CLINICAL STUDY
Great Auricular Nerve Preservation During Parotidectomy for Benign Tumors Roberto Becelli, PhD, MDS, Roberto Morello, MDS, ENT, Giancarlo Renzi, MDS, and Giorgio Matarazzo, MD
Abstract: The great auricular nerve, the largest sensory branch of the cervical plexus, arises from the third cervical nerve (C3) with irregular contribution from the C2. The first part of its course is deep to the sternocleidomastoid muscle. In few years, many experiences by different authors concerning the issue of great auricular nerve integrity during parotidectomy were published in the literature. The aims of our article were to report our experience with 78 consecutive patients who underwent standard superficial, subtotal, or total parotidectomy for benign tumors and to illustrate postsurgical findings regarding the sensibility of the pinna and mandibular angle as subjectively reported in the early postsurgical period and after 3, 6, and 12 months from surgery. Key Words: Great auricular nerve, parotidectomy (J Craniofac Surg 2014;25: 422Y424)
T
he great auricular nerve (GAN) originates from the cervical plexus at the levels of the second (C2) and third (C3) cervical nerves, supplying sensation to the skin overlying the lower aspect of the pinna and angle of the mandible.1 The GAN can be injured during many procedures in the head and neck, including parotidectomy. The main trunk of the GAN follows a consistent course over the midbody of the sternocleidomastoid muscle (SCM) before bifurcating into anterior lobular branches and posterior auricular branches and terminal arborization.1,2 Injury to the GAN leads to a permanent or transient lack of sensibility at the mandibular angle or pinna. In the past years, modified parotidectomies aiming to avoid injury to the GAN were reported in the literature, including modified aesthetic incisions or posterior-based parotid fascia flap.3Y5 Other authors assessed the feasibility of the preservation of the GAN during standard parotidectomy,6Y11 but on the other hand, different researchers stressed that the GAN might be sacrificed12 because spontaneous recovery occurs and impairments in average do not affect daily activities.11,13
From the Sant’Andrea Hospital, Faculty of Medicine and Psychology of University of Rome ‘‘La Sapienza,’’ Rome, Italy. Received May 31, 2013. Accepted for publication June 15, 2013. Address correspondence and reprint requests to Giorgio Matarazzo, MD, S. Andrea Hospital, Second Faculty of Medicine and Surgery, University of Rome ‘‘la Sapienza,’’ Via di Grottarossa 1035 Rome, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a28c50
422
The aims of our article were to report our experience with 78 consecutive patients who underwent standard superficial, subtotal, or total parotidectomy for benign tumors and to illustrate postsurgical findings regarding the sensibility of the pinna and mandibular angle as subjectively reported in the early postsurgical period and after 3, 6, and 12 months from surgery.
MATERIALS AND METHODS Seventy-eight patients were treated with standard superficial, subtotal, or total parotidectomy between 2004 and 2011. In total, patients’ clinical and nuclear magnetic resonance findings suggested benign tumors, and in all cases, presurgical diagnosis was obtained with cytologic examination by aspiration. Seventy-eight patients were affected by pleomorphic adenoma (n = 63, 61 cases and 2 relapses previously treated elsewhere), monomorphic adenoma (n = 3), and Warthin’s tumor (n = 12). All surgical procedures included standard incision from preauricular side downward to the anterior margin of the SCM as well as elevation of the skin flap and SMAS flap, both having an anterior-based pedicle. Smooth dissection of the lower auricular district was performed with careful maneuvers to obtain adequate exposition of posterior auricular branches of the GAN. Surgical procedure was managed and concluded with standard technique. In 2 of 78 patients who were affected by pleomorphic adenoma relapse previously treated elsewhere, the posterior branch of the GAN was sacrificed owing to postsurgical soft tissue adherences. With regard to the 76 remaining patients, the GAN was spared in all cases with no amplification of surgical time. Patients were interviewed about their subjective sensibility of the mandibular angle and auricular pinna in the early postsurgical period and after 3, 6, and 12 months from surgery.
