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Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients
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ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients W.-l. Chen ∗ , S. Fan, D.-m. Zhang Department of Oral and Maxillofacial Surgery, Sun Yet-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China Accepted 9 January 2017
Abstract We evaluated the aesthetic outcomes in 11 young patients (mean (range) age 21.7 (16–28) years) who had endoscopically assisted extracapsular dissection of benign pleomorphic adenomas of the parotid gland through a postauricular sulcus approach. The tumours varied in size from 1.5 × 1.0 cm to 2.5 × 2.0 cm, and all were removed completely without rupture. The cosmetic result was excellent in 10 patients and good in one. Patients were followed up for eight to 40 months, and there was no recurrence. The technique is simple and feasible, and it achieves excellent aesthetic results in young patients. © 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. Keywords: parotid tumours; salivary gland neoplasm; endoscopy; surgery; facelift incision; young patient
Introduction Pleomorphic adenoma is the most common benign tumour, and 69% of cases involve the parotid gland.1 Excision is commonly done through a modified Blair incision, but this can result in obvious scars and a poor aesthetic outcome. Other points of incision that allow good exposure and complete excision, that have low rates of complication and recurrence, and do not leave a visible scar on the neck, can be challenging for the surgeon. We have previously described extracapsular dissection of parotid pleomorphic adenomas in children through minimal preauricular and retroauricular incisions,2 endoscopically assisted transoral resection of large benign parapharyngeal space tumours,3 and endoscopically assisted
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital of Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou 510120, China. E-mail address: [email protected] (W.-l. Chen).
resection of benign tumours of the accessory parotid gland.4 In this paper we evaluate the feasibility of endoscopically assisted extracapsular dissection of benign pleomorphic adenomas of the parotid through a postauricular sulcus approach in young patients, and assess the outcomes.
Patients and methods Between April 2012 and September 2015, 11 young patients had endoscopically assisted extracapsular resection of pleomorphic adenomas of the parotid gland through a postauricular sulcus approach at the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China. The study was approved by the Institutional Review Board of the university. The patients (eight male, three female) had a mean (range) age of 21.7 (16–28) years at the time of operation. The tumours varied in size from 1.5 × 1.0 cm to 2.5 × 2.0 cm
http://dx.doi.org/10.1016/j.bjoms.2017.01.010 0266-4356/© 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010
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Table 1 Patients’ details, clinical characteristics, and outcomes in 11 young patients with pleomorphic adenoma of the parotid gland. No tumours recurred. Case no.
Age (years)
Sex
Site and size of tumour (cm)
Complication
Aesthetic results
Follow up (months)
1 2 3 4 5 6 7 8 9 10 11
24 18 26 24 16 19 23 20 19 28 22
M M F M M M F M M F M
Superficial lobe, 2.0 × 2.0 Superficial lobe, 1.8 × 1.5 Superficial lobe, 2.5 × 2.0 Superficial lobe, 2.0 × 2.0 Superficial lobe, 1.5 × 1.0 Deep lobe, 1.8 × 1.5 Superficial lobe, 2.5 × 2.0 Superficial lobe, 2.5 × 2.0 Deep lobe, 2.0 × 2.0 Deep lobe, 2.5 × 2.0 Superficial lobe, 2.5 × 2.0
None None None None None None None None Transient facial paresis None None
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Good Excellent Excellent
24 30 40 40 12 18 10 8 33 13 38
Transient facial paresis resolved spontaneously within 6 weeks.
Fig. 2. Cutaneous markings on the postauricular sulcus, and the tumour. Fig. 1. A 24-year-old man with a 2.0×2.0 cm pleomorphic adenoma in the left parotid gland.
