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Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its’ location
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Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its’ location Q. Zhang , Y. Yang , P. Yang , Y. Tan , X. Liu , B. Xiong , J. Qiu PII: DOI: Reference:
S1748-6815(19)30473-5 https://doi.org/10.1016/j.bjps.2019.10.012 PRAS 6290
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
15 March 2019 5 October 2019
Please cite this article as: Q. Zhang , Y. Yang , P. Yang , Y. Tan , X. Liu , B. Xiong , J. Qiu , Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its’ location, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.10.012
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its’ location Authors: Q. Zhanga,*, Y. Yanga, P. Yanga, Y. Tana, X. Liua, B. Xionga, J. Qiua a
Department of Oral & Maxillofacial Surgery, First Affiliated Hospital of Nanchang University
* Corresponding author. Tel.: +86-791-88694925. E-mail address: [email protected] (Q. Zhang).
Summary
Objective: The aim of this study is to evaluate the feasibility and aesthetic results comparing two cosmetic approaches which were employed in parotidectomy according to the tumour location with traditional Blair approach. Design: Retrospective study. Setting: Tertiary Referral Centre. Patients: 76 patients were included in the study. Results: The degree of satisfaction with the cosmetic incision approach was significantly higher than that of the traditional Blair approach group. The incidence of transient facial paralysis, salivary fistula was not statistically significant compared with the traditional incision in follow-up 6 months postoperatively. Discussion: Conventional parotidectomy using the traditional Blair incision (or its modification) usually leaves a visible scar in this region which can have major adverse impacts on the social or psychologic well-being of an individual. To achieve better aesthetic result, according to the location of benign parotid tumour, two formal cosmetic approach incisions could be performed in patotidectomy, which was superior to the traditional Blair incision. The authors propose that these two cosmetic approaches for parotidectomy can be both technically feasible and safe.
Keywords parotidectomy; benign tumour; cosmetic approach
Among salivary gland tumours, 80% occur in the parotid gland, most (about 80%) of which are benign. More than 90% of benign parotid tumours are located in the superficial portion of the gland[1]. Surgical resection is the preferred treatment for parotid tumours, but there are complications such as visible scars, and facial nerve injury. Traditionally parotidectomy has been done through a bayonetshaped (Blair) approach with a large “S” shape incision from the lateral face down to the upper neck. Although it allows efficient exposure for dissection of the facial nerve and excision of parotid gland tumour, a permanent visible scar remains which is usually unacceptable to young patients, especially young women[2-6]. Patients may refuse to accept operative intervention for their parotid masses until they have reached a considerable size or turned malignant for fear of the expected possible poor cosmetic appearance of the surgical scar.
For many years, superficial parotidectomy (SP) was recommended as the treatment of choice owing to the low associated recurrence rate while tumour enucleation is associated with a high incidence of recurrence. Recently, many surgeons have adopted a partial superficial parotidectomy(PSP) to manage benign toumours which is a less invasive surgical technique that has all of the benefits of SP while limiting the draw-backs[7-9]. In PSP, the extent of resection is limited to the tumour-bearing area with a surrounding 0.5- to 1- cm cuff of normal parotid tissue, or the tail of the parotid gland when the tumour is located in the posteroinferior portion. It diminishes surgical trauma to the nerve, improves aesthetic results whilst maintaining the oncologic quality of the surgery compared with other parotidectomy approaches[7-9]. However, most of the studies reported the superiority of PSP in relation to postoperative complications and tumour recurrence. How to choose to an appropriate incision on the basis of PSP and to evaluate the postoperative cosmetic result after the surgery has not been reported so far.
Over the past 4 years, two types of cosmetic incision have been employed for surgery to superficial benign parotid neoplasms and the present study is aimed at evaluating the feasibility and esthetic
results comparing with traditional Blair approach. Methods Seventy-six patients presented with superficial parotid masses and who were operated on in the Department of Oral and Maxillofacial surgery of First Affiliated Hospital of Nanchang University during 2015-2018 were enrolled in this study. There were 40 cases in the cosmetic approach group (aged from 4 to 52 years, 15 males and 25 females) and 36 cases (aged from 18 to 71 years, 23 males and 13 females) in control group (traditional Blair approach). The tumours were located in the inferior pole of parotid gland and posterior auricular region in 32 cases (Group B). The volume of tumours ranged from 4.0 cm x 3.0 cm x 3.5 cm to 1.0 cm x 1.0 cm x 1.0 cm. In Blair approach group (Group C), there were19 cases located in the inferior pole of parotid gland and posterior auricular region, 16 cases in the superior part of anterior parotid region, and 1 case in the accessory parotid gland. The volume of the tumours ranged from 4.5 cm x 3 cm x 3.5 cm to 1.5 cm x 1.0 cm x 1.0 cm. This project was approved by the Medical Ethics Committee of the First Affiliated Hospital of Nanchang University and signed informed consent from were obtained from all patients.
All patients were evaluated preoperatively with computed tomograph (CT)/ or magnetic resonance imaging (MRI), and fine needle aspiration cytology (FNAC). Lesions had to shown no features of malignancy on CT/ MRI and FNAC.
