VOLUME

RIVISTA

ITALIANA

EDIZIONI

21

DI

. NUMBER

2 . AUGUST

CHIRURGIA

MINERVA

2010

MAXILLO-FACCIALE

MEDICA

IT J MAXILLOFAC

SURG 2010;21 :71-6

Parotid surgery: comparison of reconstructive techniques G. DE MARIA 1, P. GRAZIANO

1, V. ABBATE

1, E. PAVONE 2, G. DELL: AVERSANA

Aim. After parotidectomy many patients have complications such as Frey's syndrome and depression in pre and sub-auricular region. In literature several reconstructive techniques were proposed to prevent them. Methods. We aimed the present prospective study to compare three different reconstructive techniques through the postoperative evaluation of skin depression, Frey's syndrome and hematomas. Between May 2005 and March 2008 we selected for this study 45 patients with benign tumor of parotid gland operated at the Department of Maxillofacial Surgery in the University Federico II ofNaples. The sample was divided randomly into three groups depending on the type of reconstruction done: 15 with sternocleidomastoid rotational flap (SCM) flap, 15 with the subsuperficial musculoaponeurotic system e1evation of skin flap (SMAS)technique and 15 with temporoparietal fascia rotationaI flap (TPF) flap. Results. From an analysis of literature and the data obtained after 18 months of postoperative observations, we have gained the indications and complications for each of the techniques we performed. We suggest the SMAS as the technique of first choice in superficial parotidectomy. Alternatively, in patients with thin sub· cutaneous tissue, we prefer the use of SCMflap. Conclusion. We discouraged the use ofTPF flap in superficiaI parotidectomy however we propose this technique to rebuilt the area after total parotidectomy. Keywords: Parotid gland - Surgical flaps - Reconstructive surgical procedures.

Before 1989, theofparotidectoml' wastissue performed total ablation the enrire gland having bya conservative

approach

1, L. CALIFANO

1

10ivision of Maxillo-Facial Surgery, Federico /I University of Naples, Naples, Italy 2G. Pascale National Cancer Institute, Naples, Italy

Since 1989 the surgical technique has been modified to prevent and reduce postoperative complications. The first, Roscic,22argued that the benign tumors of the parotid gland, including pleomorphic adenoma, could be treated by a margin resection of 5 mm in aH directions. Later, with the technical progress of reconstructive and aesthetic surgery, it was possible to improve the technique of parotidectomy, trying to preserve both the functionality and the esthetics.8 Many techniques have been proposed for the reconstruction of post parotidectomy defects to prevent depression and Frey's syndrome: free skin grafts-fatfascial,9 skin-fat graft,lO superficial muscleaponeurotic system (SMAS) flap,n, 20 tempoparietal flap (TPF),I. sternocleidomastoid muscle (SCM) flap with top and 10\\- stem,- vascularized fat graft 2 and free flaps.4 Qur studl' compares three different reconstructive techniques in patients who undergo superficial parotidectomy: the SMAS flap, the tempoparietal fascia flap and SCM flap. through the evaluation of pre and subauricular skin depression, Frey's syndrome and hematomas.

regarding the facial nen-e1-25

Materials and methods

Recei,-ed on JanuaIT 12. 2010 Accepted for publication on June -i. 2010.

Corresponding author: P. Graziano. :\lD. 5 Pansi.ni Street. 80131. :\aples. E-mail: [email protected]

Val. 21 - NO.2

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ITAlV\T\ JOU~\AL

Bern-een Mal' 2005 and March 2008, we conducted a prospective study on 45 patients with benign tumor of the parotid gland operated at the Department of

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I.-Reconstruction (SMAS)flap.

TABLE

Sex FFM 44 M 46 18 Pathology Whartin 47 22 Name T 64 IvI 40 39 38 55 62 Age 43 34 Pleomorphic adenoma Pleomorphic adenoma

using musculoaponeurotic

system

T-illLE

II.-Reconstruction

Name 48 42 31 54 66 62 45 49 55 72 -t8 36 34 54

Complicarions

using SCM muscleflap.

Sex T !vI F\'(Ilurtin Whartin .VI NI M M No Hematoma Parhology Complicarions Pleomorphic adenoma Pleomorphic adenoma Frey's sindrome

vv

'\0

D.A

'\0

]E

'\0

:"1.0.

"lo "lo 1\0 1\0

Age

SURGERY

S.B.

TA. S.G.

SL

'\0

TG.

'\0

A.L

'\0

CF

]\0

\-.Y.

Skin depression and Fre\-· Sn1drome

CG. PF G.C.

