Parotidectomy through a rhytidectomy incision

Efficacy of modified face lift incision for the resection of benign parotid gland tumor located anteriorly or superiorly

OBJECTIVES

The goals of resection of benign parotid gland tumor are complete resection of lesion and preservation of the facial nerve function. Traditionally, the bayonet-shaped incision (Blair incision: BI) and the modified face lift incision (mFLI) are commonly used for parotidectomy. However, concerns exist about the adequacy of exposure and identification of the facial nerve in anterior or superior parotid lesions. The aim of this study was to compare the surgical outcomes between BI and mFLI and to evaluate the adequacy, possible indications, and limitations of mFLI for the resection of benign parotid gland tumors located anteriorly or superiorly.

METHODS

This retrospective study analyzed the medical records of 175 patients with various types of benign parotid tumor who underwent partial parotidectomy via BI (97 patients) or mFLI (78 patients). Tumors were divided into five categories depending on their location: anterior, superior, inferior, middle, and deep lobe tumors. The outcomes of operation were analyzed according to tumor location between the incision types.

RESULTS

Tumor locations were not significantly different between the two groups. Transient facial palsy occurred in 23 out of 152 patients (15.1%); permanent palsy was not observed in either group. The incidence rates of facial palsy were higher among patients with superior and deep lobe tumors; in the mFLI and BI groups, proportions of superior tumors were 22.2% and 27.2%, respectively, and those of deep lobe tumors were 35.7% and 23.5%, respectively. With regard to superior and anterior tumors, the incidence rate of postoperative facial palsy was insignificantly lower in the mFLI group (10.5%) than in the BI group (18.2%).

CONCLUSIONS

There were no differences in the incidence rates of postoperative facial palsy between mFLI and BI for any tumor location. Use of the mFLI is feasible for the resection of most benign parotid tumors located anteriorly or superiorly.

Modified facelift incision and superficial musculoaponeurotic system flap in parotid malignancy: a retrospective study and review of the literature

Background

Data reporting the use of modified facelift incision (MFI) approach with or without superficial musculoaponeurotic system (SMAS) reconstruction in parotid malignancy are limited. To enhance the limited knowledge in this subject, the authors of the current study report quality data of MFI in patients with parotid malignancy with or without SMAS reconstruction.

Methods

We performed a retrospective review of parotid malignancy patients treated with the MFI over a 5-year period (2015–2019) in the 1st ENT University Department, University of Athens, Greece.

Results

We identified five patients with parotid malignancy. We performed MFI parotidectomy in 5/5 patients and SMAS reconstruction in 2/5 patients. All tumors were classified as T1N0M0. After a mean follow-up of 43.6 months (minimum, 36; maximum, 55), we noted no recurrence. The patients reported no Frey’s syndrome.

Conclusions

The authors of the current study suggest consideration of the MFI approach in parotid malignancy. A MFI approach should at least favor small parotid tumors without neck metastatic disease (T1cN0). Surgeons could also address larger tumors with a MFI approach. Surgeons should reconstruct the parotid lodge with a SMAS advancement flap in tumors not in proximity with the SMAS.

A modified V-shaped incision combined with superficial musculo-aponeurotic system flap for parotidectomy

BACKGROUND

V-shaped incision (VSI) for parotidectomy had been introduced for cosmetic purpose. Despite having aesthetic superiority, it required excessive retraction or an additional hairline incision for adequate surgical exposure. To overcome these problems, we conceptualized a modified VSI approach combined with a separate superficial musculo-aponeurotic system flap.

AIMS

This study aimed to propose this approach and evaluate its technical feasibility and efficacy for excision of parotid tumors.

MATERIALS AND METHODS

This is a prospective, nonrandomized study involving 74 patients with small-to-medium (<4 cm), benign parotid tumors located superficially. The patients were divided into two groups based on the incision techniques used: modified VSI and modified Blair incision (MBI). The clinical outcomes of both approaches for parotidectomy were analyzed.

RESULTS

Thirty-four patients underwent modified VSI approach, while 40 underwent MBI. All parotidectomies with modified VSI were successfully completed without any further incision, and no facial nerve injury or intraoperative tumor rupture complication was reported. There were no significant differences in the complications between both approaches, such as hematoma, infection, wound dehiscence, skin necrosis, sialocele, or sensory disturbance. The modified VSI group showed better cosmetic satisfaction results than did the MBI group (9.2 and 7.8, respectively; p < .001).

CONCLUSIONS AND SIGNIFICANCE

The modified VSI approach is safe and feasible for small-to-medium benign parotid tumors. This approach could be a possible option for patients with a high cosmetic demand.

LEVEL OF EVIDENCE

4.

STUDY DESIGN

Prospective pilot study.

Cervicomastoidfacial versus modified rhytidectomy incision for benign parotid tumors

The modified rhytidectomy incision is an alternative to the classic cervicomastoidfacial approach for parotid surgery, camouflaging the scar in barely visible areas, resulting in better cosmesis. However, there are very few studies comparing the incidence of complications and functional results of patients submitted to parotidectomy through these two different approaches.