Patients were advised that PSP would be performed and the surgical specimen would be sent to pathologist for intraoperative frozen sections. Frozen section might not be able to confirm the definitive pathology; however, in most instances it could indicate accurately whether the lesion was benign or malignant in nature. If the frozen section pathology was suggestive of benign in nature, PSP was adequate. Otherwise the frozen section pathology was suggestive of malignant tumour, total parotidectomy would be performed immediately after the frozen section.
Surgical technique According to the location of the tumour, two cosmetic approaches were adapted: a preauricular crutch approach (Group A) and a rhytidectomy approach (Group B). In Group A, the vertical incision started at the caudal of the earlobe and was directed upward along the natural pretragal crease. At the upper end of the vertical incision, the incision was extended obliquely forward and upward approximately 2.0-2.5 cm to the temporal hairline (Fig 1). According to the location of the tumours and the scope of exposure, the upper end of incision could be extended further. In Group B, the incision started at the level of the tragus in the preauricular area and proceeded along the natural skin crease and continued downwards to the ear lobe, then it curved around the ear lobe then continued posterosuperiorly along the postauricular sulcus, and usually stopped at the level of the external auditory canal (Fig 2). If necessary it could readily be extended at both ends.
All patients were operated under general anaesthesia by a single head and neck surgeon. Dissection of the parotid skin flap in the subcutaneous plane was thereafter performed to expose the parotid gland. In group A, the dissection could be extended to expose the superior part of the gland even the accessory parotid gland. Afterwards, the flap is elevated posteroinferiorly beginning its dissection 1 cm below the zygomatic arch to the anterior border of the parotid gland. The zygomatic branch was dissected first and then temperofacial trunk. The flap was retracted anteriorly and the relevant branch of the facial nerve was carefully dissected and the tumour removed completely. In Group B, the dissection extended to the anterior border of the sternocleidomastoid muscle, and the earlobe was detached from the parotid fascia and retracted superiorly. Dissection between the parotid gland and sternocleidomastoid muscle enabled easy identification of the main trunk of the facial nerve using the tympanomastoid fissure as a landmark. With appropriate retraction of the flap, the relevant branch of the facial nerve was carefully dissected and the tumour removed completely with an adequate resection margin that included normal parotid tissue. The incision, if necessary, can be extended easily in two ways: through the hair as in Group A technique; or by extending the retroauricular incision
through the hair-line.
Patients in which the traditional Blair approach (Group C) was used had their operation performed as described in literaure. A suction drain was then inserted and the wound tightly was closed in two layers with interrupted 3/0 Vicryl and 5/0 nylon sutures. The drain is usually removed after 24 h and the skin sutures were removed after seven days.
Assessment variables Patients were evaluated for facial appearance, numbness of earlobe, and pain/discomfort in surgical area. At the follow-up 6 months after operation, patients made a subjective evaluation of the appearance of the operation area. A visual analogue scale, which is a versatile and sensitive measurement technique was applied for measuring subjective experience including numbness of the earlobe and cosmesis. The score ranged from 1 to 10. Facial nerve function was evaluated at 1 week after operation. If transient facial paralysis occurred, patients were instructed to perform facial muscle function training, and neuro- muscular reevaluated for 6 months after operation. Statistical analysis Statistical significance of the data presented was determined using the Chi-square test and one-way ANOVA. P<0.05 was considered to be significant.
Results A total of 76 patients were enrolled in the study: the experiment cosmetic approach group comprised 40 patients, while the traditional Blare approach group 36 patients. The final diagnosis in all patients but one was of a benign tumour. In cosmetic approach, 26 were pleomorphic adenoma, 6 myoepithelioma, 5 Warthin's tumour, 2 eosinophilic adenoma and 1 lymphoepithelial cyst. Different cosmetic incisions were used to remove parotid tumours. The control group (group C) consisted of 36 patients,
23 cases were pleomorphic adenoma, 8 Warthin's tumour, 3 myoepithelioma and 2 eosinophilic adenoma.
Patients of group A and B who had successful complete removal of the parotid mass with the minimally invasive cosmetic approach. Intraoperative frozen sections detected one malignant tumour nature in the group using the rhytidectomy approach. A total parotidectomy procedure was performed through extending incision at both ends (this patient was excluded in our study).
There were no cases of permanent facial paresis though 3 patients had transient slight disfunction of the facial nerve in group B and C respectively(X2=0.08, P>0.05). There were 2 cases in group B and 3 cases in group C appeared salivary fistula (X2=0.015, P>0.05) and which were controlled by compression bandaging on surgical area. There were 6 cases in group B and 10 cases in group C complained numb of earlobe even 6 months postoperatively (P>0.05). All patients showed no tumour recurrences in the follow-up (Tab 1).
At 6 months after operation, the patients’ satisfaction with the appearance were investigated. The vertical part of the incision in group A was similar to the creases in front of the tragus while the superior part of the incision was hidden in the hair, which make it unnoticeable (Fig 3). In group B, owing to the incision was naturally drooping at the back of the neck and was concealed in the postauricualr hairline, the scar was not obvious (Fig 4). All the patients were satisfied with their esthetic result achieved to their expectation, and no patient had any complaint about the cosmetic problem of the scar. Symmetry of the cheeks was completely restored except for a minimum retromandibular depression in the seven patients that presented in the large tumours. Visual analogue scale was 9.2± 0.7 and 8.7± 1.1 in Group A and B respectively (Tab 1). Contrary to the results of these two groups, the patients showed less satisfaction (5.8± 1.7) and expressed anxiety with the scar following the modified Blair approach(Fig 5). There was significantly statistical differences between the cosmetic incision groups and the traditional Blair approach group (F=43.61, P<0.05). The adverse impacts on social
well-being especially in young unmarried female patient (Tab 1)was reported. Visual analogue scale showed lower score in female than in male patient in the same group, which indicates the more importance of cosmetic approach selection in female.
