pioneered by Dr.Larian, the Micro-Parotidectomy is a revolutionary way to perform parotid surgery. This versatile approach allows access to the entire parotid gland, to remove either a small portion of the gland (small benign tumors), the deep lobe (deep lobe tumors), a large portion of the parotid (larger tumors), or the entire gland if necessary.
During the micro-parotidectomy procedure, or minimally invasive parotid surgery, Dr. Larian will remove a portion or all of the parotid gland through a very small and well-hidden incision around the bottom portion of the ear – an approach that results in reduced pain, minimal scarring, and quicker recovery. Simultaneously, EMG facial nerve monitoring is used to help preserve the FACIAL NERVE & all it’s branches. At the end of the procedure the facial nerve is again examined to ensure all branches are working appropriately. The GREATER AURICULAR NERVE is also preserved to keep sensation of the ear lobe.
All micro-parotidectomies are combined with a reconstructive procedure to fill in the defect left behind by the removed portion of the gland. In addition to restoring symmetry to the face, this corrective procedure provides an added layer of protective tissue on top of the facial nerve. It also prevents FREY’S SYNDROME, a condition that occurs when the nerve branches from the parotid grow into the skin and cause sweating while eating. Reconstruction will allow improved aesthetics, facial symmetry and result in minimal to no scarring. Micro-parotidectomy is commonly performed as an outpatient procedure; most patients do not require hospitalization and can return home the same day as surgery.
The minimally invasive micro-parotidectomy is the most cutting edge parotid removal technique available today. Although Dr. Larian and his team strive to use this advanced approach whenever possible, in some cases other more extensive parotid removal techniques may be required. Because of the variety of cell types, there are many different types of tumors and cancers that can develop in the parotid gland. As such, the type of parotid surgery that will yield the best results for the patient is dependent on the size, location, and aggressiveness of the tumor or disease.
During your consultation at the CENTER for Advanced Parotid & Facial Nerve Surgery, Dr. Larian will thoroughly examine you, and any imaging studies that have been performed. Oftentimes, he will perform his own ultrasound in the office and if necessary a needle biopsy will be done to determine if the tumor is cancerous or not. Once the nature of the tumor is determined, he will decide the extent of your surgery and if you are a candidate for micro-parotidectomy.
Our goal at the CENTER is to provide our patients the best parotid surgery outcomes, full facial nerve function, quick recovery, alongside the most trusted and compassionate care. Our entire team is here for YOU. We will help you every step of the way.
Consult with Parotidectomy Surgeons - Dr. Larian & Dr. Azizzadeh
Micro-parotidectomy is the most minimally invasive technique available for parotid tumor removal; it involves a very small incision around the earlobe, to minimize scarring, that hides in the natural skin lines in front (green line) & behind the ear (green dashed line). This approach involves a lot less tissue trauma and thus leads to a lot less pain & much shorter recovery time. At the CENTER, most micro-parotidectomy & reconstruction surgeries are performed by Dr. Larian. But in more complex cases Dr. Azizzadeh and/or Dr. Slattery may be involved as well. We have found that a team approach may be needed in the more complicated cases to get optimal results. Utilizing the expertise of these surgeons ensures the best functional & cosmetic result for larger more aggressive tumors. Having perfected micro-parotidectomy in the past 2 decades, Dr. Larian prefers this less invasive parotidectomy approach, and uses it in most cases. Make a consultation appointment to see if you are a candidate.
Dr. Azizzadeh, Slattery & Larian have been working collaboratively to also treat facial nerve diseases. The CENTER is world-renowned for treatment of facial nerve paralysis and injury. We treat facial nerve injuries that occur when patient’s have facial, parotid or brain surgeries elsewhere. As such we have a healthy respect and deep understanding of the facial nerve anatomy & function. Alongside our team’s unparalleled experience, we take every safety measure and precaution possible before, during and after surgery to protect and preserve the facial nerve. Therefore, the occurrence of permanent facial paralysis from parotidectomy is extremely low at our CENTER (less than 0.1%). In addition to preserving the facial nerve, we also go to great lengths to protect the greater auricular nerve, which is in charge of providing sensation to the ear lobe. The incidence of Frey’s syndrome is also greatly reduced to significantly less than 1% due to the fact that our team immediately reconstructs the area. The reconstruction is done by using fascial flap (SMAS) in all cases for greater contouring, muscle flap or fat grafting for filling in the defect, or a combination for larger defects. When needing surgery on such an important area of the face, it is extremely important to find a surgeon who regularly performs micro-parotidectomy to protect you from unwanted & avoidable complications.
Pictures above show the micro-parotidectomy incision at the end of the surgery after it was sutured close in front & behind the ear with dissolvable sutures that are under the surface (do not need to be removed). These are the surgery pictures of the young lady pictured above these set of pictures where the incision is marked in green.
