Int. J. Oral Maxillofac. Surg. 2007; 36: 72–76doi:10.1016/j.ijom.2006.09.008, available online at http://www.sciencedirect.com

Reconstructive Surgery

Minimal incision inparotidectomy

C. Martı-Pages, E. Garcıa-Dıez, L. Garcıa-Arana, D. Mair, M . J. Biosca, X.Gimeno-Medina, F. Hernandez-Alfaro: Minimal incision in parotidectomy. Int. J.Oral Maxillofac. Surg. 2007; 36: 72–76. # 2006 Published by Elsevier Ltd on behalfof International Association of Oral and Maxillofacial Surgeons.

0901-5027/01072 + 05 $30.00/0 # 2006 Pu

blished by Elsevier Ltd on behalf of International

C. Martı-Pages, E. Garcıa-Dıez,L. Garcıa-Arana, D. Mair,M . J. Biosca, X. Gimeno-Medina,F. Hernandez-AlfaroInternational University of Catalonia,Department of Oral and Maxillofacial Surgery,General Hospital of Catalonia and Institute ofOral and Maxillofacial Surgery, TeknonMedical Center, Barcelona, Spain

Abstract. Conservative parotidectomy has been for years an effective and well-established technique. Recently, aesthetic considerations have been reviewed. Aminimal pre- and retroauricular incision is proposed that does not extend to the hair-bearing skin. This reduces the length of the scar and the extent of the dissectionimproving aesthetic results. This is a retrospective study of 32 parotidectomiesperformed through this incision because of benign parotid diseases and diagnosedby fine needle aspiration cytology. The minimal incision is mainly indicated insmall and medium-sized tumours located in the superficial lobe of the parotid gland.Neither operating time nor the morbidity associated with parotidectomy is increasedwith this safe and effective technique for the treatment of benign parotid masses.

Accepted for publication 6 September 2006

Conservative parotidectomy is an effec-tive and well-established technique for thetreatment of parotid gland pathology15,16,but there are complications such as visiblescars, retromandibular depression, Frey’ssyndrome and facial nerve injury.Recently, aesthetic considerations for thisarea of surgery have been reviewed. Thefacelift incision improves scar appearancecompared to the classic bayonet-shapedincision by eliminating its cervical por-tion, although it maintains an often-visibleoccipital scar3,7,18. The superficial muscu-loaponeurotic system (SMAS) flap helpsto maintain facial symmetry, dissimulat-ing the post-parotidectomy retromandibu-lar depression6. The incidence of Frey’ssyndrome has been reduced due to thisflap2,6. Alternatives such as sternocleido-mastoid muscle transposition3 and thetemporoparietal fascial flap2 have beendescribed.

One of the main objectives in treatingbenign pathology of the parotid gland is

preservation of the facial nerve. Recently,limited resections, with safety margins,have been proposed, but are still subjectto controversy. Such resections diminishsurgical trauma to the nerve, improveaesthetic results and maintain the oncolo-gic quality of the surgery5,13. Proposedhere is a minimal pre- and retroauricularincision with no extension to the hair-bearing skin to improve the parotidectomyapproach with three objectives: to reducedissection of areas situated out of thesurgical field, shorten the approach timeand diminish postoperative complications.

Patients and methods

The mini-incision has been performedfrom July 2003 until July 2005 in all casesof parotidectomy due to benign parotidlump, tumoural or not tumoural, and anysize and localization, with diagnosis byfine-needle aspiration cytology (FNAC).All cases were performed by the oral and

maxillofacial surgeons at the TeknonMedical Center (Barcelona, Spain) andHospital General de Catalunya (Barce-lona, Spain).

This is a retrospective study of the first31 consecutive patients operated on usingthis technique. Factors recorded preopera-tively were age, gender and parotid glandaffected (left or right). Preoperative studyincluded FNAC and a radiological evalua-tion of the lesion either by computerizedtomography or magnetic resonance. Inci-sion length, operating time, complica-tions, specimen size and pathologydiagnosis were recorded.

