Parotidectomy for benign parotid tumors: An aesthetic approach

[Complications in the surgery of the parotid salivary glands. Causes, mechanisms of development, methods of prevention]

Operations for neoplasms of the parotid salivary gland require from the surgeon a deep knowledge of the anatomical and topographic features of this area and technical skill, which puts it in a number of «jewelry» operations that require patience and concentration. The review is devoted to the topic of specific postoperative complications after parotidectomy or subtotal resection of the gland. These include relapses of tumors, paralysis or paresis of facial muscles, Frey syndrome, salivary fistulas or sialocele, violation of skin sensitivity, soft tissue deformity. The review presents the frequency and causes of complications, mechanisms of their development, methods of prevention and elimination.

Different Surgical Strategies in the Prevention of Frey Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE/HYPOTHESIS

To define the best surgical technique able to reduce Frey syndrome (FS) incidence after parotidectomy.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were the incidence of subjective (clinical) and objective (positive starch-iodine test result) FS, respectively.

RESULTS

A total of 3830 patients with a median age of 50.35 years (n = 2323; IQR 44.25-54.18) were included for six interventions [temporoparietal fascia (TPFF), free fat graft (FFG), acellular dermal matrix (ADM), sternocleidomastoid muscle (SCM) flap, and superficial musculoaponeurotic system (SMAS) flap]. If compared to no treatment, the greatest reduction of subjective (clinical) FS incidence was measured for the TPFF (OR: 0.07, CI: 0.004-0.57), the ADM (OR: 0.09, CI: 0.02-0.35), and the FFG (OR: 0.11, CI: 0.03-0.42) techniques. However, a significant difference was measured also for the SCM flap (OR: 0.38, CI: 0.18-0.73) and for the SMAS flap (OR: 0.42, CI: 0.19-0.97). All treatments showed a significant reduction of the objective FS incidence if compared to no treatment (FFG, OR: 0.06, CI: 0.002-0.62; TPFF, OR: 0.07, CI: 0.01-0.33; ADM, OR: 0.11, CI: 0.03-0.44; SMAS, OR: 0.36, CI: 0.17-0.71; SCM, OR: 0.40, CI: 0.19-0.74).

CONCLUSIONS

TPFF, ADM, and FFG seem to be the best treatment strategies to prevent FS after parotidectomy. Further randomized controlled trials comparing these techniques should be conducted to define specific indications. Laryngoscope, 131:1761-1768, 2021.

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.

Minor Parotidectomy Complications: A Systematic Review

OBJECTIVES

To report descriptive statistics for minor parotidectomy complications.

METHODS

A systematic review was performed, selecting 235 studies for analysis. The incidence of complications was tabulated, and descriptive statistics calculated. Outlier studies, 1 standard deviation above the mean, were reexamined to determine potential causal factors for each complication. All studies were examined for statistically significant differences for any potential causal factor.

RESULTS

The pooled incidence of minor complications reported were hematoma 2.9% (95% confidence interval [CI]: 2.4-3.5), wound infection 2.3% (95% CI: 1.8-2.9), sialocele 4.5% (95% CI: 3.5-5.7), salivary fistula 3.1% (95% CI: 2.6-3.7), flap necrosis 1.7% (95% CI: 1.1-2.5), scar issues 3.6% (95% CI: 2.4-5.4), numbness 33.9% (95% CI: 25.6-43.4), and deformity 11.8 (95% CI: 6.9-19.5). Implants result in more wound complications, such as hematoma, sialocele, or salivary fistula. Sialocele and salivary fistula appear more frequently after less extensive parotid surgery, whereas hematoma, wound infections, flap necrosis, and aesthetic considerations are worse with more extensive resections.

CONCLUSIONS

Minor parotidectomy complications are more frequent than generally assumed and related to certain factors that should be investigated. Laryngoscope, 131:571-579, 2021.

Cosmetic approach selection in parotidectomy for benign parotid gland tumour according to its location

OBJECTIVE

The aim of this study is to evaluate the feasibility and aesthetic results when comparing two cosmetic approaches that were employed in parotidectomy according to the tumour location with the traditional Blair approach.

DESIGN

Retrospective study.

SETTING

Tertiary Referral Centre.

PATIENTS

Seventy-six patients were included in the study.

RESULTS

The degree of satisfaction with the cosmetic incision approach was significantly higher than that with the traditional Blair approach. The incidence of transient facial paralysis and salivary fistula were not statistically significant when compared with those in the traditional incision in 6-month follow-up post-operatively.

