Is This Novel Incision for Benign Parotid Tumors the Answer for Improved Esthetics and Access?

Abstract

Background

Incision scars and postoperative cosmesis are critical in the management of benign parotid tumors. Traditional incisions have a typical visible scar in the retromandibular area or require wide skin flaps.

Purpose

In this study, we introduced a new surgical approach called the tri-split flap approach and evaluated its technical feasibility and surgical outcomes.

Materials and Methods

Eleven patients with clinically benign parotid gland tumors underwent the tri-split flap approach and were followed for six to ten months postoperatively. Facial weakness, salivary fistula formation, first bite syndrome, earlobe numbness, and the subjective cosmetic results were evaluated.

Results

All tumors were completely excised, and the patients were highly satisfied with the esthetic outcome of the surgery. No patients developed wound dehiscence, facial nerve injury, or first bite syndrome during the follow-up period. One patient developed a minor salivary fistula that resolved after three weeks.

Conclusion

The tri-split flap approach not only provides adequate exposure of the surgical site to achieve complete resection of benign parotid gland neoplasms but also results in a very short and highly concealed post-operative scar. This technique is a potential surgical approach in parotidectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-021-01605-1.

Introduction

Parotid gland neoplasms constitute 75 to 80% of tumors among all salivary glands, and most parotid gland neoplasms are benign [1]. Surgical resection is the primary treatment and produces oncologically safe outcomes with a low complication rate [2–5]. The post-operative cosmetic appearance, mainly the incision design, is the core surgical consideration. The traditional and common incisions for parotidectomy are the modified Blair and rhytidectomy incisions. These incisions are located around the earlobe and/or in the hairline and are thus hidden [6, 7]. However, both incisions have limitations. In the modified Blair incision, a scar is typically visible in the retromandibular area, particularly in patients with unwrinkled necks, which reduces patients’ satisfaction. The rhytidectomy incision is long and requires wide skin flap elevation.

A trend toward a more limited range of parotid tumor surgery has recently developed [8, 9]. Total superficial parotidectomy and superficial parotidectomy are less commonly performed, while partial superficial parotidectomy and extracapsular dissection have become more accepted as the main surgical modalities [10–12]. Intraoperative complete exposure of the superficial lobe of the parotid gland is not mandatory, and many types of shortened surgical incisions have been proposed [13, 14]. Among these shorter incisions, a pre-retroauricular incision without extension to the retromandibular area and nape hairline has been most frequently reported. This incision has been referred to as a periauricular incision [15], V-shaped incision [16, 17], U-shaped incision [18], rhytidectomy approach [13], modified rhytidetomy incision [19], and microparotidectomy incision [20].

The V-shaped pre-retroauricular incision approach does not provide adequate surgical exposure when the tumor is large or far from the earlobe. Therefore, a short inferoauricular incision was added to the pre-retroauricular incision, forming a Y-shaped incision. Because the inferoauricular incision is at the ideal position to expose the parotid gland, adding this incision greatly improves the extent of exposure. Three flaps are raised during the operation; therefore, we named this approach the tri-split flap approach. This study was performed to evaluate the technical feasibility and surgical outcomes of this novel surgical incisional design.

Materials and Methods

Patients

This study was performed in the Department of Oral and Maxillofacial Surgery of a tertiary-level university hospital (Peking University School and Hospital of Stomatology). Approval was obtained from the institutional review board of the hospital. After obtaining informed consent, the incision design was used in 11 patients with clinically benign neoplasms in the parotid salivary gland from May to September 2019. Preoperatively, we confirmed the tumor site, extent, and pathology using magnetic resonance imaging or enhanced computed tomography. Fine-needle aspiration cytology was used to rule out malignancy. Patients with suspected malignancy and a history of parotid surgery were not included in the study. The size of the tumor was limited to < 5.0 cm in its greatest dimension, and the tumor location was classified as anterior, superior, middle, or inferior [14, 17]. The cosmetic outcome of the surgery and post-operative complications, as discussed in the later sections, was recorded.

Surgical procedures

The patient was positioned supine with the head rotated to the opposite side and with the operation table at a contralateral tilt of approximately 10 degrees. All operations were performed with the patient under general anesthesia with laryngeal mask ventilation.

