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Extracapsular dissection of benign parotid tumors using a retroauricular hairline incision approach
The American Journal of Surgery (2009) 197, e53– e56
How I Do It
Extracapsular dissection of benign parotid tumors using a retroauricular hairline incision approach Jong-Lyel Roh, M.D., Ph.D.* Department of Otolaryngology, Asan Medical Center, University of Ulsan, College of Medicine, 388 –1 Pungnap-dong, Songpa-gu, Seoul 138 –736, Korea KEYWORDS: Parotid tumors; Parotidectomy; Extracapsular dissection; Retroauricular hairline incision; Approach; Esthetic
Abstract. Extracapsular dissection has emerged as a more conservative approach to parotid surgery. The parotid surgery commonly begins with a modified Blair or facelift incision. Although minor, the incision scar from these incisions is visible on the face and neck. I initially developed a retroauricular hairline incision (RAHI) for the removal of benign lesions in the upper neck with a more esthetic look. The RAHI approach also may be used for selected patients with benign parotid neoplasms. Mobile benign tumors arising in the inferior superficial part of the parotid gland may be removed by the RAHI approach without compromising surgical visualization. This surgery appears to show excellent cosmetic outcomes in addition to the benefits of extracapsular dissection, lower complication rates, and preservation of secretory function. The RAHI without a preauricular incision is a feasible technique in the surgical management of parotid tumors. © 2009 Elsevier Inc. All rights reserved.
Surgery for parotid gland neoplasms has evolved from enucleation to superficial or total parotidectomy. Tumor enucleation is not an ideal procedure for parotid tumors because of high risks of tumor rupture and subtotal removal, with tumor recurrence rates ranging from 20% to 45%.1,2 These recurrence rates were reduced dramatically by a more comprehensive dissection method, involving identification of the main trunk and branches of the facial nerve, followed by removal of the entire superficial and/or deep lobe of the parotid gland.3,4 This procedure, however, results in greater risks to the facial nerve and other complications.5 In response to these risks, more conservative surgical approaches have been developed, including partial parotidectomy6 and extracapsular dissection (ECD).7 These methods preserve the uninvolved parotid parenchyma and obviate the This study was supported by a Korea Research Foundation grant funded by the Korea Government (MOEHRD, Basic Research Promotion Fund) (KRF-2007-331-E00146), Seoul, Korea. * Corresponding author: Tel.: ⫹82-2-3010-3965; fax: ⫹82-2-489-2773. E-mail address: [email protected] Manuscript received April 27, 2008; revised manuscript June 24, 2008
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.06.040
need for more extensive facial nerve dissection, resulting in decreases in facial nerve paralysis and other complications, as well as increased preservation of parotid secretory function.5,8 –11 Parotid surgery commonly begins with a modified Blair’s incision, an S-shaped preauricular and submandibular incision that may leave a visible incision scar on the naked surface of the face and neck of some patients. In addition to the possibility of facial paralysis, patients undergoing parotid surgery may worry about the possibility of postoperative scars, especially when a hypertrophic scar or keloid occurs at the site. This cosmetic problem largely has been ameliorated by a modified facelift incision (ie, a preauricular and hairline incision).12 Although minor, the incision scar from a preauricular incision is visible on the face. Therefore, a retroauricular hairline incision (RAHI), without preauricular incision, may be used for selected patients with benign parotid neoplasms (Fig. 1).13,14 I initially developed this method for the removal of benign lesions in the upper neck, subsequently applying it to ECD of benign tumors located in the lower half of the parotid gland. Here,
e54
The American Journal of Surgery, Vol 197, No 5, May 2009 parotid masses are identified and preserved. Careful attention is given to avoid capsular rupture and nerve damage, particularly in patients with tumor lobulations or deepseated tumors. The tumors are removed completely, along with a small amount of normal parotid parenchyma just outside the capsule of the parotid tumor (Fig. 2E and F). After mass removal, the capsule and tissues of the remaining parotid gland are approximated (Fig. 2G) and a suction drain is inserted into the hair behind the lower portion of the hairline incision. The skin incision is closed tightly with interrupted sutures using 4-0 Vicryl and nylon. Compressive dressings are applied to the wounds. Drains and dressings usually are removed on the second postoperative day, at which time the patients are discharged from the hospital.