(median 2.1 × 1.8 cm). Nine were in the superficial lobe of the parotid gland and three in the deep lobe (Table 1). The diagnoses were based on clinical history, physical examination, and computed tomography (CT) or magnetic resonance imaging (MRI), and were confirmed histopathologically.2 Patients with histologically confirmed malignant tumours were excluded. Three senior maxillofacial surgeons from our hospital assessed the clinical outcome, which included the cosmetic appearance based on preoperative and postoperative photographs, and locoregional recurrence. Surgical technique All operations are done under general anaesthesia through nasoendotracheal intubation. After positioning the patient so that the neck is extended and the head rotated away from the lesion (Fig. 1), we make a skin incision in the postauricular sulcus and extend it upwards to the middle or upper third of the sulcus to a length of about 3.0 cm (Fig. 2). We then raise the skin flap with the superficial musculoaponeurotic system (SMAS) superficially to the tumour and explore the lesion using a 0◦ 5 mm diameter endoscope (Karl-Storz
Corp, Tuttlingen, Germany) through a postauricular sulcus approach. Under endoscopic guidance, we use Harmonic ® ACE + 7 shears with advanced haemostasis mode (Ethicon, Somerville, NJ, USA) to separate the tumour extracapsularly from the surrounding tissue and seal the vessels. After checking the mobility of the tumour, we decide whether to proceed to extracapsular dissection. Dissection of the SMAS adequately exposes the parotid gland and the tumour. The great auricular nerve, which runs within the SMAS, is then identified and preserved to maintain sensation in the ear lobe, and the tumour is carefully separated and removed (Fig. 3), preventing injury to the facial nerve. We check the wound bed for haemostasis and any questionable areas if the capsule has been disrupted, and cover the defect with the flap. Finally, a pressure dressing is applied for two weeks.
Results All tumours were completely removed without rupture, and there were no permanent postoperative complications (no haematomas, salivary fistulas, or Frey syndrome). One patient with a tumour in the deep lobe had slight transient postoperative facial paresis, but it resolved spontaneously within 6 weeks. No scars were visible, and the postoperative cosmetic
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010
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Fig. 3. The tumour is removed extracapsularly.
effects were excellent in ten patients (Fig. 4) and good in one. Patients were followed up for a mean (range) of 24 (8–40) months, and no tumours recurred (Table 1).
Discussion Rates of recurrence and rupture of the capsule, and time to recurrence differ according to the surgical technique used, but with regard to recurrence, total parotidectomy and extracapsular dissection have the lowest rates.5 These procedures are similarly effective, but extracapsular dissection has lower rates of recurrence and complication than parotidectomy. Extracapsular dissection should therefore be the treatment of choice for tumours in the superficial portion of the parotid,6,7 and it is a conservative and safe procedure for extirpation of pleomorphic adenomas.8 George and McGurk9 reported low rates of complications and no recurrence in 156 patients treated by extracapsular dissection of benign parotid tumours. In our experience, careful extracapsular dissection under endoscopic guidance through an incision in the postauricular sulcus completely removes the tumour from parotid gland tissue and prevents recurrence. In a previous report, nine children, who had extracapsular dissection of pleomorphic adenomas of the parotid, were followed up for 5.1–7.0 years, and recurrence developed in only one who subsequently had curative parotidectomy.2 These results suggest that the technique is simple and feasible. Numerous studies on the treatment of benign parotid neoplasms have investigated the association between the site of incision and cosmetic outcome. We have previously reported preauricular and retroauricular approaches for parotidectomies for haemangiomas involving the parotid10 and for extracapsular dissection of parotid pleomorphic adenomas,2 both in children. Kim et al reported partial superficial parotidectomy through a postauricular hairline incision,11 and Woo et al reported endoscopically assisted extracapsular dissection of benign parotid tumours through a hairline incision.12 Our approach ensures that the scar is concealed in the postauricular sulcus, and all the patients were satis-
Fig. 4. Outcome six months postoperatively (A: frontal view; B: lateral view) Photographs published with the patient’s permission.
fied with the result. The only approaches that have better aesthetic results are through the hairline, or preauricular and retroauricular incisions. Slight transient facial paresis in one of our patients with a tumour in the deep lobe of the parotid may have been caused by swelling that compressed the facial nerve, so the prevention of oedema may be key.2 Malignant tumours of the parotid are clinically indistinguishable from benign tumours, and any
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010
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W.-l. Chen et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
palpable mass should be accurately diagnosed without delay. Fine needle aspiration cytology, which is used to diagnose most salivary gland tumours, has only intermediate sensitivity for the diagnosis of malignant neoplasms. Preoperative evaluation with MRI or CT can help to establish the extent of the lesion and aid surgical planning.2 Conflict of interest We have no conflicts of interest. Ethics statement/confirmation of patient’s permission This study was approved by the Institutional Review Board of the University. The patient gave his consent. References 1. Tian Z, Li L, Wang L, et al. Salivary gland neoplasms in oral and maxillofacial regions: a 23-year retrospective study of 6982 cases in an eastern Chinese population. Int J Oral Maxillofac Surg 2010;39:235–42. 2. Li JS, Chen WL, Zhang DM, et al. Extracapsular dissection of pleomorphic adenoma of the parotid gland through minimal preauricular and retroauricular incisions in children. J Craniofac Surg 2012;23:661–3.