Surgical technique

Surgery is performed under general anaes-thesia. The minimal incision is drawn withan indelible pen. Then the subcutaneousplane is infiltrated with local anaesthesiaplus vasoconstrictor (articaine 40 mg andepinephrine 0.01 mg). Incision starts at the

Association of Oral and Maxillofacial Surgeons.

Minimal incision in parotidectomy 73

Fig. 1. Preauricular incision.

Fig. 2. Retroauricular incision.

helix insertion and is carried out along theinternal face of the tragus (Fig. 1). Itcontinues inferiorly anterior to the earand is curved, separated by 1 mm fromthe lobule. The incision rises 2 mm awayfrom the crease behind the conchal carti-lage and ends at the level of the middle ofthe ear (Fig. 2).

Dissection of the parotid skin flap in thesubcutaneous plane is then performed(Fig. 3) by undermining of the anteriorcervical skin and the superior sternomas-toid muscle’s insertion. The posteriorbranch of the greater auricular nerve isidentified and preserved. Afterwards, aSMAS flap is elevated antero-inferiorlybeginning its dissection 1 cm below thezygomatic arch to the anterior borderof the parotid gland. At this point it isimportant not to damage the terminalbranches of the facial nerve that appearin the anterior aspect of the parotidgland. The inferior and posterior limitsof the SMAS flap are generally deter-mined by the anterior border of thesternomastoid muscle and the greaterauricular nerve.

Once the SMAS flap is elevated thecomplete parotid gland is exposed sur-rounded by the parotid fascia (Fig. 4).Parotidectomy proceeds according to theclassical technique: the facial nerve’smain trunk is identified by dissecting thepretragal cartilage down to the ‘pointer’and the anterior border of the sternoclei-domastoid muscle down to the posteriorbelly of the digastric muscle4. Both refer-ence points facilitate the identification ofthe facial nerve main trunk. Dissection ofthe nerve branches is then performed car-rying out the conservative parotidectomy(Fig. 5).

Haemostasis is revised and the SMASflap is repositioned (Fig. 6) in a tent fash-ion, folding its excess so that the parotidbed is filled. A vacuum drain is placed.The incision is closed in two layers.Vicryl1 is used subcutaneously andresorbable monofilament is used in a run-ning intradermic fashion. The drain isusually removed after 24 h. The incision,if necessary, can be extended easily in twoways: through the hair as in the rhytidect-omy technique; or by extending the retro-auricular incision through the hair-line andcervical region as with the classic bay-onet-shaped incision.

Fig. 3. Dissection of the skin flap in the subcutaneous plane.

Results

A total of 32 parotidectomies were per-formed in 31 patients (21 female/10 male).Patient age ranged between 26 and 78years (mean 43 years). Twenty-eight par-

otidectomies (28 patients) were carriedout because of a benign tumoural diseaseand four parotidectomies (three patients)because of a non-tumoural disorder.

Sixteen superficial parotidectomies, 11partial parotidectomies, four total paroti-dectomies (two cases with extension toparapharingeal space and two cases with

74 Martı-Pages et al.

Fig. 4. Elevated SMAS flap and exposed parotid gland.

Fig. 5. Dissection of the facial nerve branches and resection piece.

Fig. 6. Reconstruction of postparotidectomy defect with SMAS flap.

facial nerve retrograde dissection) and oneaccessory parotid gland resection werecarried out. Histopathologic diagnosiswas: 20 pleomorphic adenomas, threewarthin tumours, two benign lymphoe-pithelial lesions, one lymphoma ofmucosa-associated lymphoid tissue, onechoristoma, one adenopathy, one chronicsialadenitis due to intraglandular lithiasis,one bilateral sialosis in an ex-bulimicpatient and one Sjogren’s syndrome.

The average length of the incisionwas 60.2 mm (range 50–75), and themean operating time was 115 min (range70–180). Mean size of the specimenswas 51 mm � 36 mm � 20 mm (range20 mm � 15 mm � 6 mm–85 mm �45 mm � 80 mm) and the mean size of thetumours was 21 mm � 15 mm (range10 mm � 8 mm–60 mm � 40 mm). In nocases were tumour capsule ruptures found.

