In Reference to “Surgical Outcomes of U-Shaped Incisions Versus Conventional Incisions in Parotidectomy”

Dear Editor,

We read with great interest the article by Fong et al, ¹ “Surgical Outcomes of U-Shaped Incisions Versus Conventional Incisions in Parotidectomy” published in Journal of Otolaryngology—Head & Neck Surgery. The study provides valuable insights into an alternative surgical approach that may enhance cosmetic outcomes in parotidectomy. Nevertheless, we would like to respectfully raise several concerns regarding interpretation and generalizability.

First, the sample size is notably small (n = 33), with only 16 patients undergoing the U-shaped incision. While the authors matched controls for certain baseline characteristics, the study remains underpowered to detect subtle but clinically relevant differences, particularly in complications such as facial nerve dysfunction. Multicenter variability in surgical technique, which the authors acknowledge, may further confound the results.

Second, the study design blends retrospective and prospective components. Most surgical outcomes were derived retrospectively, whereas scar assessments relied on prospective telephone-based surveys. This hybrid design raises the risk of selection and reporting bias. The reliance on subjective measures such as Visual Analogue Scale (VAS) and Patient Scare Assessment Scale (PSAS) without corresponding objective or blinded evaluations (eg, Observer Scar Assessment Scale), may overestimate cosmetic benefits.

Third, while the authors emphasize oncological safety, the short follow-up period (mean ~22 months) limits conclusions regarding recurrence risk, especially for malignant tumors. The inclusion of only 6 malignant cases, all low-grade, precludes firm conclusions about oncological adequacy. Given that local recurrence may occur several years after surgery,^2,3 longer surveillance is essential before advocating the U-shaped incision for malignant disease.

Fourth, perioperative metrics deserve cautious interpretation. The markedly shorter operative time in the U-shaped group (145 vs 243 minutes) seems surprising, particularly given the potential technical challenges of a more restricted incision. Differences in surgeon experience, operative complexity, or extent of resection may not have been fully controlled. Similarly, the significantly higher rate of sialocele (43.8% vs 5.9%) in the U-shaped group raises concern. While the authors propose possible mechanisms, the complication is clinically relevant and may offset cosmetic advantages. Preventive strategies (eg, drain management, sealants) require further systematic study before broad recommendations can be made.

Finally, while the study situates its findings in the context of prior literature, it may overstate generalizability. Previous series largely restricted periauricular approaches to benign, superficial tumors. ⁴ Expanding their use to deep lobe and malignant cases—based on limited data—should be approached with caution.

In conclusion, this work represents an important preliminary step toward validating the U-shaped incision in parotidectomy. However, limitations in design, sample size, complication rates, and oncological follow-up suggest that further prospective, multicenter studies with larger cohorts and longer surveillance are necessary before widespread adoption can be recommended.