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��ࡱ�>��	z|����y��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	�R�U�bjbj��;�r�r�>0*���������+++++����???8w�$?x/������!!!�.�.�.�.�.�.�.$2��4F�.9+!!!!!�.++��T2/999!,+�+��.9!�.999������o��������Mv9�.H/0x/95�v599�5+�*�!!9!!!!!�.�.9!!!x/!!!!��������������������������������������������������������������������5!!!!!!!!!�+�:	Parotidectomy by U-shaped skin incision for small benign tumors

Yasushi Furuta, Takashi Tsubuku, Michiya Matsumura

Department of Otolaryngology-Head & Neck Surgery, Teine-Keijinkai Hospital, Sapporo, Japan


Running title: U incision for parotidectomy
Financial support: None.
The authors declare that they have no conflicts of interest.

Correspondence to: Yasushi Furuta, MD, Department of Otolaryngology-Head & Neck Surgery, Teine-Keijinkai Hospital, 1-12 Maeda, Teine-ku, Sapporo 006-8555, Japan. 
Tel: +81-11-681-8111; Fax: +81-11-685-2998; E-mail: yasushifuruta@nifty.com 
ABSTRACT
Objectives: The facelift incision has been used as a more cosmetically favorable alternative to the traditional cervicofacial, S-shaped incision for parotidectomy. However, the facelift incision has the disadvantage of requiring a long skin incision and wide skin-flap elevation. As an alternative, we analyzed the application and safety of a more limited U-shaped skin incision for parotidectomy.
Methods: A U-shaped incision, consisting of pre- and post-auricular incisions and a curved incision around the earlobe, was applied in 28 female patients. Their tumors were located in the superficial region of the parotid gland except one patient with a deep lobe tumor. Maximum diameter of the tumor was <3 cm. As a control, 18 patients with a S-shaped incision, who had superficial tumors <3 cm in diameter, were selected. Operative time and postoperative complications were retrospectively compared between the two incision approaches.
Results: No significant difference in operative time was observed between U-shaped incision and S-shaped incision. The frequencies of temporal facial paralysis and salivary fistula were comparable between the two surgical methods. 
Conclusion: The U-shaped incision approach is feasible for parotidectomy in patients with small (<3 cm) benign tumors located in the superficial region of the parotid gland.

Key Words: cosmetic approach, facelift incision, parotidectomy, U-shaped skin incision
Introduction
The facelift incision (FLI) has been reported to offer a more cosmetically favorable alternative to the traditional cervicofacial, lazy S-shaped incision (the Blair incision) for parotidectomy [1, 2]. A systematical review showed that complication rates were not increased with the FLI [2]. However, this necessitates a long skin incision and wide skin-flap elevation, prolonging the operative time. To overcome these disadvantages, we have employed a U-shaped skin incision (UI) for selected cases, with the skin incision and flap elevation limited to around the earlobe. The present study analyzed the feasibility and safety of the UI for parotidectomy.

Patients and methods 
Patients
Between January 2009 and December 2013, 111 parotidectomies were performed for benign parotid tumors in 60 male patients and 51 female patients at Teine Keijinkai Hospital (Sapporo, Japan). In 51 female patients, an FLI (n=20) or UI (n=28) was used as the cosmetic approach depending on the size and location of the tumor as evaluated by pre-operative ultrasonography and magnetic resonance imaging (MRI). When tumors were predicted to be located in the superficial region of the parotid gland and the maximum diameter of the tumor was <3 cm, the UI was applied. An S-shaped Blair incision (SI) was used in the remaining 63 patients (60 males, 3 females). We did not propose a cosmetic incision to male patients during this study periods. The three female patients did not choose a cosmetic incision after providing informed consent.