RESULTS As shown in Table 1 in the early postsurgical period, of the 78 patients, 4 reported a complete lack of sensibility of the auricular pinna (including both of cases of GAN sacrifice), and 2 complained numbness. No lack of sensibility involved the mandibular angle. During follow-up at the third postsurgical month, a complete lack of sensibility of the auricular pinna was reported by 3 patients (both patients who received GAN sacrifice and 1 patient who reported loss of sensibility in the early postsurgical stage), whereas numbness was referred by 3 patients (in the early postsurgical period, 2 have been reporting numbness, and 1 has been reporting complete loss of sensibility). After 6 months from surgery, only 1 patient complained lack of sensibility of the pinna (the patient who had GAN trunk sacrificed), and 3 had numbness (1 with GAN sacrificed, 1 reporting complete loss of sensibility on the early stage and numbness at the third month, and the remaining one reporting numbness since the
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
TABLE 1. Subjective Evaluation Over Time of Sensitive Impairment as Experienced by 6 of 78 Patients Who Underwent Standard Parotidectomy Patient Number 1* 2* 3 4 5 6
Early Postsurgery
3rd Month
6th Month
12th Month
Loss Loss Loss Loss Numbness Numbness
Loss Loss Loss Numbness Numbness Numbness
Loss Numbness Numbness Numbness Good Good
Numbness Numbness Good Good Good Good
*The GAN sacrificed during surgery in 2 cases of PA relapse previously treated elsewhere.
early stage). After 12 months from surgery, no patient had a complete loss of sensibility, and only both patients with GAN sacrificed reported numbness of the auricular pinna. Furthermore, both of them qualified their impairment as not relevant.
DISCUSSION AND CONCLUSIONS The GAN, the largest sensory branch of the cervical plexus, arises from the third cervical nerve (C3) with irregular contribution from the C2. The first part of its course is deep to the SCM. Then, it winds around the posterior border of the SCM to reach the lateral surface of the muscle14,15 and then runs anteriorly, covered by the deep surface of platysma. It is just above the angle of the mandible where the GAN sends out its posterior and anterior branches. The GAN and external jugular vein run in the same layer and nearly in parallel, whereas the terminal branches of the GAN remain in the superficial lamella of the parotid gland fascia (PGF) . The posterior branch of the GAN provides sensory innervations for both surfaces of the external ear in varying extension, the skin over the mastoid process, small areas behind and above the auricle, and most of the skin covering the parotid gland. In few years, many experiences by different authors concerning the issue of GAN integrity during parotidectomy were published in the literature. Zhao et al5 advised to perform a modification of the standard parotidectomy through conserving the subYsuperficial musculoaponeurotic system (sub-SMAS) and GAN trunk as well as reconstructing with sternocleidomastoid flap and concluded that conserving the GAN prevents sensitivity of the auricular lobule. Zumeng et al4 in 2006 illustrated a modified approach for parotidectomies where the PGF was elevated to form a posterior-based pedicle flap so as not to sacrifice the GAN branches running into the PGF. Liu et al3 presented in 2011 a modified face-lift incision with a superficially anterior and superior pedicled SCM flap and reported faster recovery, occurring in average after 3 postsurgical months, from anesthesia at the cheek and upper cervical part. The literature offers not only pieces of advice on the modification of parotidectomy but also recommendations to save the GAN whenever feasible during standard surgery, although sensory impairments after its sacrifice tends to recover and stabilize over time. According to Suen et al,10 GAN preservation leads to a decreased sensory impairment, and it should be performed whenever tumor removal is not compromised. As stressed by Ryan and Fee7 in 2009 in their report concerning morbidity and recovery after GAN sacrifice during parotidectomy, patients tend to recover from anesthesia since the first postsurgical year, and after 5 years only, minor impairment remains; the authors concluded that the posterior GAN should be preserved if this will not influence tumor resection and pointed that if GAN is sacrificed,
Great Auricular Nerve Preservation
