ORIGINAL ARTICLE
Endoscope-assisted extracapsular dissection of benign parotid tumors using hairline incision Seung Hoon Woo, MD,1,2* Jin Pyeong Kim, MD,1 Chung-Hwan Baek, MD3 1
Department of Otolaryngology, Gyeongsang National University, Jinju, Korea, 2Institute of Health Sciences, Gyeongsang National University, Jinju, Korea, 3Department of Otorhinolaryngology – Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea.
Accepted 24 October 2014 Published online 27 May 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23901
ABSTRACT: Background. This study evaluated the feasibility of endoscopic-assisted extracapsular dissection of benign parotid tumors using only hairline incision. Methods. Endoscope-assisted extracapsular dissection via only hairline incision was performed in 18 cases (5 men and 13 women) of benign parotid gland tumor (pleomorphic adenoma in 4 cases, Warthin’s tumor in 14 cases). Results. All 18 operations were successfully performed and no conversions to conventional open resection were necessary. One patient had
transient facial paresis and recovered within 1 month. The duration of the procedure was 82.5 6 18.5 minutes. Conclusion. Endoscope-assisted extracapsular dissection using only hairline incision is a feasible method for treatment of benign parotid tumors. The main advantage of this procedure is that the operative scar is concealed in the C 2015 Wiley Periodicals, Inc. Head Neck 38: 375–379, 2016 hairline area. V
INTRODUCTION
surgery, there is a trend toward limited operations based on extracapsular dissection techniques. This procedure was initially described by Gleave et al7 in 1979. It involves careful dissection of the benign parotid tumor in a plane 3 to 4 mm peripheral to the tumor capsule without identification of the facial nerve. Endoscope-assisted surgery has emerged as the standard and most frequently preferred technique in a number of surgical disciplines because of its advantages of leaving a minimal postoperative scar or concealed scar compared to the conventional approach.8–13 However, such operations are not yet a standard procedure in the parotid region because of the anatomic complexity of this region. Head and neck applications of endoscope-assisted surgery are becoming more frequent these days. We have presented several advanced techniques for endoscope-assisted surgery in the head and neck region.14–17 In this study, we present a new approach to endoscope-assisted parotid surgery via only hairline incision.
Benign parotid gland tumors account for the majority of parotid gland tumors.1,2 The recommended treatment for small benign tumors located in the superficial lobe of the parotid gland is superficial or partial parotidectomy.3 Parotidectomy is a well-established surgical technique, and it is performed using a modified Blair incision or facelift incision, allowing complete tumor resection with safe facial nerve dissection. However, the facelift incision and small incision for the extracapsular dissection leave a scar on the face.4–6 In the last decade, a general trend adopted by all surgical disciplines has been an attempt to reduce the magnitude of surgery (including endoscopic surgery) in order to reduce morbidity while keeping the outcome results the same. In an attempt to extend this approach to parotid
*Corresponding author: S. H. Woo, Department of Otolaryngology, Institute of Health Sciences, Gyeongsang National University, 90 Chilam-dong, Jinju, South Korea, Jinju, Korea. E-mail: [email protected] Contract grant sponsor: This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT, and Future Planning (2013R1A1A1012542); This research was supported by Leading Foreign Research Institute Recruitment Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (MEST) (2012K1A4A3053142).. Seung Hoon Woo and Chung-Hwan Baek contributed equally to this work. This article supplements the video presentation, which can be viewed online on Head & Neck’s home page at http://onlinelibrary.wiley.com/journal/10. 1002/(ISSN)1097-0347. Additional Supporting Information may be found in the online version of this article.
KEY WORDS: endoscope, invisible scar, parotidectomy, tumor, parotid
MATERIALS AND METHODS Patients From February 2012 to December 2013, 18 patients with benign parotid tumors were selected to undergo endoscope-assisted parotid surgery via only hairline incision. The group consisted of 5 men and 13 women ranging in age from 19 to 42 years (Table 1). The method of endoscope-assisted parotid surgery via only hairline incision was explained to all the patients and their written consent was obtained. The institutional review board of our hospital had previously approved the entire study. HEAD & NECK—DOI 10.1002/HED
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TABLE 1. Subject characteristics and outcomes.
