American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 533–536

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American Journal of Otolaryngology–Head and Neck

Medicine and Surgery
journal homepage: www.elsevier.com/locate/amjoto

Retrograde Parotidectomy and facial nerve outcomes: A case series of

44 patients☆
Maxwell P. Kligerman a,⁎, Yohan Song b, David Schoppy b, Vasu Divi b, Uchechukwu C. Megwalu b,
Bruce H. Haughey c,d, Davud Sirjani b
a
Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305
b
Department of Otolaryngology/Head and Neck Surgery, Stanford University, 801 Welch Rd, Stanford, CA 94305
c
Department of Surgery, University of Auckland, 2 Park Road, Grafton 1023, Auckland, New Zealand
d
Florida Hospital Celebration Health, 400 Celebration Pl, Kissimmee, FL 34747

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The most common surgical method to remove benign parotid tumors remains the prograde approach. We
Received 14 March 2017 examined if a retrograde surgical technique offers better outcomes than historical prograde controls.
Materials and methods: A retrospective chart review at Stanford Hospital was conducted to identify retrograde
Keywords: parotidectomies between February 2012 and October 2014 that were staffed by the senior author (DS) with res-
Parotidectomy ident involvement. Facial nerve (FN) outcomes and other post-surgical parameters were recorded.
Retrograde Parotidectomy
Results: We identified 44 consecutive cases and found that 18.2% (n=8) of patients experienced temporary paresis
Pleomorphic adenoma
Facial nerve
and 2.3% (n=1) experienced minor (HB 2) permanent paresis limited to one branch. The average hospital length
Parotid mass of stay was 0.64 days and complication rate was 6.8%.
Conclusion: The retrograde technique has complication rates comparable to historical rates for the prograde tech-
nique and is amenable to minimally invasive outpatient superficial parotidectomy.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
The goal of a parotidectomy for benign and low-grade malignant tu-
mors is to remove diseased parotid tissue while preserving facial nerve
(FN) function. Given the course of the FN through the parotid gland,
the surgeon usually must dissect and identify the FN prior to parotid re-
moval. This dissection can take place in one of two ways. In the prograde
technique, the FN trunk is visually identified then followed distally to lo-
cate its peripheral branches. The majority of Otolaryngologists-Head and
Neck Surgeons utilize this technique [1]. The alternative method is the
retrograde surgical technique wherein the peripheral branches of the
FN are identified first and then dissected posteriorly to the main trunk.
Although the retrograde technique is employed in fewer than 5% of
parotidectomy cases for benign disease [1], recent studies suggest it
may have specific advantages, including smaller incisions, decreased fa-
cial hollowing due to less removal of healthy parotid tissue, shorter oper-
ative times, and improved facial nerve outcomes [2,3].
Studies detailing outcomes with the retrograde technique are still
sparse and based on relatively small case series. We present one of the
☆ Previous Presentations: American Academy of Otolaryngology – Head and Neck
Surgery 2015 Meeting; Dallas, Texas. September 30, 2015.
⁎ Corresponding author at: Welch RD., 2nd FL., Stanford, CA 94305-5739.
E-mail address: maxwell3@stanford.edu (M.P. Kligerman).
largest case series to date for retrograde parotidectomies staffed by a sin-
gle surgeon in the United States. The aim of this study was to evaluate
outcomes associated with the retrograde technique and compare these
to historically published outcomes for the prograde technique.
2. Materials and methods
2.1. Chart selection
Charts of patients who underwent parotidectomies that were staffed
by a single surgeon (DS), using retrograde facial nerve dissection tech-
nique were reviewed. Patients who underwent primary parotidectomy
for benign conditions and low-grade malignancy (acinic cell carcinoma
and low-grade mucoepidermoid carcinoma) between February 2012
and October 2014 were included. Revision surgeries were excluded as
the majority of revision cases were performed using a mixed retro-pro-
grade approach in order to minimize tension injury to the FN. All patients
included in this study received imaging to confirm unifocal disease and
preoperative fine needle aspiration (FNA) to ensure benign or low-
grade cytology. Malignant processes (with the exception of acinic cell
carcinoma and low grade mucoepidermoid carcinoma given their non-
aggressive behavior) were not included in this study as gross perineural
invasion may require FN sacrifice and skew an accurate representation of
the surgical technique. Our study was approved by the Stanford IRB.

http://dx.doi.org/10.1016/j.amjoto.2017.05.003
0196-0709/© 2017 Elsevier Inc. All rights reserved.

