Step 4 Dissection to the Pterogomasseteric Muscular Sling

After retraction of the skin edges, the scant platysma muscle is sharply incised in the same plane as the skin incision (Fig. 10-5). At this point, the superficial musculoaponeurotic layer (SMAS) and parotid capsule are incised and blunt dissection begins within the gland in an anteromedial direction toward the posterior border of the mandible. A homostat is repeatedly inserted and spread open -parallel to the anticipated direction of the facial nerve branches (Fig. 10-6). The marginal mandibular branch of the facial nerve is often, but not always, encountered during this dissection and may intentionally sought with a nerve stimulator. The cervical branch of the facial nerve may

Figure 10-5 Sharp dissection through the thin platysma muscle, SMAS, and parotid capsule after undermining with a hemostat.
Cpt Smas Flap Parotid
Figure 10-6 Blunt hemostat dissection throungh the parotid gland, spreading in the direction of the fibers of VII.

Also be encountered, but it is of little consequence as it runs vertically, out of the field. In many instances, the marginal mandibular branch interferes with exposures and may be retracted superiorly depending on its location. A useful adjunct in retracting the marginal mandibular branch involves dissecting it free from surrounding tissues proximally for 1 cm and distally for 1,5 to 2 cm. This simple maneuver determines whether the nerve is better retracted superiorly or inferiorly. Dissection then continues until the only tissue remaining on the posterior border of the mandible is the periosteum of the pterygomasseteric sling (Fig. 10-7). One should also be cognizant of the retromandibular vein, which runs vertically in the same plane of dissection and is commonly exposed along its entire retromandibular course. This vein rarely requires ligation unless it has been inadvertently transected.

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