Patient no.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Sex/age, y
Size of tumor, D, mm
Pathology
Incision, cm
Operation time, min
Follow-up, mo
Patient satisfaction
F/25 F/22 F/19 M/42 F/40 F/20 F/27 F/25 M/35 F/22 F/24 F/31 M/27 M/27 F/21 F/33 F/28 F/24
25320 20320 20315 30330 20315 20320 25320 20315 15315 20320 20315 20320 20315 15315 20320 25325 20315 15315
Warthin Pleomorphic Warthin Warthin Pleomorphic Warthin Warthin Warthin Warthin Pleomorphic Pleomorphic Warthin Warthin Warthin Warthin Warthin Warthin Warthin
5 6 5 5 6 6 5 5 5 7 6 5 6 5 5 6 5 6
90 110 100 110 110 95 80 90 60 90 90 60 60 70 60 80 60 70
12 15 14 13 15 16 15 17 13 14 17 16 16 24 22 21 24 23
10 10 10 9 8 10 10 10 10 10 9 10 9 10 10 10 10 10
All patients underwent CT scans, and fine-needle aspiration biopsy was performed. The indication for endoscopeassisted parotid surgery was a benign tumor located in the superficial lobe of the parotid gland. The tumors in this study included 14 parotid tail tumors and 4 parotid superficial lobe tumors (Table 1).
Complication
Facial paresis
Those patients who met the following inclusion criteria were selected for this endoscope-assisted parotid surgery: benign neoplasms located in the superficial lobe of the parotid gland, no history of radiotherapy, and no preexisting facial paresis. Patients with suspicious malignant parotid tumors, signs of acute inflammatory stages, and
FIGURE 1. (A, B) A 42-year-old male patient visited our clinic for a 3- 3 3cm sized right parotid mass. The mass was confirmed to be Warthin’s tumor. He wanted to conceal the operation scar. (C) The skin preparation (including the scalp area) and draping were the same as for the conventional parotid surgery. (D) A 50 mm incision was made over the post-inferior auricular scalp 1 cm posterior to the hairline and sutured. A Penrose drain was inserted (white arrow). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Surgical technique
FIGURE 2. Endoscope-assisted parotid surgery. (A, B) The scalp flap was dissected anteriorly to expose the sternocleidomastoid (SCM) muscle (black arrow) and the superficial layer of the parotid (white arrowhead). (C) Dissection could be performed between the posterior part of the parotid gland (white arrowhead) and the SCM muscle (black arrow). (D) Dissection proceeded around the tumor. Any peripheral branch of the facial nerve (white arrow) encountered should be retracted gently away from the tumor. (E) The tumor was dissected and then extracted through the surgical wound. (F) After tumor removal, the peripheral branch of the facial nerve (white arrow) was seen in the operative field. (G) The specimen of a 3- 3 3-cm sized mass. This tumor was covered in soft tissue around the tumor. (H) One month later, the operation scar was concealed by the hair. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
recurrent parotid tumors were excluded. The patients in this series were followed up for 12 to 24 months (mean 5 17.05 6 3.95 months). Evaluation of patient satisfaction was based on patient interviews conducted after surgery. Parameters reported by patients were assigned a score ranging from 0 to 10.
With the patients under general anesthesia, all patients were placed in the supine position with a pillow under their shoulder. Their heads were inclined to the healthy side. Skin preparation (including the scalp area) and draping were the same as for the conventional parotid surgery (Figure 1C). A 50 to 70 mm incision was made over the post-inferior auricular scalp 1 cm posterior to the hairline (Figure 1D). The scalp flaps were elevated using Metzenbaum scissors and right-angled retractors, and the surgical plane was easily dissected under the endoscope (rigid, 10 mm, 0 degrees; Olympus, Tokyo, Japan). Next, the scalp flap was dissected anteriorly to expose the sternocleidomastoid (SCM) muscle and the superficial layer of the parotid (Figure 2A and 2B). In addition, a dissection could be performed between the posterior part of the parotid gland and the SCM muscle (Figure 2C). At this stage, elevation of the scalp flaps for surgical exposure was complete. It is important to identify the connective tissue around the tumor. Dissection proceeding in this plane is only around the tumor. Any peripheral branch of the facial nerve encountered should be retracted gently away from the tumor (Figure 2D). A nerve monitoring system and endoscope system were essential. Because of the amplification of the endoscope, the branches of the facial nerve can be identified clearly, and the current used for facial nerve stimulation in the present study was 0.5 to 1 mA per stimulus. Stimulation was verified by using the NIMResponse 2.0 (Xomed, Jacksonville, FL) nerve monitoring system. Good illumination and magnified viewing enabled successful dissection of the tumor after it was extracted through the surgical wound (Figure 2E and 2G). For histologic examination, the specimens were sent for frozen section biopsy, and the results showed that all the tumors were benign. Finally, wound irrigation and bleeding control were performed. After tumor removal, the peripheral branch of the facial nerve was seen in the operative field. Patients were kept in the hospital for 1 to 2 days until the Hemovac had been removed (Video clip, online only).
