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8 Salivary Glands Tumours andIts Surgery
201
intraparotid facial nerve distal trunk and branches
are not consistently visible on conventional MR
or CT images. There is currently no MR imaging
technique commonly used to imagine the facial
nerve [14]. Condent identication of the more
distal branches of the facial nerve appears to be
primarily hindered by three factors:
1. The small size of the nerve bres in the intervening parotid plexus below the current practical clinical imaging resolution
2. Variant terminal branch anatomy, including
variation in the number and location of the
branches, which precludes location-based
identication
3. Difculty discriminating small nerve bres,
small ducts, and small vessels [14]
The use of the retromandibular vein as a
facial nerve marker has been shown to be
another sensitive method for identifying the
facial nerve [18]. The anatomical landmark can
be used as a virtual line drawn from the lateral
border of the posterior belly of the digastric
muscle and the retromandibular vein to the lateral edge of the mandible. In the majority of the
cases, the facial nerve lies supercial to the retromandibular vein. In few cases, the nerve may
also be located below the facial nerve. The retromandibular vein has to be ligated proximal
and distal to the tumoural mass, after the identication and preservation of the facial nerve
branches.
The facial nerve, the Utrecht line, the Conn’s
arc, and the retromandibular vein were among the
landmarks used for CT scan and MRI presurgical
evaluation of parotid tumour patients by the radiologist. Vaiman etal. reported that in cases where
selective deep lobe parotidectomy is planned, no
existing CT scan landmark can be accepted as
completely reliable. The anatomy can be distorted due to the expanding mass. If the location
of the tumour in the deep gland lobe is suspected,
MRI imaging is necessary to assess the tumour
for a better surgical extirpation [19]. As in this
parapharyngeal space area, critical neurovascular
structures might be involved or compressed by
tumours. These structures include the last four
cranial nerves, parasympathetic bres, and deep
muscles of neck.
The tumour location was determined in relation to four computerized tomography (CT)
scans, the facial nerve line, Utrecht line, Conn’s
arc, and retromandibular vein, and conrmed
by intraoperative ndings [20]. In predicting
the tumour location, the Utrecht line was the
most precise, sensitive, and specic of the four
landmarks. However, the FN line was signicantly more precise than the Utrecht line and
Conn’s arc for tumours less than 2cm in diameter. Magnetic resonance imaging is used to
determine the effectiveness of multiplanar analysis of the retromandibular vein in determining
the position of the parotid gland tumour and its
relationship to the facial nerve, together with
the most common radiological criteria [21].
Combined with the evaluation of the parapharyngeal space, the multiplanar modality is
effective in helping the surgeon to achieve precise planning: it allows the tumour to be located
and the course of the facial nerve to be predicted with good precision.
The parotid duct and the retromandibular vein
criterion can be used to assess the accurate location of the parotid tumours [22]. In fact, for the
determination of the location of parotid tumours,
the parotid duct criterion is highly useful.
Combining the criterion for the parotid duct with
the criterion for the retromandibular vein could
improve the diagnostic accuracy of the location
of the parotid tumour compared to using the latter
criterion alone. This allows a comprehensive presurgical planning to ensure that a safe and effective surgery can be performed.
Other techniques include preoperative MR
imaging using steady-state double echo with
water excitation sequence. Based on this, the
facial nerve line, the retromandibular vein, and
the Utrecht line, the tumour locations were categorized as deep or supercial [23]. By directly
visualizing the intraparotid facial nerve using
the 3D double-echo steady state with water
excitation sequence compared to indirect methods, surgeons can achieve greater diagnostic
performance in localizing parotid gland
tumours.
202
N. Mat Lazim
8.6 Parotid Gland Surgery
Parotid gland surgery is exquisite as it involves
the facial nerve identication and preservation.
Injury to the facial nerve will result in signicant
cosmesis deformity and cause interruption of an
individual’s communication and social integration. The affected patient can be presented with
facial asymmetry, inability to drink due to
drooling, or exposure keratopathy due to incomplete closure of eyelids. Thus, it is imperative to
identify the nerve and preserve the facial nerve’s
function. The aim of parotid gland surgery is to
remove the tumour with adequate margins while
maintaining the facial nerve integrity.