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534 M.P. Kligerman et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 533–536

2.2. Surgical technique
We started each operation with a modified Blair Incision. Sub
platysmal and sub superficial muscular aponeurotic system (SMAS)
flaps were then elevated anteriorly and posteriorly to allow for identifi-
cation and preservation of the posterior branch of the great auricular
nerve. In cases of superficial pleomorphic adenomas, we also resected a
cuff of the overlying SMAS for adequate lateral margins. In cases where
the tumor resided in the inferior parotid gland, we first identified a pe-
ripheral branch of the FN by dissecting perpendicular to the angle of
the mandible (Figs. 1a, 1b). For disease processes that limited access to
the angle of the mandible, the dissection was started anterior to the loca-
tion of abnormal tissue at the inferior mandibular body. We dissected in
thin broad translucent layers and divided the tissue using bipolar cau-
tery. An intraoperative FN monitor with commercially available electro-
myography units (2–4 leads) was used in all cases. The nerve stimulator
was used to identify the peripheral branches and ensure that the most
inferior branch had been identified. Once all the peripheral branches
within the planned resection area were identified, each branch was dis-
sected in a retrograde manner to the pes and main trunk, often peeling
the tumor from at least one branch and splitting the normal parotid
gland above the most superiorly dissected branch (Fig. 1c). At the inter-
face of the tumor with the nerve, additional deep lobe parotid gland tis-
sue was resected for margins (Fig. 1d). Cases requiring superficial
parotidectomy were performed with the intent to provide greater than
one cm margins and preservation of the parotid duct. In those cases of
a deep lobe tumor or those requiring resection of the duct, a total
parotidectomy was performed. For most cases we performed a retro-
grade dissection of at least two peripheral branches of the FN. All retrac-
tion was performed by self-retaining elastic stays with blunt hooks
preset to the minimum required tension (traditional army-navy, Sewall,
or spoon retractors were not used). All cases were performed by a team
consisting of the attending surgeon (DS) and at least one resident sur-
geon. Neither loops nor magnification were used.
Indications for admission included intraoperative use of pressors, ad-
vanced age with significant cardiopulmonary comorbidities, inadequate
social support, long travel distance to home, or patient preference. All pa-
tients were discharged with a drain to be removed no sooner than post-
operative day two with output of less than 15cm3 over 24 h.
2.3. Outcome measures
The primary outcome assessed was FN outcome at one month and
one year or more. FN outcomes were recorded in the chart by percent
of estimated deficit per branch and then converted to the corresponding
House-Brackmann (HB) score. FN weakness was defined as paresis to
any branch of the FN noticed by a resident, nurse, the patient, or the at-
tending physician during follow-up visit. We also assessed the chart for
parotidectomy type (superficial vs total), pathology diagnosis, tumor
size, surgical time, estimated blood loss, complications, length of hospital
stay, duration of postoperative drain, and excised tissue volume. We cal-
culated tumor volume and excised tissue volume using the pathologist's
measurements of the excised specimen.

Fig. 1. Retrograde Parotidectomy Dissection and Excision Technique Caption: Figures 1a and 1b demonstrate the dissection technique for retrograde parotidectomy. Note the dissection
occurs perpendicular to the angle of the mandible to identify and trace the peripheral branches of the FN. Figure 1c demonstrates splitting the normal parotid gland above the most
superiorly dissected branch once all of the peripheral branches within the planned resection have been identified. Figure 1d demonstrates tumor excision. All images show a nasally
intubated patient. Figures illustrated by Chris Gralapp.