RESULTS Extracapsular dissection was performed by means of endoscopic surgery for 5 men and 13 women with benign parotid tumors. The average age of the patients was 27.33 6 6.57 years (range, 19–42 years). Postoperative pathologic examination revealed pleomorphic adenoma in 4 cases and Warthin’s tumor in 14 cases. It also proved that the tumor removal was complete in all cases. All operations were successfully performed via the endoscope-assisted parotid surgical procedure by a single operator (S.H.W.), with no conversions to the classical procedure. The mean length of the skin incision was 55 6 0.62 mm (range, 5–6 mm). The median tumor size was 20.56 3 18.33 mm, and all of the resection margins were free of tumor invasion. The operating time was 82.5 6 18.5 minutes (range, 60–110 minutes), and blood loss was minimal. One patient had transient grade II facial paresis and recovered within 1 month, and no other operative complications occurred. None of the patients had capsular HEAD & NECK—DOI 10.1002/HED
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ruptures. All the incisions healed completely. The mean patient satisfaction score was 9.77 6 0.57 points (range, 8–10 points), and patients remained disease-free at follow-up for an average of 17.05 6 3.95 months (range, 12–24 months; Table 1).
DISCUSSION Parotid surgery commonly begins with a modified Blair incision, an S-shaped preauricular and submandibular incision that may leave a visible incision scar on the naked surface of the face and neck of some patients. In addition to the possibility of facial paralysis, patients undergoing parotid surgery may worry about the possibility of postoperative scars, especially when a hypertrophic scar or keloid occurs at the site. Many surgeons try to improve the cosmetic results by modifying the surgical technique, using such methods as the face-lifting technique.4 However, we think the skin incision wound is still obvious, and, without extending to the neck, the surgical field is quite limited. Although minor, the incision scar from a preauricular incision is visible on the face. Lin et al18 reported the first endoscope-assisted parotidectomy in addition to the classic procedure. The preliminary result of applying the endoscope to the classic parotidectomy was satisfactory except that the skin incision still required a length of 60 to 81 mm. Some studies have concluded that the alternative surgical techniques could improve the cosmetic results safely and without increased complications. Endoscopic surgery is suitable for places that have natural cavities. The endoscopic technique has several benefits, including reduced tissue damage, improved cosmesis, and fewer wound-related complications. Because of these benefits, head and neck surgeons have performed endoscopic surgery by creating a working space in thyroidectomy, parathyroidectomy, submandibular gland dissection, thyroglossal duct cysts, and dermoid cysts, among others. All of these surgeries have resulted in patients satisfied with the results.8–13,19–21 However, endoscopic parotid surgery is still in the exploratory stage; only a few studies have been reported, and the surgical method is not yet fully understood.18 The parotid gland area does not have a natural cavity. Therefore, to perform endoscopic surgery, one needs to first create a working cavity. In this study, it was found that the scalp incision could be separated from the surface of the superficial parotid gland through scalp incisions. In addition, a dissection could be performed between the posterior part of the parotid gland and the SCM muscle. After this, an effective working cavity was made by lifting the flap with retractors. The operative area was then clearly seen with the help of an endoscope. The key point of endoscope-assisted parotid surgery is to safely dissect the tumor without facial nerve damage, and this was found to be feasible with the help of magnification and lighting of the endoscope and a nerve monitoring system. The endoscopic technique provides good illumination and magnification for surgical procedures under the video monitor, and with the addition of the nerve monitoring system they can be dissected efficiently. In this study, 1 patient experienced transient facial paresis. The endoscope-assisted hairline approach, in which 378
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incisions are made on an invisible area of the head and neck, was developed for the removal of upper neck masses.22–24 Therefore, a hairline approach, without any skin incision, may be used for selected patients for the superficial part of benign parotid tumors. It will be difficult to apply this approach to patients with large-sized tumors, tumors localized to the anterior or upper parotid gland, and tumors suspected of being malignant.22 Among the potential advantages of this approach are excellent cosmetic outcomes, in addition to the benefits of extracapsular dissection, including lower rates of facial paralysis and Frey’s syndrome, and preservation of the secretory function of the parotid gland. Sunken defects