Introduction

The evolution of parotidectomy techniques has prioritized minimizing complications and optimizing aesthetic outcomes while maintaining low recurrence rates [1]. Partial parotidectomy and extracapsular dissection (ECD) have become preferred approaches for treating benign parotid tumors, supplanting more extensive procedures [2, 3]. These advancements have spurred the development of various cosmetic incisional techniques to enhance postoperative aesthetics [1]. However, the feasibility and safety of limited access parotidectomy via a preauricular approach remain uncertain. Utilizing ECD through a preauricular incision with tailored modifications presents a potential solution for addressing benign tumors situated in the anterior or upper regions of the parotid gland. This study aims to assess the feasibility and clinical efficacy of this technique, shedding light on its potential as a viable surgical approach.

Materials and methods

The procedure for ECD via the preauricular approach closely mimics that of limited access parotidectomy [4]. Following preoperative imaging and fine-needle aspiration biopsy, patients are positioned supinely with contralateral head rotation under general anesthesia. A single vertical incision or curvilinear incision superiorly extending to the temporal hairline is precisely made along the skin crease and tragus, with elevation of a skin flap along the outer parotid capsule (Figs. 1 and 2). Incision of the overlying parotid capsule exposes tumors within the gland, with excision of small adjacent parotid tissues adhering to tumor capsules. Careful dissection is undertaken to avoid injury to peripheral branches of the facial nerve, ensuring the preservation of facial nerve integrity, particularly in cases where tumors are close to nerve pathways. Measures are taken to prevent capsule disruption and minimize the potential spread of tumor cells. In cases where lesions near the superficial parotid layer are identifiable, the parotid capsule is incised directly along the facial nerve pathway to expose the lesion. Rigorous assessments are conducted to confirm complete lesion removal and facial nerve integrity. Intraoperative neuromonitoring of the facial nerve was used. Hemostasis is achieved using bipolar bovie and saline solution, followed by meticulous closure of the surgical site using absorbable sutures without drainage. Fibrin sealant is applied, and tissue adhesive is carefully administered over the incision site.

Fig. 1
figure 1

Illustration of parotid pleomorphic adenoma removal via preauricular incision. (A–B) T2-weighted axial MR image, incision, and flap elevation. (C) Tumor excision (asterisk) with facial nerve preservation. (D) Postoperative one-month view

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Fig. 2
figure 2

Depiction of anterior parotid tumor removal via preauricular incision. (A–B) T2-weighted axial MR image, incision, and surgical exposure. (C) Tumor removal (asterisk) with facial nerve preservation (arrows). (D) Postoperative 2nd day view

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External compression is maintained for two days postoperatively before self-removal at home. Patients are discharged either on the day of the procedure or the following day, with a prompt return to their daily activities. Pre- and post-discharge evaluations include a thorough examination of the surgical site, facial nerve function assessment, and pain perception and cosmetic satisfaction using a visual analog scale (VAS). VAS scoring and salivary scintigraphy further assess individual satisfaction and salivary gland performance. This study received approval from the institutional ethics committee.

Results

Eight patients underwent ECD via the preauricular approach, consisting of three male and five female participants aged between 26 and 78 years. All cases presented with benign pathologies, including six pleomorphic adenomas, a basal cell adenoma, and a venous malformation. Tumor sizes ranged with a median of 1.8 cm (1.1–3.4 cm), primarily located anteriorly in five cases and superiorly in three cases. Tumor distribution involved superficial layers in five instances and extended to deeper layers in three cases. According to the classification of parotidectomy proposed by the European Salivary Gland Society [5], two cases were in level I, two in levels I-II, two in levels II-III, one in level II, and one in levels I and IV. The median duration of the procedure was 55 min (42–65 min), with an average blood loss of 25 mL (15–44 mL). None of the patients required extension to the neck or retroauricular region. Notably, there were no documented instances of facial nerve or Stensen’s duct injury. Additionally, no incidents of tumor capsule rupture or spillage were recorded during excision. Histological examination revealed the absence of malignancy within the specimens, with clear resection margins observed in all cases. Patients reported high satisfaction regarding the appearance of the incision scar and facial contour, with median VAS scores of 9 (range: 7–10) and 10 (range: 9–10), respectively. The postoperative secretory function of the affected gland closely mirrored that of the unaffected gland (P > 0.1). Importantly, no cases of recurrence were observed among the eight patients during the median follow-up period of 42 months (range: 24–60 months).

Discussion

Our findings underscore the safety and viability of employing a preauricular incision for ECD in managing benign parotid tumors. Our results demonstrate effective disease control and a notable absence of tumor recurrence during the follow-up period. Existing literature has emphasized conservative approaches to benign parotid tumors, focusing on strategies to preserve maximal parotid tissue [6]. In alignment with prior research, our study reaffirms the importance of preserving facial nerve function, salivary secretion, and cosmetic outcomes while achieving effective local tumor control. This approach offers several advantages, including shorter operative times, decreased blood loss, and reduced rates of facial nerve complications. Additionally, patients experience minimal postoperative discomfort, resulting in shorter hospital stays.

Furthermore, gland-preserving surgery may affect oral health by maintaining parotid gland secretory function [6]. Mastery of this technique may necessitate experience; in some instances, endoscopy may offer additional benefits. It is crucial to acknowledge the potential risks of this approach, including the possibility of facial nerve compromise due to restricted visual fields and the theoretical risk of tumor spillage. Comparative studies comparing this approach with alternative parotidectomy methods are warranted to validate its efficacy further.

The evolution of gland-preserving surgical techniques has been accompanied by a shift towards cosmetic-oriented approaches that selectively expose the parotid gland and adjacent facial nerve [1]. Our study highlights the effectiveness of the preauricular incision approach, which minimizes postoperative complications and preserves salivary function and facial contour. While alternative incisions like the modified Blair, facelift, and retroauricular hairline approaches offer adequate visual fields, they often require longer skin incisions [2, 6]. Despite the perceived limitations of the preauricular approach, meticulous flap elevation provides sufficient visual access for tumor excision. However, caution should be exercised when considering this approach for malignant tumors, and obtaining a preoperative pathological diagnosis is imperative.

The preauricular incision technique is particularly suitable for patients with non-multifocal tumors localized in the anterior or superior parotid gland region. In addition, a single preauricular incision approach can be applied to tumors smaller than 2.5 cm because of the potential limitations of surgical access and visibility. Tumors > 2.5 cm may require the incision extended to the temporal hairline, postauricular sulcus, or neck. For more complex cases involving large tumors, deep lobe locations, or lesions with compromised visibility, alternative approaches with larger incisions may be more appropriate. Our study contributes valuable insights into the functional benefits of the preauricular approach for selective parotid cases, further establishing its merit as a compelling treatment option.

Conclusion

Our investigation substantiates the safety and viability of employing ECD through the preauricular incision for parotid tumors situated in the anterior or superior compartment of the parotid glands. This approach yields favorable outcomes across functional, aesthetic, and disease control domains. Notably, it safeguards facial nerve integrity, preserves salivary function, and enhances aesthetics while minimizing surgical complications and operative durations, thus culminating in exceptional cosmetic outcomes. Based on the findings gleaned from this study, ECD via the preauricular approach emerges as a promising and reliable therapeutic modality for benign parotid tumors, ensuring robust local control without compromising functional integrity.