ARTÍCULO ESPECIAL

 

Parotidectomy and facial vein

Parotidectomía y vena facial

 

 

F. Hernández Altemir¹, S. Hernández Montero², S. Hernández Montero³, E. Hernández Montero⁴

1 Licenciado Médico Estomatólogo y Médico Especialista en Cirugía Oral y Maxilofacial. Miembro Fundador de la Sociedad Europea de Cirugía Cráneo-Maxilofacial. Académico Correspondiente de la Real Academia de Medicina de Zaragoza. España.
2 Dra. en Medicina y Cirugía y Licenciada Médico Odontólogo y Médico Especialista en Cirugía Oral y Maxilofacial. Directora Academia del Master Oficial de Implantología Dental y Prótesis Implantosoportada de la Universidad Alfonso X el Sabio de Madrid.
3 Licenciada en Medicina y Cirugía, Médico Odontólogo. Profesora de Patología Bucal de la Licenciatura de Odontología de la Facultad de Ciencias de la Salud y del Deporte (Huesca) en la Universidad de Zaragoza. España.
4 Facultativo Médico Especialista en Otorrinolaringología del Hospital de Viladecans y del Instituto de Neuro-Otología García Ibáñez de Barcelona. España.

Correspondence

 

 

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ABSTRACT

Benign parotid tumor surgery is related to fundamental nervous structures, defined simply: that when damaged cause great psychosomatic problems. In order to make peripheral facial nerve surgery easy to handle for the surgeon this article emphasizes the importance of the facial vein in the dissection and conservation of the nerve. Its dissection can be compromised if the caudal branches are damaged. The study that we develop should be seen as praise for the vein structures in the follow up and control of the peripheral facial nerve, and the main auricular nerve that is often undervalued when it is no longer the protagonist in the face.

Key words: Facial; Facial nerve; Great auricular nerve; facial vein.

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RESUMEN

La cirugía de los tumores benignos de la parótida, es una cirugía de relaciones con estructuras fundamentalmente nerviosas cuyo daño, representa un gravísimo problema psicosomático por definirlo de una manera genérica. Para ayudar al manejo quirúrgico del nervio facial periférico, es por lo que en el presente artículo tratamos de enfatizar la importancia de la vena facial en la disección y conservación del nervio, precisamente donde su disección suele ser más comprometida, esto es en las ramas más caudales. El trabajo que vamos a desarrollar hay que verlo pues, como un ensalzamiento de las estructuras venosas en el seguimiento y control del nervio facial periférico y de porqué no, el nervio auricular mayor no siempre suficientemente valorado en la cirugía de la parótida al perder protagonismo con el facial.

Palabras clave: Facial; Nervio facial; Nervio auricular mayor; Vena facial.

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Introduction

We have always been surprised by conventional parotid surgery, the surgical benefit is to conserve the facial nerve, the major auricular nerve, the external jugular and extend its dissection until the cephalic regions, the connecting intraparotid and the facial vein to see and feel the relationship in practically all of the peripheral branches of the facial nerve. In turn creating an ideal surface for its dissection and it also allows for secure abscission of all of the supposedly pathological content of the gland.

 

Materials and Methods

The one we have obtained over the more than forty years that our Medical Surgery Practice has been around studying the treatment of pathologies of the salivary glands.

They have always said that the parotid surgery is the best procedure to avoid the severe effects of partial or total lesion of the facial nerve. It has been emphasized that conservation of the peripheral nerve from its main exit to the deep valley built by the digastriacus and the gorge of the external auditory duct. At first, this appears without a doubt the most common of ways and the best and most secure procedure for its control.

Maneuvers and key anatomic points are always discussed in reference to this surgery. These maneuvers are intended to first find and then follow the main facial nerve at its mastoid style hole and allow the follow-up and dissection of its branches.

We are going to try to emphasize what is perhaps the most neglected and forgotten aspect of the gland surgery.

We refer to the control and dissection of the main auricular nerve in all or part of the branches, and above all the caudal vein system of the parotid. This is formed by the external jugular, the connecting intra parotid and the facial vein. It must be mentioned that maybe it seems that it could have, for no apparent reason, lower anatomic entity than the most essential points that we already indicated.

The key point is known, practiced referenced among others by Conley 1961,^1,2 1973,³ J.J. Redon H.³ 1972, L. M. Gil-Carcedo 1992.⁴ All of which is intended to support a possible "new philosophy", not only a surgical one but also a conceptual one. In an effort to improve the approach and dissection and above all, the weak inferior face branches in the most caudal of the ace and parotid.