secondary to the loss of parotid volume are prevented and bilateral symmetric facial contours are preserved. In addition, the incision is frequently invisible because it is hidden by the auricle and hair even if a hypertrophic scar develops.22 Surgery for parotid gland neoplasms has evolved from enucleation to superficial or total parotidectomy. Tumor enucleation is not an ideal procedure for parotid tumors because of high risks of tumor rupture and subtotal removal, with tumor recurrence rates ranging from 20% to 45%.2,22 These recurrence rates were reduced dramatically by a more comprehensive dissection method, involving identification of the main trunk and branches of the facial nerve, followed by removal of the entire superficial and/or deep lobe of the parotid gland.22,25 This procedure, however, results in greater risks to the facial nerve and other complications.22,26 In response to these risks, more conservative surgical approaches have been developed, including partial parotidectomy and extracapsular dissection.7 Extracapsular dissection is an alternative approach to the removal of such lumps involving meticulous dissection immediately outside the tumor capsule, still preserving the facial nerve; thus, it is distinct from enucleation. Extracapsular dissection differs from enucleation because the tumor is removed with an intact capsule as opposed to shelling out the tumor contents and leaving the capsule in situ, as is the case with enucleation.6,27 These methods preserve the uninvolved parotid parenchyma and obviate the need for more extensive facial nerve dissection, resulting in decreases in facial nerve paralysis and other complications, as well as increased preservation of parotid secretory function. Nevertheless, extracapsular dissection has been considered with caution according to the traditional view that many parotid tumors (notably pleomorphic adenomas) breach their capsule and are, therefore, theoretically at risk of recurrence from surgery close to the capsule.28 A previous report showed no difference in recurrence rates (2%) between a group of 503 patients who underwent extracapsular dissection and a group of 159 patients who underwent superficial parotidectomy.22,29 In the treatment of parotid pleomorphic adenomas, another procedure, extracapsular lumpectomy, has been shown to reduce morbidity without oncologic compromise. The exact volume of parotid tissue to be removed has not yet been determined, but a few millimeters of surrounding parotid tissue may be sufficient for complete resection. This technique, with a margin of intact parotid tissue, can be applied in pleomorphic adenoma and Warthin’s tumor, aiming at dissection with a safety margin.30
ENDOSCOPE–ASSISTED
There remain some limitations in this study. The major advantage of this new approach is the concealed scar; verification of other advantages, such as avoidance of facial nerve paresis, and shorter hospitalization, will require a larger series of patients with longer follow-up because the benign mixed tumor has a mean of 7 years to recurrence. However, endoscopic parotid surgery is still in its infancy. Only a few studies have been reported, and the surgical method is far from perfect. Our experience indicates that this technique can be used for a benign tumor located in the tail of the parotid gland. In this study, extracapsular dissection via only hairline incision was feasible for benign tumors located in the tail of the parotid gland. Only 1 patient experienced transient facial paresis. With this procedure, extracapsular dissection via the hairline approach may become an alternative to conventional partial or superficial parotidectomy in selected patients with benign parotid tumors. All the patients in the current study were satisfied with the concealed scalp scars because they were invisible.
CONCLUSIONS The advantages of endoscope-assisted hairline parotidectomy through a scalp incision include an invisible scar and magnification of key structures. This operative method is feasible for benign tumors located in the tail of the parotid gland.
REFERENCES 1. Eveson JW, Cawson RA. Salivary gland tumours. A review of 2410 cases with particular reference to histological types, site, age and sex distribution. J Pathol 1985;146:51–58. 2. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg 1986;8:177–184. 3. O’Brien CJ. Current management of benign parotid tumors–the role of limited superficial parotidectomy. Head Neck 2003;25:946–952. 4. Lee SY, Koh YW, Kim BG, Hong HJ, Jeong JH, Choi EC. The extended indication of parotidectomy using the modified facelift incision in benign lesions: retrospective analysis of a single institution. World J Surg 2011;35: 2228–2237. 5. Zhi K, Ren W, Gao L, et al. Face-lift incision combined with sternomastoid muscular flap in parotidectomy. Aesthetic Plast Surg 2011;35:558–562. 6. Shehata EA. Extra-capsular dissection for benign parotid tumours. Int J Oral Maxillofac Surg 2010;39:140–144. 7. Gleave EN, Whittaker JS, Nicholson A. Salivary tumours–experience over thirty years. Clin Otolaryngol Allied Sci 1979;4:247–257.
