Accepted Manuscript

PAROTIDECTOMY INCISIONS

Nigar Ahmedli MD , David Myssiorek MD, FACS

PII: S1043-1810(18)30033-2
DOI: 10.1016/j.otot.2018.06.003
Reference: YOTOT 818

To appear in: Operative Techniques in Otolaryngology - Head and Neck Surgery

Please cite this article as: Nigar Ahmedli MD , David Myssiorek MD, FACS , PAROTIDECTOMY
INCISIONS, Operative Techniques in Otolaryngology - Head and Neck Surgery (2018), doi:
10.1016/j.otot.2018.06.003

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PAROTIDECTOMY INCISIONS

Nigar Ahmedli, MD1 and David Myssiorek, MD, FACS2

1 Department of Otolaryngology Head and Neck Surgery, Montefiore Medical Center, the Albert
Einstein College of Medicine, Bronx, NY, 10467, USA

2 Director of Head and Neck Surgery, Department of General Surgery, division of

Otolaryngology Head and Neck Surgery, the Albert Einstein College of Medicine, Bronx, NY

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10461, USA

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Corresponding Author:
David Myssiorek, MD, FACS
Jacobi Medical Center
1400 Pelham Parkway South
Building 1, 5N49
Bronx, NY 10461

Phone (718) 918-5018

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FAX (718) 918-7492
myss@optonline.net
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Key Words: parotidectomy, incision, surgical approach, facelift incision, u-incision,

microparotidectomy incision
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Abstract

The surgical approach to a parotidectomy was first described by Blair in 1912 for the resection

of all parotid tumors. It has since evolved and changed into numerous permutations. The

modern-day approach considers the size, location and sometimes anticipated pathology of the

parotid tumor in addition to the need for a possible neck dissection. As the concern for cosmesis

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increases in today’s society, the well-known Modified Blair incision has been revised to limit the

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cutaneous scar while preserving access and oncologic principles. The evolution of the

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parotidectomy incision from its first description to the various changes that have recently

occurred are presented. These modifications occurred to take into account aesthetic concerns.

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The techniques are outlined as a surgical guide.
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Introduction

The surgical approach to a parotidectomy has evolved and morphed since its first description by

Blair in 1912.1 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

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cutaneous scar.

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The facial skin is supplied by a robust network of anastomoses in a subdermal plexus

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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

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artery and buccal branch of the internal maxillary artery.2 The elevated subcutaneous flap is

based solely on this subdermal plexus, which is mainly supplied by muscular cutaneous arteries
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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
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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
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flaps divide the skin from the underlying perforators. However, in most patients, there are few

complications arising from poor flap perfusion.

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Modified Blair Incision

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In 1912, Blair was the first to use the incision that is employed today with a modification by

Bailey in 1941.3 The modified Blair incision is the workhorse incision for most parotid surgery. It
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combines the inverted L-shaped (hockey stick) pre-auricular incision of Blair with a cervical limb

extending into the neck.1,3 (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

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elevation. It is cosmetically acceptable and if placed in a natural skin crease, it is difficult to

discern.

Lazy-S Incision

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

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inches along the anterior border of the sternocleidomastoid muscle along an upper cervical

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crease. (Figure 1) A benefit of this incision is that the retroauricular portion of the incision is

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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.

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Facelift (Rhytidectomy) Incision

This incision was first described in 1967.4 It originates at the superior root of the helix and lies
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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
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crease to the occipital hairline without traversing the hairless mastoid region and then descends

inferiorly approximately 6cm to the edge of the hairline.5 (Figure 2) The inferior incision can
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alternatively curve around the lobule onto the posterior conchal cartilage and back into the

hairline.6 Of note, the postauricular incision should be placed either onto the posterior surface of
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the auricle or approximately 3-5mm 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
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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

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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.

U-shaped/Microparotidectomy Incision

This incision consists of pre- and post-auricular incisions joined to curve around the lobule. It

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begins in a preauricular crease at the superior root of the helix descending in the crease to

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curve below the lobule, extending superiorly around the lobule towards the mastoid in a

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postauricular crease.7 (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

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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. 4-6 cm of dissection can
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be accomplished through this approach (Figure 3B) The superior extension of both the pre- and

postauricular limbs depend on the size and location of the tumor within the parotid gland. This
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incision does not allow access to the neck if a neck dissection is needed.
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Retroauricular Hairline Incision

The incision begins at the inferior end of the postauricular sulcus, extending superiorly to the
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upper one-third point of the sulcus and angles downward to continue 0.5 to 1 cm along the

inside of the hairline.8 (Figure 4) Dissection proceeds anteriorly to the mastoid fascia to the base
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of the conchal bowl. This incision is ideal for posterior, superficial, benign parotid tumors.
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Technique

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

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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

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incision is marked and injected with 1% lidocaine with 1:100,000 parts epinephrine. The incision

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begins in a preauricular crease at the superior root of the helix descending in the crease to

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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

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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
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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

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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
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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
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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
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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
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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

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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

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the inferior and posterior edges of the skin flap beneath the lobule. The anterior edge of the

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sternocleidomastoid muscle is identified. The greater auricular nerve and external jugular vein,

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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

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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.
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Table 1

Incision Ideal Tumor Site Strength Limitation

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Modified Blair No limitations Wide exposure. Robust flap. Longer, more visible scar.
Allows for neck dissection.

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Facelift Posterior and small
deep lobe
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Wide exposure.
Camouflaged scar.
More suited for benign
pathology. Limits
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a neck dissection.
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U-incision Tail of the parotid Shorter & camouflaged scar. Limited exposure.
gland or near tragus
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Lazy S-incision Posterior and Shorter scar. Limited exposure & access
superficial to the neck.
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Retroauricular Posterior and Small and camouflaged scar. Better suited for benign
Hairline superficial pathology given limited
exposure.

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References
1. Blair, VP (1918). Surgery and Disease of the Mouth and Jaws. 3rd Edition, C.V. Mosby, St.
Louis, Mo. pp 492-523.
2. Kridel R.W.H and Chacra Z.A. “Rhytidectomy (Face-Lift).” Bailey’s Head & Neck Surgery
Otolaryngology. Baltimore: Lippincott Williams & Wilkins. 2013. 3103-3130.
3. Bailey H. The treatment of tumours of the parotid gland with special reference to total
parotidectomy. Br J Surg. 1941; 111:337-46.
4. Appiani A. Surgical management of parotid tumours. Revista Argentina de Cirugia 1967;

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21:236.

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5. Kim IK, Cho HW, Cho HY, Seo JH, Lee DH and Park SH. Facelift incision and superficial
musculoaponeurotic system advancement in parotidectomy: case reports. Maxillofac Plast
Reconstr Surg. 2015; 37-40.

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6. Terris DJ, Tuffo KM and Fee WE. Modified facelift incision for parotidectomy. J Laryngol Otol.
1994; 108:574-8.
7. Furuta Y, Tsubuku T, Matsumura M. Parotidectomy by U-shaped skin incision for small
benign tumors. J Otol Rhinol. 2015; 4:2.
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8. Kim DY, Park GC, Cho YW and Choi SH. Partial superficial parotidectomy via retroauricular
hairline incision. Clin Exp Otorhinolaryngol. 2014; 7:119-22.
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Figures

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1. Modified Blair incision with an overlay of lazy S-incision. The stippled area is the portion

of the flap prone to pincushioning and occasional necrosis.

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2. Facelift incision
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3. A. U-incision B. Forcep demonstrating depth of access via the incision.

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4. Retroauricular incision
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5. Flap elevation deep to the SMAS and on the parotidomasseteric fascia

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