then after a 2-year mean point, 70% of the patients of their analysis have had their disability faded. Hu et al6 in 2010 demonstrated that preservation of the lobular branches of the GAN during standard parotidectomy leads to better sensory recovery and requires no extra operating time. As experienced by different authors,11 the average quality of life of patients having had GAN sacrifice is not significantly affected, and any significant degree of discomfort during daily activities is not reported.13 However, on the other hand, other authors do not advise to make an effort to expose GAN and preserve it because sensory impairments are minimal. According to Linke et al16 in 2012, trying to preserve the GAN in any way could lead to an increase in the possible complications such as neuralgia. Porter and Wood12 analyzed in 1997 2 groups of patients with GAN sacrifice and without GAN sacrifice and reported that the area of sensory loss had no difference between the groups, that it decreased exponentially in both groups, and that most of the improvements occurred within 6 months from surgery. According to them, preservation of the posterior branches of the GAN is not necessary. Finally, Min et al17 in 2007 evaluated 2 groups of patients who underwent parotidectomy (22/46 with GAN sacrifice and 24/46 with GAN sparing) and did not register large differences between the 2 groups; furthermore, they found that sensory deficit improves over time regardless if the GAN is sacrificed or not and concluded that its preservation might not be necessary. Anyway, although experiences, pieces of advice, and recommendations about the GAN and parotidectomy for benign tumors are not unanimous, the common line exposed in the literature seems to suggest that sparing the GAN during standard parotidectomies is desirable for patients and achievable for surgeons. In our analysis, cautious dissection of the GAN was performed in all the standard parotidectomies, and no extra time was needed. Except for 2 cases of pleomorphic adenoma relapse where soft tissue postsurgical adherences made clear and safe exposition impossible, GAN was divided to ensure a secure approach to the mass. With regard to postsurgical recovery of sensory impairments, a spontaneous improvement was observed after few months from surgery. In all the 4 patients with early postsurgical numbness and had the GAN saved, a slight numbness was reported still after 3 or 6 months, and a good sensitive function was reached after 6 or 12 months, whereas both patients with GAN sacrificed had recovered from loss of sensitivity after 6 months (patient 2) or 12 months (patient 1). As many previous experiences were reported in the literature, the patients of our series stated that sensitive impairment has not been damaging their daily activities and that they considered the disturbance very mild, too. A careful dissection of the GAN, which is overall less demanding than the one that is required in facial nerve isolation, can be achieved during standard parotidectomies for benign salivary tumor without spending extra time. In case the GAN is to be divided or its preservation fails, still, patients report a good recovery over time, and they consider their temporary sensory impairment not severe.
REFERENCES 1. Murphy R, Dziegielewski P, O’Connell D, et al. The great auricular nerve: an anatomic and surgical study. J Otolaryngol Head Neck Surg 2012;41(suppl 1):S75YS77 2. Lefkowitz T, Hazani R, Chowdhry S, et al. Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthet Surg J 2013;33:19Y23
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
423
Becelli et al
The Journal of Craniofacial Surgery
3. Liu H, Li Y, Dai X. Modified face-lift approach combined with a superficially anterior and superior-based sternocleidomastoid muscle flap in total parotidectomy. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:593Y599 4. Zumeng Y, Zhi G, Gang Z, et al. Modified superficial parotidectomy: preserving both the great auricular nerve and the parotid gland fascia. Otolaryngol Head Neck Surg 2006;135:458Y462 5. Zhao HW, Li LJ, Han B, et al. Preventing post-surgical complications by modification of parotidectomy. Int J Oral Maxillofac Surg 2008;37:345Y349 6. Hu J, Ye W, Zheng J, et al. The feasibility and significance of preservation of the lobular branch of the great auricular nerve in parotidectomy. Int J Oral Maxillofac Surg 2010;39:684Y689 7. Ryan WR, Fee WE. Long-term great auricular nerve morbidity after sacrifice during parotidectomy. Laryngoscope 2009;119:1140Y1146 8. Hui Y, Wong DS, Wong LY, et al. A prospective controlled double-blind trial of great auricular nerve preservation at parotidectomy. Am J Surg 2003;185:574Y579 9. Ryan WR, Fee WE Jr. Great auricular nerve morbidity after nerve sacrifice during parotidectomy. Arch Otolaryngol Head Neck Surg 2006;132:642Y649
