Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4372_Библиотеки_им_академика_М_И_Перельмана

TCP is indicated for multifocal recurrent pleomorphic ade­noma, as an ultimate attempt to remove all parotid tissues encompassing what may be many tiny foci of pleomorphic adenoma. TCP is also performed when removing a superi­orly located deep-lobe parotid tumour (ESGS level IV, high tumours abutting the facial nerve from beneath), when the facial nerve is stretched over the tumour. CN VII thus must be identied rst, dissected, and released off the deep-lobe tumour so as to facilitate the tumour’s safe removal whilst preserving the nerve’s integrity.

radiotherapy to control potential microscopic disease and/or involved deep-lobe parotid lymph nodes [14–19]. Some authors stay in the middle and suggest that one should “inspect and resect the deep lobe if there is suspicion of deep lobe nodal metastasis” [5]. Other authors suggest proceeding with TCP in these specic situations, observing a high rate of intraparotid lymph node metastasis in resected deep parotid lobes [13, 20–22]. This area of controversy would certainly benet from additional prospective research.

with cancer, such as all those listed on Table17.1, and can involve an appropriate neck dissection based on nodal meta­static disease [6, 10].

The use of facial nerve monitoring is controversial and is based on the surgeon’s individual preference and on individ­ual surgical situations. Guntinas-Lichius and Eisele [23] conclude, in their recent review, that facial nerve monitoring is reasonable in all instances where facial nerve identica­tion, dissection, and preservation are potentially difcult; surgery for malignant and difcult benign tumours is included in their list. Makeieff etal. [24] found in their study on recurrent pleomorphic adenoma that both the rate of facial nerve palsy and the duration of the procedure were signi­cantly reduced when using CN VII monitoring. Sood etal. [25] performed a meta-analysis and concluded that “the number needed to treat” was nine, so in order to prevent one immediate postoperative CN VII dysfunction, nine patients needed to be monitored. Facial nerve monitoring should be considered for revision surgical cases, patients with prior radiotherapy, patients with extensive tumours, and patients in whom radical parotidectomy is being performed and iden­tication of distal facial nerve branches is required for reconstruction.

posterior belly of the digastric. Alternative landmarks such as the tragal pointer can be used. A retrograde dissection is sometimes required for tumours arising around the stylomas­toid foramen.

Whether the tumour is located supercially or deep to CN VII, the rst step is to perform a complete supercial paroti­dectomy, as described in Chap. 19 (Fig.17.4). An elegant technique of subsequently performing an en bloc deep-lobe parotidectomy with facial nerve preservation has been described by Olsen and Moore [12]. First, CN VII is sepa­rated from the deep lobe with meticulous microdissection. Operating loupes and micro-instruments (such as used in microvascular reconstruction) greatly aid in this step. There uniformly is a branch of CN VII passing into the deep lobe (the connecting branch to the auriculotemporal nerve, at the posterior border of the masseter muscle [MM]) [27]. This branch is divided without effect on the motor function (Fig.17.5). Anteriorly, the deep parotid lobe is then mobi­lized off the MM (Fig.17.6). On its inferior aspect, the deep lobe is mobilized from the stylohyoid, stylopharyngeus, and posterior digastric muscles. Essential for a controlled en bloc deep lobe removal is division and ligation of the externa carotid artery and the retrofacial vein inferiorly (Fig.17.7) and the supercial temporal artery and the vein superiorly. Then the deep parotid lobe can be mobilized downward, off the temporomandibular joint (Fig. 17.8). The nal step is elevation of the deep lobe off the posterior border of the mandible. Following division and ligation of the internal maxillary veins and artery, the deep lobe is then released from underneath the CN VII branches (Fig.17.9).

tor blood vessels is avoided. When supporting tissues such as the MM must be resected (resulting in denuded mandibular bone), the parapharyngeal space (PPS) or infratemporal fossa tissues or lateral temporal bone composite aps are required to restore the defect [28]. One can consider using pedicled aps (pectoralis major myocutaneous and pedicled latissimus dorsi ap), especially in the unt patient, in failed free-ap recon­structions, or in combination with free-ap reconstructions, but generally, microvascular free aps are preferred. The anterolat­eral thigh (ALT) perforator ap can be adapted to the needs and thus is very popular in this area. It can be dissected suprafas­cially as a thin cutaneous ap; alternatively, vastus lateralis or rectus femoris muscle can be included, so that it becomes a musculocutaneous ap. It combines a relatively constant anat­omy, a possible two-team approach (the donor site being at a distance from the ablative eld), and a long (8–16cm) and large-calibre (2–2.5 mm) pedicle. When mainly volume is needed, a de- epithelialized ALT ap combined with a cervico­facial rotation ap can give a superior esthetic result.

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