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 M.P. Kligerman et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 533–536 535

Table 1 patients experienced weakness of the main trunk of the FN, and there
FN outcomes at one month. were no sialocele complications. This represents one of the largest case
Superficial Parotidectomy Total Parotidectomy Total series to date for retrograde parotidectomies and adds to the growing
HB1 34 2 36 (81.8%)
body of literature comparing the prograde and retrograde techniques.
HB2 5 2 7 (15.9%) The FN outcomes found in this study correspond with the historic
HB3 – – – range of values from the literature for both the retrograde and prograde
HB4 – 1 1 (2.3%) techniques. Studies of the prograde technique for benign disease suggest
Total 39 5 44
a temporary FN paresis rate that ranges from 10 to 68% and a permanent
paresis rate that ranges from 0 to 19% [4,5]. Prior studies assessing the
retrograde technique have found rates of temporary paresis ranging
3. Results from 14.4–26.6% and permanent paresis rates from 0 to 1.4% [6,7,8,9,
10]. Prior studies of superficial parotidectomies have found sialocele
3.1. Patient demographics and diagnoses rates as high as 39% [11,12].
A review of the literature demonstrates that in small head to head
A total of 94 parotidectomies were identified during this time period, of comparisons of the retrograde and prograde techniques, the retrograde
which 44 met our study qualifications as non-revision retrograde technique offers either equivalent or improved facial nerve and second-
parotidectomies for benign or low-grade disease with resident involve- ary outcomes. Furusaka et al., for instance, compared 90 retrograde
ment. This included 29 women and 15 men with an average age of parotidectomeis to 100 prograde controls. Not only did retrograde
52.2 years. Our series included 24 pleomorphic adenomas, 7 Warthin's tu- cases have significantly improved facial nerve outcomes but they also
mors, 4 basal cell adenomas, 2 acinic cell carcinomas, 2 low-grade required less operative time and resulted in less intraoperative blood
mucoepidermoid carcinomas, and 5 other miscellaneous benign diagnoses. loss as compared to prograde controls [2]. Retrospective chart reviews
comparing retrograde parotidectomies to historic prograde controls
3.2. Surgical technique and outcomes for the retrograde Parotidectomy from both Emodi et al. and Bhattacharrya et al. find similar results of im-
cohort proved operative time, decreased intraoperative blood loss, less healthy
parotid tissue removed, and improved FN outcomes [3,6]. O′Regan et al.
In our series, 86.4% (n = 38) of cases were superficial has performed the first and only randomized trial comparing the two
parotidectomies and 12.8% (n = 5) were total parotidectomies. The techniques to date [13]. In their cohort of 40 patients they found that pa-
mean operative time was 167.3 min (± 76.9), mean blood loss was tients randomized to the prograde arm had more severe temporary HB
28 ml (± 33.1), mean tumor size was 2.56 cm (± 1.24), and mean deficits but recovered more quickly than retrograde counterparts. No
tumor volume on average constituted 33% of the total excised tissue vol- head to head comparisons have yet shown the retorgade technique to
ume. The mean hospital length of stay was 0.64 days (±0.63), and the perform inferiorly [7].
mean duration of postoperative drains was 4.7 days (±2.8). Outpatient We attribute the comparable rate of FN weakness in our study to sev-
surgeries constituted 39% (n = 17) of all cases. The total wound compli- eral factors. First, the retrograde technique relies less on manipulation of
cation rate was 6.8% (n = 3), including two cases of cellulitis and one the main trunk than its prograde counterpart, possibly reducing rates of
seroma. There were no complications in the outpatient surgery group. global paresis. While few studies have distinguished between paresis of
Analysis of FN outcomes within one month of the operation the main trunk of the FN versus its subsidiary branches, one study by
revealed 81.8% (n = 36) of cases as HB1, 15.9% (n = 7) as HB2, 0% Laccourreye et al. did identify a 5.6% temporary paresis rate of the main
as HB3, 2.3% (n = 1) as HB4, and no HB5 (Table 1). Overall, 18.2% trunk in a cohort of 229 prograde parotidectomy patients [4]. Our
(n = 8) of patients experienced some degree of acute, temporary study found no temporary or permanent main trunk paresis associated
FN paresis, all of which were limited to two or fewer branches of with the retrograde technique. Next, we believe that the retrograde tech-
the FN. One case of temporary paresis involved the zygomatic nique offers improved visibility for both the attending and resident sur-
branch, while the remainder of cases involved the marginal branch. geons due to the superficial position of the nerve in the distal segments.
Superficial parotidectomies had an overall 13.6% (n = 5) temporary The prograde technique, on the other hand, requires identification of the
paresis rate (none greater than HB2). No patient sustained tempo- nerve in a trough and has a surgical field that is obstructed by the ear
rary or permanent injury to the main trunk of the FN. posteriorly and preauricular parotid tissue anteriorly. We also hypothe-
Analysis of FN outcomes one year after the operation revealed 97.7% size that the retrograde technique may result in less traction injury to
(n = 43) of cases as HB1, 2.3% (n = 1) as HB2, and no patients were HB3 the main trunk because the superficial access and improved view en-
or above (Table 2). The permanent paresis in a single patient resulted ables blunt elastic hooks to be used in place of army-navy retractors.
from a superficial parotidectomy and was HB2 limited to the marginal This reduced retraction, we hypothesize, results in less traction injury
branch. on the nerve. The retrograde technique has also been shown to be ame-
nable to minimally invasive partial parotid surgery [6,14], which allows
4. Discussion most of the main trunk to remain undisturbed. The excess of normal
healthy tissue removed in this study suggests that adequate resections
Forty-four retrograde parotidectomy cases were identified as part of were still performed, and recent analyses of partial parotidectomies
this study, of which 18.2% (n = 8) resulted in temporary paresis and demonstrate equivalent tumor recurrence rates as compared to superfi-
2.3% (n = 1) resulted in minor (HB grade 2) permanent paresis. No cial or total parotdectomies [15,16].
Our study also found rates of complications and FN injury that were
either on par with or improvement from historic controls. We attribute
Table 2 the lack sialocele complications in this study to a postoperative drain reg-
FN outcomes at one year.
imen of nearly five days on average. The single patient with unresolved
Superficial Parotidectomy Total Parotidectomy Total paresis in the marginal branch presented with a parotid tumor greater
HB1 38 5 43 (97.7%) than 5 cm in diameter. The marginal branch of the FN was identified
HB2 1 – 1 (2.3%) and preserved during the operation, however, the cervical branch was
HB3 – – – sacrificed, likely contributing to unresolved lower facial weakness [17].
HB4 – – – The single patient who experienced HB 4 temporary weakness limited
Total 39 5 44
singly to the zygomatic branch of the FN made a full recovery.