8.6.1 Benign Parotid Tumour Surgery
The goal of surgical management of benign
parotid tumours is to eliminate the mass completely with the preservation of the function of the
facial nerve. In the setting of benign parotid gland
tumour such as pleomorphic adenoma, breaching
of the capsule is highly associated with recurrence. Additionally, the facial nerve has to be preserved in all operated benign cases. The surgical
excision of this lesion remains the subject of signicant debate. The objective is to prevent facial
disability and achieve complete resection without
capsule or pseudocapsule perforation [3].
Different surgical options are currently available for the treatment of benign parotid gland
tumours. Despite several meta-analyses, the discussion on optimal treatment continues: for
instance, more limited resections like extracapsular dissection and partial lateral parotidectomy
versus more extensive and traditional options are
included in these options (lateral parotid lobectomy, total parotidectomy) [24]. Currently, most
surgeons prefer to perform supercial parotidectomy for pleomorphic adenoma that is limited to
the supercial lobe of the parotid gland.
There are a variety of terms used to describe
parotid gland surgery for benign tumours. These
include either complete supercial parotidectomy, partial supercial parotidectomy, or extra-
capsular dissection during surgery [25]. Since
extracapsular dissection has resulted in a signicantly higher percentage of permanent facial
paralysis, recurrent disease, and positive margins
of resection than supercial parotidectomy,
supercial parotidectomy is recommended for
the treatment of benign parotid gland tumours
[26]. Even though the supercial parotidectomy
is associated with signicant prolonged surgery
time, it is the most effective treatment of benign
parotid tumour such as pleomorphic adenoma. In
the expert hands, surgical complications and
facial nerve injury are rare.
In the extracapsular dissection, the rate of positive margins was signicantly higher compared
to the supercial parotidectomy group. After
extracapsular dissection, recurrent disease is
higher compared to supercial parotidectomy,
and permanent facial palsy was signicantly
more frequent than supercial parotidectomy.
The high rate of tumour recurrence that
occurred with simple enucleation of parotid pleomorphic adenoma was signicantly reduced by
supercial parotidectomy. For the treatment of
pleomorphic adenoma, supercial parotidectomy
or partial supercial parotidectomy is commonly
practised worldwide. Reports covering a spectrum from total parotidectomy to extracapsular
dissection are common in Europe and Asia. The
results of surgical treatment of mobile, supercial pleomorphic adenoma smaller than 4cm are
not signicantly altered by the surgical approach
[27]. The capsular exposure, tumour-facial nerve
interface, capsular rupture, recurrence, facial
nerve dysfunction, and Frey’s syndrome are similar in occurrence.
The availability of a staging system of parotid
gland tumour would be ideal to facilitate the
making of clinical decisions and the comparison
of treatment outcomes. Based on the size of the
tumour and its location within the parotid gland,
there are four categories (Table8.2).
A guideline for surgical approach is proposed
for each category and for different pathological
types. Other criteria need to be considered in
deciding the best surgical approach for each type
of tumours, not merely based on this guideline.
These include details of the patient’s factors,
8 Salivary Glands Tumours andIts Surgery
203
Table 8.2 Classication of parotid gland tumours
Category Classication of parotid gland tumours
Category 1 Tumours up to 3cm, which are mobile,
close to the outer surface, and close to
the parotid borders, are included in
category I.
Category 2 Deeper tumours up to 3cm are included
in category II.
Category 3 This comprises tumours larger than 3cm
involving two parotid gland levels.
Category 4 Tumours are larger than 3cm involving
more than two parotid gland levels.
availability of the expertise, instrumentation, etc.
Additionally, the purpose of this classication is
to facilitate prospective multicentre studies of
surgical techniques for the treatment of benign
parotid tumours and to allow the results of various clinical studies to be compared [24]. A
rened classication of salivary gland tumour
should be made available at a near future. This
enhances the management of this tumour and
improves patient’s prognosis and survival.
8.6.2 Malignant Parotid Tumour Surgery
In malignant parotid surgery, the approach is different. The aim of the surgery is to remove the
tumour with free surgical margin, and the issue of
facial nerve preservation is dependent on whether
the facial nerve is involved or not, intraoperatively
and post-operatively. The neck dissection should
also be performed during the initial parotidectomy.
The micrometastases for salivary gland malignant
tumour are at level II, III, and IV neck nodes.
