Скачать или смотреть Episode 11 — Incisions : Approaches to the Parotid Gland and Neck Dissection

1️⃣ Approaches to the Parotid Gland

Parotid surgery incisions are primarily designed to expose the gland while protecting the facial nerve and achieving an acceptable cosmetic result, often using the natural curves and creases around the ear.

*A. Blair Incision*

*Location:* This is a comprehensive incision that starts in the *preauricular crease**, extends superiorly to the helix, curves around the **ear lobule* to the mastoid process, and then curves down into a *neck crease* over the sternocleidomastoid muscle.
*Modification:* If a simultaneous *neck dissection* is planned, the inferior limb can be extended further into the neck.
*Indications:* The gold standard for most parotid gland surgeries.
*Precautions:* Requires vigilance to protect the *superficial temporal artery**, the **auriculotemporal nerve**, and critically, the **marginal mandibular nerve* as the incision curves into the neck.

*B. Incision Variations*

Several modifications exist, all based on the preauricular and cervical components of the Blair incision, designed to optimize exposure and aesthetics:

*Gutierrez Incision:* Includes a temporal extension, a preauricular component, and a neck limb.
*Redon and Vaillant Incision:* Similar, featuring a preauricular sector that curls around the lobule and extends down into the neck crease.
*Adson and Ott Incision:* A 'Y' shaped incision with preauricular, postauricular, and cervical limbs. Its advantage is *improved esthetics* due to the lack of a superior temporal extension.
*Appiani's Incision:* Uniquely places the superior portion within the *lower scalp (hidden by hair)* to improve cosmesis, though this shorter temporal limb may restrict superior access.

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2️⃣ Incisions for Neck Dissection

Neck dissection incisions must allow thorough access to the deep cervical structures while providing *safe skin coverage* for the underlying vital structures, especially the carotid artery.

*A. Triradiate Incisions (Y-shaped)*

These incisions provide liberal exposure but create vulnerable triangular skin flaps.

*Crile’s ‘Y’ Incision (Triradiate Incision):* Consists of a submandibular limb that meets a vertical limb.
*Crucial Precaution:* The vertical component **must not lie directly over the carotid artery**. If the incision line dehisces (opens), the exposed artery is at risk of a catastrophic complication called a "carotid blowout."
*Hayes Martin Incision:* Similar submandibular component but extends into the neck as an *inverted ‘Y’* in the supraclavicular region, creating **four triangular flaps**.
*Main Drawback:* The multiple triangular flaps increase the risk of *compromised vascularity* and *necrosis* at the tips, which can, again, expose the underlying carotid artery.
*Schobinger Incision:* A modification of the triradiate design where the vertical limb is *curved posteriorly* to ensure it lies clear of the carotid artery. However, the fundamental risk associated with sharp triangular flaps remains.

*B. Horizontal Incisions (Apron-like)*

These designs prioritize safety and cosmesis by utilizing natural skin creases and avoiding triangular flaps.

*MacFee Incision:* Consists of *two parallel horizontal incisions**—one submandibular and one supraclavicular—with a bridge of skin called a **bipedicled flap* between them.
*Advantages:* *Minimal risk of necrosis or dehiscence* because no triangular edges are formed. Excellent esthetic results as the lines fall in natural creases.
*Disadvantage:* Technically *more demanding* to perform the dissection through the restricted access between the horizontal cuts, making it less suitable for beginners.
*Freund and Latyshevsky Apron Incision:* Begins at the mastoid, curves below the mandible and down across the SCM, and extends toward the chin.
*Advantage:* Highly effective for *supraomohyoid neck dissections* (Levels 1-3) with **no triangular areas**, leading to excellent healing.
*Freund Apron Incision (for Larynx):* A longer apron incision extending from one mastoid process to the other, used for midline malignancies and bilateral supraomohyoid dissections.