Discussions Parotid tumours are generally located superficially in the parotid which leads to early detection and early treatment. Large size parotid tumours are rarely seen today. In recent years, the patient's attitude to postoperative facial appearance has changed and patients are more critical of poor cosmesis.. In general, conventional Blair incision is considered worldwide to be a standard approach for benign tumours localized in the superficial parotid lobe, however, with this method, a number of complications have been reported, including auricular lobule numbness and facial contour disfigurement, which can have major adverse impacts on the social or psychologic well- being of an individual after parotidectomy[10-13]. A conventional parotid incision (Blair) is sometimes fails to meet the patient's requirements of minimal scarring, maintenance of aesthetic facial form and function, in addition to preventing tumour recurrence.
Rhytidectomy incision was first applied to parotid gland surgery by Appianiin 1967[14]. Compared with the traditional incision, this incision provides as good a surgical exposure as Blair’s incision without noticeable scar[3,8]. But the long incision and wide range of skin flap separation are its shortcomings.
Over the past 20 years, researchers have improved the parotidectomy to achieve the goal of preserving the function of the parotid gland and its related tissues as much as possible[15-24]. Many studies showed PSP can preserve parotid gland function without increasing the risk for recurrence[7-9]. These improvements prompted surgeons to adopt less invasive but more cosmetic surgical techniques. Meanwhile, PSP make it possible to choose different cosmetic incisions for the treatment of benign parotid tumours. Shaaban [24] proposed more studies are required to evaluate the limited periauricular
incision for different types of parotidectomy and in different locations of parotid tumours.
Therefore, we designed two types of cosmetic surgical approaches according to the location of the tumours. The preauricular crutch approach is suitable for benign tumours located in the upper part of parotid gland or accessory parotid gland. The advantage is that the vertical incision is similar to the natural crease and the upper part is hidden in the hairline, which make the postoperative scar not easily visible. The surgical technique is that the zygomatic branch was dissected first at the junction between the outer canthus-lobe line and the zygomatic arch, then temperofacial trunk searched. Afterwards, the relevant branch of the facial nerve could be easily dissected and the tumour removed completely.
The rhytidectomy approach is suitable for tumours in the lower part of parotid gland and in the posterior auricular region. Its greatest advantage is that both ends of the incision can be extended, so that superficial and total parotidectomy can be completed through this incision.
For malignant parotid tumours with no preoperative lymph node metastasis, the rhytidectomy incision approach could also be used to remove the total gland and tumour. Similarly, for patients with benign preoperative diagnosis but intraoperative frozen examination showing malignant (just as one patient we encountered but not enrolled in this study), this incision could also achieve good surgical exposure for total parotidectomy with better results, including postoperative aesthetic appearance. This was one of the important points which encouraged us to use these two approaches in our department as there was no fear of failure of the procedure.
In addition, the preauricular crutch approach can also be extended to a rhytidectomy incision. Except the potential advantage of a better, less prominent scar, these two approaches we designed is beneficial to preservation of the posterior branch of the greater auricular nerve which is the sensory nerve of the earlobe and should be preserved as far as possible during the operation. The preauricular incision
involves less the posterior branch of the greater auricular nerve, while rhydidectomy incision could expose and retain the greater auricular nerve well[25,26].
Although more attention has been paid to the appearance after parotidectomy, the principles of oncology surgery must firstly be conformed to. Preoperative fine needle aspiration cytological examination and CT/orMRI are necessary, and routine frozen section examination should be performed during operation. If preoperative diagnosis is malignant, be careful to perform cosmetic incision approach, and if intraoperative diagnosis is malignant, the incision can be extended at both ends to achieve good surgical exposure for total parotidectomy. For the elderly and the physically weak patient, we suggest Blare incision be used as far as possible to save operation time. We must keep in mind that patient’ safety, facial nerve function and no tumour recurrence are more important than facial disfigure causing by scar [20,27].
Acknowledgment Conflict of Interest: There is no conflict of interest.
Funding: National Nature Science Foundation of China (81260169); Star and Fire Plan of Jiangxi Ministry of Health and Family Planning Commission (20188013)
Reference
1. Donovan DT, Conley JJ. Capsular significance in parotid tumor surgery: reality and myths of lateral lobectomy. Laryngoscope 1984;94:324-329. 2. Salgarelli AC, Bellini P, Consolo U, et al. Technical tips for a cosmetic approach to parotid sur-
gery. J Craniofac Surg 2012;23:e106-108. 3. Amin A, Mostafa A, Rifaat M, et al. Parotidectomy for benign parotid tumors: an aesthetic ap-
proach. J Egypt Natl Canc Inst 2011;23:67-72. 4. Boynton JF, Cohen BE, Barrera A. Rhytidectomy and parotidectomy combined in the same patient.
