FNAC – Fine-needle aspiration cytology MRI – magnetic resonance imaging PPS– parapharyngeal space
ABBREVIATIONS
CT – computed tomography
Lifting twarzy w resekcji łagodnych
nowotworów przestrzeni przygardłowej
A Facelift Procedure for Resection of Benign Parapharyngeal
Tumors
Nobuo Ohta
1,2, Kentaro Matsuura
3, Hiroshi Osafune
3, Takahiro Suzuki
1, Naoya Noguchi
1, Ryoto Hirabayashi
1, Shiori
Kitaya
1, Yusuke Kusano
1, Yutaro Saito
1, Rei Kawata
1, Ryoukichi Ikeda
1, Yusuke Ishida
1,4, Hiroki Shimada
5, Keigo
Murakami
5, Kazuhiro Murakami
5, Yasuhiro Nakamura
5, Kota Wada
31Division of Otolaryngology, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
2Department of Otolaryngology, Yamagata City Hospital Saiseikan, Yamagata, Japan
3Department of Otolaryngology, Head and Neck Surgery, Toho University Faculty of Medicine, Tokyo, Japan
4Division of Anatomy and Cell Biology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
5Division of Pathology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
Article history: Received: 21.05.2020 Accepted: 01.06.2020 Published: 01.06.2020
STRESZCZENIE: Cel: Przeanalizowano opcje terapeutyczne, wyniki leczenia, potencjalne ryzyko i powikłania w czasie zabiegu liftingu twarzy u pacjentów z guzami przestrzeni przygardłowej (PPG).
Metody: W retrospektywnej analizie uwzględniono 10 pacjentów poddawanych leczeniu operacyjnemu w naszym ośrodku w okresie od kwietnia 2015 r. do sierpnia 2019 r. z powodu guza PPG z wykorzystaniem cięcia do liftingu.
Wyniki: W badaniu uwzględniono cztery guzy zarylcowate (łagodne nowotwory z osłonek nerwów obwodowych) i sześć guzów przedrylcowatych (gruczolak wielopostaciowy). Średnie wymiary guza wynosiły 4,1 x 4,2 x 3,8 cm. U żadnego pacjenta nie zaistniała potrzeba konwersji do otwartej resekcji. Przejściowe zaburzenia czucia w obrębie płatka pojawiły się u 30% osób, przy czym u wszystkich zmiany wycofały się w ciągu czterech miesięcy. U pacjentów ranę pooperacyjną całkowicie zakrywała małżowina uszna i włosy. Nie obserwowano wznowy w okresie obserwacji przez średnio 16,6 miesięcy.
Wnioski: Lifting twarzy zapewnia dobre uwidocznienie guza, właściwe pole operacyjne i doskonałe efekty kosmetyczne u wybranych chorych.
SŁOWA KLUCZOWE: lifting twarzy, nowotwory przestrzeni przygardłowej
ABSTRACT: Objective: The feasibility, surgical outcomes and possible risks and complications encountered during a facelift procedure for patients with parapharyngeal space (PPS) tumor were analyzed.
Method: This retrospective analysis examined 10 patients who underwent surgery for PPS tumor using a facelift incision at our institutes between April 2015 and August 2019.
Results: This study included four retro-styloid (benign nerve sheath tumor) and six pre-styloid tumors (pleomorphic adenoma). Mean tumor dimensions were 4.1 x 4.2 x 3.8 cm respectively. None of the patients needed conversion to conventional open resection. Transient sensory changes in the auricle occurred in 30%
of the patients; however, all recovered within four months. In all the patients, postoperative scars were fully concealed by the auricle and hair. No recurrences were detected during a mean follow-up period of 16.6 months.
Conclusion: The facelift procedure provides adequate visualization, workspace and excellent cosmetic results in properly selected cases.
KEYWORDS: facelift procedure, parapharyngeal tumor
INTRODUCTION
Although parapharyngeal space (PPS) tumors are rare and account for only 0.5% of head and neck neoplasms, various surgical pro- cedures for PPS tumors have been described in response to histo- pathological diagnosis (benign or malignant), location (prestyloid or poststyloid) and tumor size [1, 2].
Various surgical procedures, including transcervical, transcervical- transparotid, transcervical-transmandibular, transoral, and tran- soral robotic surgery have been performed in patients with PPS tumors [1–3]. Postoperative scars on visible parts cause aesthetic problems for PPS tumor patients after surgery.
Our facelift procedure is conducted using a retro-auricular inci- sion and positioning the cut close to the hairline to disguise the most visible part of the scar and thus has the potential to improve aesthetic outcomes [4, 5]. However, the role of facelift procedures in the resection of PPS tumors has not previously been reported on. This prompted us to analyze the feasibility, surgical outcomes and possible risks and complications encountered during facelift procedures for patients with such tumors.