Data
Figure 1 RAHI was made along the postauricular sulcus and hairline without preauricular incision.
the surgical technique, advantages, and application of this procedure in parotid surgery are presented.
Technique All of these procedures are performed in an operating room setting, with the patient under general anesthesia. The location and size of each lesion are identified preoperatively by computed tomography scans (Fig. 2A) and lesion pathology is diagnosed by fine-needle aspiration cytology. An incision is made along the postauricular sulcus and hairline, starting from the lower end of the postauricular sulcus, moving upward to the upper one-third point of the sulcus, and smoothly angled downward to continue 0.5 to 1 cm along the inside of the hairline (Fig. 2B). The incision is continued through the subcutaneous fat onto the sternocleidomastoid muscle, and the skin flap is elevated anteriorly onto the parotid gland and the lesion site (Fig. 2C). To minimize postoperative alopecia along the incision line, great care is taken to avoid injury to the hair follicles during incision, subcutaneous dissection, and hemostasis. The sensory nerves running along the sternocleidomastoid and the parotid gland also carefully are preserved during flap elevation and dissection. After incision and dissection of the overlying parotid capsule and parenchyma, the lesions are exposed (Fig. 2D), and the lower branches of the facial nerve adjacent to the
After a randomized clinical trial comparing partial parotidectomy with superficial or total parotidectomy,5 partial parotidectomy was compared with ECD in patients with benign parotid neoplasms. Although more than 60 of these patients have been randomized with 2 surgical modalities of partial parotidectomy or ECD between 2005 and 2006, the oncologic results cannot be reported now because of a lack of long-term follow-up evaluation to assess tumor recurrences.15 In my experience, however, the recurrence rate is the same for the 2 procedures, but the complication rate appears to be lower for ECD. The comparison of morbidities and oncologic results between partial parotidectomy and ECD will be reported in the future. During the study period, the parotid ECD via the RAHI approach has been applied in 23 patients with benign tumors in the inferior superficial part of the parotid gland: pleomorphic adenoma in 15 patients, Warthin’s tumor in 4 patients, basal cell adenoma in 1 patient, lipoma in 1 patient, benign cyst in 1 patient, and benign lymph node in 1 patient. Of the 23 patients, only a small number of patients had minor complications: temporary paralysis of the marginal mandibular nerve in 1 patient and a seroma in 1 patient. None of the patients had tumor recurrence to date. The incision scars of the patients were commonly invisible in the natural hair and behind the auricle (Fig. 3). No excessive adhesion or fibrosis in the surgical area has been found in these patients.
Comments Over the past 2 decades, partial parotidectomy and ECD have emerged as more conservative approaches to parotid surgery.5,9 –11 During partial parotidectomy, only the main trunk and facial nerve branches adjacent to the tumor are dissected and only the tumor-bearing area of the parotid parenchyma, plus a .5- to 2-cm limited margin, is removed.5,6,8,10 ECD differs markedly from other parotid surgery techniques in that facial nerve dissection is not per-
J.-L. Roh
Parotid ECD via RAHI approach
e55
Figure 2 Surgical procedure of limited parotidectomy via a RAHI approach. (A) Axial computed tomography showing a 3-cm, well-defined, heterogeneous enhancing mass (arrow) in the right parotid gland. (B) An incision was made along the postauricular sulcus and hairline without preauricular incision. (C) The parotid gland and mass (asterisk) were accessed after elevation of a skin flap. (D) Careful dissection was performed around the mass (asterisk). (E) The mass was removed completely, along with a small amount of normal parotid parenchyma, but there was no capsular rupture. (F) The picture shows the surgical exposure of the parotid gland and facial nerve branches (arrow) after mass excision. (G) The remaining parotid parenchyma and capsule were approximated (arrow) and the skin incision was closed at the end of surgery.
formed. ECD also involves meticulous dissection of a small cuff of the normal parotid parenchyma just outside the capsule of the parotid tumor, as opposed to the shelling out
Figure 3 Postoperative photograph of a patient showing a good cosmetic outcome without a visible incision scar or sunken defect of the parotid region.