Aesthetic Plast Surg 2006;30:125-31.
5. Petroianu A. Parotidectomy by periauricular incision. Otolaryngol Head Neck Surg 2012;146:247-
249.
6. Bulut OC, Plinkert P, Federspil PA. Modified facelift incision for partial parotidectomy versus
bayonet- shaped incision: a comparison using visual analog scale. Eur Arch Otorhinolaryngol 2016;273:3269-3275. 7. Kim DY, Park GC, Cho YW, et al. Partial Superficial Parotidectomy via Retroauricular Hairline
Incision.Clin Exp Otorhinolaryngol 2014;7:119-122. 8. Emodi O, El-Naaj IA, Gordin A, et al. Superficial parotidectomy versus retrograde partial superfi-
cial parotidectomy in treating benign salivary gland tumor (pleomorphic adenoma). J Oral Maxillofac Surg 2010;68:2092-2098. 9. Li C, Xu Y, Zhang C, et al. Modified partial superficial parotidectomy versus conventional superfi-
cial parotidectomy improves treatment of pleomorphic adenoma of the parotid gland. Am J Surg 2014;208:112-118. 10. Fernández Olarte H1, Gómez-Delgado A, Rivera-Guzmán A. Modification of Blair approach with
a modified endaural component to access the parotid region. J Craniofac Surg. 2015;26:1972-1974. 11. Martí-Pagès C, García-Díez E, García-Arana L, et al. Minimal incision in parotidectomy. Int J
Oral Maxillofac Surg 2007;36:72-76. 12. Upile T, Jerjes WK, Nouraei SA, et al. Further anatomical approaches to parotid surgery. Eur
Arch Otorhinolaryngol 2010;267:793-800. 13. Ahn D, Sohn JH, Lee GJ. Feasibility of a new V-shaped incision for parotidectomy: a preliminary
report. Br J Oral Maxillofac Surg 2018;56:406-410.
14. Appiani E, Delfino MC. Plastic incisions for facial and neck tumors. Ann Plast Surg 1984;
13:335–352.
15. Nouraei SA, Al-Yaghchi C, Ahmed J, et al. An anatomical comparison of Blair and facelift incisions for parotid surgery. Clin Otolaryngol. 2006;31:531-534. 16. Gao L, Ren W, Li S, et al. Comparing modified with conventional parotidectomy for benign parotid tumors. ORL J Otorhinolaryngol Relat Spec 2017;79:264-273. 17. Roh JL, Kim HS, Park CI. Randomized clinical trial comparing partial parotidectomy versus su-
perficial or total parotidectomy. Br J Surg 2007;94:1081-1087. 18. Jost G, Guenon P, Gentil S. Parotidectomy: a plastic approach. Aesthetic Plast Surg 1999;23:1-4.
19. Arden RL, Miguel GS. Aesthetic parotid surgery: evolution of a technique. Laryngoscope
2011;121:2581-2585. 20. Panda NK, Kaushal D, Verma R. Do we need to modify the parotidectomy incision? Indian J Oto-
laryngol Head Neck Surg 2016;68:487-489. 21. Yuen AP. Small access postaural parotidectomy: an analysis of techniques, feasibility and safety.
Eur Arch Otorhinolaryngol. 2016;273:1879-1883. 22. Majumdar A. Facial surgical incisions--role of maxillofacial surgeons. Ann R Coll Surg Engl
2010;92:267. 23. Liu H, Pei J, He Y, et al. Comparison of functional change in parotid gland after surgical excision
of pleomorphic adenoma by two different types of parotidectomy. Oral Surg Oral Med Oral Pathol Oral Ra- diol 2016;122:385-391. 24. Shaaban A, Abdelmohsen M. A new evolving incision for partial superficial parotidectomy. J
Egypt surg 2018;37:581-587. 25. Lefkowitz T, Hazani R, Chowdhry S, et al. Anatomical landmarks to avoid injury to the great au-
ricular nerve during rhytidectomy. Aesthet Surg J 2013;33:19-23. 26. Iwai H, Konishi M. Parotidectomy combined with identification and preservation procedures of
the great auricular nerve. Otolaryngol 2015;135:937-941. 27. Wang RC, Barber AE, Ditmyer M, et al. Distal facial nerve exposure: a key to partial parotidec-
tomy. Otolaryngol Head Neck Surg. 2009;140:875-879.
Figure Legend
Fig 1. In group A, a 58-year-old woman with myoepithelioma, 2.0 cm*1.5 cm *1.0 cm in size, designed a preaurecular crutch incision in parotidectomy.
Fig 2. In group B, a 32-year-old woman with pleomorphic adenoma, 3.0 cm x 2.5 cm x 2.0 cm in size, rhytidectomy incision for parotid gland surgery.
Fig 3. The appearance of the patient in Fig 1 postoperatively 6 months.
Fig 4. The appearance of the patient in Fig 2 postoperatively 6 months.
Fig 5. The appearance of the patient with the traditional Blair approach postoperatively 6 months.
Tab 1 Patients with different incisions three months after operation
Group
Cases
VAS Scores
A
8 32 36
9.2± 0.7 8.7± 1.1 5.8± 1.7
B C.