DISCUSSION

Conventional parotidectomy using the traditional Blair incision (or its modification) usually leaves a visible scar in this region, which can have major adverse impacts on the social or psychological well-being of an individual. To achieve better aesthetic results, according to the location of the benign parotid tumour, two formal cosmetic approach incisions could be performed in parotidectomy, which was superior to the traditional Blair incision. The authors propose that these two cosmetic approaches for parotidectomy can be both technically feasible and safe.

The Effects of Superficial Musculoaponeurotic System Flap on the Development of Frey's Syndrome and Cosmetic Outcomes After Superficial Parotidectomy

Objective

To investigate the outcomes of superficial musculoaponeurotic system (SMAS) flap and classic techniques in superficial parotidectomy in terms of Frey's syndrome (FS) and cosmetic satisfaction.

Methods

In this study, a retrospective chart review of patients that underwent superficial parotidectomy was performed. These patients were divided into two subgroups: group 1 included patients in which the SMAS flap was harvested and group 2 comprised the remaining patients on whom classic superficial parotidectomy was performed. All the patients were evaluated clinically and with Minor's starch-iodine test for FS. For the evaluation of the cosmetic results, the patient's satisfaction was queried according to the incision scar and surgical field skin retraction/facial symmetry. Both groups were compared in terms of complications and numbness of surgical area.

Results

Fifty-five patients (31 male and 24 female) with a mean age of 50.19 years were included in the study. Thirty-two patients were in group 1 and 23 in group 2. Thirteen patients (23.7%) described as having FS and six of them were in group 1, while seven were in group 2. Minor's starch-iodine test was positive in nine patients in group 1 (28.1%) and six patients in group 2 (26.1%) (p=1.000). With regard to cosmetic satisfaction, eight patients (25%) stated mild discomfort from the incision scar and two patients (6.3%) stated cosmetic dissatisfaction for facial asymmetry in group 1. In group 2 for the same factors the number of patients were 11 (47.8%) and 2 two (8.7%), respectively (p=0.027). There were no statistically significant differences in means of complication and numbness (p>0.05).

Conclusion

According to our study results, there was no superiority between both the groups in terms of FS and incision scar satisfaction. We determined that there was a significant benefit of SMAS flap application in the prevention of volume loss and surgical area retraction.

Anteriorly Based Partial Thickness Sternocleidomastoid Muscle Flap Following Parotidectomy

The anteriorly based partial thickness sternocleidomastoid (SCM) muscle flap is among the various methods described to correct parotidectomy defects, but its indications and limitations are not clearly demonstrated in several reports. This study was done to test the aesthetic outcome of this method, its indications and limitations. At Dr. Babasaheb Ambedkar Memorial hospital, Mumbai, 20 patients presenting with benign parotid tumors underwent parotidectomy. 16 underwent superficial parotidectomy and 3 underwent adequate parotidectomy, 1 had total parotidectomy. The anteriorly based partial thickness SCM muscle flap was used to correct the contour deformity and to prevent Frey syndrome. The aesthetic result was evaluated by assessing and scoring the overall appearance of the scar, the degree of symmetry of the reconstructed parotid region and the site of the donor muscle in comparison to their contralateral normal sides. The overall aesthetic appearance was good in 17 patients, and moderate in 3 patients. 17/20 patients had an overall deep satisfaction with the result. The residual hollowness following total parotidectomy defect and the poor quality of scars were the main reasons affecting the aesthetic outcome. Superficial parotidectomy through modified Blair's incision with immediate reconstruction with anteriorly based partial thickness SCM flap allows a satisfactory aesthetic outcome and minimal donor site morbidity. Scores of the above two parameters were accessed. Patients' satisfaction was assessed by patients questionnaire.

Facelift incision and superficial musculoaponeurotic system advancement in parotidectomy: case reports

Surgical procedures for parotidectomy had been developed to gain adequate approach, prevent morbidity of nerve, and give esthetic satisfaction.

We performed two cases of parotidectomy through facelift incision. One case was reconstructed with superficial musculoaponeurotic system (SMAS) flap and sternocleidomastoid (SCM) muscle rotated flap at the parotid bed. In second case, same procedures were performed, but collagen membrane was additionally implanted for prevention of Frey’s syndrome. After surgery, two cases showed esthetic results without neck scar and hollow defect on parotid bed area.

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.