the digastric muscle

again this is a relatively a vascular

fascial plane and there's no potential

injury to the facial nerve of this plane

it can perform quickly with sharp

dissection those two dissections are

then joined up by blunt dissection and

bipolar cautery to divide any small

vascular branches as we elevate the rest

of the product land away from the upper

sternocleidomastoid muscle and from the

mastoid tip at the termination of these

maneuvers the entire posterior border

the product land ship and surrett

separated from the adjacent soft tissue

demonstrates the posterior ability that

gastric muscle behind the angle of the

mandible and then blunt dissection here

ensues to separate small vascular

branches and to identify the facial

nerve the facial nerve is easily

identified in a small triangular

depression between the mastoid tip and

the tracheal cartilage once the facial

nerve trunk has been identified than

blunt dissection ensues with mosquito

forceps and bipolar cautery followed by

scissors to separate out the lower

division this part of the dissection is

within the perineum of the parotid gland

and as we do this we separate out the

superficial part of the parotid gland

from the deep part of the parotid gland

using the facial nerve as the typical

divisor between the two after dissecting

out the inferior division dissection

then continues along the superior

division to fully skeletonize all the

branches of the facial nerve shown here

is dissection on the upper division of

the facial nerve again with blunt

dissection in the direction of the

fascia there are fibers and separating

the tissue over the top of it with a

combination of blunt dissection and

bipolar cautery and cutting

the superficial portion of the parotid

gland is becoming elevated to its

anterior attachments to the parotid duct

here there's a mass within the

superficial of the parotid gland it's a

malignant metastasis to a lymph node

from a cutaneous carcinoma the parotid

gland contains multiple lymph nodes

within it that are frequently the basin

for lymphatic metastasis from skin

malignancies after the dissection of all

the branches of a Sherman of the product

line is tethered on the parotid duct

which is ligated distally and divided

within the parotid gland being shown

here are multiple lymph nodes which will

be evaluated by the pathologist after

removal the superficial over the parotid

gland the deep lobe of the parotid gland

also contains a lymphatic Basin of

several lymph nodes to remove the deep

lobe of the parotid gland this becomes

an exercise in vascular control the

superficial temporal vessels are divided

and ligated they are found easily

posterior to the fern abridge of the

facial nerve after ligating the

superficial temporal vessels dissection

continues in fearly here over the top of

the posterior belly of the digastric

muscle separating the gland away from it

to expose the external terminal branch

of the carotid artery the external

terminal branch of the carotid artery

flows through the parotid gland giving

off the transverse facial artery in the

internal maxillary artery before it

exits as the superficial temporal artery

along the top of the gland and this

arterial supply within the parotid gland

is divided and ligated again this is

most easily family reflecting the

parotid gland off the posterior belly

that that gastric muscle and just at the

top of the posterior build at a gastric

muscle the external carotid artery can

Fountain be found passing beneath it and

passing into the parotid gland

posterior belly digastric muscle is

shown here external carotid artery as a

convenience on up through the parotid

gland it's being shown here the terminal

external carotid artery is divided with

being claimed with mosquito forceps and

ligated at this point the vascular

supply to the parotid gland has been

largely attenuated but there still is

backflow from the internal maxillary

artery

four spatial branches that have to be

addressed it's very important to

securely tie the external carotid artery

proximal and distal stump as they can

easily contain bris bleeding both the

integrator and retrograde deep lobe of

the parotid gland is separated from the

facial nerve branches by blunt

dissection and their inferior surface

this maneuver can cause temporary

neuropraxia in the post-operative period

and it's important to counsel the

patient that after deep lower the

parotid removal they may have some

neuropraxia that may last for several

months after the operation these

branches will typically return fully and

function even after these maneuvers as

long as they're not extensively

stretched or DFAS karai's by rubbing no

branches of the facial nerve will cross

each other so these transverse liore

structures are blood vessels that need

to be 500 cauterized at the anterior

edge of the parotid gland there's loose

attachments to the masseter muscle that

are divided and it's along this