Transient Ficial nerve disfunction 0 3 3
Dry mouth
Numb of earlobe
Fistula
0 0 0
0 6 10
0 2 3
Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its’ location Q. Zhang , Y. Yang , P. Yang , Y. Tan , X. Liu , B. Xiong , J. Qiu PII: DOI: Reference:
S1748-6815(19)30473-5 https://doi.org/10.1016/j.bjps.2019.10.012 PRAS 6290
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
15 March 2019 5 October 2019
Please cite this article as: Q. Zhang , Y. Yang , P. Yang , Y. Tan , X. Liu , B. Xiong , J. Qiu , Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its’ location, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.10.012
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its’ location Authors: Q. Zhanga,*, Y. Yanga, P. Yanga, Y. Tana, X. Liua, B. Xionga, J. Qiua a
Department of Oral & Maxillofacial Surgery, First Affiliated Hospital of Nanchang University
* Corresponding author. Tel.: +86-791-88694925. E-mail address: [email protected] (Q. Zhang).
Summary
Objective: The aim of this study is to evaluate the feasibility and aesthetic results comparing two cosmetic approaches which were employed in parotidectomy according to the tumour location with traditional Blair approach. Design: Retrospective study. Setting: Tertiary Referral Centre. Patients: 76 patients were included in the study. Results: The degree of satisfaction with the cosmetic incision approach was significantly higher than that of the traditional Blair approach group. The incidence of transient facial paralysis, salivary fistula was not statistically significant compared with the traditional incision in follow-up 6 months postoperatively. Discussion: Conventional parotidectomy using the traditional Blair incision (or its modification) usually leaves a visible scar in this region which can have major adverse impacts on the social or psychologic well-being of an individual. To achieve better aesthetic result, according to the location of benign parotid tumour, two formal cosmetic approach incisions could be performed in patotidectomy, which was superior to the traditional Blair incision. The authors propose that these two cosmetic approaches for parotidectomy can be both technically feasible and safe.
Keywords parotidectomy; benign tumour; cosmetic approach
Among salivary gland tumours, 80% occur in the parotid gland, most (about 80%) of which are benign. More than 90% of benign parotid tumours are located in the superficial portion of the gland[1]. Surgical resection is the preferred treatment for parotid tumours, but there are complications such as visible scars, and facial nerve injury. Traditionally parotidectomy has been done through a bayonetshaped (Blair) approach with a large “S” shape incision from the lateral face down to the upper neck. Although it allows efficient exposure for dissection of the facial nerve and excision of parotid gland tumour, a permanent visible scar remains which is usually unacceptable to young patients, especially young women[2-6]. Patients may refuse to accept operative intervention for their parotid masses until they have reached a considerable size or turned malignant for fear of the expected possible poor cosmetic appearance of the surgical scar.
For many years, superficial parotidectomy (SP) was recommended as the treatment of choice owing to the low associated recurrence rate while tumour enucleation is associated with a high incidence of recurrence. Recently, many surgeons have adopted a partial superficial parotidectomy(PSP) to manage benign toumours which is a less invasive surgical technique that has all of the benefits of SP while limiting the draw-backs[7-9]. In PSP, the extent of resection is limited to the tumour-bearing area with a surrounding 0.5- to 1- cm cuff of normal parotid tissue, or the tail of the parotid gland when the tumour is located in the posteroinferior portion. It diminishes surgical trauma to the nerve, improves aesthetic results whilst maintaining the oncologic quality of the surgery compared with other parotidectomy approaches[7-9]. However, most of the studies reported the superiority of PSP in relation to postoperative complications and tumour recurrence. How to choose to an appropriate incision on the basis of PSP and to evaluate the postoperative cosmetic result after the surgery has not been reported so far.
Over the past 4 years, two types of cosmetic incision have been employed for surgery to superficial benign parotid neoplasms and the present study is aimed at evaluating the feasibility and esthetic
results comparing with traditional Blair approach. Methods Seventy-six patients presented with superficial parotid masses and who were operated on in the Department of Oral and Maxillofacial surgery of First Affiliated Hospital of Nanchang University during 2015-2018 were enrolled in this study. There were 40 cases in the cosmetic approach group (aged from 4 to 52 years, 15 males and 25 females) and 36 cases (aged from 18 to 71 years, 23 males and 13 females) in control group (traditional Blair approach). The tumours were located in the inferior pole of parotid gland and posterior auricular region in 32 cases (Group B). The volume of tumours ranged from 4.0 cm x 3.0 cm x 3.5 cm to 1.0 cm x 1.0 cm x 1.0 cm. In Blair approach group (Group C), there were19 cases located in the inferior pole of parotid gland and posterior auricular region, 16 cases in the superior part of anterior parotid region, and 1 case in the accessory parotid gland. The volume of the tumours ranged from 4.5 cm x 3 cm x 3.5 cm to 1.5 cm x 1.0 cm x 1.0 cm. This project was approved by the Medical Ethics Committee of the First Affiliated Hospital of Nanchang University and signed informed consent from were obtained from all patients.
All patients were evaluated preoperatively with computed tomograph (CT)/ or magnetic resonance imaging (MRI), and fine needle aspiration cytology (FNAC). Lesions had to shown no features of malignancy on CT/ MRI and FNAC.
