Preauricular Subtemporal-Infratemporal Fossa Approach to the Petrous Carotid. A, The skin incision (inset) and flap are positioned so that a neck dissection and a frontotemporal craniotomy can be completed. The scalp flap has been reflected forward while protecting the facial nerve and its branches. The facial nerve branches passing deep to the parotid have been preserved. B, The parotid gland has been removed and the branches of the facial nerve distal to the stylomastoid foramen have been exposed. The internal jugular vein is exposed below the facial nerve. C, An osteotomy of the zygomatic arch and across the base of the coronoid process (yellow arrow) allows the temporalis muscle to be folded upward to expose the medial and lateral pterygoid muscles, maxillary artery, and branches of the trigeminal nerve in the infratemporal fossa. D, The lateral pterygoid muscles have been reflected to expose the internal carotid, maxillary, and accessory meningeal arteries; the mandibular nerve and its auriculotemporal, lingual, and inferior alveolar branches; and the medial pterygoid and tensor veli palatini muscles. The accessory meningeal artery enters the foramen ovale. The middle meningeal artery passes between the 2 bundles of the auriculotemporal nerve. (Images courtesy of AL Rhoton, Jr.)