Right superficial and deep lobe parotidectomy with complete facial nerve dissection, continuous facial nerve monitoring, and layered wound closure

PREOPERATIVE DIAGNOSIS:  Right parotid mass.

POSTOPERATIVE DIAGNOSIS:  Right parotid mass.

PROCEDURE:  Right superficial and deep lobe parotidectomy with complete facial nerve dissection, continuous facial nerve monitoring, and layered wound closure.

ANESTHESIA:  General.

COMPLICATIONS:  No complications.

ESTIMATED BLOOD LOSS:  10 mL

DESCRIPTION OF THE PROCEDURE:  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was induced via an endotracheal tube to facilitate facial nerve monitoring.  No paralysis was used throughout the case.  The head of bed was turned to 90 degrees and a shoulder roll was placed under the patient.  The modified Blair incision was marked with a marking pen and was injected with 1% lidocaine with 1:100,000 epinephrine.  The patient was then prepped and draped in the standard fashion.  The incision was made with a #15 blade down to the preparotid fascia.  An anterior flap was elevated in the plane just above the preparotid fascia.  Elevation continued anteriorly all the way until the anterior border of the parotid and inferiorly down to the inferior border of the parotid.  Posteriorly, elevation was performed until the anterior border of the sternocleidomastoid muscle was clearly skeletonized all the way toward the mastoid tip.  The soft tissue was then carefully dissected bluntly off the external auditory canal until the tragal pointer could be identified.  Anterior to the anterior border of the sternocleidomastoid muscle, the digastric was identified and was followed up towards its insertion in the mastoid bone.  Using the tragal pointer and the digastric muscle as our landmarks, dissection was bluntly performed in the area of the sternomastoid foramen.  All fibers were carefully stimulated with the nerve stimulator to make sure that they were not the facial nerve.  This was performed into the facial nerve itself.  Main trunk was identified.  Stimulation confirmed firing of all branch and again this was in fact the nerve, with the nerve identified, it was carefully dissected anteriorly along all of its branches in the following fashion.  The nerve was bluntly dissected over the nerve itself.  The soft tissue over the nerve was elevated keeping the nerve carefully in mind.  It was cauterized with a bipolar and then transected with a #12 blade.  This was performed along the inferior branches of the main trunk including both the branch to the marginal mandibular as well as to the orbicularis.   Both of these branches were noted to be inferior to the level of the parotid mass itself.  Attention was then turned to the mid portion of the nerve extending to the buccal area.  This was noted to transverse the mass itself and actually head in and through the parotid mass which was consistent with a lymphangioma.  Dissection was carefully performed through the lymphangioma following the nerve until its anterior most aspect where it exited the parotid gland and started to insert towards the muscles.  Attention was then turned towards the superior branches, towards the forehead, and eye.  These branches were noted to be stilling having the parotid parenchyma, but above the lymphangioma mass itself.  Once these were followed superiorly, the parotid tissue medially superficial to it was divided and superficial lobe of the parotid was sent off to pathology on block as a specimen.  The wound was then copiously irrigated and hemostasis was confirmed.  There was noted to be marked lymphangiomatous tissue in the midportion of the gland just under the upper branch of the facial nerve.  That portion of the nerve was carefully dissected off the parotid lymphangioma deep to it and the vein retractor was placed underneath the nerve.  The nerve was retracted very gently inferiorly allowing access to the deep lobe lymphangioma mass.  The lymphangioma could be palpated and was noted to be sitting right against the ramus of the mandible.  Rather than resecting the mass completely and risk of further injury to the surrounding structures, the lateral surface of the deep part of the lymphangioma was carefully divided with bipolar electrocautery keeping the facial nerve branches in view at all times and ensuring they were not injured.  The lymphangioma was thereby unroofed in its deep lobe leaving just a single layer of lymphangioma wall along the medial most aspect of the parapharyngeal space to scar down on its own. The wound was then again copiously irrigated.  Hemostasis was confirmed.  A TLS suction drain was passed through the stab incision posterior to the wound and laid in the inferior aspect of the parotid bed cavity.  The deep tissues were closed using interrupted 4-0 chromic suture and the skin was closed using 5-0 fast-absorbing suture followed by a layer of Mastisol and Steri-Strips.  Suction dressing, had suction applied, and a dry compression dressing was applied.  The patient was reversed from the anesthesia where the face was noted to move postoperatively and was taken back to recovery room in stable condition.  I do note that before the wound was closed but after it was irrigated, the facial nerve monitor was again used to stimulate the facial nerve about its trunk and all the branches stimulated.