Patients were advised that PSP would be performed and the surgical specimen would be sent to pathologist for intraoperative frozen sections. Frozen section might not be able to confirm the definitive pathology; however, in most instances it could indicate accurately whether the lesion was benign or malignant in nature. If the frozen section pathology was suggestive of benign in nature, PSP was adequate. Otherwise the frozen section pathology was suggestive of malignant tumour, total parotidectomy would be performed immediately after the frozen section.
Surgical technique According to the location of the tumour, two cosmetic approaches were adapted: a preauricular crutch approach (Group A) and a rhytidectomy approach (Group B). In Group A, the vertical incision started at the caudal of the earlobe and was directed upward along the natural pretragal crease. At the upper end of the vertical incision, the incision was extended obliquely forward and upward approximately 2.0-2.5 cm to the temporal hairline (Fig 1). According to the location of the tumours and the scope of exposure, the upper end of incision could be extended further. In Group B, the incision started at the level of the tragus in the preauricular area and proceeded along the natural skin crease and continued downwards to the ear lobe, then it curved around the ear lobe then continued posterosuperiorly along the postauricular sulcus, and usually stopped at the level of the external auditory canal (Fig 2). If necessary it could readily be extended at both ends.
All patients were operated under general anaesthesia by a single head and neck surgeon. Dissection of the parotid skin flap in the subcutaneous plane was thereafter performed to expose the parotid gland. In group A, the dissection could be extended to expose the superior part of the gland even the accessory parotid gland. Afterwards, the flap is elevated posteroinferiorly beginning its dissection 1 cm below the zygomatic arch to the anterior border of the parotid gland. The zygomatic branch was dissected first and then temperofacial trunk. The flap was retracted anteriorly and the relevant branch of the facial nerve was carefully dissected and the tumour removed completely. In Group B, the dissection extended to the anterior border of the sternocleidomastoid muscle, and the earlobe was detached from the parotid fascia and retracted superiorly. Dissection between the parotid gland and sternocleidomastoid muscle enabled easy identification of the main trunk of the facial nerve using the tympanomastoid fissure as a landmark. With appropriate retraction of the flap, the relevant branch of the facial nerve was carefully dissected and the tumour removed completely with an adequate resection margin that included normal parotid tissue. The incision, if necessary, can be extended easily in two ways: through the hair as in Group A technique; or by extending the retroauricular incision
through the hair-line.
Patients in which the traditional Blair approach (Group C) was used had their operation performed as described in literaure. A suction drain was then inserted and the wound tightly was closed in two layers with interrupted 3/0 Vicryl and 5/0 nylon sutures. The drain is usually removed after 24 h and the skin sutures were removed after seven days.
Assessment variables Patients were evaluated for facial appearance, numbness of earlobe, and pain/discomfort in surgical area. At the follow-up 6 months after operation, patients made a subjective evaluation of the appearance of the operation area. A visual analogue scale, which is a versatile and sensitive measurement technique was applied for measuring subjective experience including numbness of the earlobe and cosmesis. The score ranged from 1 to 10. Facial nerve function was evaluated at 1 week after operation. If transient facial paralysis occurred, patients were instructed to perform facial muscle function training, and neuro- muscular reevaluated for 6 months after operation. Statistical analysis Statistical significance of the data presented was determined using the Chi-square test and one-way ANOVA. P<0.05 was considered to be significant.
Results A total of 76 patients were enrolled in the study: the experiment cosmetic approach group comprised 40 patients, while the traditional Blare approach group 36 patients. The final diagnosis in all patients but one was of a benign tumour. In cosmetic approach, 26 were pleomorphic adenoma, 6 myoepithelioma, 5 Warthin's tumour, 2 eosinophilic adenoma and 1 lymphoepithelial cyst. Different cosmetic incisions were used to remove parotid tumours. The control group (group C) consisted of 36 patients,
23 cases were pleomorphic adenoma, 8 Warthin's tumour, 3 myoepithelioma and 2 eosinophilic adenoma.
Patients of group A and B who had successful complete removal of the parotid mass with the minimally invasive cosmetic approach. Intraoperative frozen sections detected one malignant tumour nature in the group using the rhytidectomy approach. A total parotidectomy procedure was performed through extending incision at both ends (this patient was excluded in our study).
There were no cases of permanent facial paresis though 3 patients had transient slight disfunction of the facial nerve in group B and C respectively(X2=0.08, P>0.05). There were 2 cases in group B and 3 cases in group C appeared salivary fistula (X2=0.015, P>0.05) and which were controlled by compression bandaging on surgical area. There were 6 cases in group B and 10 cases in group C complained numb of earlobe even 6 months postoperatively (P>0.05). All patients showed no tumour recurrences in the follow-up (Tab 1).
At 6 months after operation, the patients’ satisfaction with the appearance were investigated. The vertical part of the incision in group A was similar to the creases in front of the tragus while the superior part of the incision was hidden in the hair, which make it unnoticeable (Fig 3). In group B, owing to the incision was naturally drooping at the back of the neck and was concealed in the postauricualr hairline, the scar was not obvious (Fig 4). All the patients were satisfied with their esthetic result achieved to their expectation, and no patient had any complaint about the cosmetic problem of the scar. Symmetry of the cheeks was completely restored except for a minimum retromandibular depression in the seven patients that presented in the large tumours. Visual analogue scale was 9.2± 0.7 and 8.7± 1.1 in Group A and B respectively (Tab 1). Contrary to the results of these two groups, the patients showed less satisfaction (5.8± 1.7) and expressed anxiety with the scar following the modified Blair approach(Fig 5). There was significantly statistical differences between the cosmetic incision groups and the traditional Blair approach group (F=43.61, P<0.05). The adverse impacts on social
well-being especially in young unmarried female patient (Tab 1)was reported. Visual analogue scale showed lower score in female than in male patient in the same group, which indicates the more importance of cosmetic approach selection in female.