METHODS
This study is a retrospective review of the clinical records of 10 patients (5 male, 5 female, mean age 47.3 years), treated for PPS tumors using the facelift procedure from April 2015 to August 2019. In all cases, magnetic resonance imaging (MRI) and com- puted tomography (CT) were conducted to confirm the mass site and size, its relationship with the surrounding vessels and nerves, and the nature of the tumors before surgery. Fine-needle aspira- tion cytology (FNAC) for pathological diagnosis was conducted in all cases before surgery at least once. For esthetic reasons, the facelift procedure, using a retro-auricular incision and positioning the cut close to the hairline to disguise the most visible part of the scar was applied. All operations were carried out under general anesthesia with the patient in a supine position. This study was approved by the Institutional Review Board.
RESULTS
The clinical characteristics of the patients are summarized in Tab. I. This study included four retro-styloid (benign nerve sheath
Age (years) 48.3 (28–67)
Sex male:female / 5:5
Mean size of tumor (cm) 4.1 × 4.2 × 3.8
Site of tumor Pre-styloid Retro-styloid
64
Pathology Schwannoma Pleomorphic adenoma
46
Follow up (months) 16.6 (4–72)
Tab. II. Surgical outcomes and complications (n = 10).
Operating time (min) 148 (82–201)
Bleeding (mL) 21 (15–46)
Drain out (days) 3.4 (3–5)
Surgical complications X
VII Auricle
11 3
Post-operative scar Noticeable Hidden or invisible
010
Recurrence
X: cranial nerve X palsy
VII; temporary marginal mandibular or facial nerve dysfunction 0 Auricle: transient sensory changes
in the auricle
Fig. 1. A 52-year-old woman with left PPS tumor. (A) Preoperative enhanced-computed tomography findings show a heterogeneously enhancing mass with mixed densities measuring about 4.6 x 4.6 cm in the PPS; (B) Preoperative T1-weighted MRI findings show a homogeneous mass in the PPS; (C) Preoperative T2-weighted MRI findings show a heterogeneous mass with mixed intensities in the PPS; (D) The skin incision for the facelift procedure was begun with a retro-auricular incision, positioning the cut close to the hairline; (E) Intraoperative view after elevation of the skin flap, broadly exposing the superficial muscular aponeurotic system; (F) Intraoperative view of the protruding mass from the PPS; (G) Postoperative view showing preoperative shaving of retro-auricular hair (arrow), continuous vacuum drainage (arrow), and wound closure with a stapler (arrow); (H) The clearly demarcated, hard and elastic specimen with a diameter of about 5.0 x 3.9 x 3.8 cm; (I) Histological section showing the tumor to be composed predominantly of spindle cells, many of which were large and stained darkly. A diagnosis of schwannoma was eventually made (HE, original magnification ×400);
(J) Postoperative scar at six months was invisible.
tumor) and six pre-styloid tumors (pleomorphic adenoma). Mean tu- mor dimensions were 4.1 x 4.2 x 3.8 cm, with the largest antero-poste- rior, medial-lateral and cranio-caudal dimensions being 5.2 x 6.1 x 6.2 cm, respectively. FNAC allowed a definitive diagnosis before surgery.
A facelift procedure was applied to all cases. No patient need- ed conversion to conventional open resection and no patient required the use of an endoscopic device to guarantee safe resection for reasons of limited surgical view. Post-operative complications occurred in 4/10 patients: three developed tran- sient sensory changes in the auricle and one patient presented a temporary marginal mandibular facial nerve branch dysfunc- tion, but spontaneously recovered within four months (Tab. II.).
One patient developed X nerve palsy due to damage sustained during resection and is being followed up. In all the patients, the postoperative scars were invisible due to concealment by the auri- cle and hair. No recurrences were detected during a mean follow- up period of 16.6 months. Two representative cases are presented in Fig. 1. and Fig. 2.
DISCUSSION
Surgical removal is the best treatment for PPT; however, owing to the complex anatomy of the PPS, which is close to many vital or- gans such as the internal carotid artery, the internal jugular vein,
E
H I J
F G
D
C
B
A
the IX, X, XI and XII cranial nerves, and the sympathetic nerve, a range of surgical resection techniques has been applied to en- sure safety and clear visualization during surgery. These surgical resection techniques are classified as transcervical, transcervi- cal-transparotid, transcervical-transmandibular, transoral, and transoral robotic surgery, and the optimal choice depends on ac- curate information on mass size and location, its relationship with the surrounding vessels and nerves, and its nature [1–5].
An accurate diagnosis is essential for planning the best surgical procedure to ensure safe and radical removal of PPS tumors. For this purpose, MRI and CT were performed and the lesions were detected in all cases. FNAC was also conducted in all cases.
