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Retromandibular approaches

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Principles
The retromandibular approaches expose the entire ramus from behind the posterior border. They
therefore may be useful for procedures involving the area on or near the condylar process/head,
or the ramus itself.
There are two varieties of retromandibular approach used to access the posterior mandible. They
differ in the placement of the incision and the anatomic dissection to the mandible.
The transparotid approach has the advantage of close proximity of the skin incision to the area of
interest. The retroparotid approach has the advantage of not dissecting through the parotid gland.
The facelift (rhytidectomy) approach can be considered as an alternative to retromandibular
approaches.

Anatomical structures
The main anatomic structures in this approach are the main trunk and branches of the facial nerve
(CN VII) and the retromandibular vein.

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Exposure offered by extraoral approaches
Submandibular approach
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Retromandibular approaches
Transparotid
Retroparotid

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Preauricular approach

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Facelift incision (rhytidectomy)
Transparotid approach: skin incision
General consideration
Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. The two
options currently available are the use of local anesthetic or a physiologic solution with
vasoconstrictor alone.
Use of a local anesthetic with vasoconstrictor may impair the function of the facial nerve and
impede the use of a nerve stimulator during the surgical procedure. Therefore, consideration
should be given to using a physiological solution with vasoconstrictor alone or injecting the local
anesthetic with vasoconstrictor very superficially.

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A vertical incision through skin and subcutaneous tissue is made, extending from just below the ear
lobe towards the mandibular angle. It should parallel the posterior border of the mandible.

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Transparotid approach: dissection
The subcutaneous tissue is undermined, exposing the superficial musculoaponeurotic system
(SMAS).
A vertical incision is made through the SMAS into the parotid gland.

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Blunt dissection of the parotid gland
Bluntly dissect the parotid gland parallel to the direction of the facial nerve branches and towards
the posterior border of the mandible. The dissection should be anterior to the retromandibular
vein.
Branches of the facial nerve may be found during the dissection. A nerve stimulator may be helpful
to identify them. They should be mobilized and protected.
Once the posterior border of the mandible has been reached, an incision is made through the
pterygomasseteric sling.

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Subperiosteal dissection of the mandibular ramus
A periosteal elevator is used to strip the masseter muscle from the ramus. Further dissection
superiorly along the posterior border exposes the condylar process.

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Transparotid approach: exposure
Illustration of the amount of exposure obtained using this approach.

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Clinical view of the access gained.
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Transparotid approach: wound closure
The wound is reapproximated in layers for anatomic realignment and avoidance of dead space.
The parotid gland capsule must be closed tightly to prevent salivary fistula.
The SMAS is resuspended.

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The skin and subcutaneous tissues is then closed based on surgical preference.
Consider anticholinergic medication (transcutaneous patch) postoperatively to decrease salivary
flow and so lessen the risk of salivary fistula.
Alternative: retroparotid approach
Principles
A frequently used alternative to the retromandibular transparotid approach described above is one
in which the parotid gland is lifted rather than dissected through. This requires the incision to be
placed more posteriorly which means that exposure of the mandible is more limited. Rather than
approaching the mandible from directly over the ramus, it is approached more posteriorly.
General consideration
Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. The two
options currently available are the use of local anesthetic or a physiologic solution with
vasoconstrictor alone.
Use of a local anesthetic with vasoconstrictor may impair the function of the facial nerve and
impede the use of a nerve stimulator during the surgical procedure. Therefore, consideration
should be given to using a physiological solution with vasoconstrictor alone or injecting the local
anesthetic with vasoconstrictor very superficially.
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Skin incision
An oblique incision through skin and subcutaneous tissue is made, extending from the mastoid
process to a point just below the angle of the mandible.

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Dissection
The subcutaneous tissue is undermined, exposing the superficial musculoaponeurotic system
(SMAS).
An oblique incision is made through the SMAS. The posterior aspect of the parotid gland is
identified and dissection continues behind the gland.

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The gland is lifted off the masseter muscle and retracted anteriorly.
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Dissection
Once the posterior border of the mandible has been reached, an incision is made through the
pterygomasseteric sling.

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Subperiosteal dissection of the mandibular ramus
A periosteal elevator is used to strip the masseter muscle from the ramus. Further dissection
superiorly along the posterior border exposes the condylar process.

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Exposure
Illustration of the amount of exposure obtained using this approach.
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Wound closure
The wound is reapproximated in layers for anatomic realignment and avoidance of dead space.
The SMAS is resuspended.
A suction drain may be placed.

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The skin and subcutaneous tissues is then closed based on surgical preference.
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v1.0 2008-12-01