Surgical procedures
All surgical procedures were carried out under general anesthesia. The UI consisted of a pre- and post-auricular incision (Figure 1a) that usually started and ended at the upper level of the tragus. After the skin incision was completed, the skin flap was elevated superficial to the superficial muscular aponeurotic system anteriorly, caudally, and posteriorly to gain adequate access for tumor removal (Figure 1b). The posterior border of the parotid gland was dissected from the auditory canal, and the anterior border of the sternocleidomastoid muscle was identified and separated from the tail of the parotid gland. The main trunk of the facial nerve was identified using the cartilage pointer of the auditory canal and the posterior belly of the digastric muscle as anatomic landmarks (Figure 1c). Because the tail of the parotid gland is separated from the anterior border of the sternocleidomastoid muscle only 1-2 cm from the muscle attachment to the mastoid process, the main trunk of the facial nerve could be identified under a narrow and deep operative field (Figure 1c). We used an intraoperative nerve stimulator (VARI-STIM III; Medtronic Xomed, Jacksonville, FL) during the procedure. After identification of the main trunk of the facial nerve, part of the parotid gland surrounding the tumor was resected using a Harmonic Focus� (Ethicon Endo-Surgery, Cincinnati, OH) and a bipolar electrode probe (Figure 1d). A monopolar electrocoagulation probe was not used during exposure of the facial nerve and dissection of the parotid gland. After removal of the tumor and confirmation of hemostasis, a vacuum drain or Penrose drain was inserted and the wound was closed (Figure 1e). A representative post-operative photograph is shown in Figure 2.
All parotidectomies were performed by attending surgeons under supervision by Y.F. Informed consent was obtained from all patients, and the study protocol was approved by the institutional ethics committee.

Analysis
Tumor location (superficial or deep) and maximum diameter, operative time, and postoperative complications were retrospectively analyzed. Tumors located shallower and deeper than the facial nerve were categorized as superficial and deep tumors, respectively. Tumors located inferior to the mandibular branch of the facial nerve were classified as superficial tumors. Maximum tumor diameter was measured by ultrasonography or MRI. Statistical analyses were performed using EZR statistical software [3]. Fisher�s exact test and the Mann-Whitney U test were used to calculate the significance of any correlations between variables. Values of p<0.05 were considered statistically significant.

Results
Tumors were located in the superficial region of the parotid gland in all but one patient who underwent UI. By contrast, 45 of 63 (71%) patients with SI and 10 of 20 (50%) patients with FLI had a tumor in the superficial region (Table I). Maximum diameter of the tumor was <3 cm in all patients with UI, consistent with the indication for the surgical method. Two patients underwent FLI even though the tumor was located in the superficial region and <3 cm. In one of those two patients, the operative approach was altered from UI to FLI during surgery to obtain adequate exposure. The other case was considered to involve a deep lobe tumor preoperatively. 
Next, operative time and postoperative complications were retrospectively compared between patients with a UI and a SI. Maximum diameter of the superficial tumor was <3 cm in 18 of the 45 patients with SI (Table I) and these18 patients were selected as a control. No significant difference in operative time was observed between patients with UI (range, 75-239 min; median, 112 min) and those with SI (range, 75-210 min; median, 127 min; p=0.32, Mann-Whitney U test). Postoperative facial nerve paralysis was observed in 4 of the 28 patients (14%) with UI and in 2 of the 18 (11%) with SI. The difference in the incidence of postoperative facial nerve paralysis was not significant (p=0.99, Fisher exact test). In all patients, facial nerve paralysis was temporary and no permanent paralysis was observed. The incidence of salivary fistula was comparable between two approaches (3.6% in the UI, 5.6% in the SI). Postoperative hematoma was observed in one patient with SI, but in none of the patients with UI.