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8. Gagner M, Inabnet WB III. Endoscopic thyroidectomy for solitary thyroid nodules. Thyroid 2001;11:161–163. 9. Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336–340. 10. Miccoli P, Bendinelli C, Berti P, Vignali E, Pinchera A, Marcocci C. Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study. Surgery 1999;126:1117– 1121; discussion 1121–1122. 11. Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 2000;10:1–4. 12. Shimizu K, Akira S, Tanaka S. Video-assisted neck surgery: endoscopic resection of benign thyroid tumor aiming at scarless surgery on the neck. J Surg Oncol 1998;69:178–180. 13. Yeung HC, Ng WT, Kong CK. Endoscopic thyroid and parathyroid surgery. Surg Endosc 1997;11:1135. 14. Kim JP, Park JJ, Lee EJ, Woo SH. Intraoral removal of a thyroglossal duct cyst using a frenotomy incision. Thyroid 2011;21:1381–1384. 15. Woo SH. Endoscope-assisted intraoral removal of the thyroid isthmus mass using a frenotomy incision. J Laparoendosc Adv Surg Tech A 2013;23: 787–790. 16. Woo SH, Jeong HS, Kim JP, Park JJ, Baek CH. Endoscope-assisted frenotomy approach to median upper neck masses: clinical outcomes and safety (from a phase II clinical trial). Head Neck 2014;36:985–991. 17. Woo SH, Jeong HS, Kim JP, Park JJ, Baek CH. Endoscope-assisted intraoral removal of ectopic thyroid tissue using a frenotomy incision. Thyroid 2013;23:605–608. 18. Lin SD, Tsai CC, Lai CS, Lee SS, Chang KP. Endoscope-assisted parotidectomy for benign parotid tumors. Ann Plast Surg 2000;45:269–273. 19. Chen MK, Su CC, Tsai YL, Chang CC. Minimally invasive endoscopic resection of the submandibular gland: a new approach. Head Neck 2006; 28:1014–1017. 20. H€ uscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877. 21. Reilly J, Myssiorek D. Facial nerve stimulation and postparotidectomy facial paresis. Otolaryngol Head Neck Surg 2003;128:530–533. 22. Roh JL. Extracapsular dissection of benign parotid tumors using a retroauricular hairline incision approach. Am J Surg 2009;197:e53–e56. 23. Roh JL. Retroauricular hairline incision for removal of upper neck masses. Laryngoscope 2005;115:2161–2166. 24. Woo SH. Endoscopic-assisted total thyroidectomy via lateral keloid scar incision. Clin Exp Otorhinolaryngol 2014;7:321–324. 25. Janes RM. The treatment of tumours of the salivary glands by radical excision. Can Med Assoc J 1940;43:554–559. 26. Terris DJ, Tuffo KM, Fee WE Jr. Modified facelift incision for parotidectomy. J Laryngol Otol 1994;108:574–578. 27. Patey DH, Thackray AC. The treatment of parotid tumours in the light of a pathological study of parotidectomy material. Br J Surg 1958;45:477–487. 28. Zeebregts CJ, Mastboom WJB, van Noort G, van Det RJ. Synchronous tumours of the unilateral parotid gland: rare or undetected? J Craniomaxillofac Surg 2003;31:62–66. 29. McGurk M, Thomas BL, Renehan AG. Extracapsular dissection for clinically benign parotid lumps: reduced morbidity without oncological compromise. Br J Cancer 2003;89:1610–1613. 30. Iizuka K, Ishikawa K. Surgical techniques for benign parotid tumors: segmental resection vs extracapsular lumpectomy. Acta Otolaryngol Suppl 1998;537:75–81.
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Endoscope-assisted extracapsular dissection of benign parotid tumors using hairline incision Seung Hoon Woo, MD,1,2* Jin Pyeong Kim, MD,1 Chung-Hwan Baek, MD3 1
Department of Otolaryngology, Gyeongsang National University, Jinju, Korea, 2Institute of Health Sciences, Gyeongsang National University, Jinju, Korea, 3Department of Otorhinolaryngology – Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea.
Accepted 24 October 2014 Published online 27 May 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23901
ABSTRACT: Background. This study evaluated the feasibility of endoscopic-assisted extracapsular dissection of benign parotid tumors using only hairline incision. Methods. Endoscope-assisted extracapsular dissection via only hairline incision was performed in 18 cases (5 men and 13 women) of benign parotid gland tumor (pleomorphic adenoma in 4 cases, Warthin’s tumor in 14 cases). Results. All 18 operations were successfully performed and no conversions to conventional open resection were necessary. One patient had
transient facial paresis and recovered within 1 month. The duration of the procedure was 82.5 6 18.5 minutes. Conclusion. Endoscope-assisted extracapsular dissection using only hairline incision is a feasible method for treatment of benign parotid tumors. The main advantage of this procedure is that the operative scar is concealed in the C 2015 Wiley Periodicals, Inc. Head Neck 38: 375–379, 2016 hairline area. V
INTRODUCTION
surgery, there is a trend toward limited operations based on extracapsular dissection techniques. This procedure was initially described by Gleave et al7 in 1979. It involves careful dissection of the benign parotid tumor in a plane 3 to 4 mm peripheral to the tumor capsule without identification of the facial nerve. Endoscope-assisted surgery has emerged as the standard and most frequently preferred technique in a number of surgical disciplines because of its advantages of leaving a minimal postoperative scar or concealed scar compared to the conventional approach.8–13 However, such operations are not yet a standard procedure in the parotid region because of the anatomic complexity of this region. Head and neck applications of endoscope-assisted surgery are becoming more frequent these days. We have presented several advanced techniques for endoscope-assisted surgery in the head and neck region.14–17 In this study, we present a new approach to endoscope-assisted parotid surgery via only hairline incision.