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& Volume 25, Number 2, March 2014
10. Suen DT, Chow TL, Lam CY, et al. Sensation recovery improved by great auricular nerve preservation in parotidectomy: a prospective double-blind study. ANZ J Surg 2007;77:374Y376 11. Patel N, Har-El G, Rosenfeld R. Quality of life after great auricular nerve sacrifice during parotidectomy. Arch Otolaryngol Head Neck Surg 2001;127:884Y888 12. Porter MJ, Wood SJ. Preservation of the great auricular nerve during parotidectomy. Clin Otolaryngol Allied Sci 1997;22:251Y253 13. Colella G, Rauso R, Tartaro G, et al. Skin injury and great auricular nerve sacrifice after parotidectomy. J Craniofac Surg 2009;20:1078Y1081 14. Almand J, Boydell CL, Parry SW, et al. The greater auricular nerve revisited: pertinent anatomy for SMAS-platysma rhytidectomy. Ann Plast Surg 1990;27:44Y48 15. Peuker ET, Filler TJ. The nerve supply of the human auricule. Clin Anat 2002;15:35Y37 16. Linke R, Wollenberg B, Schro¨der U. Diagnosis and management of pain syndromes following parotidectomy [in German]. HNO 2012;60:725Y729 17. Min HJ, Lee HS, Lee YS, et al. Is it necessary to preserve the posterior branch of the great auricular nerve in parotidectomy? Otolaryngol Head Neck Surg 2007;137:636Y641
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Great Auricular Nerve Preservation During Parotidectomy for Benign Tumors Roberto Becelli, PhD, MDS, Roberto Morello, MDS, ENT, Giancarlo Renzi, MDS, and Giorgio Matarazzo, MD
Abstract: The great auricular nerve, the largest sensory branch of the cervical plexus, arises from the third cervical nerve (C3) with irregular contribution from the C2. The first part of its course is deep to the sternocleidomastoid muscle. In few years, many experiences by different authors concerning the issue of great auricular nerve integrity during parotidectomy were published in the literature. The aims of our article were to report our experience with 78 consecutive patients who underwent standard superficial, subtotal, or total parotidectomy for benign tumors and to illustrate postsurgical findings regarding the sensibility of the pinna and mandibular angle as subjectively reported in the early postsurgical period and after 3, 6, and 12 months from surgery. Key Words: Great auricular nerve, parotidectomy (J Craniofac Surg 2014;25: 422Y424)
T
he great auricular nerve (GAN) originates from the cervical plexus at the levels of the second (C2) and third (C3) cervical nerves, supplying sensation to the skin overlying the lower aspect of the pinna and angle of the mandible.1 The GAN can be injured during many procedures in the head and neck, including parotidectomy. The main trunk of the GAN follows a consistent course over the midbody of the sternocleidomastoid muscle (SCM) before bifurcating into anterior lobular branches and posterior auricular branches and terminal arborization.1,2 Injury to the GAN leads to a permanent or transient lack of sensibility at the mandibular angle or pinna. In the past years, modified parotidectomies aiming to avoid injury to the GAN were reported in the literature, including modified aesthetic incisions or posterior-based parotid fascia flap.3Y5 Other authors assessed the feasibility of the preservation of the GAN during standard parotidectomy,6Y11 but on the other hand, different researchers stressed that the GAN might be sacrificed12 because spontaneous recovery occurs and impairments in average do not affect daily activities.11,13
From the Sant’Andrea Hospital, Faculty of Medicine and Psychology of University of Rome ‘‘La Sapienza,’’ Rome, Italy. Received May 31, 2013. Accepted for publication June 15, 2013. Address correspondence and reprint requests to Giorgio Matarazzo, MD, S. Andrea Hospital, Second Faculty of Medicine and Surgery, University of Rome ‘‘la Sapienza,’’ Via di Grottarossa 1035 Rome, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a28c50
422
The aims of our article were to report our experience with 78 consecutive patients who underwent standard superficial, subtotal, or total parotidectomy for benign tumors and to illustrate postsurgical findings regarding the sensibility of the pinna and mandibular angle as subjectively reported in the early postsurgical period and after 3, 6, and 12 months from surgery.