procedure used during enucleation.7,9 The branches of the facial nerve adjacent to the mass are preserved carefully. ECD has been reported to have lower risks of complications and lower rates of recurrence.9 –11 A previous report showed no difference in recurrence rates (2%) between a group of 503 patients who underwent ECD and a group of 159 patients who underwent superficial parotidectomy.9 The RAHI approach, in which incisions are made on a potentially less visible area of the head and neck, was developed for the removal of upper neck masses.13,14 This approach also has been used to treat patients with benign masses of the upper neck, including second branchial cleft cysts, abscesses, schwannomas, inflammatory diseases, and benign tumors arising in the submandibular gland and lower parapharynx. These studies,13,14 however, did not include patients with parotid tumors treated with the RAHI approach. In my ongoing study, modified facelift incision12 or RAHI13 was used as the starting procedure for ECD. Mobile benign tumors arising in the inferior superficial part of the parotid gland may be removed by the RAHI approach without a preauricular incision. It will be difficult to apply this approach to patients with large-sized tumors, tumors localized to the anterior or upper parotid gland, and tumors suspected of being malignant. Among the potential advantages of this approach are excellent cosmetic outcomes, in addition to the benefits of ECD, including lower rates of facial paralysis and Frey’s
e56
The American Journal of Surgery, Vol 197, No 5, May 2009
syndrome and preservation of the secretory function of the parotid gland. Sunken defects secondary to the loss of parotid volume are prevented and bilateral symmetric facial contours are preserved. In addition, the incision frequently is invisible because it is hidden by the auricle and hair even if a hypertrophic scar develops (Fig. 3). In summary, RAHI without preauricular incision, here introduced as an alternative surgical approach, is a feasible technique in the surgical management of parotid tumors. ECD via the RAHI approach may become an alternative to conventional partial or superficial parotidectomy in selected patients with benign parotid tumors. This should be confirmed in randomized, controlled studies with longer follow-up periods.
5. Roh JL, Kim HS, Park CI. Randomized clinical trial comparing partial parotidectomy versus superficial or total parotidectomy. Br J Surg 2007;94:1081–7. 6. Iizuka K, Ishikawa K. Surgical techniques for benign parotid tumors: segmental resection vs extracapsular lumpectomy. Acta Otolaryngol Suppl 1998;537:75– 81. 7. Gleave EN, Whittaker JS, Nicholson A. Salivary tumours— experience over thirty years. Clin Otolaryngol Allied Sci 1979;4:247–57. 8. Yamashita T, Tomoda K, Kumazawa T. The usefulness of partial parotidectomy for benign parotid gland tumors. A retrospective study of 306 cases. Acta Otolaryngol Suppl 1993;500:113– 6. 9. McGurk M, Thomas BL, Renehan AG. Extracapsular dissection for clinically benign parotid lumps: reduced morbidity without oncological compromise. Br J Cancer 2003;89:1610 –3. 10. Witt RL. Minimally invasive surgery for parotid pleomorphic adenoma. Ear Nose Throat J 2005;84:308 –11. 11. Smith SL, Komisar A. Limited parotidectomy: the role of extracapsular dissection in parotid gland neoplasms. Laryngoscope 2007;117: 1163–7. 12. Terris DJ, Tuffo KM, Fee WE Jr. Modified facelift incision for parotidectomy. J Laryngol Otol 1994;108:574 – 8. 13. Roh JL. Retroauricular hairline incision for removal of upper neck masses. Laryngoscope 2005;115:2161– 6. 14. Roh JL. Removal of the submandibular gland by a retroauricular approach. Arch Otolaryngol Head Neck Surg 2006;132:783–7. 15. Wittekindt C, Streubel K, Arnold G, et al. Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients. Head Neck 2007;29:822– 8.
References 1. McFarland J. Three hundred mixed tumours of the salivary glands of which 69 recurred. Surg Gynecol Obstet 1936;63:457– 68. 2. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg 1986;8:177– 84. 3. Janes RM. The treatment of tumours of the salivary glands by radical excision. CMAJ 1940;43:554 –9. 4. Bailey H. Treatment of tumours of the parotid gland with special reference to total parotidectomy. Br J Surg 1941;28:337– 46.