Management of facial nerve in the setting of
malignant parotid tumour is challenging. Issue of
scarication or preservation of facial nerve
should be judiciously considered. The balance
between the benet and the risk of facial nerve
preservation or scarication will dictate the nal
approach for the facial nerve. If preoperatively,
the clinical examination showed evidence of
facial nerve paralysis, and intraoperatively if the
nerve adherent to the tumoural mass cannot be
skeletonized, then the facial nerve should be sacriced. This is crucial to achieve an oncologically
sound treatment outcome. If, however, facial
nerve is intact preoperatively, and the nerve is
able to be dissected of the mass, and there is no
suspicion of the facial nerve inltration, then the
nerve should be preserved.
Total parotidectomy is performed for malignant tumours, tumours that arise either from the
supercial lobe or from the deep lobe. All bulky
tumoural tissue plus the periparotid tissue should
be removed in total to reduce recurrent tumour.
The periparotid tissues contain microscopic
tumour deposit that might be left behind if it is
not excised together with the bulk of parotid
tumour mass. During the surgery, cutting through
the tumour should be avoided as this will cause
tumour spillage onto the surgical bed. This is
another risk factor for recurrent tumour postsurgery. Ideally, the tumour capsule should be
maintained intact during the dissection.
Selective neck dissection should be conducted
during the initial parotidectomy in suspicious
neck node inltration or clinically positive neck
nodes ipsilaterally. Most of the time, the lateral
neck dissection incorporating the neck node levels II–IV is performed. Otherwise, the choice of
types of neck dissection will depend on the neck
node status characteristics. The extent of adjacent
structure resection such as mandible, muscle of
mastication, and skin depends on the inltration
that can be assessed clinically and radiologically.
Intraoperatively, the neck dissection should be
carried out rst before embarking on the parotidectomy. This is the same principle that applies
to other head and neck malignant tumours. If the
parotidectomy is performed rst, the tumour cells
from the parotid surgical bed might be transferred
to the fresh uncontaminated area of the neck,
either via gloves or via instrumentation.
8.7 Surgical Techniques
andDissection
8.7.1 Supercial Parotidectomy
During an operative session of supercial parotidectomy, the patient should be well prepared.
The consent should have been comprehensively
204
prepared during the outpatient clinic review. The
anaesthetic team should also be informed on the
procedure and the necessary equipment required
preoperatively. This is particularly with the
choice of intubation, use of intraoperative neural
monitoring, and requirement of short-acting
muscle relaxant, as it will interfere with the nerve
monitoring during the surgery. The instrument
should be checked and made available before the
surgery.
N. Mat Lazim
8.7.1.1 Patient Positioning andFacial
Nerve Application
Patient will be placed in supine position, with
head turned to contralateral side. If a neck dissection is planned, the neck can be extended with
rolled towel or shoulder bag. The facial nerve
monitoring should be done with four-channel
electrodes secured to the respective sites, frontalis, orbicularis oculi, orbicularis oris, and mentalis. The requirement of short-acting muscle
relaxant should be communicated with the incharge anaesthetist.
8.7.1.2 Skin Incision
The area is cleaned with diluted povidone iodine,
and the draping is done. The draping should
expose the half face on the operative side, which
includes the angle of mouth and lateral eyelid
exposure. This is important for the observation of
contraction of the muscles during dissection, so
as to give a clue whether the facial nerve branch
is in close proximity.
The landmark will be drawn, especially the
margins of the tumour, the typical skin incision,
and modied Blair incision which starts at
1–3mm anterior to tragal cartilage and extending
down to the earlobe before curved down to the
neck, along the skin crease, two nger breadths
below the angle of mandible (Fig.8.15).
8.7.1.3 Raising oftheSkin Flap
The skin ap is raised anteriorly till anterior margins of the parotid mass. The supercial musculoaponeurotic system (SMAS) can be
incorporated to the ap to thicken the ap. The
thicker the ap, the better the ap viability due to
vascular supply. The subplatysmal ap is raised
using blade size 15 or monopolar with Colorado
Fig. 8.15 Subplatysmal skin ap is raised via a modied
Blair skin incision (arrow). The left parotid mass tumour
(2 stars) and ear lobule (a star)
Fig. 8.16 The greater auricular nerve (GAN) runs across
supercial to SCM, and its branch to ear lobule should be
preserved. The parotid mass (star) will be dissected away
from the nerve
tip. Countertraction and traction of skin by assistant will facilitate the process, without deeper
cutting of the tissues. The platysma muscle is
decient in the midline of the neck and posteriorly at the region of level V.Some patients have a
very thin platysma, whereas others may have
thicker platysma. The thicker the ap, the better
the vascular supply and viability of the ap.