We marked a Y-shaped incision line comprising three incisions: preauricular, retroauricular, and inferoauricular. The pre-retroauricular incisions were similar to the traditional V-shaped incisions, which have been well described [15–20]. However, the pre-retroauricular incisions could be shortened; they did not normally exceed the level of the tragus because they were anteroinferiorly extended as the inferoauricular incision. The inferoauricular incision was newly designed in this study. Generally, the inferoauricular incision was 1.0 to 2.0 cm long, was parallel to the retroauricular incision, and could be intentionally modified according to the size and location of the tumor (Fig. 1). When the Y-shaped pre-retro-inferoauricular incisions were made and the parotid skin flaps were raised below or above the superficial musculoaponeurotic system layer, three skin flaps were formed: the superior earlobe flap, anterior skin flap, and inferior skin flap. The three flaps pulled in three different directions (superior, anterior, and inferior), providing adequate surgical site exposure. Preservation of the posterior and lobular branches of the great auricular nerve was feasible in all cases. If preservation of the encountered branches of the great auricular nerve hindered facial nerve preservation or tumor clearance, the branches of the great auricular nerve were sacrificed. The tumor was dissected with at least 0.2 cm margins (Fig. 2). If facial nerve branches were encountered, they were carefully protected and dissected. The facial nerve trunk was not routinely exposed. However, retrograde facial nerve dissection could be performed along the tumor borders if needed.

Fig. 1.

Parotid tumorectomy via the tri-split flap approach. a Y-shaped pre-retro-inferoauricular incision. The superficial epidermis in the dotted area will be trimmed. b Forming the subcutaneous flap before making the skin incision. c The superior earlobe flap and the anterior and inferior skin flaps are distracted in three different directions, and the tumor is exposed. d The first suture fixes the subcutaneous tissue, which is advanced toward the ear. e The inferoauricular incision is covered by the repositioned earlobe or left as an inconspicuous notch. The inferoauricular flap is advanced cephalad into the postauricular area, forming a dog-ear. f Abundant tissue is removed, and the skin pleating is hidden from view

Fig. 2.

Tri-split approach to excising a parotid neoplasm (patient 3). a Photograph showing the incision line and skin where the superficial epidermis will be trimmed. b The prepared subcutaneous flap before making the skin incision. c The superior earlobe flap and the anterior and inferior skin flaps are distracted in three different directions, which exposes the tumor. d Surgical bed following tumor removal. The facial nerve (arrow) is well preserved. e The first suture (arrow) fixes the anterior and inferior skin flaps, which are advanced toward the ear. f The earlobe is repositioned, and the skin is sutured without tension. g The tumor specimen

After tumor removal, we performed a Y-V plasty to shorten the inferoauricular incision. The anterior and inferior skin flaps were advanced posterosuperiorly, and the superior earlobe flap was passively returned to its initial position; thus, the inferoauricular incision was covered by the earlobe. In this procedure, tension-free closure of the superior earlobe flap is crucial to obtain the initial position of the earlobe. The initial Y-shaped incision turned into a short V-shaped incision, completely concealing the auricle or leaving a short, inconspicuous inferoauricular notch. Excessive tissue was trimmed, and a dog-ear was formed and managed in the retroauricular area, where resultant skin pleating was hidden from view.

To prevent postoperative wound dehiscence and improve the cosmetic appearance of the pre-retroauricular incision lines, we used an internal splinting technique [21] to eliminate skin and lobule tension. The marginal anteroinferior skin was trimmed superficially, and the resultant subcutaneous tissue was sutured to the periosteum over the mastoid bone and anchored under appropriate tension. After fixing the advanced subcutaneous flap, both the earlobe and the superficial skin were sutured without tension. Furthermore, the trimmed area of skin could be folded into the surgical bed to overcome a postoperative hollow appearance. We trimmed the planned skin triangle at the beginning of the surgery because this procedure is relatively difficult if the flap is raised (see Supplemental Video S1). This is why we named the technique the tri-split flap approach.

The wound was closed in two layers, and a drain was then inserted from the retroauricular part of the incision. The drain was typically removed on the second post-operative day. Pressure dressing was routinely applied for approximately 14 days postoperatively, and the sutures were removed five to seven days after surgery. If needed, the patients consulted the operation team via internet telemedicine or through the outpatient clinic after discharge from the hospital (in three days postoperatively).