Objective

Compare the incidence of complications and functional results of patients with benign parotid neoplasms submitted to surgery through the classical incision versus the modified rhytidectomy approach.

Method

Retrospective cohort study evaluating the demographics, surgical and post-operative characteristics of an equally distributed group of sixty patients submitted to parotidectomy via cervicomastoidfacial incision or modified rhytidectomy approach.

Results

There were no significant differences in complications rates and functional results between the groups, except for a lower incidence of early facial movement dysfunction for the modified rhytidectomy approach - which was 86% lower in this group of patients.

Conclusion

Modified rhytidectomy incision has shown comparable complication rates to those of the classic approach and a lower incidence of immediate facial movement impairment.

Facelift approach for parotidectomy: an evolving aesthetic technique

OBJECTIVE

To systematically review the literature on the modified facelift incision for parotidectomy and to identify the scope and safety of this approach, along with cosmetic outcomes. Where available, a direct comparison was made with Blair's incision (BI).

DATA SOURCES

Medline, PubMed, Cochrane, and CINHAL databases for English-language studies published between 1960 and 2011 on the facelift approach for parotidectomy.

REVIEW METHODS

Exclusion criteria were studies reporting on concurrent facelift, studies that used synthetic material for reconstruction of the surgical bed, descriptive studies, and studies with duplicate patient data. Outcome measures were candidacy for surgery, variations in incision, cosmetic outcomes, surgical time, complication rates, and limitations.

RESULTS

Of the initial 139 studies, 11 studies encompassing 628 patients were included. Male-to-female ratio was 0.49:1, and average age was 47.1 years. In total, 582 surgeries were performed for benign lesions. Only 10 studies specified the extent of surgery: 8 authors used it for performing superficial/partial parotidectomy, and 2 described 17 cases of total parotidectomy. Tumors up to 8 cm have been excised, with a median value of 4 cm. Operative time, formally analyzed in 3 studies, was not significantly different when compared with BI. Complication rates were not increased with this approach. Aesthetic outcomes pertaining to postoperative scar were good, as reported by the patients.

CONCLUSION

The facelift approach is a cosmetically superior approach to parotid tumors as proven by objective data. Most publications in the literature pertaining to the modified facelift incision for parotidectomy have been in the past decade, lending credence to its rising popularity.

Improving the quality of life of parotid surgery patients through a modified facelift incision and great auricular nerve preservation

Postoperative quality of life after parotidectomy depends not only on surgical outcomes, such as the complete removal of a tumour, non-recurrence and the preservation of facial nerve function, but also on scar satisfaction and the degree of sensory dysfunction in the upper cervical area and at the ear lobe. Especially young patients and women consider the scar in the infra-auricular area and in the neck region to be distressing and even disfiguring. Resection of the great auricular nerve leads to paraesthesia and hypoesthesia, which leads to discomfort in many patients especially when using the telephone, shaving or wearing earrings. A modified approach to the parotid gland via a facelift incision and the careful exposure of the great auricular nerve can reduce the aforementioned problems considerably and improve postoperative quality of life. We present our experiences with the modified approach at our institution.

Superficial Parotidectomy via Facelift Incision

The stigma of a visually prominent facial scar following parotid surgery can be distressing to a young patient. The surgical technique of parotidectomy via a facelift incision is described and evaluated. Thirty patients with a benign lesion of the parotid gland underwent a partial superficial parotidectomy via a modified facelift incision. After operation, all patients had excellent cosmesis and complete function of the facial nerve. The facelift incision provides adequate exposure of the parotid gland for (partial) superficial parotidectomy. It can be offered as an alternative to a select group of patients who present with a small, mobile tumor in the tail of the parotid gland and an explicit request for an invisible postoperative scar.

'Minor' morbidity after parotid surgery via the modified Blair incision

OBJECTIVE

To assess the 'minor' morbidities subjectively experienced by the patient after parotid surgery; these include scar cosmesis and pain, 'contour' deformity following removal of parotid bulk, numbness of the pinna and gustatory sweating.

DESIGN

Retrospective study

SETTING

Tertiary Referral Centre.

PATIENTS

28 patients were included in the study.

RESULTS

Contour deformity, scarring and paraesthesia of the pinna secondary to great auricular nerve sacrifice are the most noticeable sequelae following parotidectomy.

DISCUSSION

Although facial nerve injury is the most serious morbidity following parotidectomy, it is relatively uncommon. Other 'minor' morbidities are more likely to cause post-operative problems. Despite there being a number of different approaches to the parotidectomy, with or without reconstruction, these have not been satisfactorily compared.