Postoperative complications were twohaematomas that required surgical drai-nage (one of them by open drainage, andthe other one by needle aspiration), twoseromas that required puncture and 13cases of transient facial nerve dysfunction.There has been no permanent facial nervedysfunction and no patient has presentedwith clinical Frey’s syndrome to date.Data were collected from surveys of thepatients and from medical records. Aes-thetic results were very/extremely satis-factory. There have been no alterations inrelation to the scars. Symmetry of thecheeks was completely restored exceptfor a minimum retromandibular depres-sion in the seven patients that presentedthe largest tumours and those with a deep-lobe tumour.

Discussion

Parotidectomy has been classically per-formed through a bayonet-shaped incisionwithout parotid bed reconstruction. Thisapproach allows quick and wide access fordissection of the facial nerve and easesparotid gland removal, but is associatedwith visible cervical scarring, retroman-dibular depression and Frey’s syndrome.These three drawbacks have lead to thedevelopment of alternative approachesbased on the facelift incision7,18 andSMAS flap6.

Numerous studies support the theorythat the rhytidectomy incision providessufficient exposition and visualization ofthe parotid gland without too conspicuousscarring7. The retroauricular region dis-section is unnecessary owing to the elasticproperties of the skin, so it is possible toreduce the incision with no extension intothe scalp. This minimal incision provides a

Minimal incision in parotidectomy 75

Fig. 7. Occipital queloid of facelift incision for parotidectomy.

Fig. 8. (a and b). Scar 2 years after parotidectomy.

wide exposition that allows easy elevationof the SMAS flap and safe treatment ofparotid tumours of small and medium size,located in the superficial lobe of the par-otid gland, around the ear. Recently, asimilar incision has been proposed toassist in face lifts19.

With this technique placing incisions inthe hairline is avoided, eliminating the riskof hypertrophic scars (Fig. 7), distortionsin the hairline and local alopecia in theoccipital area, a complication that isreported to be 2.8%14. An importantadvantage is the possibility to extend theincision in two different ways: extendingthrough the rythidectomy incisionincreases the surgical field very slightlybut gives a good aesthetic result, hidingthe incision in the hair. If a wider surgicalfield is needed, the extension can be madethrough the cervical region, leaving amore visible scar. Minimal incision isnot the goal of treatment but rather a safeparotidectomy, with a good view of thefacial nerve, removing the tumour withsafety margins and avoiding capsule rup-ture and tumour spillage.

We agree with most authors in recom-mending the SMAS flap elevation since ithelps to prevent Frey’s syndrome, avoids asunken facial appearance and better out-lines the angle of the mandible1,2,11,12. Weroutinely use the SMAS flap except insuperficial tumours affecting the SMASitself, where we make partial resections ofthe SMAS with the tumour, Most of thepatients (72.8%) were satisfied with theaesthetic outcome (Fig. 8a and b). Onlypatients (21.8%, seven patients) withdeep-lobe and the largest tumours pre-sented a slight retromandibular depres-sion. There are alternatives to filling theparotid bed postparotidectomy, includingthe sternocleidomastoid muscle flap3,digastric muscle flap8 and temporoparietalfascial flap2,8,17. These are indicated onlyif the SMAS is not available.

With this conservative approach lim-ited, superficial and in selected cases totalparotidectomies can be safely performed,and it also provides limited access to theparapharingeal space without increasingthe risk of injuring the facial nerve. Inthe present series, 40.6% of patients suf-fered temporal facial paralysis. All ofthem completely recovered within the firsttwo postoperative months, with no perma-nent injury to the nerve. MEHLE et al.10

reported immediate dysfunction in 46.1%,with permanent palsy in 3.9%. Theyshowed that the incidence of long-termdysfunction was higher in revision casesand when an extended parotidectomy wasperformed. LACCOURREYE et al.9 presented

76 Martı-Pages et al.

a large series in which temporal dysfunc-tion was frequently encountered (64.6%)but permanent dysfunction was uncom-mon (5.6%). O’BRIEN

13 in 363 parotidec-tomies following these criteria reportedtemporary postoperative facial weaknessin 27%, with permanent weakness in2.5%.