Small parotid tumor (grey)
SCM muscles & facial nerve branches
Cross-section of parotid & tumor
Facial nerve (white) going through parotid
Facial Nerve branches in the area of tumor identified. Tumor removed with a small cuff of normal parotid tissue.
Skin (pink) & SMAS layer (dark orange under skin) lifted off of parotid. Tumor & a small portion of parotid removed
Superficial parotid tissue brought together & sutured. Facial nerve covered
Parotid tissue sutured together
Facial nerve fully intact & covered
Incision closed with absorbable sutures under the surface
SMAS layer (dark orange) is preserved & placed between skin & parotid to prevent Frey’s syndrome, & create smooth contour
Large parotid tumor (grey)
SCM muscles & facial nerve branches
Cross-section of a superficial lobe tumor
Facial nerve (white) going through parotid
Facial nerve & branches identified protected. Then the tumor is removed with an extra cuff of normal parotid tissue
Cross-section of parotid & tumor removed
Facial nerve identified, preserved & exposed
A small portion of SCM muscle (10-15%) brought into parotid defect. Facial nerve covered.
SCM muscle placed in the parotid defect. Facial nerve fully intact & covered. SCM flap does NOT cause neck weakness or stiffness/limitation in movement.
Incision closed with absorbable sutures under the surface. Small drain place to prevent fluid accumulation when muscle flap is used.
SMAS layer (dark orange) is preserved & placed between skin (pink) & muscle flap to prevent Frey’s syndrome & create a smooth contour. Drain placed next to muscle.
Actual surgery transformed into animation.
As surgical techniques advanced from traditional parotidectomy, the next phase in the evolution of parotid surgery was the facelift incision, which opened the door for simultaneous facial reconstruction surgery. The use of the facelift incision results in less scarring than the traditional parotidectomy and a better aesthetic outcome. It allows for access to the facial nerve and greater auricular nerve, as well as critical muscles that are necessary for cosmetic reconstruction. Dr. Larian and his team still use the facelift incision when the tumor is positioned in a way that prohibits visibility of the facial nerve with a micro-parotidectomy. Fortunately, this occurs rarely.
This approach can be used if a person is also considering a face or neck lift procedure to be done at the same time.
A traditional parotidectomy is performed through a Modified Blair Incision (or lazy S incision). During the procedure, an incision several inches in length is made extending from the top of the ear down toward the jaw. From there, the surgeon is able to visualize the entire side of the face, including the parotid gland, facial nerve, and neck lymph nodes.
Although this approach is still useful when the removal of lymph nodes is also required, it’s simply not necessary in most cases. Additionally, very few surgeons perform facial reconstruction at the same time as a traditional parotidectomy, leaving patients with a large defect or hollowness in the face & neck where the gland used to be. This also causes most patients to have Frey’s syndrome, which is sweating on the side of the face when hungry or eating (easily preventable by performing a reconstructive surgery at the same time). The traditional surgery also involves cutting the greater auricular nerve, which causes numbness of the lower part of the ear (again this is avoidable).
Definitely not. The greater auricular nerve (GAN) is immediately under the skin & during every parotid surgery it is preserved. It is in charge of feeling of the earlobe and the skin around the lower part of the ear and over the parotid.
It may be at times in our path to get to the other important nerve (facial nerve) in which case the nerve is identified, separated from the parotid and preserved out of the way. This may make the GAN temporarily not work well, which can cause numbness in the area of surgery (parotid). Which is in fact a big advantage because numbness in the area after surgery makes this a relatively pain-free surgery. Fortunately, the numbness is short-lived, and the feeling in this area returns usually within 6 weeks.
Absolutely not. The facial nerve is too important for any of its branches to be compromised. Majority of the time during this surgery is spent on identification of the facial nerve and its branches. Facial nerve expertise is of vital importance as is attention to detail and patience. There is no reason to not take extra time to try to preserve every single branch of this vital nerve.
Yes, in every single case a facial nerve monitoring system is used. This system continuously checks the activity of the facial nerve. When it senses the slightest activity close to the nerve it sends alerts. The alarms let the surgeon know they are close to the nerve and to exercise extreme caution. This is no substitute for expertise but is an additional measure of safety for the nerve. In the video, the monitors can be seen as a blue probe, next to the eye & red probe for the lip.
After all the facial nerve branches in the area of the surgery are identified and the tumor removed; then each of the branches of the facial nerve are stimulated with a Checkpoint nerve stimulator to make sure each branch is working to definitively confirm during surgery that the facial nerves are intact and functioning.