Rhytidectomy and parotidectomy combined in the same patient

Until now, aesthetic goals in parotid surgery have seldom been addressed because oncologic concerns have largely overshadowed aesthetic issues for patients with parotid masses. Fortunately, the majority of parotid masses are benign pleomorphic adenomas that rarely recur, leaving a large group of patients healthy after their parotid surgery, with some desiring aesthetic improvement in their facial appearance. Traditional parotidectomy incisions leave a visible scar on the neck as well as a visible hollow in the retromandibular region, which can extend onto the cheek. A rhytidectomy approach to the parotid gland allows for a more concealed, aesthetically appealing scar while maintaining good visibility and access to the parotid gland. By performing bilateral sub-SMAS (superficial musculoaponeurotic system) rhytidectomy after a parotidectomy, facial symmetry and balance is enhanced, and these aesthetic deformities can be minimized. The SMAS flap can help to fill the hollow and form a tissue barrier over the resected gland to prevent gustatory sweating. Finally, the incision scarring is minimized with a rhytidectomy-type approach. Two cases are reported in which patients underwent both rhytidectomy and parotidectomy. In the one case, the procedures were performed in the same surgical setting. In the other case, they were performed in a delayed fashion. These cases exemplify the possibility of addressing facial aesthetic goals of rejuvenation in a patient requiring parotid resection.

Omega incision face-lift approach and SMAS rotation advancement flap in parotidectomy for prevention of contour deficiency and conspicuous scars affecting the neck

To overcome the disadvantages after the surgical removal of tumours of the parotid gland, especially the depressed facial deformity and conspicuous cervical scar formation subsequent to parotid surgery, we have concentrated on omega face-lift incision in combination with an SMAS rotation advancement flap for the last several years using a lazy omega incision. Nine patients (3 male and 6 female) ranging in age from 43 to 68 years (mean age: 56.3 years) fulfilled the selection criterion of having a clinically benign discrete parotid lump with a benign preoperative fine needle cytology result. Parotidectomy was performed using the modified omega face-lift incision in conjunction with the rotation advancement SMAS flap. All patients underwent follow-up every 3 months in the first year. During the follow-up, the patients were specifically asked about their satisfaction with the post-operative appearance and whether they would consent to the operation again. The vascularized SMAS rotation advancement flap is clinically simple to perform and provides satisfactory cosmetic and functional results in patients undergoing conservative parotidectomy. There are no drawbacks in the use of modified face-lift incision to remove tumours of the parotid gland.

Preservation of the Superficial Lobe for Deep-Lobe Parotid Tumors: A Better Aesthetic Outcome

Deep-lobe parotid tumors are relatively uncommon. Most of these tumors present as external masses. They can also present in the oral cavity or oropharynx. Magnetic resonance imaging and ultrasound-guided fine-needle aspiration for biopsy and cytology have made it possible to establish a definitive diagnosis and identify the exact location of the tumor in almost all cases before surgery. Traditionally, deep-lobe tumors have been managed by a formal superficial parotidectomy and identification and preservation of the facial nerve, followed by removal of the deep lobe that contains the tumor. Superficial parotidectomy is associated in most cases with periauricular depression secondary to a loss of volume, leading to variable aesthetic deformities. A complete parotidectomy is more likely to be associated with a larger aesthetic deficit secondary to a greater loss of tissue volume. The incidence of gustatory sweating is high after superficial parotidectomy, particularly in the early postoperative period. We hypothesize that if the superficial lobe is preserved, there is less likelihood of gustatory sweating because of the interposition of tissue between the skin and the cut ends of the secretomotor fibers. Approximately 80% of parotid tissue volume is made up of the superficial lobe, and therefore preservation of the superficial lobe should be associated with less postparotidectomy depression. Therefore, we decided to preserve the superficial lobe of the gland for deep-lobe tumors. Nine patients underwent deep-lobe parotidectomy with preservation of the superficial lobe over a 6-year period. Patients were studied prospectively with regard to technical difficulty, complications, and cosmetic outcome. Follow-up ranged from 12 months to 6 years. We did not experience any undue technical difficulty, and there were no cases of facial weakness. One patient developed gustatory sweating, which almost completely resolved over a 2-year period. There were no cases of postparotidectomy depression, and both patients and surgeons were satisfied with the cosmetic appearance. We present our technique and experience.

Facelift Approach With a Hybrid SMAS Rotation Advancement Flap in Parotidectomy for Prevention of Scars and Contour Deficiency Affecting the Neck and Sweat Secretion of the Cheek

Tumors of the parotid gland are generally be removed by the standard external bayonet-shaped incision approach without reconstruction of the parotid bed. The disadvantage of this approach is frequently an obvious scar affecting the neck and a conspicuous hollow contour around the angle of the mandible in addition to a sweat secretion of the cheek (Frey syndrome). To overcome these disadvantages, especially the facial depressed deformity subsequent to parotid surgery, during the last several years, the author has concentrated on facelift incision used in combination with a hybrid SMAS rotation advancement flap. Twelve patients (7 male; 5 female) ranging in age from 32 to 73 years (mean age, 57.8 years) fulfilled the selection criterion of having a clinically benign discrete parotid lump with a benign preoperative fine-needle cytology result. Parotidectomy was performed using the modified facelift incision in conjunction with the rotation advancement hybrid SMAS flap. All patients were followed up every 3 months during the first year. During follow-up, the patients were specifically asked about their satisfaction with their postoperative appearance and whether they would consent to the operation again. The vascularized hybrid vicryl mesh/SMAS rotation advancement flap is clinically simple to perform and provides satisfactory cosmetic and functional results in patients undergoing conservative parotidectomy and prevents the gustatory sweating. There are no drawbacks to the use of the modified facelift incision to remove tumors of the parotid gland.