Resident Manual of Trauma to the Face, Head and Neck

The submandibular approach was described by Risdon in 1934. 41,42 y y Make the incision 2 centimeters (cm) below the angle of the man- dible in a natural skin crease. 43 y y Dissect through skin, subcutaneous fat, and superficial cervical fascia to expose platysma muscle. y y Dissect the platysma, identify the superficial layer of the deep cervical fascia. The marginal mandibular nerve is deep to this layer. 44 y y Dissect through deep cervical fascia with the aid of a nerve stimula- tor/monitor to the mandibular bone. y y Dissect down to the level of the pterygomassitric sling, dividing it to expose bone. d. Retromandibular Approach The retromandibular approach was described by Hinds in 1958. 45,46 y y Make a vertical incision 0.5 cm below the lobe of the ear, and con- tinue it inferiorly 3.0–3.5 cm. It should be behind the posterior mandibular boarder and should extend to the level of the angle. y y Dissect through the platysma and superficial musculoaponeurotic layer and parotid capsule. y y Consider using the aid of a nerve stimulator or facial nerve monitor, as the marginal mandibular branch and the cervical branch of the facial nerve may be encountered here. y y The retromandibular vein runs vertically in the parotid and should be identified and ligated or retracted to gain access to the lateral mandible. y y Sharply incise the pterygomasseteric sling and elevate the muscle off the lateral surface of the mandible superiorly. This will give access to the ramus and subcondylar region of the mandible. e. Preauricular Approach The preauricular approach is excellent for exposure to the TMJ. 47,48 y y Make the incision in the preauricular fold 2.5–3.5 cm in length, as described by Thoma 48 and Rowe. 49 Take care not to extend the incision inferiorly, since it may encounter the facial nerve as it enters the posterior border of the parotid gland. y y Carry the incision and dissection along the lateral perichondrium of the tragal cartilage. y y Superiorly, if the temporal fascia is encountered, the dissection should be carried deep through the superficial temporal fascia or the temporoparietal fascia. The aid of a nerve stimulator or facial nerve monitor should be considered if the dissection approaches the orbital or frontal branch of the facial nerve.

121

www.entnet.org