3. Chen WL, Wang YY, Zhang DM, et al. Endoscopy-assisted transoral resection of large benign parapharyngeal space tumors. Br J Oral Maxillofac Surg 2014;52:970–3. 4. Zhang DM, Wang YY, Liang QX, et al. Endoscopic-assisted resection of benign tumors of the accessory parotid gland. J Oral Maxillofac Surg 2015;73:1499–504. 5. Colella G, Cannavale R, Chiodini P. Meta-analysis of surgical approaches to the treatment of parotid pleomorphic adenomas and recurrence rates. J Craniomaxillofac Surg 2015;43:738–45. 6. Dell’Aversana Orabona G, Bonavolontà P, Iaconetta G, et al. Surgical management of benign tumors of the parotid gland: extracapsular dissection versus superficial parotidectomy—our experience in 232 cases. J Oral Maxillofac Surg 2013;71:410–3. 7. Barzan L, Pin M. Extra-capsular dissection in benign parotid tumors. Oral Oncol 2012;48:977–9. 8. Iro H, Zenk J, Koch M, et al. Follow-up of parotid pleomorphic adenomas treated by extracapsular dissection. Head Neck 2013;35:788–93. 9. George KS, McGurk M. Extracapsular dissection—minimal resection for benign parotid tumours. Br J Oral Maxillofac Surg 2011;49:451–4. 10. Chen W, Li J, Yang Z, et al. SMAS fold flap and ADM repair of the parotid bed following removal of parotid haemangiomas via pre- and retroauricular incisions to improve cosmetic outcome and prevent Frey’s syndrome. J Plast Reconstr Aesthet Surg 2008;61:894–9. 11. Kim DY, Park GC, Cho YW, et al. Partial superficial parotidectomy via retroauricular hairline incision. Clin Exp Otorhinolaryngol 2014;7:119–22. 12. Woo SH, Kim JP, Baek CH. Endoscope-assisted extracapsular dissection of benign parotid tumors using hairline incision. Head Neck 2016;38:375–9.
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010
No. of Pages 4
ARTICLE IN PRESS Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients W.-l. Chen ∗ , S. Fan, D.-m. Zhang Department of Oral and Maxillofacial Surgery, Sun Yet-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China Accepted 9 January 2017
Abstract We evaluated the aesthetic outcomes in 11 young patients (mean (range) age 21.7 (16–28) years) who had endoscopically assisted extracapsular dissection of benign pleomorphic adenomas of the parotid gland through a postauricular sulcus approach. The tumours varied in size from 1.5 × 1.0 cm to 2.5 × 2.0 cm, and all were removed completely without rupture. The cosmetic result was excellent in 10 patients and good in one. Patients were followed up for eight to 40 months, and there was no recurrence. The technique is simple and feasible, and it achieves excellent aesthetic results in young patients. © 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. Keywords: parotid tumours; salivary gland neoplasm; endoscopy; surgery; facelift incision; young patient
Introduction Pleomorphic adenoma is the most common benign tumour, and 69% of cases involve the parotid gland.1 Excision is commonly done through a modified Blair incision, but this can result in obvious scars and a poor aesthetic outcome. Other points of incision that allow good exposure and complete excision, that have low rates of complication and recurrence, and do not leave a visible scar on the neck, can be challenging for the surgeon. We have previously described extracapsular dissection of parotid pleomorphic adenomas in children through minimal preauricular and retroauricular incisions,2 endoscopically assisted transoral resection of large benign parapharyngeal space tumours,3 and endoscopically assisted
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital of Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou 510120, China. E-mail address: [email protected] (W.-l. Chen).
resection of benign tumours of the accessory parotid gland.4 In this paper we evaluate the feasibility of endoscopically assisted extracapsular dissection of benign pleomorphic adenomas of the parotid through a postauricular sulcus approach in young patients, and assess the outcomes.
Patients and methods Between April 2012 and September 2015, 11 young patients had endoscopically assisted extracapsular resection of pleomorphic adenomas of the parotid gland through a postauricular sulcus approach at the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China. The study was approved by the Institutional Review Board of the university. The patients (eight male, three female) had a mean (range) age of 21.7 (16–28) years at the time of operation. The tumours varied in size from 1.5 × 1.0 cm to 2.5 × 2.0 cm
http://dx.doi.org/10.1016/j.bjoms.2017.01.010 0266-4356/© 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010
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No. of Pages 4
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Table 1 Patients’ details, clinical characteristics, and outcomes in 11 young patients with pleomorphic adenoma of the parotid gland. No tumours recurred. Case no.