dissection on the posterior border the

masseter muscle and mandible that the

transverse facial vessels and internal

maxillary vessels are encountered

again it's very important to keep all

the facial nerve branches in view shown

here is the internal maxillary artery

emanating from the entire surface of the

product land to pass beneath the

mandible and again it's divided with

mosquito clamps that tied the internal

maxillary venous branches will be

multiple in this area and often out to

be control with multiple manoeuvres with

the bipolar cautery dissection at this

point ensues between the terminal

branches the facial nerve protecting all

those fine branches and dividing the

basilar small pedicles that are passing

between the parotid gland and the master

muscle notice the retraction of the skin

anteriorly retraction of the gland in

multiple directions by securing it with

a cloak or clamp and moving it posterior

and anterior helps identify all these

planes of dissection this is

demonstrating the transverse branch of

the facial artery which is also divided

and ligated to prevent back bleeding

once all these vascular branches are

controlled and blunt a section of the

parotid gland off of the temporalis

muscle and off of the undersurface of

the facial nerve completes the

dissection

temporal and zygomatic branches of the

facial nerve are demonstrated here and

the parotid gland is separated from

beneath these branches and separated

from its loose factual attachments to

the superficial temporal vessels often

at this point of the dissection there

are small branches passing deep in a

vertical orientation off the facial

nerve

these small branch and main branches

passing deep are not important in the

muscles of facial expression and they

are divided sharply from the under

surface of the facial nerve

the sharp dissection is necessary to

prevent excess traction on the facial

nerve branches as they pass severely the

parotid gland is then passed from

beneath the facial nerve either

inferiorly or superiorly

it's very important to keep the trunk of

the facial nerve in view during this

portion of procedures that it's not

inadvertently

pulled into an abnormal position during

this part of the dissection final loose

attachments are by pleura cauterized and

then the deep lobe of the parotid gland

can be completely removed this

dissection again is most common in

malignant high-grade tumors that involve

the deep portion of parotid gland or

tumors that have a metastasized to the -

between two and four lymph nodes that

are contained within the deep portion of

the parotid gland it's often surprising

to people and the first few times that

they encounter deep low parotid tumor

removal in an in block fashion like this

how much tissue is actually contained in

this area the parotid ved total product

immediate

contour defect because of the thickness

of this tissue this leaves the patient

with a significant contour defect around

their mandible we often fill this in

with soft tissue fillings such as dermal

fat grafts or even bass cries tissue if

left unfilled this ultimate remain a

significant cosmetic defect for the

patient the facial nerve fiber is shown

here are completely intact and attached

to the trunk but the parotid gland has

been removed completely both above and

deep to the fibers many times total

product ectomy particularly when it's

performed for lymphatic metastasis as a

company by neck dissection which can

easily be incorporated into this

incision in this procedure there are two

lymph nodes

aren't quite visible and accessible

after removal of the deep portion of the

pirata gleam shown here again our

landmarks of the posterior belly of that

gastric muscle the accessory nerve some

crosses over the internal jugular vein

the external cloud of mastered muscle

being retracted most dearly carotid

artery and vagus nerve visible beneath

the internal jugular vein abdominal

dermal fat graft makes a nice contour

filler this can be harvested idea path

EO lies in a portion of skin and the

abdomen and including Katina a

subcutaneous fat layer with it this fat

graft is placed in is a free nonvascular

eyes graft almost like a skin graft and

it's going to survive by a vascular and

growth in the surrounding tissue to

enable this it's fixated to the tragus

and the sternocleidomastoid fascia post

Gigli in the mass enteric fasciae

anteriorly and is placed in no thicker

than what was removed in the parotid

gland it's a nice filler defect the

drain is usually brought out through the

hairline post directly to prevent a

cosmetic defect from the drain site

Exodus skin closure absorbable sutures

and an application of a layer of

dermabond patients usually kept over the

Haas in the hospital overnight with the

drain removed the next day and again

facial nerve paresis is you put

protection methods are used such as

adequate hydration of the eye annoyin at

night till the facial nerve function

returns