Assessment of complications

We evaluated the patients for facial nerve weakness one week postoperatively. Other complications were assessed in an outpatient examination and/or internet telemedicine interview. All patients were followed for six to ten months postoperatively. We asked the patients to assess the following post-operative issues: (1) whether they had experienced unilateral facial nerve weakness; (2) whether they had experienced sweating, flushing, or pain in the surgical area while eating; (3) whether clear fluid was present in the surgical area; and (4) whether they had felt earlobe numbness. Each question was presented as a closed question (yes/no response).

We recorded the patients’ subjective cosmetic results using a three-point scale. Satisfaction was graded as follows: 1 = “I am NOT satisfied with the esthetics of my parotid surgery,” 2 = “I am satisfied with the cosmetic results of my parotid surgery,” and 3 = “I am highly satisfied with the cosmetic results of my parotid surgery” [22]. A detailed earlobe position assessment was not performed during the follow-up period. The position of the earlobe was visually assessed intraoperatively for any obvious asymmetry.

Results

The patients’ demographics and tumor characteristics are shown in Table 1. Most of the patients were women in their 40 s and 50 s, and the tumor size (greatest dimension) ranged from 2 to 5 cm. All neoplasms were completely removed with intact tumor integrity in ≤ 2 h. Post-operative pathological examinations showed that all tumors were benign and constituted pleomorphic adenomas, basal cell adenomas, and benign lymphoepithelial lesions.

Table 1.

Patients’ demographics and tumor characteristics

Case	Gender	Age	Location	Tumor size* (cm)	Duration of operations (min)	Surgical outcome	Pathological result
1	F	51	Inferior	3 cm	110	Completely removed	Benign lymphoepithelial lesion
2	F	29	Inferior	2 cm	100	Completely removed	Pleomorphic adenoma
3	F	47	Middle	4 cm	80	Completely removed	Pleomorphic adenoma
4	M	43	Anterior	4 cm	75	Completely removed	Pleomorphic adenoma
5	F	79	Anterior	2 cm	120	Completely removed	Basal cell adenoma
6	F	49	Middle	2 cm	100	Completely removed	Pleomorphic adenoma
7	F	59	Middle	5 cm	95	Completely removed	Pleomorphic adenoma
8	M	50	Inferior	3 cm	80	Completely removed	Warthin tumor
9	F	32	inferior	3 cm	75	Completely removed	Pleomorphic adenoma
10	M	36	Middle	4 cm	90	Completely removed	Pleomorphic adenoma
11	F	52	Inferior	2 cm	80	Completely removed	Pleomorphic adenoma

^*Tumor size: greatest dimmension; F, female; M, male

All patients were highly satisfied with the cosmetic results of the parotid surgery because of the concealed incision (Fig. 3). During the six to ten months follow-up period (median = 8, mean = 7), no patients developed hematomas, surgical site infections, wound dehiscence, facial weakness, or first bite syndrome. Only one patient (Patient 7) reported a mild salivary fistula during the second post-operative week. The patient recovered completely with aspiration of the fluid and pressure dressings during the following three weeks. The patients’ post-operative sequelae and complications are shown in Table 2. Earlobe numbness was reported by all of the patients, but this resolved within six to ten months in half of the patients.

Fig. 3.

The esthetic outcome two months postoperatively

Table 2.

Postoperative sequelae and complications

Case	Facial Weakness (yes/no)	Fistula (yes/no)	Numbness of earlobe (yes/no)	FBS* (yes/no)	Subjective cosmetic result
1	No	No	Yes	No	3
2	No	No	Yes	No	3
3	No	No	Yes	No	3
4	No	No	Yes	No	3
5	No	No	Yes	No	3
6	No	No	Yes	No	3
7	No	Yes	Yes	No	3
8	No	No	Yes	No	3
9	No	No	Yes	No	3
10	No	No	Yes	No	3
11	No	No	Yes	No	3

*FBS, first bite syndrome

Discussion

Recent clinical evidence supports that limited-extent parotid tumorectomy (i.e., partial parotidectomy and extracapsular dissection) achieves complete clearance of nonmalignant neoplasms and results in few postoperative complications [8, 23]. Complete exposure of the superficial gland is not mandatory, and shorter incisions are thus possible. This factor led to our development of the tri-split flap approach, which is a novel incision. All 11 parotid gland neoplasms in our study were removed completely, regardless of the tumor site within the gland. The maximum tumor size was 5 cm in its greatest dimension.