MATERIALS AND METHODS Seventy-eight patients were treated with standard superficial, subtotal, or total parotidectomy between 2004 and 2011. In total, patients’ clinical and nuclear magnetic resonance findings suggested benign tumors, and in all cases, presurgical diagnosis was obtained with cytologic examination by aspiration. Seventy-eight patients were affected by pleomorphic adenoma (n = 63, 61 cases and 2 relapses previously treated elsewhere), monomorphic adenoma (n = 3), and Warthin’s tumor (n = 12). All surgical procedures included standard incision from preauricular side downward to the anterior margin of the SCM as well as elevation of the skin flap and SMAS flap, both having an anterior-based pedicle. Smooth dissection of the lower auricular district was performed with careful maneuvers to obtain adequate exposition of posterior auricular branches of the GAN. Surgical procedure was managed and concluded with standard technique. In 2 of 78 patients who were affected by pleomorphic adenoma relapse previously treated elsewhere, the posterior branch of the GAN was sacrificed owing to postsurgical soft tissue adherences. With regard to the 76 remaining patients, the GAN was spared in all cases with no amplification of surgical time. Patients were interviewed about their subjective sensibility of the mandibular angle and auricular pinna in the early postsurgical period and after 3, 6, and 12 months from surgery.
RESULTS As shown in Table 1 in the early postsurgical period, of the 78 patients, 4 reported a complete lack of sensibility of the auricular pinna (including both of cases of GAN sacrifice), and 2 complained numbness. No lack of sensibility involved the mandibular angle. During follow-up at the third postsurgical month, a complete lack of sensibility of the auricular pinna was reported by 3 patients (both patients who received GAN sacrifice and 1 patient who reported loss of sensibility in the early postsurgical stage), whereas numbness was referred by 3 patients (in the early postsurgical period, 2 have been reporting numbness, and 1 has been reporting complete loss of sensibility). After 6 months from surgery, only 1 patient complained lack of sensibility of the pinna (the patient who had GAN trunk sacrificed), and 3 had numbness (1 with GAN sacrificed, 1 reporting complete loss of sensibility on the early stage and numbness at the third month, and the remaining one reporting numbness since the
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
TABLE 1. Subjective Evaluation Over Time of Sensitive Impairment as Experienced by 6 of 78 Patients Who Underwent Standard Parotidectomy Patient Number 1* 2* 3 4 5 6
Early Postsurgery
3rd Month
6th Month
12th Month
Loss Loss Loss Loss Numbness Numbness
Loss Loss Loss Numbness Numbness Numbness
Loss Numbness Numbness Numbness Good Good
Numbness Numbness Good Good Good Good
*The GAN sacrificed during surgery in 2 cases of PA relapse previously treated elsewhere.
early stage). After 12 months from surgery, no patient had a complete loss of sensibility, and only both patients with GAN sacrificed reported numbness of the auricular pinna. Furthermore, both of them qualified their impairment as not relevant.