8.7.1.4 Greater Auricular Nerve Preservation
During the incision over the sternocleidomastoid
muscle, the greater auricular nerve can be identied crossing the muscle, as a thick whitish nerve
(Figs.8.16 and 8.17). Its anterior branches supply
the parotid capsule that can be sacriced. Its posterior branch supplies the ear lobule and should be
preserved, especially in benign cases. The transected nerves can result in neuroma as a late complication and tend to cause signicant pain.
8 Salivary Glands Tumours andIts Surgery
205
1.0 cm deep and inferior to the tragal pointer.
When the area is near, the dissection continues
with cold instruments. Lahey swab can be used to
push the tissues and to nd the trunk with ease.
The facial nerve stimulator is used to conrm
the nerve. The voltage reduces to 0.5 ampoule
when stimulating the nerve. Higher voltage and
frequent testing can lead to neuropraxia, in addition to the traction on nerves.
Fig. 8.17 The GAN (arrow) runs across supercial to
SCM and is preserved
8.7.1.5 Skeletonization ofSCM Muscle
The anterior border of sternomastoid can be skeletonized using the monopolar or tissue scissors.
Care needs to be taken as deep to the SCM muscle is the carotid sheath, which harbours the
carotid artery, the vagus nerve, and the internal
jugular vein. At inferior third of SCM, the omohyoid muscle can be identied as it runs across
the SCM.The omohyoid muscle is the landmark
for identication of the IJV. The IJV lies just
beneath the omohyoid muscle.
8.7.1.6 Dissection at theTragal Area
The subcutaneous tissues near the tragal area are
deepened, and dissection is carried out in continuity to the anterior border of SCM that has been
skeletonized and deepened. The stylomastoid
artery should be identied in this region, as it can
cause heavy bleeding, if inadvertent cut of the
artery occurs. Sometimes it is difcult to nd the
bleeding end, especially due to high fatty deposition in this region. The stylomastoid artery can be
easily clipped, hence secured.
If the dissection area is red with blood stain,
warm normal saline wash can be performed to
make the dissection area whiter so as to identify
the facial nerve trunk better.
8.7.1.7 Facial Nerve Trunk
Identication
The dissection continues at the tragal area, deepening the tissue superiorly and inferiorly, so as to
create a shallow bowl. If the bowl is too deep, it
will be difcult to dissect tissue structures and
nd the facial nerve trunk.
The tragal pointer is used as a landmark to nd
the facial nerve trunk. The facial nerve trunk lies
8.7.1.8 Facial Nerve Branch Preservation
The facial nerve trunk is followed until it divides
into two main branches, the upper temporozygomatic branch and the lower cervicomandibular branch (Fig.8.18). The parotid tissue
is dissected over the nerve, lifted, and cut. This
technique is performed along the nerve, to expose
the nerve until the anterior border of the parotid
mass.
At this stage of dissection, the retromandibular vein should be identied and ligated. The vein
lies very close to the nerve, just inferior to it.
Thus, vigilant ligation of the vein is necessary to
avoid the facial nerve injury.
The anterior branch becomes very thin, and
meticulous dissection is necessary. The nerve
stimulator can be used to guide dissection at this
stage. However, sometimes, the nerve becomes
fatigue already. Thus, the use of surgical loupes
will be of great help in identifying these smaller
branches of the facial nerve.
8.7.1.9 Removal oftheParotid Mass
Once all the branches of the nerve have been
traced and preserved (Fig.8.19), the remaining
parotid tissue can be released, in order to facilitate the removal of the tumour mass in total.
In case of malignant carcinoma of parotid, it is
important to ensure the removal of periparotid
tissues also as this can be the area of micrometastatic tumour foci. This technique will also ensure
negative surgical margins post-operatively, which
is vital to reduce the likelihood of locoregional
recurrence.
8.7.1.10 Homeostasis Control
After the parotid mass has been removed, the
homeostasis is secured. Any bleeding vessels are
206
N. Mat Lazim
a b
Fig. 8.18 Lower branches (a) and upper branches (b) of facial nerve are tested with a facial nerve stimulator proe
(arrow) to ensure its functionality
Fig. 8.19 Facial nerve stimulator (arrow) is used to
assess the functioning of facial nerve. All branches of the
nerve are preserved. Skin ap is retracted (star)
cauterized. Warm saline wash can help the oozing vessels, and sometimes the surgical can be
applied to the wound to help stop the bleeding.