References

1. Bonanno PC, Palaia D, Rosenberg M,Casson P. Prophylaxis against Frey’ssyndrome in parotid surgery. Ann PlastSurg 2000: 44: 498–501.

2. Cesteleyn L, Helman J, King S, van

de Vyvere G. Temporoparietal fasciaflaps and superficial musculoaponeuroticsystem placation in parotid surgeryreduces Frey’s syndrome. J Oral Maxil-lofac Surg 2002: 60: 1284–1297.

3. Chow TL, Lam CYW, Chiu PWY, Lim

BH, Kwok SPY. Sternomastoid-muscletransposition improves the cosmetic out-come of superficial parotidectomy. Br JPlast Surg 2001: 54: 409–411.

4. GUERRIER Y. Chirurgie de glandes sali-vaires. In: Masson, ed: Traite de Techni-que Chirurgicale ORL et Cervicofaciale.10th edn. Tome 4eme: cou et cavitebucale 1988: 200–201.

5. Helmus C. Conservative versus super-ficial parotidectomy for benign lesionsof the parotid tail. Arch Otolaryngol HeadNeck Surg 1999: 125: 1166–1167.

6. Honig JF. Facelift approach with hybridSMAS rotation advancement flap in par-otidectomy for prevention of scars andcontour deficiency affecting the neck andsweat secretion of the cheek. J CraniofacSurg 2004: 15: 797–803.

7. Honig JF. Omega incision face-liftapproach and SMAS rotation advance-ment flap in parotidectomy for preventionof scars affecting the neck. Int J OralMaxillofac Surg 2005: 34: 612–618.

8. Jost G, Guenon PH, Gentil S. Paroti-dectomy: a plastic approach. AestheticPlast Surg 1999: 23: 1–4.

9. Laccourreye H, Laccourreye O,Cauchois R, Jouffre V, Menard M,Brasnu D. Total conservative parotidect-omy for primary benign pleomorphic ade-noma of the parotid gland: a 25-yearexperience with 229 patients. Laryngo-scope 1994: 104: 1487–1494.

10. Mehle ME, Kraus DH, Wood BG,Benninger MS, Eliachar I, Levine

HL, Tucker HM, Lavertu P. Facialnerve morbidity following parotid sur-gery for benign disease: the ClevelandClinic Foundation experience. Laryngo-scope 1993: 103: 386–388.

11. Meningaud JP. Parotidectomy: the face-lift access route. EMC Stomatol 2005: 1:80–84 in French.

12. Moulton-Barret R, Allison G, Rap-

paport I. Variations in the use of SMAS(Superficial musculoaponeurotic system)to prevent Frey’s syndrome after paroti-dectomy. Int Surg 1996: 81: 174–176.

13. O’Brien CJ. Current management ofbenign parotid tumours. The role of lim-ited superficial parotidectomy. HeadNeck 2003: 946–952.

14. Parkes ML, Kamer FM, Bassilios MI.Treatment of alopecia in temporal regionfollowing rhytidectomy procedures. Lar-yngoscope 1977: 87: 1011–1014.

15. Patey DH, Thackray AC. The treat-ment of parotid tumours in the light ofa pathological study of parotidectomymaterial. Br J Surg 1958: 55: 477–487.

16. Roscic Z. Conservative parotidectomy: anew surgical concept. J Maxillofac Surg1980: 8: 234–240.

17. Sultan MR, Wider TM, Hugo NE.Frey’s syndrome: prevention with tem-poroparietal fascial flap interposition.Ann Plast Surg 1995: 34: 292–296.

18. Terris DJ, Tufo KM, Fee Jr WE. Mod-ified facelift incision for parotidectomy. JLaryngol Otol 1994: 108: 574–578.

19. Zager WH, Dyer WK. Minimal incisionfacelift. Fac Plast Surg 2005: 21: 21–27.

Address:Carlos Martı PagesTeknon Medical CenterCalle Vilana 12Consultorios Vilanadespacho 18508022 BarcelonaSpainTel.: +34 93 393 3185Fax: +34 93 393 3085E-mail: secretaria@institutomaxilofacial.com