Adequate surgical site exposure can be obtained via our tri-split flap approach, which is characterized by an inferoauricular incision. The inferoauricular incision is not only in the best direction and position to expose the gland and most neoplasms, but it also allows for elongation of both the preauricular and retroauricular incisions. The earlobe is located near the center of the lateral parotid gland, and the mean dimensions of the parotid gland are reportedly 36.15 ± 12.45 mm along the anteroposterior axis and 43.6 ± 10.1 mm along the craniocaudal axis [24]; thus, the 2 cm length of the inferoauricular incision facilitates the surgical approach to all areas of the parotid gland. It is important to note that the tri-split approach involves an inferoauricular incision plus a mini-pre-retroauricular incision. The preauricular and retroauricular incisions can be shortened compared with the conventional pre-retroauricular incision because of their aforementioned anteroinferior elongation via the inferoauricular incision.

The inferoauricular incision is a transient incision for intraoperative exposure. This incision disappears totally or becomes a short, inconspicuous notch below the earlobe after the operation. The final post-operative scar following the tri-split approach results from the mini-pre-retroauricular incision, which can be camouflaged around the ear contour. This optimal esthetic appearance is obtained via Y-V plasty by advancing the inferior and anterior skin flaps toward the ear and closing the wound, which is also the basic element of rhytidectomy. Regarding wound closure, the tri-split flap approach is a localized facelift around the parotid gland area. The inferoauricular incision is a “fringe incision” in rhytidectomy [25]. Using an inferoauricular incision has also been reported in parotidectomy with a facelift incision [26].

Previous reports have described the feasibility and safety of performing rhytidectomy in the same patient after parotidectomy [27, 28] or even simultaneously with parotidectomy [29]. The special consideration in wound closure is mitigating tissue tension because advancing the inferior and anterior skin flaps generates tension. In the tri-split flap approach, the transposed subcutaneous flaps are best prepared at the beginning of the operation before making the skin incisions. The flaps are fixed with sutures to the periosteum of the mastoid process under tension, achieving tension-free skin closure. No wound dehiscence occurred in the present case series. Using our flap technique, passive repositioning of the earlobe can be achieved without tension, avoiding earlobe distortion or pixie ear deformity.

We hypothesized that folding subcutaneous tissue into a depressive deformity may help avoid Frey syndrome. No patients in this study developed Frey syndrome or first bite syndrome; however, longer follow-up is warranted to confirm whether this is a promising technique with which to avoid Frey syndrome. Another minor complication secondary to operations in the parotid area is injury to the great auricular nerve; however, such injury does not affect patients’ overall quality of life [30]. Among all structures in the parotid area, the earlobe area sustains the highest sensory loss and the lowest recovery following surgery [31]. Preservation of the lobular branch of the great auricular nerve reduces the sensory deficit at the earlobe with a faster recovery time of 6 to 12 months [32]. In the present study, earlobe numbness was assessed by questionnaire, and half of the patients had no complaints about earlobe numbness by six to ten months postoperatively. In our tri-split flap approach, earlobe sensation is expected to recover in the long term because this technique disrupts only the nerve endings of the great auricular nerve.

The tri-split flap approach, which is actually a mini-pre-retroauricular incision plus an inferoauricular incision, provides adequate surgical exposure, results in a short and highly concealed incisional scar postoperatively, and may be an option as a surgical approach for most parotidectomies. The main concept of this approach is similar to that of Y-V plasty; therefore, this approach can be performed easily even by junior surgeons.

The tri-split flap approach may not have advantages for high-grade malignant tumors because treating malignancy involves the probability of neck dissection and adjuvant radiotherapy. However, if reoperation is indicated after the tri-split flap approach, conversion to the modified Blair approach with neck dissection is still safe and practical. In male patients with heavy beards, additional destruction of hair follicles using electrocoagulation is needed to correct the distortion of the beard line.

The main limitation of this pilot study is that the number of patients was low. Further prospective studies with larger patient numbers and longer follow-up durations are warranted.

Conclusion

The tri-split flap approach provides adequate surgical site exposure to achieve complete clearance of circumscribed neoplasms in the parotid gland, and it results in a short and highly concealed postoperative scar.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

No funding was received for this study.

Availability of data and material

All authors confirm that all data and materials support their published claims and comply with field standards.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Approval was obtained from the ethics committee of Peking University School and Hospital of Stomatology. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Consent to participate

Informed consent was obtained from all individual participants included in the study.