The parotid surgery usually starts in the digastricus valley (key point for excellence), made up of not only this but also its mastoid union, by the auricular cartilage, in its external face and in the inferior and anterior zone of the external ear, where it transmits a prolonged and projected signal, similar to an indicator of the nerve exit (1 and 2) Conley 1961 and 1973). In reference to the anterior mastoid next to the third cervical anterior of the sternocleidomastoid muscle, that is not only the principal muscle in the radical anatomy but also functional in the neck surgery.

Years ago parotid surgery was started by Ramon Castillo Escandón and others who were looking for the peripheral margin, reactionary technique that today is compared to the frequency of anterograde⁷ (Barry O'Regan, 2008). Coming close to the knee nerve³ (Redon 1972) although again,^5,6 Castillo said that he did it dragging himself along (I think that despite everything many of us continue to have the same attitude) out of fear of leaving the patient with a crooked lip and because of our own prestige, but even more now because of our judicial connotations that are not relevant to development.

Returning to our valley, from which we should almost never separate ourselves, the place where we often make an incorrect gesture of authority, leaving out with relaxed certainty at the beginning of surgery, noting with our index fingers the vertex filled with uncertainty. We do this where we hoped the trunk would be, with hope of almost touching it to discover it, control it and everything to follow the branches that are situated just before the anatomic abyss, until they pass over the maseter surface in order to fall in a contained cascade and make its route enigmatic again. It imitates some surprising rivers in Andalucía Spain where it is more functional in proximity and depth that comes from the unquestionable individual creases and changing nosogenesis. Sometimes it depends on its vicissitude designs or individual emotions more or less chronified by the patient.

Obviously we, with sensitivity, refer, in this description perhaps too dreamlike, without removing their importance, because of its very important labor function, the superior facial branches, without a doubt of more convincing and noble anatomic presence in its frontal orbit path and because of this it is more vulnerable to our impertinent surgical possibilities. It is obvious that they deserve all of our attention and respect because they are going to have excellent functional connotations, especially in the frontal palpebral.

But we must emphasize that apart from what we said, dissection, follow-up and facial respect. Another big key is the recognition, dissection and preservation of the bluish, rich, abundant and almost vertical venous garland (exter nal jugular, connecting intraparotid and facial vein), understood like this when considering the decubitus of the patient and the lateralization of the surgical field. Which we can see in the iconography (Figs. 1 to 9) of the attached clinical case, especially in figure 6.

 

 

 

 

 

 

 

 

 

 

Garland, which is formed by the high cervical portion of the external jugular vein, the connecting referred to s the facial vein. Both just below the medial portion of the unstable cervico margin facial branches where a more anatomical designs, morphology, stability are almost always missing, that suspends and swings and at the same time divides. Its peripheral path in the anterior functional part to the blue vein axle that takes the nosogenic enigmatic valley where we want to lose with every surgical intention knowing that they come from another posterior region that is inert and a functional. From a peripheral birth point of view, it is a little bit more than the cervicomastoid vertex of the digastrics, in other words when the trunk is divided into different branches.

We are going to diffuse this poisonous concept, that in our surgical experience gland pathology surgeries with the intention of increasing recognition, path, dissection, conservation and perhaps the nerves possible lesions They involved harm not only functionally evident but the ones that can justify how we conclude that psychosomatic aftereffects that all surgeons in this area are know are many times unpredictable and are an indubitable help to correct excision of the pathology attached to the parotid.

The neck surgeon is mainly a vein fascia surgeon. It is known that he practices from⁸ Crile, 1905,⁹ Hayes Martin 1951,¹⁰ Oswaldo Suarez 1963,^5,6,16 Hernandez Altemir 1973, 1974, 1986) but in all this time, very few have emphasized how we now know the importance that the veins have in the parotid surgery. Not caring for them is credited to the anatomic and functional personality of the facial nerve that is omnipresent and the obsession that the surgeon has with the particularities of the exceptional surgical field. We could try to announce an axiom "correct vein surgery is very often determined by the good work of the surgeon".

In this sense what we want to transmit to the operated parotid, we don't want to forget that the sub maxilla gland, that we already tried to do, is also a vein manifestation in ^1,12,16,17 Hernandez Altemir 1985 and 1986. The artery was already done¹³ (Yoav P. Talmi 2003) with microsurgical ends like (Yoel J 1986), conserving the facial artery in the conventional submaxillectomy to avoid certain sinking of the sub maxilla region when it is sectioned and attached. This same author describes, in excellent conditions, the¹⁴ Triangle of R. Finochietto and of the14 J. Yoel (that we tried to call the triangle of doubt) although the existence of the famous work by Hayes Martin,⁹ to carry along with the facial vein, the marginal vein outside the surgical camp and try to avoid its lesion during the numerous surgeries in this zone, where there its continuity is always compromised despite the already mentioned technique.

All head and neck surgeons perform the work by H. Martin; ⁹ we do it and often say to our residents: "This technique helps us separate and protect the facial marginal branch" which makes way for a new generation of surgeons.