The nerve is stimulated for a last time to make
sure that it is functioning and intact (Fig.8.19).
The nerve impulse as well as the contraction
muscle of expression is observed.
8.7.1.11 Drain Insertion andWound
Closure
The drain size 10 is inserted and secured with silk
3.0. The wound is closed in two layers with
Vicryl 2.0. The subcuticular closure with white
Vicryl or Sal is excellent for post-operative aesthetics. The patient is prescribed with IV dexamethasone, analgesia, and antibiotics for
2–3days post-operatively.
8.7.1.12 Post-operative Follow-Up
Patient is reviewed at 1 week, 4 weeks, and
12 weeks post-operatively. During this follow up, the wound is inspected for any evidence of
infection or seroma.
8.7.2 Total Parotidectomy
withFacial Nerve Preservation
Total parotidectomy is indicated in case if
tumours involved both the supercial and deep
lobe of parotid glands. In this type of surgery,
both the supercial and deep lobe of the parotid
glands will be removed. The facial nerve, which
runs between the supercial and deep lobe of
parotid glands, needs to be identied, skeletonized, and preserved.
In the majority of cases, the supercial parotidectomy will be performed rst followed by the
identication of the facial nerve, and the nerve
8 Salivary Glands Tumours andIts Surgery
207
will be skeletonized from the tumour tissues.
Subsequently, the facial nerve will be lateralized
and the deep lobe parotidectomy can then be carried out.
Indications of total parotidectomy with pres-
ervation of facial nerve:
1. Pleomorphic adenoma of deep lobe parotid
gland
2. High-grade mucoepidermoid carcinoma of
supercial parotid gland
3. Carcinoma of deep lobe of the parotid glands
4. Recurrent carcinoma at supercial or deep
lobe parotid glands
8.7.2.1 Case Illustration 1
This is a case of pleomorphic adenoma of right
parotid glands. Clinical examination of the patient
does reveal a small, rm mass measuring 4.0cm
× 5.0cm, mobile and non-tender (Fig.8.20). The
overlying skin is not xed to the mass. There was
no medialization of lateral pharyngeal wall.
However, CT scan showed mass arising from the
right parotid gland, with extension to deep lobe.
There was no enlarged cervical node. FNAC
revealed that it is pleomorphic adenoma.
incision, mandibulotomy might be considered.
However, only selected cases of malignant deep
lobe involvement require mandibulotomy as the
majority can be addressed with correct dissection
technique.
Intraoperatively, skin ap is raised anteriorly
to the level of anterior border of the mass, with
preservation of greater auricular nerve (Fig.8.22),
which runs across the sternocleidomastoid muscle. The anterior branch of greater auricular nerve
(GAN) supplies the parotid capsule, which can
be sacriced. The posterior branch that supplies
the ear lobule should be preserved, especially
when operating on a benign case. In malignant
cases, both branches can be sacriced if it causes
difcult access to the clearance of malignant
tumour.
The facial nerve trunk is identied (Fig.8.23)
and followed anteriorly to trace the peripheral
branches. Meticulous dissection is necessary as
the branches can be very ne and at risk of being
8.7.2.1.1 Step 1: Patient’s Positioning
andSurgical Landmark
Identication
The steps are similar to those of the supercial
parotidectomy. The modied Blair skin incision
can be modied accordingly (Fig.8.21), depending on the size of the parotid tumour and need for
surgical access. If the tumour is large and difcult access is anticipated with the standard skin
Fig. 8.20 Right parotid mass, 4.0 cm × 4.0 cm, rm,
mobile (arrow). The right facial nerve is intact
Fig. 8.21 The tumour mass is outlined (star) and the
modied Blair incision is marked, which extends from
anterior to tragal cartilage and descends to the neck
(arrow)
Fig. 8.22 Parotid mass is retracted (star), and the greater
auricular nerve (arrow) that runs supercial to sternomastoid muscle is preserved (white star)
208
Fig. 8.23 Facial nerve trunk (arrow) going through the
tumour (star), while the tumour is retracted anteriorly
N. Mat Lazim
Fig. 8.25 The parotid mass which is excised measuring
3.0cm × 3.0cm
Fig. 8.24 Parotid mass (star) is located supercial to the
peripheral branches of the nerves (arrow), which has been
traced and exposed
transected. Usage of ne haemostat with techniques of lift, spread, and cut can be practised to
better protect this ne peripheral branches.