How I Do It
Extracapsular dissection of benign parotid tumors using a retroauricular hairline incision approach Jong-Lyel Roh, M.D., Ph.D.* Department of Otolaryngology, Asan Medical Center, University of Ulsan, College of Medicine, 388 –1 Pungnap-dong, Songpa-gu, Seoul 138 –736, Korea KEYWORDS: Parotid tumors; Parotidectomy; Extracapsular dissection; Retroauricular hairline incision; Approach; Esthetic
Abstract. Extracapsular dissection has emerged as a more conservative approach to parotid surgery. The parotid surgery commonly begins with a modified Blair or facelift incision. Although minor, the incision scar from these incisions is visible on the face and neck. I initially developed a retroauricular hairline incision (RAHI) for the removal of benign lesions in the upper neck with a more esthetic look. The RAHI approach also may be used for selected patients with benign parotid neoplasms. Mobile benign tumors arising in the inferior superficial part of the parotid gland may be removed by the RAHI approach without compromising surgical visualization. This surgery appears to show excellent cosmetic outcomes in addition to the benefits of extracapsular dissection, lower complication rates, and preservation of secretory function. The RAHI without a preauricular incision is a feasible technique in the surgical management of parotid tumors. © 2009 Elsevier Inc. All rights reserved.
Surgery for parotid gland neoplasms has evolved from enucleation to superficial or total parotidectomy. Tumor enucleation is not an ideal procedure for parotid tumors because of high risks of tumor rupture and subtotal removal, with tumor recurrence rates ranging from 20% to 45%.1,2 These recurrence rates were reduced dramatically by a more comprehensive dissection method, involving identification of the main trunk and branches of the facial nerve, followed by removal of the entire superficial and/or deep lobe of the parotid gland.3,4 This procedure, however, results in greater risks to the facial nerve and other complications.5 In response to these risks, more conservative surgical approaches have been developed, including partial parotidectomy6 and extracapsular dissection (ECD).7 These methods preserve the uninvolved parotid parenchyma and obviate the This study was supported by a Korea Research Foundation grant funded by the Korea Government (MOEHRD, Basic Research Promotion Fund) (KRF-2007-331-E00146), Seoul, Korea. * Corresponding author: Tel.: ⫹82-2-3010-3965; fax: ⫹82-2-489-2773. E-mail address: [email protected] Manuscript received April 27, 2008; revised manuscript June 24, 2008
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.06.040
need for more extensive facial nerve dissection, resulting in decreases in facial nerve paralysis and other complications, as well as increased preservation of parotid secretory function.5,8 –11 Parotid surgery commonly begins with a modified Blair’s incision, an S-shaped preauricular and submandibular incision that may leave a visible incision scar on the naked surface of the face and neck of some patients. In addition to the possibility of facial paralysis, patients undergoing parotid surgery may worry about the possibility of postoperative scars, especially when a hypertrophic scar or keloid occurs at the site. This cosmetic problem largely has been ameliorated by a modified facelift incision (ie, a preauricular and hairline incision).12 Although minor, the incision scar from a preauricular incision is visible on the face. Therefore, a retroauricular hairline incision (RAHI), without preauricular incision, may be used for selected patients with benign parotid neoplasms (Fig. 1).13,14 I initially developed this method for the removal of benign lesions in the upper neck, subsequently applying it to ECD of benign tumors located in the lower half of the parotid gland. Here,
e54
The American Journal of Surgery, Vol 197, No 5, May 2009 parotid masses are identified and preserved. Careful attention is given to avoid capsular rupture and nerve damage, particularly in patients with tumor lobulations or deepseated tumors. The tumors are removed completely, along with a small amount of normal parotid parenchyma just outside the capsule of the parotid tumor (Fig. 2E and F). After mass removal, the capsule and tissues of the remaining parotid gland are approximated (Fig. 2G) and a suction drain is inserted into the hair behind the lower portion of the hairline incision. The skin incision is closed tightly with interrupted sutures using 4-0 Vicryl and nylon. Compressive dressings are applied to the wounds. Drains and dressings usually are removed on the second postoperative day, at which time the patients are discharged from the hospital.
