Hidden scar or its absence: is it always safe?

Abstract

We have read with great interest the online published article of Kim et al. [1], and would like to make some comments on this surgical approach, which we find interesting and provocative at the same time. Although the described small series was successful, it is difficult to speak with certainty about perfect results. First, the authors wrote that there was no harm caused to the facial nerve; however, they did not mention anything regarding the great auricular nerve (GAN). In our opinion, potential damage for the GAN and its branches could be caused during the flap raising. This injury is not always noticed, because many surgeons pay not much attention to sequels of such lesion [2]. In addition to that most patients accept superficial explanations that the numbness around the ear is an inevitable consequence of the operation, and a cheap price to pay for the results achieved. However, such injuries could be symptomatic [3]. Secondly, it was reported that five out of six patients presented a pleomorphic adenoma. At the same time, the reported mean follow-up period was only 10 months, which is too short to judge the non-recurrent rate. Even though patients were well informed about possibility to convert this surgical approach to another one, they were not aware of the risk of pleomorphic adenoma recurrence. This risk must be kept in mind by every surgeon and should not be forgotten even many years after the tumor excision [4]. As far as we are concerned, these tumors should be excised by a more simple approach to avoid a recurrence depending on the initial surgical procedure. Our choice in this case is the standard time-tested lateral open transcervical approach. Finally, as for the postoperative scar, another disadvantage of this approach is a risk to destroy hair follicles during incision and dissection of the skin flap. It might make the postoperative scar more visible, especially for people with short hair. Certainly, it is true that many people are more and more preoccupied with the way their body looks: they paint and pierce it, they keep it in shape through exercise and diet, and if they should really undergo a surgical intervention they ask to make it without any visible scar [5]. But surprisingly, they are less aware of the complications like temporary lingual nerve paresis and limitation of tongue movement, than facial marginal mandibular branch palsy, or constant GAN deficiency. That is why since 2009 we have used the transoral submandibulectomy approach, except for the tumor cases and cases with contraindications described by Weber et al. [6]. This approach, well known since 1952, is feasible and could be a procedure of choice in selected patients to avoid postoperative cervical scar [7].