The parotid mass is dissected out supercial
to the facial nerve peripheral branches
(Fig. 8.24). The yellow vessel loop is placed
under the nerve and can be used for identication and retraction. Care should be taken not to
accidentally pull the loop to avoid iatrogenic
injury of facial nerve.
Intraoperatively, after the supercial lobe of
parotid gland has been dissected, the facial nerves
and its branches are skeletonized and retracted
laterally as tumour at the deep lobe also has to be
removed.
The mass has been removed (Fig. 8.25), and
surgical bed is irrigated with warm normal saline.
The facial nerve and all the branches are tested with
nerve stimulation to ensure its function (Fig.8.26).
Surgical bed is examined for any suspicious
residual mass and any active bleeders before
wound closure. A drain is secured to facilitate
Fig. 8.26 Facial nerve trunk and all its branches are
preserved
Fig. 8.27 The wound is closed in two layers with Vicryl
3.0, and a Redivac drain size 10 is secured (white arrow)
drainage post-surgery. This will prevent haematoma or seroma post-surgery. A meticulous skin
closure should be done by two-layer closure with
Vicryl 3.0 (Fig.8.27).
8 Salivary Glands Tumours andIts Surgery
209
8.7.3 Case ofExtended Total
Parotidectomy withSkin
Excision andFlap
Reconstruction
This is a case of an elderly Malay male who presented with a long-standing left parotid mass.
Investigation revealed that it was a malignant
parotid carcinoma (Fig.8.28a). Patient is planned
for total parotidectomy with left modied radical
neck dissection and pedicle rotational ap
(Fig.8.28b).
The skin incision should be designed meticulously, with consideration of attaining negative
surgical margins. This skin incision needs to
include primary tumour excision with ipsilateral
neck dissection and for rotational ap
utilization.
A modied Blair skin incision is used with
inferior limb extension to accommodate for neck
dissection. Once skin ap is raised and retracted
anteromedially, this exposes the sternocleidomastoid muscle (Fig.8.29). The neck dissection
should be carried out rst, so as to prevent the
contamination of a fresh area if the primary
tumour is addressed rst. The anterolateral neck
(levels I–IV) brofatty and lymph node tissues
are dissected and removed (Fig.8.30).
Once the neck dissection is completed, the
primary tumour is dissected (Fig.8.31). The
tumour is excised together with the overlying
skin due to involvement by the tumour
Fig. 8.29 The skin ap is elevated via a modied Blair
skin incision and retracted anteromedially (white star).
The skin is thin and xed at the uppermost of the parotid
mass (black star). The sternocleidomastoid muscle is visible at lateral-most part of the surgical bed (arrow)
ab
Fig. 8.28 Clinically, the skin overlying mass is tensed
(arrow) with limited mobility signifying inltration by
tumour. Thus, the skin needs to be excised together with
the tumour (a). The skin incision is marked at 1.5 cm
around the primary parotid mass (star), and outline of
SCM, trapezius, and level V neck nodes (arrow) is marked
to facilitate the ipsilateral MRND (b)
210
Fig. 8.30 The neck dissection is performed rst before
dissection of parotid mass to ensure no tumour tissue
seedling onto the neck if parotid tumour is excised rst
(white arrow). The manipulation of parotid mass (black
arrow) causes contamination to glove and cold instruments that can be transferred to the neck surgical bed. The
skin around the tumour (star) is excised together with the
tumour
N. Mat Lazim
(Figs.8.33 and 8.34). Any suspicious residual
malignant tissue is removed by piecemeal
techniques (Fig. 8.32). The tumour that has
been excised needs to be prepared for histopathology examination by the pathologist. This
is normally done by placing a number of
sutures at the anterior, posterior, superior,
inferior, and deep margins of the mass
(Fig.8.35).
Post removal of the mass and neck dissection,
the surgical defect is assessed for a rotational
myocutaneous ap. This is done by the plastic
reconstructive team at our centre. The deltopectoral skin ap is harvested and rotated to the neck
and sutured to the neck surgical defect (Figs.8.36
and 8.37).
Fig. 8.31 The parotid mass has been dissected and
retracted (arrow) to facilitate dissection at the medial side
of the mass
a
Fig. 8.33 (a, b) The skin and parotid mass that are excised measuring 6.0 cm × 5.0 cm
Fig. 8.32 The residual tissue at neck dissection area
excised using monopolar cautery. The parotid mass has
been completely excised
b