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536 M.P. Kligerman et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 533–536
This study does have limitations. This study faces the same limita-
tions and biases subject to all retrospective case series and lacks the
power of a prospective randomized trial. A statistical comparison of our
results with other reports in the literature was not possible due to varia-
tion in data type, amount of parotid removed, and recording methodol-
ogy. It is also important to note that superficial parotidectomies were
performed for three patients with low-grade malignancy due to benign
FNA results prior to surgery. Had the FNA accurately captured the low-
grade disease process, these patients may have received total
parotidectomies. To date all patients with low-grade disease have had
no recurrences. A common concern about the retrograde technique is
variability in location and smaller size of the peripheral branches of the
FN. We found a high degree of consistency in locating the marginal man-
dibular branch or the cervical branch within 2 cm of the angle of the
mandible in orally intubated patients.
5. Conclusion
In this report we identify one of the largest case series to date for
retrograde parotidectomies and identify rates of both temporary
and permanent FN weakness that are on par with historic averages
for the prograde technique. No patients experienced weakness
(either temporary or permanent) of the main trunk of the FN, and
there were no sialocele complications. Further research on this
topic is still necessary, especially with regard to possible differ-
ences in rates of main trunk paresis. Also, future head to head trials
of the retrograde and prograde techniques may improve under-
standing of the advantages and disadvantages between these two
techniques.
Conflicts of Interest
None.
Financial disclosures
None.
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