DISCUSSION AND CONCLUSIONS The GAN, the largest sensory branch of the cervical plexus, arises from the third cervical nerve (C3) with irregular contribution from the C2. The first part of its course is deep to the SCM. Then, it winds around the posterior border of the SCM to reach the lateral surface of the muscle14,15 and then runs anteriorly, covered by the deep surface of platysma. It is just above the angle of the mandible where the GAN sends out its posterior and anterior branches. The GAN and external jugular vein run in the same layer and nearly in parallel, whereas the terminal branches of the GAN remain in the superficial lamella of the parotid gland fascia (PGF) . The posterior branch of the GAN provides sensory innervations for both surfaces of the external ear in varying extension, the skin over the mastoid process, small areas behind and above the auricle, and most of the skin covering the parotid gland. In few years, many experiences by different authors concerning the issue of GAN integrity during parotidectomy were published in the literature. Zhao et al5 advised to perform a modification of the standard parotidectomy through conserving the subYsuperficial musculoaponeurotic system (sub-SMAS) and GAN trunk as well as reconstructing with sternocleidomastoid flap and concluded that conserving the GAN prevents sensitivity of the auricular lobule. Zumeng et al4 in 2006 illustrated a modified approach for parotidectomies where the PGF was elevated to form a posterior-based pedicle flap so as not to sacrifice the GAN branches running into the PGF. Liu et al3 presented in 2011 a modified face-lift incision with a superficially anterior and superior pedicled SCM flap and reported faster recovery, occurring in average after 3 postsurgical months, from anesthesia at the cheek and upper cervical part. The literature offers not only pieces of advice on the modification of parotidectomy but also recommendations to save the GAN whenever feasible during standard surgery, although sensory impairments after its sacrifice tends to recover and stabilize over time. According to Suen et al,10 GAN preservation leads to a decreased sensory impairment, and it should be performed whenever tumor removal is not compromised. As stressed by Ryan and Fee7 in 2009 in their report concerning morbidity and recovery after GAN sacrifice during parotidectomy, patients tend to recover from anesthesia since the first postsurgical year, and after 5 years only, minor impairment remains; the authors concluded that the posterior GAN should be preserved if this will not influence tumor resection and pointed that if GAN is sacrificed,
Great Auricular Nerve Preservation
then after a 2-year mean point, 70% of the patients of their analysis have had their disability faded. Hu et al6 in 2010 demonstrated that preservation of the lobular branches of the GAN during standard parotidectomy leads to better sensory recovery and requires no extra operating time. As experienced by different authors,11 the average quality of life of patients having had GAN sacrifice is not significantly affected, and any significant degree of discomfort during daily activities is not reported.13 However, on the other hand, other authors do not advise to make an effort to expose GAN and preserve it because sensory impairments are minimal. According to Linke et al16 in 2012, trying to preserve the GAN in any way could lead to an increase in the possible complications such as neuralgia. Porter and Wood12 analyzed in 1997 2 groups of patients with GAN sacrifice and without GAN sacrifice and reported that the area of sensory loss had no difference between the groups, that it decreased exponentially in both groups, and that most of the improvements occurred within 6 months from surgery. According to them, preservation of the posterior branches of the GAN is not necessary. Finally, Min et al17 in 2007 evaluated 2 groups of patients who underwent parotidectomy (22/46 with GAN sacrifice and 24/46 with GAN sparing) and did not register large differences between the 2 groups; furthermore, they found that sensory deficit improves over time regardless if the GAN is sacrificed or not and concluded that its preservation might not be necessary. Anyway, although experiences, pieces of advice, and recommendations about the GAN and parotidectomy for benign tumors are not unanimous, the common line exposed in the literature seems to suggest that sparing the GAN during standard parotidectomies is desirable for patients and achievable for surgeons. In our analysis, cautious dissection of the GAN was performed in all the standard parotidectomies, and no extra time was needed. Except for 2 cases of pleomorphic adenoma relapse where soft tissue postsurgical adherences made clear and safe exposition impossible, GAN was divided to ensure a secure approach to the mass. With regard to postsurgical recovery of sensory impairments, a spontaneous improvement was observed after few months from surgery. In all the 4 patients with early postsurgical numbness and had the GAN saved, a slight numbness was reported still after 3 or 6 months, and a good sensitive function was reached after 6 or 12 months, whereas both patients with GAN sacrificed had recovered from loss of sensitivity after 6 months (patient 2) or 12 months (patient 1). As many previous experiences were reported in the literature, the patients of our series stated that sensitive impairment has not been damaging their daily activities and that they considered the disturbance very mild, too. A careful dissection of the GAN, which is overall less demanding than the one that is required in facial nerve isolation, can be achieved during standard parotidectomies for benign salivary tumor without spending extra time. In case the GAN is to be divided or its preservation fails, still, patients report a good recovery over time, and they consider their temporary sensory impairment not severe.