Benign parotid gland tumors account for the majority of parotid gland tumors.1,2 The recommended treatment for small benign tumors located in the superficial lobe of the parotid gland is superficial or partial parotidectomy.3 Parotidectomy is a well-established surgical technique, and it is performed using a modified Blair incision or facelift incision, allowing complete tumor resection with safe facial nerve dissection. However, the facelift incision and small incision for the extracapsular dissection leave a scar on the face.4–6 In the last decade, a general trend adopted by all surgical disciplines has been an attempt to reduce the magnitude of surgery (including endoscopic surgery) in order to reduce morbidity while keeping the outcome results the same. In an attempt to extend this approach to parotid
*Corresponding author: S. H. Woo, Department of Otolaryngology, Institute of Health Sciences, Gyeongsang National University, 90 Chilam-dong, Jinju, South Korea, Jinju, Korea. E-mail: [email protected] Contract grant sponsor: This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT, and Future Planning (2013R1A1A1012542); This research was supported by Leading Foreign Research Institute Recruitment Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (MEST) (2012K1A4A3053142).. Seung Hoon Woo and Chung-Hwan Baek contributed equally to this work. This article supplements the video presentation, which can be viewed online on Head & Neck’s home page at http://onlinelibrary.wiley.com/journal/10. 1002/(ISSN)1097-0347. Additional Supporting Information may be found in the online version of this article.
KEY WORDS: endoscope, invisible scar, parotidectomy, tumor, parotid
MATERIALS AND METHODS Patients From February 2012 to December 2013, 18 patients with benign parotid tumors were selected to undergo endoscope-assisted parotid surgery via only hairline incision. The group consisted of 5 men and 13 women ranging in age from 19 to 42 years (Table 1). The method of endoscope-assisted parotid surgery via only hairline incision was explained to all the patients and their written consent was obtained. The institutional review board of our hospital had previously approved the entire study. HEAD & NECK—DOI 10.1002/HED
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WOO ET AL.
TABLE 1. Subject characteristics and outcomes.
Patient no.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Sex/age, y
Size of tumor, D, mm
Pathology
Incision, cm
Operation time, min
Follow-up, mo
Patient satisfaction
F/25 F/22 F/19 M/42 F/40 F/20 F/27 F/25 M/35 F/22 F/24 F/31 M/27 M/27 F/21 F/33 F/28 F/24
25320 20320 20315 30330 20315 20320 25320 20315 15315 20320 20315 20320 20315 15315 20320 25325 20315 15315
Warthin Pleomorphic Warthin Warthin Pleomorphic Warthin Warthin Warthin Warthin Pleomorphic Pleomorphic Warthin Warthin Warthin Warthin Warthin Warthin Warthin
5 6 5 5 6 6 5 5 5 7 6 5 6 5 5 6 5 6
90 110 100 110 110 95 80 90 60 90 90 60 60 70 60 80 60 70
12 15 14 13 15 16 15 17 13 14 17 16 16 24 22 21 24 23
10 10 10 9 8 10 10 10 10 10 9 10 9 10 10 10 10 10
All patients underwent CT scans, and fine-needle aspiration biopsy was performed. The indication for endoscopeassisted parotid surgery was a benign tumor located in the superficial lobe of the parotid gland. The tumors in this study included 14 parotid tail tumors and 4 parotid superficial lobe tumors (Table 1).
Complication
Facial paresis
Those patients who met the following inclusion criteria were selected for this endoscope-assisted parotid surgery: benign neoplasms located in the superficial lobe of the parotid gland, no history of radiotherapy, and no preexisting facial paresis. Patients with suspicious malignant parotid tumors, signs of acute inflammatory stages, and
FIGURE 1. (A, B) A 42-year-old male patient visited our clinic for a 3- 3 3cm sized right parotid mass. The mass was confirmed to be Warthin’s tumor. He wanted to conceal the operation scar. (C) The skin preparation (including the scalp area) and draping were the same as for the conventional parotid surgery. (D) A 50 mm incision was made over the post-inferior auricular scalp 1 cm posterior to the hairline and sutured. A Penrose drain was inserted (white arrow). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Surgical technique
FIGURE 2. Endoscope-assisted parotid surgery. (A, B) The scalp flap was dissected anteriorly to expose the sternocleidomastoid (SCM) muscle (black arrow) and the superficial layer of the parotid (white arrowhead). (C) Dissection could be performed between the posterior part of the parotid gland (white arrowhead) and the SCM muscle (black arrow). (D) Dissection proceeded around the tumor. Any peripheral branch of the facial nerve (white arrow) encountered should be retracted gently away from the tumor. (E) The tumor was dissected and then extracted through the surgical wound. (F) After tumor removal, the peripheral branch of the facial nerve (white arrow) was seen in the operative field. (G) The specimen of a 3- 3 3-cm sized mass. This tumor was covered in soft tissue around the tumor. (H) One month later, the operation scar was concealed by the hair. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
recurrent parotid tumors were excluded. The patients in this series were followed up for 12 to 24 months (mean 5 17.05 6 3.95 months). Evaluation of patient satisfaction was based on patient interviews conducted after surgery. Parameters reported by patients were assigned a score ranging from 0 to 10.