Discussion 
Several methods have been described for improving cosmetic outcomes after parotidectomy, including the facelift approach, the periauricular incision, the endoscopic approach, fat-graft interposition, and the superficial musculoaponeurotic system flap [1,2, 4-8]. Petroianu [4] reported treating 41 patients for benign parotid diseases using periauricular incisions alone, in a method similar to the UI. However, that report lacked the details on the application of the approach. The present study showed that UI is feasible for parotidectomies in patients with small (maximum diameter, <3 cm) benign tumors within the superficial region of the parotid gland. One disadvantage of the FLI approach is that it requires a long skin incision and wide skin-flap elevation, prolonging the operative time. In the present series, no significant difference in operative time was observed for patients receiving UI compared with those undergoing SI. 
The frequencies of postoperative facial paralysis and salivary fistula were comparable in both UI and SI. We observed no hematoma in patients who underwent UI. In all cases, tumors were resected completely and no recurrences have been encountered as of the time of writing, suggesting that UI does not increase the risk of complications. As surgical exposure and subsequent complications are independent of the sex of the patient, we now plan to apply the UI to male patients.
To obtain an appropriate operative field for UI, the skin flap is elevated through a small skin incision. Appropriate tractions of the skin flap by the first assistant are important. However, exposing tumors located in the inferior or anterior part of the parotid gland is more difficult for UI. For inferior locations, the pre-auricular incision can be extended more cranially to allow good exposure of the operative field under the skin flap, but removal of tumors at the anterior part of the parotid gland is not always possible using UI alone, so the omega-incision modification approach [7] can be applied. Contraindications for the UI approach are large (e"3 cm) tumors, those located in the deep lobe, and malignancy. However, the approach can be changed from UI to FLI during surgery. In the present study, this was necessary for 1 patient to obtain adequate exposure. 
One disadvantage of the UI is that the main trunk of the facial nerve must be identified under a narrow and deep operative field. In the present series, the incidence of postoperative facial nerve paralysis was 14% in patients with UI, comparable to that in SI patients and with other reports [9]. Although no permanent paralysis was observed with the UI, it is essential that this technique be performed by skilled surgeons with sufficient parotidectomy experience via the traditional Blair incision. 

CONCLUSION
The UI approach is feasible for parotidectomy in patients with small (<3 cm) benign tumors located in the superficial region of the parotid gland. UI does not appear to increase the risk of complications.

The authors declare that they have no conflicts of interest.

REFERENCES
1. Hagan WE, Anderson JR. (1980) Rhytidectomy techniques utilized for benign parotid surgery. Laryngoscope 90:711-715.
2. Grover N, D'Souza A. (2013) Facelift approach for parotidectomy: an evolving aesthetic technique. Otolaryngol Head Neck Surg 148:548-556.
3. Kanda Y (2013) Investigation of the freely available easy-to-use software �EZR� for medical statistics. Bone Marrow Transplant 48:452-458.
4. Petroianu A (2012) Parotidectomy by periauricular incision. Otolaryngol Head Neck Surg 146: 247-249.
5. Lin SD, Tsai CC, Lai CS, Lee SS, Chang KP (2000) Endoscope-assisted parotidectomy for benign parotid tumors. Ann Plast Surg 45:269�273. 
6. Curry JM, Fisher KW, Heffelfinger RN, Rosen MR, Keane WM, et al. (2008) Superficial musculoaponeurotic system elevation and fat graft reconstruction after superficial parotidectomy. Laryngoscope 118:210�215.
7. H�nig JF (2005) Omega incision face-lift approach and SMAS rotation advancement flap in parotidectomy for prevention of contour deficiency and conspicuous scars affecting the neck. Int J Oral Maxillofac Surg 34:612�618.
8. Arden RL, Miguel GS (2011) Aesthetic parotid surgery: evolution of a technique. Laryngoscope 121:2581�2585.
9. Koch M, Zenk J, Iro H (2010) Long-term results of morbidity after parotid gland surgery in ben'?@AOPQ`astu���������������{l^O="h}%�hNBDCJH*OJQJaJo(hNBDCJOJPJQJaJo(hc�CJOJPJQJaJh�(~CJOJPJQJaJo(h�(~CJOJPJQJaJh21�h�(~CJOJQJaJo(h�(~CJOJQJaJo(hc�CJOJQJaJo(h�(~CJOJQJaJh]HthNBDCJOJQJaJ"h]HthNBD5�CJOJQJ\�aJh�	x5�CJOJQJ\�aJh�	x5�CJOJQJ\�aJo(@Atu����	T	U	�	E
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