STIMULATION OF THE FACIAL NERVES AFTER REMOVING THE TUMOR TO ASSURE ALL BRANCHES ARE WORKING (converted into animation)
Facial Nerve & all the branches are identified & preserved during surgery. (The nerves are seen as white lines in this image which is made into an animation from an actual Micro-Parotidectomy)
ABSOLUTELY NOT. Micro-parotidectomy is just as safe as any other approach to the parotid gland. As you can see from the image to the left the entire facial nerve anatomy in the parotid is visible during a micro-parotidectomy. The facial nerve is too important to ever be compromised. The key to preserving the facial nerve is to be meticulous, attentive, gentle and very patient. This is not a surgery to be rushed; rather your surgeon needs to be very experienced, caring and measured.
At the CENTER we not only treat parotid tumors but also cases of facial paralysis caused during surgery by other surgeons, as such we have an immense respect for the facial nerve and we really understand its importance.
In our experience at the CENTER the incidence of facial nerve issues during micro-parotidectomy has been significantly less than 1%. Even the incidence of temporary weakness has been exceedingly low, because we take our time and handle the tissue very gently.
Micro-parotidectomy was pioneered by Dr. Larian over a period of a decade. He has been performing it for close to 2 decades. Since parotid tumors are not very common, a surgeon must specialize in salivary gland surgery to do enough parotid surgeries to be comfortable enough with the parotid and facial nerve anatomy to be able to part ways with traditional techniques. All surgeons get trained to do the traditional parotidectomy which has a large incision and a lot of dissection and exposure of the parotid gland. This creates a comfort level for the surgeons that have only seen it done in this way or do infrequent parotid surgery. The traditional technique is a very good approach for treatment of parotid cancers that have spread to the lymph nodes; it isn’t ideal for benign tumors that are only in the parotid gland.
Traditional or Modified Blair Incision is ideal for surgical treatment of a cancer that has spread to the lymph nodes in the neck.
The micro-parotidectomy incision and approach allows access to all areas of the parotid gland, so all types of parotidectomy can be done, including superficial parotidectomy, extra-capsular dissection (ECD), and total parotidectomy.
Yes. The risk profile for micro-parotidectomy is the same as traditional surgery. The risks of parotid surgery has more to do with the experience of the surgeon, and how gentle the surgeon is handling the tissue and the facial nerve. Research shows that surgeons who perform more than 50 of the same surgeries per year have a significantly lower complication rates. We have extensive experience at the CENTER not only with parotid surgery, but also facial nerve surgery.
The recurrence rate for micro-parotidectomy is very low and in fact lower than what has been reported in the literature for traditional parotid surgery. The reported rate of recurrence for pleomorphic adenoma in the literature is 2-5%. In our experience at the CENTER the recurrence rate for pleomorphic adenomas has been significantly less. More than likely this has to do with our extensive expertise and large volume of parotid surgeries being done.
We also perform a large number of revision parotid surgeries, when the first surgery has been done elsewhere. As such we have a very healthy respect for doing the first parotid surgery very thoroughly and comprehensively to minimize the chance of needing a second surgery. Expertise is key in minimizing risk and recurrence in parotid surgery.
The answer to both questions is no. This is an outpatient procedure for the majority of patients. The only exceptions are patients who have other medical problems such as heart, lung, or kidney disease that requires more medical attention and monitoring for these particular organs rather than the parotid surgery itself.
Yes. In fact, more than 90% of parotid surgeries done at the CENTER are for patients traveling from out of town or other countries. The complication rates during and after surgery are exceedingly low and so there is only a 5-day post-surgery observation period when you may need to remain in town and be seen by Dr. Larian (usually 2-3 visits after surgery during the 5 days). The plastic surgery sutures are very fine, absorbable, and under the surface; thus there are no sutures to be removed. In short, the surgery and recovery from micro-parotidectomy is planned so patients have a very short stay in Los Angeles.
The majority of parotidectomies and reconstructions are performed by Dr. Larian alone. The more complex cases with larger or more aggressive tumors may require the assistance of Dr. Azizzadeh, especially if there is a concern for the health of the facial nerve, or if there is very complicated reconstruction to be done. Dr. Slattery is an Otologist (ear surgery specialist) who helps with surgery when the tumor is sitting against the skull and won’t allow easy identification of the facial nerve. In this case, Dr. Slattery will find the facial nerve in the bone behind the ear and allows us to more safely separate the nerve from the tumor.
Significantly less than 1%, mainly because all patients have parotid reconstruction and the SMAS layer is preserved that separates the parotid from the skin. The key to Frey’s prevention is to separate the skin and parotid gland which is always done at the CENTER.
Led by board-certified parotid surgeon, Dr. Babak Larian, our team of specialists has decades of experience successfully diagnosing and treating diseases of the parotid glands with minimally invasive procedures. Distinguished by our compassionate care and cutting-edge techniques, the CENTER has developed a reputation for delivering the best parotid tumor surgery available.
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