What is the recommended incision for parotidectomy?

Recommended Incision for Parotidectomy

The modified Blair incision remains the standard approach for parotidectomy, though modified facelift and periauricular incisions are acceptable alternatives for selected benign or small superficial tumors where cosmesis is prioritized and adequate exposure can be achieved.

Standard Approach: Modified Blair Incision

The modified Blair incision is the most commonly used and traditional approach for parotidectomy, providing reliable exposure for all tumor locations and sizes 1, 2. This incision:

• Extends from the preauricular area, curves around the earlobe, and continues into the upper neck 1
• Provides comprehensive exposure for superficial and deep lobe tumors of any size 2
• Is particularly recommended for large deep-lobe tumors, malignancies requiring extensive resection, or when total/subtotal parotidectomy is needed 2, 3
• Allows adequate visualization for facial nerve preservation, which is critical when preoperative facial nerve function is intact 3

The main disadvantage is a visible neck scar, though surgical outcomes including operative time (mean 3.25 hours), complication rates, and facial nerve preservation are excellent 1.

Alternative Cosmetic Approaches

Modified Facelift Incision

The modified facelift incision has gained increasing popularity for benign lesions and provides superior cosmetic outcomes 1, 2, 4:

• Follows natural skin creases in the preauricular and postauricular areas without extending into the neck 1, 2
• Is feasible for most benign parotid lesions regardless of tumor location, including anterior and superior tumors 2
• Provides adequate exposure even for total parotidectomy in selected cases 1
• Results in significantly higher patient satisfaction scores (mean cosmetic score significantly better than Blair incision, p<0.001) 2, 4
• Shows no significant difference in operative time (mean 3.14 hours vs 3.25 hours for Blair, p>0.1), facial nerve injury rates, or other complications 1, 2

Important limitation: For large deep-lobe tumors (particularly >3-4 cm), the modified Blair incision remains preferable due to superior exposure 2.

Periauricular Incision

A periauricular approach is appropriate for smaller superficial tumors 5:

• Provides the smallest scar that does not extend into the neck 5
• Is safe and feasible for most parotid neoplasms with mean tumor diameter around 2.1 cm 5
• Shows no difference in facial nerve injury, hospital stay, or postoperative complications compared to traditional incisions 5
• Best suited for tumors <2.5 cm in the superficial lobe 5

Retroauricular Hairline Incision (RAHI)

The RAHI offers excellent cosmetic results with the scar hidden in the hairline 4:

• Demonstrates superior cosmetic outcomes compared to both facelift and Blair incisions (p<0.001) 4
• Shows no significant differences in operative time, facial nerve paralysis rates, or Frey's syndrome occurrence 4
• Is appropriate for partial superficial parotidectomy in most benign parotid tumors 4

V-Shaped Incision

A newer V-shaped incision using only preauricular and postauricular components shows promise 6:

• Produces excellent cosmetic results (mean VAS score 9/10, Vancouver Scar Scale 0.9) 6
• Mean operative time of 120 minutes with no serious complications 6
• Currently has limited evidence and requires confirmation in larger studies 6

Clinical Decision Algorithm

For malignant tumors or high-grade/advanced (T3-T4) parotid cancers requiring at least superficial parotidectomy: Use modified Blair incision for optimal exposure, as these cases require comprehensive visualization for adequate resection and potential facial nerve management 3.

For benign tumors <2.5 cm in the superficial lobe: Consider periauricular or modified facelift incision for superior cosmetic outcomes 5, 2.

For benign tumors 2.5-4 cm or anterior/superior location: Modified facelift incision is appropriate with equivalent safety 2.

For large deep-lobe tumors (>4 cm) or when total parotidectomy is anticipated: Modified Blair incision provides superior exposure 2.

Critical Surgical Principles Regardless of Incision

• Facial nerve preservation is mandatory when preoperative function is intact and a dissection plane can be created between tumor and nerve 3
• Complete excision with adequate margins is essential, as margin status significantly affects overall survival 7
• For high-grade or advanced parotid cancers, at least superficial parotidectomy with consideration of total/subtotal parotidectomy should be performed due to risk of intraparotid nodal metastases 3