With the patients under general anesthesia, all patients were placed in the supine position with a pillow under their shoulder. Their heads were inclined to the healthy side. Skin preparation (including the scalp area) and draping were the same as for the conventional parotid surgery (Figure 1C). A 50 to 70 mm incision was made over the post-inferior auricular scalp 1 cm posterior to the hairline (Figure 1D). The scalp flaps were elevated using Metzenbaum scissors and right-angled retractors, and the surgical plane was easily dissected under the endoscope (rigid, 10 mm, 0 degrees; Olympus, Tokyo, Japan). Next, the scalp flap was dissected anteriorly to expose the sternocleidomastoid (SCM) muscle and the superficial layer of the parotid (Figure 2A and 2B). In addition, a dissection could be performed between the posterior part of the parotid gland and the SCM muscle (Figure 2C). At this stage, elevation of the scalp flaps for surgical exposure was complete. It is important to identify the connective tissue around the tumor. Dissection proceeding in this plane is only around the tumor. Any peripheral branch of the facial nerve encountered should be retracted gently away from the tumor (Figure 2D). A nerve monitoring system and endoscope system were essential. Because of the amplification of the endoscope, the branches of the facial nerve can be identified clearly, and the current used for facial nerve stimulation in the present study was 0.5 to 1 mA per stimulus. Stimulation was verified by using the NIMResponse 2.0 (Xomed, Jacksonville, FL) nerve monitoring system. Good illumination and magnified viewing enabled successful dissection of the tumor after it was extracted through the surgical wound (Figure 2E and 2G). For histologic examination, the specimens were sent for frozen section biopsy, and the results showed that all the tumors were benign. Finally, wound irrigation and bleeding control were performed. After tumor removal, the peripheral branch of the facial nerve was seen in the operative field. Patients were kept in the hospital for 1 to 2 days until the Hemovac had been removed (Video clip, online only).
RESULTS Extracapsular dissection was performed by means of endoscopic surgery for 5 men and 13 women with benign parotid tumors. The average age of the patients was 27.33 6 6.57 years (range, 19–42 years). Postoperative pathologic examination revealed pleomorphic adenoma in 4 cases and Warthin’s tumor in 14 cases. It also proved that the tumor removal was complete in all cases. All operations were successfully performed via the endoscope-assisted parotid surgical procedure by a single operator (S.H.W.), with no conversions to the classical procedure. The mean length of the skin incision was 55 6 0.62 mm (range, 5–6 mm). The median tumor size was 20.56 3 18.33 mm, and all of the resection margins were free of tumor invasion. The operating time was 82.5 6 18.5 minutes (range, 60–110 minutes), and blood loss was minimal. One patient had transient grade II facial paresis and recovered within 1 month, and no other operative complications occurred. None of the patients had capsular HEAD & NECK—DOI 10.1002/HED
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ruptures. All the incisions healed completely. The mean patient satisfaction score was 9.77 6 0.57 points (range, 8–10 points), and patients remained disease-free at follow-up for an average of 17.05 6 3.95 months (range, 12–24 months; Table 1).
DISCUSSION Parotid surgery commonly begins with a modified Blair incision, an S-shaped preauricular and submandibular incision that may leave a visible incision scar on the naked surface of the face and neck of some patients. In addition to the possibility of facial paralysis, patients undergoing parotid surgery may worry about the possibility of postoperative scars, especially when a hypertrophic scar or keloid occurs at the site. Many surgeons try to improve the cosmetic results by modifying the surgical technique, using such methods as the face-lifting technique.4 However, we think the skin incision wound is still obvious, and, without extending to the neck, the surgical field is quite limited. Although minor, the incision scar from a preauricular incision is visible on the face. Lin et al18 reported the first endoscope-assisted parotidectomy in addition to the classic procedure. The preliminary result of applying the endoscope to the classic parotidectomy was satisfactory except that the skin incision still required a length of 60 to 81 mm. Some studies have concluded that the alternative surgical techniques could improve the cosmetic results safely and without increased complications. Endoscopic surgery is suitable for places that have natural cavities. The endoscopic technique has several benefits, including reduced tissue damage, improved cosmesis, and fewer wound-related complications. Because of these benefits, head and neck surgeons have performed endoscopic surgery by creating a working space in thyroidectomy, parathyroidectomy, submandibular gland dissection, thyroglossal duct cysts, and dermoid cysts, among others. All of these surgeries have resulted in patients satisfied with the results.8–13,19–21 However, endoscopic parotid surgery is still in the exploratory stage; only a few studies have been reported, and the surgical method is not yet fully understood.18 The parotid gland area does not have a natural cavity. Therefore, to perform endoscopic surgery, one needs to first create a working cavity. In this study, it was found that the scalp incision could be separated from the surface of the superficial parotid gland through scalp incisions. In addition, a dissection could be performed between the posterior part of the parotid gland and the SCM muscle. After this, an effective working cavity was made by lifting the flap with retractors. The operative area was then clearly seen with the help of an endoscope. The key point of endoscope-assisted parotid surgery is to safely dissect the tumor without facial nerve damage, and this was found to be feasible with the help of magnification and lighting of the endoscope and a nerve monitoring system. The endoscopic technique provides good illumination and magnification for surgical procedures under the video monitor, and with the addition of the nerve monitoring system they can be dissected efficiently. In this study, 1 patient experienced transient facial paresis. The endoscope-assisted hairline approach, in which 378
