LAUSR

The report by Mlees and Elbarbary is the latest among numerous retrospective studies and a randomized clinical trial published over the recent past comparing outcomes based on the extent of surgical resection of the parotid gland for benign neoplasms. In addition to tumor control, the commonly reported endpoints in these studies were short term surgical technique‐related outcomes such as operative time, facial nerve dysfunction, and other surgical morbidity and complications, and length of hospital stay. Other longer‐term outcomes related to cosmesis, sensation and quality of life have also been the subject of scrutiny in some studies. The sustained interest in outcomes after partial superficial parotidectomy (PSP) versus superficial parotidectomy (SP) is emblematic of the universal desire to minimize the risk of postoperative sequelae without compromising chances of tumor recurrence especially for benign parotid tumors. Most studies confirm that PSP is an equally effective option as SP for tumor control in properly selected benign parotid tumors but results in better functional and cosmetic outcomes. Successful outcome after parotid surgery hinges on two basic tenets: first, complete resection of the tumor without exposure or disruption of the capsule and second, identification and preservation of the facial nerve and its branches. The amount of parotid tissue resected and the extent of dissection needed to identify and preserve the facial nerve and its branches are the major distinguishing features between the traditional operation of SP and the more conservative PSP. The issues surrounding the amount of parotid tissue that should ideally be resected around the capsule of a parotid tumor as an adequate margin have been addressed widely in the literature. The anatomic relationship of the facial nerve and/ or its branches to the capsule of a parotid lesion is an anatomic feature that is independent of the extent of parotid parenchymal resection. It is therefore not surprising that about a quarter of patients have a positive margin related to the facial nerve and/or its branches irrespective of whether they are treated with SP, PSP or extracapsular dissection (ECD). In the absence of intraoperative rupture and gross spillage of tumor, the recurrence rates following PSP versus SP and even ECD for benign parotid tumors are consequently comparable. It is based on these fundamental anatomic and biologic precepts that PSP is able to fulfil the requirements of adequate tumor resection with minimal side effects in properly selected patients. While there is dwindling debate about the effectiveness of PSP and other conservative surgical approaches for benign parotid tumors, a relatively rare but practical issue that has received minimal attention is the management and fate of patients who receive a postoperative histologic diagnosis of malignancy after PSP performed for a suspected benign tumor. Conservative parotidectomy with appropriate use of postoperative radiation therapy has been described as an acceptable management option for selected malignant parotid tumors. This paradigm can be used to manage patients who have an unexpected malignant diagnosis after PSP but again the decision must be individualized considering the risks versus benefits of adjuvant therapy. The decision for additional treatment after PSP performed for a presumed benign parotid lesion that turns out to be malignant on final histopathologic examination hinges primarily on an understanding of the biology of the tumor and its anatomic relationships to the facial nerve. More often than not, additional surgery is not a viable option especially if wider resection would pose risk of dysfunction from reoperation and/or sacrifice of the facial nerve or its branches. Subjecting the patient to a more comprehensive SP to achieve “wider margins” around the periphery of the lesion would be ill advised if the closest margin was related to the facial nerve or its branches. A subsequent SP would be of limited oncologic value in this situation and would expose the patient to risk for facial nerve dysfunction. The importance of accurate orientation of the surgical specimen before submission to the pathology lab cannot be overstated, as it is virtually impossible to make an informed decision on risks versus benefits of additional treatment in the absence of information about the location of a close or positive margin. The increasing acceptance for PSP, especially for benign parotid neoplasms is based on a sound understanding of tumor behavior and anatomic principles. More may not always result in better tumor‐ related outcomes but less is almost always better in terms of postoperative function and quality of life.