In response to extracapsular dissection for benign parotid tumors: a meta-analysis.

We appreciated Dr. Komisar’s comments that support the use of extracapsular dissection (ECD) for selected benign tumors of the parotid gland. We especially agree with his observation that the surgery can be performed with the greatest safety by experienced salivary surgeons with the use of magnification and facial nerve monitoring. The authors would like to point out that the article is a critical review and meta-analysis; therefore, it does not necessarily reflect the surgical technique advocated by the author group. Our goal was to examine and present the best evidence as it currently exists with regards to ECD of benign parotid neoplasms. Readers can decide for themselves whether the evidence is convincing enough to alter their preferred surgical approach to these tumors. The authors of the studies reviewed in the metaanalysis have their own criteria with regard to which tumors can be safely resected by ECD. For the articles that listed tumor size as a criterion for ECD, there was a general consensus that the technique works best for tumors less than 4 cm in size. Dr. Komisar makes an excellent point that a mobile interface between the tumor and the surrounding tissue is the main criteria that determines whether a given tumor can be safely removed by ECD; therefore, size should not necessarily be a contraindication to the technique. As a practical point, however, once a tumor exceeds 4 cm it occupies a large portion of the superficial gland, thereby making its resection a de facto partial parotidectomy. Dr. Komisar also contends that the dissection should occur on the tumor capsule, not 2 to 3 mm off the capsule as mentioned by the authors of the included studies. Having read about ECD techniques and observed ECD by different surgeons, and having performed ECD ourselves, it is our feeling that all surgeons perform the operation in a similar fashion, keeping the tumor capsule in a clear magnified view while carefully spreading and dividing the adjacent parotid tissue just off the capsule without concern of a definitive margin. The author group agrees that ECD satisfies a growing demand by the public for less invasive and morbid surgery that is nevertheless safe and effective. It is critical that surgeons who seek to apply this technique have experience with the full range of parotidectomy techniques and methods of facial nerve identification.