Discussions Parotid tumours are generally located superficially in the parotid which leads to early detection and early treatment. Large size parotid tumours are rarely seen today. In recent years, the patient's attitude to postoperative facial appearance has changed and patients are more critical of poor cosmesis.. In general, conventional Blair incision is considered worldwide to be a standard approach for benign tumours localized in the superficial parotid lobe, however, with this method, a number of complications have been reported, including auricular lobule numbness and facial contour disfigurement, which can have major adverse impacts on the social or psychologic well- being of an individual after parotidectomy[10-13]. A conventional parotid incision (Blair) is sometimes fails to meet the patient's requirements of minimal scarring, maintenance of aesthetic facial form and function, in addition to preventing tumour recurrence.
Rhytidectomy incision was first applied to parotid gland surgery by Appianiin 1967[14]. Compared with the traditional incision, this incision provides as good a surgical exposure as Blair’s incision without noticeable scar[3,8]. But the long incision and wide range of skin flap separation are its shortcomings.
Over the past 20 years, researchers have improved the parotidectomy to achieve the goal of preserving the function of the parotid gland and its related tissues as much as possible[15-24]. Many studies showed PSP can preserve parotid gland function without increasing the risk for recurrence[7-9]. These improvements prompted surgeons to adopt less invasive but more cosmetic surgical techniques. Meanwhile, PSP make it possible to choose different cosmetic incisions for the treatment of benign parotid tumours. Shaaban [24] proposed more studies are required to evaluate the limited periauricular
incision for different types of parotidectomy and in different locations of parotid tumours.
Therefore, we designed two types of cosmetic surgical approaches according to the location of the tumours. The preauricular crutch approach is suitable for benign tumours located in the upper part of parotid gland or accessory parotid gland. The advantage is that the vertical incision is similar to the natural crease and the upper part is hidden in the hairline, which make the postoperative scar not easily visible. The surgical technique is that the zygomatic branch was dissected first at the junction between the outer canthus-lobe line and the zygomatic arch, then temperofacial trunk searched. Afterwards, the relevant branch of the facial nerve could be easily dissected and the tumour removed completely.
The rhytidectomy approach is suitable for tumours in the lower part of parotid gland and in the posterior auricular region. Its greatest advantage is that both ends of the incision can be extended, so that superficial and total parotidectomy can be completed through this incision.
For malignant parotid tumours with no preoperative lymph node metastasis, the rhytidectomy incision approach could also be used to remove the total gland and tumour. Similarly, for patients with benign preoperative diagnosis but intraoperative frozen examination showing malignant (just as one patient we encountered but not enrolled in this study), this incision could also achieve good surgical exposure for total parotidectomy with better results, including postoperative aesthetic appearance. This was one of the important points which encouraged us to use these two approaches in our department as there was no fear of failure of the procedure.
In addition, the preauricular crutch approach can also be extended to a rhytidectomy incision. Except the potential advantage of a better, less prominent scar, these two approaches we designed is beneficial to preservation of the posterior branch of the greater auricular nerve which is the sensory nerve of the earlobe and should be preserved as far as possible during the operation. The preauricular incision
involves less the posterior branch of the greater auricular nerve, while rhydidectomy incision could expose and retain the greater auricular nerve well[25,26].
Although more attention has been paid to the appearance after parotidectomy, the principles of oncology surgery must firstly be conformed to. Preoperative fine needle aspiration cytological examination and CT/orMRI are necessary, and routine frozen section examination should be performed during operation. If preoperative diagnosis is malignant, be careful to perform cosmetic incision approach, and if intraoperative diagnosis is malignant, the incision can be extended at both ends to achieve good surgical exposure for total parotidectomy. For the elderly and the physically weak patient, we suggest Blare incision be used as far as possible to save operation time. We must keep in mind that patient’ safety, facial nerve function and no tumour recurrence are more important than facial disfigure causing by scar [20,27].
Acknowledgment Conflict of Interest: There is no conflict of interest.
Funding: National Nature Science Foundation of China (81260169); Star and Fire Plan of Jiangxi Ministry of Health and Family Planning Commission (20188013)
Reference
1. Donovan DT, Conley JJ. Capsular significance in parotid tumor surgery: reality and myths of lateral lobectomy. Laryngoscope 1984;94:324-329. 2. Salgarelli AC, Bellini P, Consolo U, et al. Technical tips for a cosmetic approach to parotid sur-
gery. J Craniofac Surg 2012;23:e106-108. 3. Amin A, Mostafa A, Rifaat M, et al. Parotidectomy for benign parotid tumors: an aesthetic ap-
proach. J Egypt Natl Canc Inst 2011;23:67-72. 4. Boynton JF, Cohen BE, Barrera A. Rhytidectomy and parotidectomy combined in the same patient.
Aesthetic Plast Surg 2006;30:125-31.