Data
Figure 1 RAHI was made along the postauricular sulcus and hairline without preauricular incision.
the surgical technique, advantages, and application of this procedure in parotid surgery are presented.
Technique All of these procedures are performed in an operating room setting, with the patient under general anesthesia. The location and size of each lesion are identified preoperatively by computed tomography scans (Fig. 2A) and lesion pathology is diagnosed by fine-needle aspiration cytology. An incision is made along the postauricular sulcus and hairline, starting from the lower end of the postauricular sulcus, moving upward to the upper one-third point of the sulcus, and smoothly angled downward to continue 0.5 to 1 cm along the inside of the hairline (Fig. 2B). The incision is continued through the subcutaneous fat onto the sternocleidomastoid muscle, and the skin flap is elevated anteriorly onto the parotid gland and the lesion site (Fig. 2C). To minimize postoperative alopecia along the incision line, great care is taken to avoid injury to the hair follicles during incision, subcutaneous dissection, and hemostasis. The sensory nerves running along the sternocleidomastoid and the parotid gland also carefully are preserved during flap elevation and dissection. After incision and dissection of the overlying parotid capsule and parenchyma, the lesions are exposed (Fig. 2D), and the lower branches of the facial nerve adjacent to the
After a randomized clinical trial comparing partial parotidectomy with superficial or total parotidectomy,5 partial parotidectomy was compared with ECD in patients with benign parotid neoplasms. Although more than 60 of these patients have been randomized with 2 surgical modalities of partial parotidectomy or ECD between 2005 and 2006, the oncologic results cannot be reported now because of a lack of long-term follow-up evaluation to assess tumor recurrences.15 In my experience, however, the recurrence rate is the same for the 2 procedures, but the complication rate appears to be lower for ECD. The comparison of morbidities and oncologic results between partial parotidectomy and ECD will be reported in the future. During the study period, the parotid ECD via the RAHI approach has been applied in 23 patients with benign tumors in the inferior superficial part of the parotid gland: pleomorphic adenoma in 15 patients, Warthin’s tumor in 4 patients, basal cell adenoma in 1 patient, lipoma in 1 patient, benign cyst in 1 patient, and benign lymph node in 1 patient. Of the 23 patients, only a small number of patients had minor complications: temporary paralysis of the marginal mandibular nerve in 1 patient and a seroma in 1 patient. None of the patients had tumor recurrence to date. The incision scars of the patients were commonly invisible in the natural hair and behind the auricle (Fig. 3). No excessive adhesion or fibrosis in the surgical area has been found in these patients.
Comments Over the past 2 decades, partial parotidectomy and ECD have emerged as more conservative approaches to parotid surgery.5,9 –11 During partial parotidectomy, only the main trunk and facial nerve branches adjacent to the tumor are dissected and only the tumor-bearing area of the parotid parenchyma, plus a .5- to 2-cm limited margin, is removed.5,6,8,10 ECD differs markedly from other parotid surgery techniques in that facial nerve dissection is not per-
J.-L. Roh
Parotid ECD via RAHI approach
e55
Figure 2 Surgical procedure of limited parotidectomy via a RAHI approach. (A) Axial computed tomography showing a 3-cm, well-defined, heterogeneous enhancing mass (arrow) in the right parotid gland. (B) An incision was made along the postauricular sulcus and hairline without preauricular incision. (C) The parotid gland and mass (asterisk) were accessed after elevation of a skin flap. (D) Careful dissection was performed around the mass (asterisk). (E) The mass was removed completely, along with a small amount of normal parotid parenchyma, but there was no capsular rupture. (F) The picture shows the surgical exposure of the parotid gland and facial nerve branches (arrow) after mass excision. (G) The remaining parotid parenchyma and capsule were approximated (arrow) and the skin incision was closed at the end of surgery.
formed. ECD also involves meticulous dissection of a small cuff of the normal parotid parenchyma just outside the capsule of the parotid tumor, as opposed to the shelling out
Figure 3 Postoperative photograph of a patient showing a good cosmetic outcome without a visible incision scar or sunken defect of the parotid region.
