Parotidectomy incisions

The surgical approach to a parotidectomy has evolved and morphed since its first description by Blair in 1912. The modern-day approach should consider the size and location of the tumor in order to guarantee access to its entirety, the pathology, and cervical node status with the need for a possible selective neck dissection as well as the cosmesis of the resulting defect and the cutaneous scar.

The facial skin is supplied by a robust network of anastomoses in a subdermal plexus comprised of branches of the external carotid artery, namely the superficial temporal artery, facial artery, transverse facial artery (a branch of the superficial temporal artery), and infraorbital artery and buccal branch of the internal maxillary artery. The elevated subcutaneous flap is based solely on this subdermal plexus, which is mainly supplied by muscular cutaneous arteries arising from branches of the facial and infraorbital arteries. The subdermal vascular network remains superficial to the superficial musculoaponeurotic system (SMAS) while the main facial artery and vein are located deep to the SMAS with their perforating branches passing through the SMAS. Unfortunately, the standard subcutaneous and even the SMAS two-layered face-lift flaps divide the skin from the underlying perforators. However, in most patients, there are few complications arising from poor flap perfusion.

In 1912, Blair was the first to use the incision that is employed today with a modification by Bailey in 1941. The modified Blair incision is the workhorse incision for most parotid surgery. It combines the inverted L-shaped (hockey stick) preauricular incision of Blair with a cervical limb extending into the neck (Figure 1).^,  Its advantages are exposure of the entire periphery of the gland and excellent access to the facial nerve. It raises a robust flap that resists flap necrosis. The incision further allows extension into a neck dissection incision and cervicofacial flap elevation. It is cosmetically acceptable and if placed in a natural skin crease, it is difficult to discern.

This incision is similar to the modified Blair except that it begins at the level of the tragus along a preauricular crease winding around the lobule in a more obtuse manner to curve anteriorly 2 inches along the anterior border of the sternocleidomastoid muscle along an upper cervical crease (Figure 1). A benefit of this incision is that the retroauricular portion of the incision is shorter and minimizes the chance of flap loss and scarring in that location. There is less “pincushioning” of the retroauricular portion of the flap. It can be readily converted into a modified neck dissection, incision as well.

This incision was first described in 1967. It originates at the superior root of the helix and lies just inside the anterior edge of the tragus, curving superiorly around the lobule towards the mastoid, preserving the sulcus between lobule and the cheek, continuing in a postauricular crease to the occipital hairline without traversing the hairless mastoid region, and then descends inferiorly approximately 6 cm to the edge of the hairline (Figure 2). The inferior incision can alternatively curve around the lobule onto the posterior conchal cartilage and back into the hairline. Of note, the postauricular incision should be placed either onto the posterior surface of the auricle or approximately 3-5 mm posterior to the mastoid-auricular skin crease to prevent a noticeable scar. Dissection must ensure that the skin over the tragus remains in the immediate subcutaneous plane to avoid elevation of the tragal perichondrium. A large skin flap is elevated, limiting anterior exposure as well as access into the neck for a dissection. This incision is ideal for benign, posteriorly located tumors. Some deep lobe tumors can be approached if they are not large and posteriorly situated. In an era when body art (tattoos) and piercings can be located on the neck, this incision can avoid violation of these markings. The disadvantage is a slightly longer operative time. The exposure of the superior portion of sternocleidomastoid muscle and lateral neck along with the parotid bed is also helpful in reconstructing the parotid bed.

This incision consists of pre- and postauricular incisions joined to curve around the lobule. It begins in a preauricular crease at the superior root of the helix descending in the crease to curve below the lobule, extending superiorly around the lobule towards the mastoid in a postauricular crease (Figure 3A). This incision is ideal for small, benign tumors within the superficial lobe of the parotid gland, especially when located in the tail of the gland or close to the tragus. As with the face-lift incision, body art and other markings can be avoided. This incision allows for dissection anteriorly to the limit of the parotid gland. A dissection of 4-6 cm can be accomplished through this approach (Figure 3B). The superior extension of both the pre- and postauricular limbs depends on the size and location of the tumor within the parotid gland. This incision does not allow access to the neck if a neck dissection is needed.

The incision begins at the inferior end of the postauricular sulcus, extending superiorly to the upper one-third point of the sulcus and angles downward to continue 0.5 to 1 cm along the inside of the hairline (Figure 4). Dissection proceeds anteriorly to the mastoid fascia to the base of the conchal bowl. This incision is ideal for posterior, superficial, and benign parotid tumors.

The various techniques mentioned are effectively performed similarly after the initial incisions are planned. All techniques attempt to spare the greater auricular nerve but frequently, the anterior branch requires sacrifice in order to access parotid tumors. This is more likely in posteriorly located parotid neoplasms. The following description applies to the modified Blair incision but the planes of elevation and anatomic landmarks are the same for the other incisions.

The patient is placed in supine position with the neck in slight extension and face turned to the side opposite the lesion. The head of the table is elevated to decrease venous pressure. The incision is marked and injected with 1% lidocaine with 1:100,000 parts epinephrine. The incision begins in a preauricular crease at the superior root of the helix descending in the crease to curve below the lobule and then turning anteriorly to extend horizontally in a skin crease approximately 2 fingerbreadths below the angle of the mandible. Some surgeons alternatively place the incision posterior to the tragus to further camouflage the incision. The senior author does not use this modification as it adds dissection external to the tarsal cartilage and produces a very thin flap at this level. It also creates more tissue to retract. The incision can be extended further into the neck to accommodate a supraomohyoid neck dissection. Superficial crosshatching with a number 15 blade is performed to assist in precise realignment during closure. An alternative is to place two staples at the junction of the lobule and facial skin. The incision is made with a number 15 blade from the superior to inferior aspect through the skin into the subcutaneous tissue. Double-pronged skin hooks are placed into the facial flap. The skin flap can be raised via one of two approaches. The first involves a dissection deep to the dermis and hair follicles in the subcutaneous fat, thus avoiding injury to the facial nerve branches while maintaining a margin of tissue over superficial tumors. However, care must be taken to avoid raising a skin flap that is too thin. Thin flaps can foster postoperative Frey syndrome. The second approach involves raising the skin with the SMAS fascia layer from the parotid-masseteric fascia directly over the parotid gland, which can be close to superficial tumors and peripheral facial nerve branches (Figure 5). The parotid flap is raised over the parotid fascia, which is the white fibrous layer deep to the subcutaneous fat and SMAS layer. The SMAS layer is elevated from the parotid fascia and distinguished by its yellowish color which contrasts the grayish color of parotid gland. The flap is raised for 1 cm with the blade and then continued with scissors spread perpendicularly to the gland capsule. Numerous small, filamentous structures coming from the capsule to the skin are cut. Dissection continues to the anterior portion of the gland until the fascia overlying the masseter muscle is identified. The SMAS layer is cephalic to the superior aspect of the platysma. Skin hooks are then placed on the inferior and posterior edges of the skin flap beneath the lobule. The anterior edge of the sternocleidomastoid muscle is identified. The greater auricular nerve and external jugular vein, which is located immediately anterior to the nerve, are identified and preserved. Some surgeons identify the greater auricular nerve at the outset of flap elevation and preserve at least the posterior branch. The flap can then be elevated remaining in this plane. After elevation of the skin flaps, the skin is secured with elastic hook retraction to allow for adequate visualization (Table 1).

The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.