5. Petroianu A. Parotidectomy by periauricular incision. Otolaryngol Head Neck Surg 2012;146:247-
249.
6. Bulut OC, Plinkert P, Federspil PA. Modified facelift incision for partial parotidectomy versus
bayonet- shaped incision: a comparison using visual analog scale. Eur Arch Otorhinolaryngol 2016;273:3269-3275. 7. Kim DY, Park GC, Cho YW, et al. Partial Superficial Parotidectomy via Retroauricular Hairline
Incision.Clin Exp Otorhinolaryngol 2014;7:119-122. 8. Emodi O, El-Naaj IA, Gordin A, et al. Superficial parotidectomy versus retrograde partial superfi-
cial parotidectomy in treating benign salivary gland tumor (pleomorphic adenoma). J Oral Maxillofac Surg 2010;68:2092-2098. 9. Li C, Xu Y, Zhang C, et al. Modified partial superficial parotidectomy versus conventional superfi-
cial parotidectomy improves treatment of pleomorphic adenoma of the parotid gland. Am J Surg 2014;208:112-118. 10. Fernández Olarte H1, Gómez-Delgado A, Rivera-Guzmán A. Modification of Blair approach with
a modified endaural component to access the parotid region. J Craniofac Surg. 2015;26:1972-1974. 11. Martí-Pagès C, García-Díez E, García-Arana L, et al. Minimal incision in parotidectomy. Int J
Oral Maxillofac Surg 2007;36:72-76. 12. Upile T, Jerjes WK, Nouraei SA, et al. Further anatomical approaches to parotid surgery. Eur
Arch Otorhinolaryngol 2010;267:793-800. 13. Ahn D, Sohn JH, Lee GJ. Feasibility of a new V-shaped incision for parotidectomy: a preliminary
report. Br J Oral Maxillofac Surg 2018;56:406-410.
14. Appiani E, Delfino MC. Plastic incisions for facial and neck tumors. Ann Plast Surg 1984;
13:335–352.
15. Nouraei SA, Al-Yaghchi C, Ahmed J, et al. An anatomical comparison of Blair and facelift incisions for parotid surgery. Clin Otolaryngol. 2006;31:531-534. 16. Gao L, Ren W, Li S, et al. Comparing modified with conventional parotidectomy for benign parotid tumors. ORL J Otorhinolaryngol Relat Spec 2017;79:264-273. 17. Roh JL, Kim HS, Park CI. Randomized clinical trial comparing partial parotidectomy versus su-
perficial or total parotidectomy. Br J Surg 2007;94:1081-1087. 18. Jost G, Guenon P, Gentil S. Parotidectomy: a plastic approach. Aesthetic Plast Surg 1999;23:1-4.
19. Arden RL, Miguel GS. Aesthetic parotid surgery: evolution of a technique. Laryngoscope
2011;121:2581-2585. 20. Panda NK, Kaushal D, Verma R. Do we need to modify the parotidectomy incision? Indian J Oto-
laryngol Head Neck Surg 2016;68:487-489. 21. Yuen AP. Small access postaural parotidectomy: an analysis of techniques, feasibility and safety.
Eur Arch Otorhinolaryngol. 2016;273:1879-1883. 22. Majumdar A. Facial surgical incisions--role of maxillofacial surgeons. Ann R Coll Surg Engl
2010;92:267. 23. Liu H, Pei J, He Y, et al. Comparison of functional change in parotid gland after surgical excision
of pleomorphic adenoma by two different types of parotidectomy. Oral Surg Oral Med Oral Pathol Oral Ra- diol 2016;122:385-391. 24. Shaaban A, Abdelmohsen M. A new evolving incision for partial superficial parotidectomy. J
Egypt surg 2018;37:581-587. 25. Lefkowitz T, Hazani R, Chowdhry S, et al. Anatomical landmarks to avoid injury to the great au-
ricular nerve during rhytidectomy. Aesthet Surg J 2013;33:19-23. 26. Iwai H, Konishi M. Parotidectomy combined with identification and preservation procedures of
the great auricular nerve. Otolaryngol 2015;135:937-941. 27. Wang RC, Barber AE, Ditmyer M, et al. Distal facial nerve exposure: a key to partial parotidec-
tomy. Otolaryngol Head Neck Surg. 2009;140:875-879.
Figure Legend
Fig 1. In group A, a 58-year-old woman with myoepithelioma, 2.0 cm*1.5 cm *1.0 cm in size, designed a preaurecular crutch incision in parotidectomy.
Fig 2. In group B, a 32-year-old woman with pleomorphic adenoma, 3.0 cm x 2.5 cm x 2.0 cm in size, rhytidectomy incision for parotid gland surgery.
Fig 3. The appearance of the patient in Fig 1 postoperatively 6 months.
Fig 4. The appearance of the patient in Fig 2 postoperatively 6 months.
Fig 5. The appearance of the patient with the traditional Blair approach postoperatively 6 months.
Tab 1 Patients with different incisions three months after operation
Group
Cases
VAS Scores
A
8 32 36
9.2± 0.7 8.7± 1.1 5.8± 1.7
B C.
Transient Ficial nerve disfunction 0 3 3
Dry mouth
Numb of earlobe
Fistula
0 0 0
0 6 10
0 2 3