Age (years)
Sex
Site and size of tumour (cm)
Complication
Aesthetic results
Follow up (months)
1 2 3 4 5 6 7 8 9 10 11
24 18 26 24 16 19 23 20 19 28 22
M M F M M M F M M F M
Superficial lobe, 2.0 × 2.0 Superficial lobe, 1.8 × 1.5 Superficial lobe, 2.5 × 2.0 Superficial lobe, 2.0 × 2.0 Superficial lobe, 1.5 × 1.0 Deep lobe, 1.8 × 1.5 Superficial lobe, 2.5 × 2.0 Superficial lobe, 2.5 × 2.0 Deep lobe, 2.0 × 2.0 Deep lobe, 2.5 × 2.0 Superficial lobe, 2.5 × 2.0
None None None None None None None None Transient facial paresis None None
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Good Excellent Excellent
24 30 40 40 12 18 10 8 33 13 38
Transient facial paresis resolved spontaneously within 6 weeks.
Fig. 2. Cutaneous markings on the postauricular sulcus, and the tumour. Fig. 1. A 24-year-old man with a 2.0×2.0 cm pleomorphic adenoma in the left parotid gland.
(median 2.1 × 1.8 cm). Nine were in the superficial lobe of the parotid gland and three in the deep lobe (Table 1). The diagnoses were based on clinical history, physical examination, and computed tomography (CT) or magnetic resonance imaging (MRI), and were confirmed histopathologically.2 Patients with histologically confirmed malignant tumours were excluded. Three senior maxillofacial surgeons from our hospital assessed the clinical outcome, which included the cosmetic appearance based on preoperative and postoperative photographs, and locoregional recurrence. Surgical technique All operations are done under general anaesthesia through nasoendotracheal intubation. After positioning the patient so that the neck is extended and the head rotated away from the lesion (Fig. 1), we make a skin incision in the postauricular sulcus and extend it upwards to the middle or upper third of the sulcus to a length of about 3.0 cm (Fig. 2). We then raise the skin flap with the superficial musculoaponeurotic system (SMAS) superficially to the tumour and explore the lesion using a 0◦ 5 mm diameter endoscope (Karl-Storz
Corp, Tuttlingen, Germany) through a postauricular sulcus approach. Under endoscopic guidance, we use Harmonic ® ACE + 7 shears with advanced haemostasis mode (Ethicon, Somerville, NJ, USA) to separate the tumour extracapsularly from the surrounding tissue and seal the vessels. After checking the mobility of the tumour, we decide whether to proceed to extracapsular dissection. Dissection of the SMAS adequately exposes the parotid gland and the tumour. The great auricular nerve, which runs within the SMAS, is then identified and preserved to maintain sensation in the ear lobe, and the tumour is carefully separated and removed (Fig. 3), preventing injury to the facial nerve. We check the wound bed for haemostasis and any questionable areas if the capsule has been disrupted, and cover the defect with the flap. Finally, a pressure dressing is applied for two weeks.
Results All tumours were completely removed without rupture, and there were no permanent postoperative complications (no haematomas, salivary fistulas, or Frey syndrome). One patient with a tumour in the deep lobe had slight transient postoperative facial paresis, but it resolved spontaneously within 6 weeks. No scars were visible, and the postoperative cosmetic
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010
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Fig. 3. The tumour is removed extracapsularly.
effects were excellent in ten patients (Fig. 4) and good in one. Patients were followed up for a mean (range) of 24 (8–40) months, and no tumours recurred (Table 1).