REFERENCES 1. Murphy R, Dziegielewski P, O’Connell D, et al. The great auricular nerve: an anatomic and surgical study. J Otolaryngol Head Neck Surg 2012;41(suppl 1):S75YS77 2. Lefkowitz T, Hazani R, Chowdhry S, et al. Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthet Surg J 2013;33:19Y23
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
423
Becelli et al
The Journal of Craniofacial Surgery
3. Liu H, Li Y, Dai X. Modified face-lift approach combined with a superficially anterior and superior-based sternocleidomastoid muscle flap in total parotidectomy. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:593Y599 4. Zumeng Y, Zhi G, Gang Z, et al. Modified superficial parotidectomy: preserving both the great auricular nerve and the parotid gland fascia. Otolaryngol Head Neck Surg 2006;135:458Y462 5. Zhao HW, Li LJ, Han B, et al. Preventing post-surgical complications by modification of parotidectomy. Int J Oral Maxillofac Surg 2008;37:345Y349 6. Hu J, Ye W, Zheng J, et al. The feasibility and significance of preservation of the lobular branch of the great auricular nerve in parotidectomy. Int J Oral Maxillofac Surg 2010;39:684Y689 7. Ryan WR, Fee WE. Long-term great auricular nerve morbidity after sacrifice during parotidectomy. Laryngoscope 2009;119:1140Y1146 8. Hui Y, Wong DS, Wong LY, et al. A prospective controlled double-blind trial of great auricular nerve preservation at parotidectomy. Am J Surg 2003;185:574Y579 9. Ryan WR, Fee WE Jr. Great auricular nerve morbidity after nerve sacrifice during parotidectomy. Arch Otolaryngol Head Neck Surg 2006;132:642Y649
424
& Volume 25, Number 2, March 2014
10. Suen DT, Chow TL, Lam CY, et al. Sensation recovery improved by great auricular nerve preservation in parotidectomy: a prospective double-blind study. ANZ J Surg 2007;77:374Y376 11. Patel N, Har-El G, Rosenfeld R. Quality of life after great auricular nerve sacrifice during parotidectomy. Arch Otolaryngol Head Neck Surg 2001;127:884Y888 12. Porter MJ, Wood SJ. Preservation of the great auricular nerve during parotidectomy. Clin Otolaryngol Allied Sci 1997;22:251Y253 13. Colella G, Rauso R, Tartaro G, et al. Skin injury and great auricular nerve sacrifice after parotidectomy. J Craniofac Surg 2009;20:1078Y1081 14. Almand J, Boydell CL, Parry SW, et al. The greater auricular nerve revisited: pertinent anatomy for SMAS-platysma rhytidectomy. Ann Plast Surg 1990;27:44Y48 15. Peuker ET, Filler TJ. The nerve supply of the human auricule. Clin Anat 2002;15:35Y37 16. Linke R, Wollenberg B, Schro¨der U. Diagnosis and management of pain syndromes following parotidectomy [in German]. HNO 2012;60:725Y729 17. Min HJ, Lee HS, Lee YS, et al. Is it necessary to preserve the posterior branch of the great auricular nerve in parotidectomy? Otolaryngol Head Neck Surg 2007;137:636Y641
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