For us the H. Martin technique has already completed its task an it should generally continue to do it when it comes in handy. Giving it just the safeguard value that above all the marginal facial vein. We insist that it remain useful but it can hidden if its performance is carried out more or less systematically with highly aggressive levels when interrupting the continuity of the artery and facial veins, hiding certain inabilities and ways and for no good reason, it is the absolute safeguard of the marginal branch.

All of us can rest when during surgery, especially a neck surgery, when we have the top, bottom and internal jugular controlled because that is what we tried to do with the parotid glands that helped us dominate the field.

We insist on revindicating the vein system. The classic cervicofacial surgery will have determined indisputable objectives, granting it a place in our practice. Not only because its control provides optimal results but also because we want to ask that it is part of the conventional anatomic surgery and get rid of the idea that veins should be removed as soon as possible because of their fragility and variability.

Our mission is to revindicate the veins, particularly the ones in the parotid region. We consider them surgical support not inconveniences.

The matrix of vein treatment is what the surgeon usually attaches and he burns them. As if they were heretical, but the arteries are rarely burned, and they are attached only if they have decreasing calibers, for obvious reasons and because they are more functional, selective and easier to recognize and follow.

The facial vein and its connective intraparotid, the posterior facial vein, has an entity that can find the cervical branch of the face within the parotid tissue. As we see very well in the anatomic preparations described by Gil Caicedo, 1992 and that require recognition and when attached and tractioned using a rake towards the facial cervical as we talked about prior. We conserve it to see what is more helpful that what normally concedes.

Vein dissection and recognition of the cervical facial branch have been and can continue to be dissection movements not only to discover the facial trunk, but also to conserve and expose the marginal branch. Without a doubt it is the brain of the most common head and neck surgeon.

All of this includes recognizing the facial vein, its suprameseter longitude development, passing over the anterior border of the master and continuing along some branches, where we dare to dominate the facial vein sheet.

The facial vein is more caudal, sub mandible maseter and we have already commented on its indubitable pre maseter perceptibility. Until the caudal portion of the molar along with the major sub parotid vein , probably of the most beautiful and complex anatomic zones where structures of great chromatic richness (it has been said that the parotid surgery is recognized in distinct structures that are recognized by a symphony of colors. If not we went overboard with the perfusion of the blue methylene at the beginning of our conduct and acini glandules.

We need not forget about everything after what we have said. The Caudal portion of the facial nerve where the most determinant and vulnerable facial nerves of the parotid surgery are as well as the fundamental aspects of facial expressiveness or what is the same. In the infra parotid portion of the superficial lobe where these caudal branches are, in its most anterior portion they submerge in the depth. In order to innervar the most sensitive muscle of the peribuccal faces. It would be as if the exit of the facial was like it was before, when we went on "functional" to recover. When they hide and sink in cascade immediately under the nosogenic groove to make it extraordinarily active.

We acknowledge our surgical effort from the beginning and in the first place the main auricular nerve (that we will try to respect and follow where the pathology allows us), the same as the external jugular, the connecting intraparotid and the facial vein. We leave them amply dissected and it surprises us to see that the caudal branches of the facial nerve are supported by them. This makes their control and follow up easier and our surgical well being in all of its benefits. Among other obvious conservative attempts with the Frey L syndrome, 1923,^11,12 Hernandez Altemir, 1985, 1986 and²⁰ Sanchez Cuellar, 2008.

For us it is important to conserve the vasculoveinous caudal structures of the parotid, a key point that we want to recuperate from the parotid surgery.

 

Discussion

It is obvious that in our study we don't incorporate basic changes to what has classically been tumor and parotid benign pathology surgery. But it does seem depict able that we have been able to see in parotid surgery publications that they emphasize how we carefully and conservatively note the vein system of the region that is contemplated for this work. Not because of purely anatomic reasons and the possible surgical action, but rather to help by providing more security when controlling the working integrity of the facial nerve and also the large auricular nerve whose initial dissection and parotid surgery keeps us entertained in our conservative surgical ambition.

 

Conclusions

In our opinion it has been understood that our intention when making a facial vein, a little more protagonist in role, that what is really, in surgical intensity and because there is not always emotion of the parotid surgeon and perhaps it deserves this public tribute.

We should not think for now that the parotid surgery could be carried out with endoscopic procedures that separate us from what has been classically established.

Parotid surgery is always a challenge and to reach it with humility, activates an indubitable right with which we should give our patients and ourselves because of the challenge and its achievement is quite significant.

 

 

Correspondence:
Dr. F. Hernández Altemir
Web: www.headandneck.es
E-mail: drhernandezaltemir@yahoo.es

Recibido: 10.03.2009
Aceptado: 25.08.2009

 

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