Discussion Rates of recurrence and rupture of the capsule, and time to recurrence differ according to the surgical technique used, but with regard to recurrence, total parotidectomy and extracapsular dissection have the lowest rates.5 These procedures are similarly effective, but extracapsular dissection has lower rates of recurrence and complication than parotidectomy. Extracapsular dissection should therefore be the treatment of choice for tumours in the superficial portion of the parotid,6,7 and it is a conservative and safe procedure for extirpation of pleomorphic adenomas.8 George and McGurk9 reported low rates of complications and no recurrence in 156 patients treated by extracapsular dissection of benign parotid tumours. In our experience, careful extracapsular dissection under endoscopic guidance through an incision in the postauricular sulcus completely removes the tumour from parotid gland tissue and prevents recurrence. In a previous report, nine children, who had extracapsular dissection of pleomorphic adenomas of the parotid, were followed up for 5.1–7.0 years, and recurrence developed in only one who subsequently had curative parotidectomy.2 These results suggest that the technique is simple and feasible. Numerous studies on the treatment of benign parotid neoplasms have investigated the association between the site of incision and cosmetic outcome. We have previously reported preauricular and retroauricular approaches for parotidectomies for haemangiomas involving the parotid10 and for extracapsular dissection of parotid pleomorphic adenomas,2 both in children. Kim et al reported partial superficial parotidectomy through a postauricular hairline incision,11 and Woo et al reported endoscopically assisted extracapsular dissection of benign parotid tumours through a hairline incision.12 Our approach ensures that the scar is concealed in the postauricular sulcus, and all the patients were satis-
Fig. 4. Outcome six months postoperatively (A: frontal view; B: lateral view) Photographs published with the patient’s permission.
fied with the result. The only approaches that have better aesthetic results are through the hairline, or preauricular and retroauricular incisions. Slight transient facial paresis in one of our patients with a tumour in the deep lobe of the parotid may have been caused by swelling that compressed the facial nerve, so the prevention of oedema may be key.2 Malignant tumours of the parotid are clinically indistinguishable from benign tumours, and any
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010
YBJOM-5105;
ARTICLE IN PRESS
No. of Pages 4
4
W.-l. Chen et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
palpable mass should be accurately diagnosed without delay. Fine needle aspiration cytology, which is used to diagnose most salivary gland tumours, has only intermediate sensitivity for the diagnosis of malignant neoplasms. Preoperative evaluation with MRI or CT can help to establish the extent of the lesion and aid surgical planning.2 Conflict of interest We have no conflicts of interest. Ethics statement/confirmation of patient’s permission This study was approved by the Institutional Review Board of the University. The patient gave his consent. References 1. Tian Z, Li L, Wang L, et al. Salivary gland neoplasms in oral and maxillofacial regions: a 23-year retrospective study of 6982 cases in an eastern Chinese population. Int J Oral Maxillofac Surg 2010;39:235–42. 2. Li JS, Chen WL, Zhang DM, et al. Extracapsular dissection of pleomorphic adenoma of the parotid gland through minimal preauricular and retroauricular incisions in children. J Craniofac Surg 2012;23:661–3.
3. Chen WL, Wang YY, Zhang DM, et al. Endoscopy-assisted transoral resection of large benign parapharyngeal space tumors. Br J Oral Maxillofac Surg 2014;52:970–3. 4. Zhang DM, Wang YY, Liang QX, et al. Endoscopic-assisted resection of benign tumors of the accessory parotid gland. J Oral Maxillofac Surg 2015;73:1499–504. 5. Colella G, Cannavale R, Chiodini P. Meta-analysis of surgical approaches to the treatment of parotid pleomorphic adenomas and recurrence rates. J Craniomaxillofac Surg 2015;43:738–45. 6. Dell’Aversana Orabona G, Bonavolontà P, Iaconetta G, et al. Surgical management of benign tumors of the parotid gland: extracapsular dissection versus superficial parotidectomy—our experience in 232 cases. J Oral Maxillofac Surg 2013;71:410–3. 7. Barzan L, Pin M. Extra-capsular dissection in benign parotid tumors. Oral Oncol 2012;48:977–9. 8. Iro H, Zenk J, Koch M, et al. Follow-up of parotid pleomorphic adenomas treated by extracapsular dissection. Head Neck 2013;35:788–93. 9. George KS, McGurk M. Extracapsular dissection—minimal resection for benign parotid tumours. Br J Oral Maxillofac Surg 2011;49:451–4. 10. Chen W, Li J, Yang Z, et al. SMAS fold flap and ADM repair of the parotid bed following removal of parotid haemangiomas via pre- and retroauricular incisions to improve cosmetic outcome and prevent Frey’s syndrome. J Plast Reconstr Aesthet Surg 2008;61:894–9. 11. Kim DY, Park GC, Cho YW, et al. Partial superficial parotidectomy via retroauricular hairline incision. Clin Exp Otorhinolaryngol 2014;7:119–22. 12. Woo SH, Kim JP, Baek CH. Endoscope-assisted extracapsular dissection of benign parotid tumors using hairline incision. Head Neck 2016;38:375–9.
Please cite this article in press as: Chen W-l, et al. Endoscopically assisted extracapsular dissection of pleomorphic adenoma of the parotid gland through a postauricular sulcus approach in young patients. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.010