Total parotidectomy describes removal of the entire parotid gland. From a practical standpoint, total parotidectomy is a difficult operation as removal of all parotid tissue with facial nerve preservation is challenging. The benefits of complete removal of all parotid tissue must be weighed against potential morbidity. Total parotidectomy is described. Less extensive resection of the gland may be appropriate based on tumor extent, type, and location.

All patients should have a complete examination of the head and neck. Cranial nerve function should be examined, and facial nerve function should be evaluated carefully. Facial weakness may be subtle, or facial muscle fasciculation may be noted. Facial nerve paralysis is usually an indication of nerve invasion by a malignant tumor. Fixation to the skin, decreased mobility, and associated cervical lymphadenopathy are other signs consistent with malignancy.

Total parotidectomy is a major operation. Significant medical comorbidities, limited life expectancy, bleeding disorders, and anticoagulated states represent contraindications.

Total parotidectomy is performed under general anesthesia. Long-term paralytic agents are avoided to allow for facial nerve monitoring and stimulation. After the induction of general anesthesia, the endotracheal tube is positioned in the contralateral oral cavity and secured by tape only on the contralateral face. A modified Blair incision is planned in a preauricular crease coursing around the ear lobule and then into an upper neck crease (Fig. 27.1). The ipsilateral face is prepared with an antiseptic solution, and nerve electrodes are placed in the ipsilateral facial muscles if intraoperative electrophysiologic facial nerve monitoring is planned. The surgical field is then draped with a transparent adhesive sterile drape to allow intraoperative visualization of facial motion and maintenance of a sterile operative field.

The skin incision is made with a scalpel and carried down through the subcutaneous tissues and platysma muscle inferiorly. Care is taken to avoid division of the greater auricular nerve. An anterior flap is elevated superficial to the greater auricular nerve and the parotid fascia (Fig. 27.2). Elevation of a thick flap is desirable to reduce the occurrence of Frey syndrome. As the flap is elevated toward the anterior aspect of the gland, the peripheral facial nerve branches are carefully avoided. A posterior-inferior flap is also elevated to expose the tail of the parotid gland. After elevation, the flaps are retracted with silk sutures or self-retaining hooks. The flaps are kept moist during the procedure to prevent tissue desiccation.

The tail of the parotid gland is dissected from the sternocleidomastoid muscle by dissecting deep to the posterior branch of the greater auricular nerve, if preservation of this nerve is feasible based on tumor location. Next, the posterior belly of the digastric muscle is exposed with further elevation of the tail of the parotid gland. During elevation of the tail of the parotid, the posterior facial vein is divided and ligated with silk ligatures.