procedure used during enucleation.7,9 The branches of the facial nerve adjacent to the mass are preserved carefully. ECD has been reported to have lower risks of complications and lower rates of recurrence.9 –11 A previous report showed no difference in recurrence rates (2%) between a group of 503 patients who underwent ECD and a group of 159 patients who underwent superficial parotidectomy.9 The RAHI approach, in which incisions are made on a potentially less visible area of the head and neck, was developed for the removal of upper neck masses.13,14 This approach also has been used to treat patients with benign masses of the upper neck, including second branchial cleft cysts, abscesses, schwannomas, inflammatory diseases, and benign tumors arising in the submandibular gland and lower parapharynx. These studies,13,14 however, did not include patients with parotid tumors treated with the RAHI approach. In my ongoing study, modified facelift incision12 or RAHI13 was used as the starting procedure for ECD. Mobile benign tumors arising in the inferior superficial part of the parotid gland may be removed by the RAHI approach without a preauricular incision. It will be difficult to apply this approach to patients with large-sized tumors, tumors localized to the anterior or upper parotid gland, and tumors suspected of being malignant. Among the potential advantages of this approach are excellent cosmetic outcomes, in addition to the benefits of ECD, including lower rates of facial paralysis and Frey’s
e56
The American Journal of Surgery, Vol 197, No 5, May 2009
syndrome and preservation of the secretory function of the parotid gland. Sunken defects secondary to the loss of parotid volume are prevented and bilateral symmetric facial contours are preserved. In addition, the incision frequently is invisible because it is hidden by the auricle and hair even if a hypertrophic scar develops (Fig. 3). In summary, RAHI without preauricular incision, here introduced as an alternative surgical approach, is a feasible technique in the surgical management of parotid tumors. ECD via the RAHI approach may become an alternative to conventional partial or superficial parotidectomy in selected patients with benign parotid tumors. This should be confirmed in randomized, controlled studies with longer follow-up periods.
5. Roh JL, Kim HS, Park CI. Randomized clinical trial comparing partial parotidectomy versus superficial or total parotidectomy. Br J Surg 2007;94:1081–7. 6. Iizuka K, Ishikawa K. Surgical techniques for benign parotid tumors: segmental resection vs extracapsular lumpectomy. Acta Otolaryngol Suppl 1998;537:75– 81. 7. Gleave EN, Whittaker JS, Nicholson A. Salivary tumours— experience over thirty years. Clin Otolaryngol Allied Sci 1979;4:247–57. 8. Yamashita T, Tomoda K, Kumazawa T. The usefulness of partial parotidectomy for benign parotid gland tumors. A retrospective study of 306 cases. Acta Otolaryngol Suppl 1993;500:113– 6. 9. McGurk M, Thomas BL, Renehan AG. Extracapsular dissection for clinically benign parotid lumps: reduced morbidity without oncological compromise. Br J Cancer 2003;89:1610 –3. 10. Witt RL. Minimally invasive surgery for parotid pleomorphic adenoma. Ear Nose Throat J 2005;84:308 –11. 11. Smith SL, Komisar A. Limited parotidectomy: the role of extracapsular dissection in parotid gland neoplasms. Laryngoscope 2007;117: 1163–7. 12. Terris DJ, Tuffo KM, Fee WE Jr. Modified facelift incision for parotidectomy. J Laryngol Otol 1994;108:574 – 8. 13. Roh JL. Retroauricular hairline incision for removal of upper neck masses. Laryngoscope 2005;115:2161– 6. 14. Roh JL. Removal of the submandibular gland by a retroauricular approach. Arch Otolaryngol Head Neck Surg 2006;132:783–7. 15. Wittekindt C, Streubel K, Arnold G, et al. Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients. Head Neck 2007;29:822– 8.
References 1. McFarland J. Three hundred mixed tumours of the salivary glands of which 69 recurred. Surg Gynecol Obstet 1936;63:457– 68. 2. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg 1986;8:177– 84. 3. Janes RM. The treatment of tumours of the salivary glands by radical excision. CMAJ 1940;43:554 –9. 4. Bailey H. Treatment of tumours of the parotid gland with special reference to total parotidectomy. Br J Surg 1941;28:337– 46.