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incisions are made on an invisible area of the head and neck, was developed for the removal of upper neck masses.22–24 Therefore, a hairline approach, without any skin incision, may be used for selected patients for the superficial part of benign parotid tumors. It will be difficult to apply this approach to patients with large-sized tumors, tumors localized to the anterior or upper parotid gland, and tumors suspected of being malignant.22 Among the potential advantages of this approach are excellent cosmetic outcomes, in addition to the benefits of extracapsular dissection, including lower rates of facial paralysis and Frey’s syndrome, and preservation of the secretory function of the parotid gland. Sunken defects secondary to the loss of parotid volume are prevented and bilateral symmetric facial contours are preserved. In addition, the incision is frequently invisible because it is hidden by the auricle and hair even if a hypertrophic scar develops.22 Surgery for parotid gland neoplasms has evolved from enucleation to superficial or total parotidectomy. Tumor enucleation is not an ideal procedure for parotid tumors because of high risks of tumor rupture and subtotal removal, with tumor recurrence rates ranging from 20% to 45%.2,22 These recurrence rates were reduced dramatically by a more comprehensive dissection method, involving identification of the main trunk and branches of the facial nerve, followed by removal of the entire superficial and/or deep lobe of the parotid gland.22,25 This procedure, however, results in greater risks to the facial nerve and other complications.22,26 In response to these risks, more conservative surgical approaches have been developed, including partial parotidectomy and extracapsular dissection.7 Extracapsular dissection is an alternative approach to the removal of such lumps involving meticulous dissection immediately outside the tumor capsule, still preserving the facial nerve; thus, it is distinct from enucleation. Extracapsular dissection differs from enucleation because the tumor is removed with an intact capsule as opposed to shelling out the tumor contents and leaving the capsule in situ, as is the case with enucleation.6,27 These methods preserve the uninvolved parotid parenchyma and obviate the need for more extensive facial nerve dissection, resulting in decreases in facial nerve paralysis and other complications, as well as increased preservation of parotid secretory function. Nevertheless, extracapsular dissection has been considered with caution according to the traditional view that many parotid tumors (notably pleomorphic adenomas) breach their capsule and are, therefore, theoretically at risk of recurrence from surgery close to the capsule.28 A previous report showed no difference in recurrence rates (2%) between a group of 503 patients who underwent extracapsular dissection and a group of 159 patients who underwent superficial parotidectomy.22,29 In the treatment of parotid pleomorphic adenomas, another procedure, extracapsular lumpectomy, has been shown to reduce morbidity without oncologic compromise. The exact volume of parotid tissue to be removed has not yet been determined, but a few millimeters of surrounding parotid tissue may be sufficient for complete resection. This technique, with a margin of intact parotid tissue, can be applied in pleomorphic adenoma and Warthin’s tumor, aiming at dissection with a safety margin.30
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There remain some limitations in this study. The major advantage of this new approach is the concealed scar; verification of other advantages, such as avoidance of facial nerve paresis, and shorter hospitalization, will require a larger series of patients with longer follow-up because the benign mixed tumor has a mean of 7 years to recurrence. However, endoscopic parotid surgery is still in its infancy. Only a few studies have been reported, and the surgical method is far from perfect. Our experience indicates that this technique can be used for a benign tumor located in the tail of the parotid gland. In this study, extracapsular dissection via only hairline incision was feasible for benign tumors located in the tail of the parotid gland. Only 1 patient experienced transient facial paresis. With this procedure, extracapsular dissection via the hairline approach may become an alternative to conventional partial or superficial parotidectomy in selected patients with benign parotid tumors. All the patients in the current study were satisfied with the concealed scalp scars because they were invisible.
CONCLUSIONS The advantages of endoscope-assisted hairline parotidectomy through a scalp incision include an invisible scar and magnification of key structures. This operative method is feasible for benign tumors located in the tail of the parotid gland.
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