It is reported that the facelift procedure using a retro-auricu- lar incision and positioning the cut close to the hairline to dis- guise the most visible part of the scar can improve the aesthetic Fig. 2. A 68-year old woman with right PPS tumor. (A) Preoperative axial enhanced-computed tomography findings show a heterogeneously enhancing mass with mixed densities measuring about 3.1 x 3 cm in the PPS; (B) Preoperative coronal enhanced-computed tomography findings show a heterogeneously enhancing mass with mixed densities measuring about 3.1 x 3 cm in the PPS; (C) Preoperative T1-weighted MRI findings show a homogeneous mass in the PPS; (D) Preoperative T2-weighted MRI findings show a heterogeneous mass with mixed intensities in the PPS; (E) The skin incision for the facelift procedure was begun with a retro-auricular incision, positioning the cut close to the hairline; (F) Intraoperative view after elevation of the skin flap, broadly exposing the superficial muscular aponeurotic system. Intraoperative view of the mass protruding from the PPS; (G) The well-demarcated, rubbery specimen with a diameter of about 3.4 x 2.7 x 3 cm; (I) Histological section showing the tumor to be composed predominantly of round and spindle cells. Many of these cells were small and large and stained lightly. A diagnosis of pleomorphic adenoma was made (HE, original magnification x 400); (J) Postoperative scar at 6 months was prominent, however, could be hidden by the auricle and hair.
H I
E F
D
G
C
B
A
outcome [4–10]. In this study, we analyzed the feasibility, surgi- cal outcomes and possible risks and complications encountered during the facelift procedure for patients with PPS tumors. Use of the facelift procedure for resecting PPS tumors allows identifica- tion and preservation of the facial nerve, the external and internal carotid arteries, the internal jugular vein, cranial nerves IX, X, XI, and XII, and the sympathetic nerve.
The PPS could be retracted to create sufficient working space to perform digital dissection of parotid deep lobe tumors by gently separating them from the adhesive fibrous surrounding tissues. Most parotid deep lobe tumors in the PPS can be removed using the facelift procedure, and it is particularly effective for small tumors. However, other surgical mo- dalities should be selected if a large mass, firmly-attached tumors, or cases of suspected malignancy are discovered.
In all cases, the postoperative scars were fully and satisfactorily concealed by the auricle and hair. This facelift procedure for be- nign PPS tumors was able to provide favorable results with respect to postoperative scarring.
The results of personal experience in the surgical management of PPS tumors confirm that careful preoperative shaving of retro-auricular hair, continuous vacuum drainage, wound closure with a stapler and appropriate dressing are mandatory to reduce surgical complications, aesthetic-functional damage and the risk of recurrence (Fig. 1.).
The facelift procedure for resecting benign PPS tumors thus pro- vides adequate visualization and working space and excellent cos- metic results in properly selected cases.
REFERENCES
1. Poletti A.M., Dubey S.P., Colombo G., Cugini G.: Surgical management of para- pharyngeal space tumors: The role of cervical and lateral skull base procedures.
Ear Nose Throat J., 2016; 95(12): E1-E6.
2. Bootz F., Greschus S., van Bremen T.: Diagnosis and treatment of parapharyngeal space tumors. HNO., 2016; 64(11): 815–821.
3. Ahmad F., Waqar-uddin, Khan M.Y., Khawar A., Bangush W. et al.: Management of parapharyngeal space tumours. J Coll Physicians Surg Pak, 2006; 16: 7–10.
4. Derby B.M., Codner M.A.: Evidence-Based Medicine: Face Lift. Plast Reconstr Surg., 2017; 139(1): 151e-167e.
5. Liu H., Li Y., Dai X.: Modified face-lift procedure combined with a superficially an- terior and superior-based sternocleidomastoid muscle flap in total parotidectomy.
Oral Surg Oral Med Oral Pathol Oral Radiol., 2012; 113(5): 593–599.
6. Lee H.S., Kim D., Lee S.Y., Byeon H.K., Kim W.S. et al.: Robot-assisted versus endoscopic submandibular gland resection via retroauricular procedure: a pro- spective nonrandomized study. Br J Oral Maxillofac Surg., 2014; 52(2): 179–184.
7. Wan D., Dayan E., Rohrich R.J.: Safety and Adjuncts in Face Lifting. Plast Reconstr Surg., 2019; 144(3): 471e-484e.
8. Rivera T., Rodríguez M., Pulido N., García-Alcántara F., Sanz L.: Current indi- cations for the osteoplastic flap. Acta Otorrinolaringol Esp., 2016; 67(1): 33–39.
9. Park J.O.: Facelift Approach for Resecting Benign Upper Neck Masses. World J Surg., 2017; 41(6): 1488–1493.
10. Park J.O., Kim S.Y., Chun B.J., Joo Y.H., Cho K.J. et al.: Endoscope-assisted face- lift thyroid surgery: an initial experience using a new endoscopic technique. Surg Endosc., 2015; 29(6): 1469–1475.
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Dr Nobuo Ohta; Division of Otolaryngology, Tohoku Medical and Pharmaceutical University Hospital, 1-12-1, Fukumuro, Miyaginoku, Sendai 983-8512, Japan; tel.: +81 22 259 1221; e-mail: noohta@hosp.tohoku-mpu.ac.jp
Ohta N., Matsuura K., Osafune H., Suzuki T., Noguchi N., Hirabayashi R., Kitaya S., Kusano Y., Saito Y., Kawata R., Ikeda R., Ishida J., Shimada H., Murakami K., Murakami K., Nakamura Y., Wada K.: A Facelift Procedure for Resection of Benign Parapharyngeal Tumors; Otolaryngol Pol, 2021: 75 (3): 28-32