'\0 '\0 '\0

Sex 42 -f-f TAdenoma M \'çhartin 48 25 46 Pleomorfo Hematoma No FFFWhartin Pleomorfo 66 50 33 67 13 Pathoiogy .\1 Adenoma .\'1 .-\denoma 3-t "lo temporoparietalfasciaflap. Age 54 Complications T\BLE 1\denoma III-Reconstruction using

se

CG. 0 ..\1. S..-\. R.\1. -"L Re. '\.R CAL ST G.A.. FO. \-.R TR AR

Name

Maxillofacial Surgety in the University Federico II of Naples. Patients were elegible for inclusion into the study if they met the following criteria: 1) preoperative diagnosis for benign tumor (Pleomorfic adenoma or Warthin tumor); 2) patients had been operated by the same surgeon; 3) only superficial parotidectomy were performed; 4) only face-lift incisions were performed; 5) Patients aged between 18 and 72. Exclusion criteria were: 1) malignant tumor with neck dissection; 2) postoperative radiotherapy. The sample was divided randomly into three groups depending on the type of reconstmction done: 15 with SCM flap, 15 with the SMAS technique and 15 with a TPF flap (Tables I-III). We followed each patient for a period of 18 months to assess any change in facial symmetry through inspection and palpation of pre-and sub-tragic region. The presence or absence of Frey syndrome was determined by performing the Minor starch-iodine test at least one year after surgety. Both the surgical side and the opposite side (contro I) of the face \Vere painted with an iodine solution. The painted areas were then sprayed with powder starch and the patients sucked on a lemon-drop candy to stimulate salivation. The tested area was examined after lO minutes for the presence of gustatory sweating. A color change of the starch to dark purple signified the presence of Frey syndrome and the test was considered positive.

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Surgical techniques SCPERFICLli

.\lUSCLEAPO'\ECROTIC

SYSTDI

FLAP

The superficial muscoloaponeurotic system (SMAS) is a layer of muscle and connective fiber with longitudinal direction located just below the skin and above the parotid fascia (Figure The front limit is approximately above the nasolabial sulcus, the upper is in continuity with the tempoparietal fascia and the frontalis muscle. Below the SMAS is in continuity with the platisma muscle, and in the back is positioned

OF \tAXlLLOFACtAL

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Zygomatic

branch of faccial n.

Orbicularis

acuii m.

Zygomaticus major m.

Figure l.-Superficial

muscoloaponeurotic

s\'srem.

Figure 3.-Separarion of rhe S.\lAS from rhe parorid fascia and pre· pararion far rhe reconsrrucri\'e srep.

prepared for the reconstructive step 13 (Figure 3). The disseetion is done ve1Y carefully to avoide damage of the facial nerve branches. After parotidectomy and redon placement, the flap is positioned to give adequate cO\-erage of surgical gap20 TnIPOP,-\RlET.-\L

Figure 2-Facelifr

skin incision.

between the platisma, the mastoid and tragus. First a facelift skin incision is make (Figure 2) and a cutaneus flap is equipped in order to expose the S.\IAS. Then the SIvIAS is separated from the parotid fascia and

Vol. 21 - NO.2

fASCLAl FLAP

Tempoparietal fascia is a ve1Y versatile anatomical structure. lt is thin. richly vascularized, pliable and adap( to rotational moyements ,,-i(h minimal risk of necrosis. The limits of TPF are: the gale a above, the frontalis musc!e in Front. (he occipi(alis behind and the auricolaris musc!es and S.\IAS belo"'. The surgical (echnique used pro\'ides an access ,,-ith a face-lift incision ex(ended in parie(al region ,,'ith zig-zag shaped incision (Figure 4). and the de,-elopment of skin flap up to the (empoparietal fascia. After parotidectomy. (he fascia is incised up and de(ached from the (emporal fascia (Figure 5). This procedure is performed ,,-ith (he utmost care to avoid injU1Y of ,-ascular ramification. Then. (he flap is rotated and sutured in order to fil! (he defect.

ITALlAl\ ]OUR1'\JAL 01' MAXTI.LOPACTAL S1JRGERY

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DEMARIA

Figure 5.-Incision fascia.

T-\BLE

of rhe fascia and derachmenr from rhe rempora!

IY.- Teebnique's

l

e0117plieations compa?'ison.

l

1O S. O 2 HemalOma 2.2% 6.6% 4.4% Frey's Reconstrucli"e Skin Teq.OO1 Depression TPF SOl Tora! % :\L\S

Figure 4.-Zig-zag

shaped incision.

STERNOCLEIDOJVIASTOID

MUSCLE FL!\P

The sternocleidomastoid muscle (SCM) arises by two heads. The sternal head is tendinous and attached to the anterior surface of the manubrium sterni. The clavicular head is a wide muscular head arising from the upper surface of the mediaI third of the clavicle. The two heads merge and the muscle passes upv.-ards. laterally and posteriorly to inselt onto the lateral surface of the mastoid process of the temporal bone and the adjacent part of the superior nuchal line. Aiter parotidectomy the SCMmuscle is incised about 6 cm from the mastoid process, the flap is harvesting and rotate to cover defect (Figures 6. 7).-

nique, present Frey's Syndrome and a pretragic depression months after parotidectomy. One patients reconstlUcted with a SCMflap present a depression in pre- and sub-auricular region, anotherone develop a subcutaneous haematoma after parotidectomy that decrise spontaneously up to three week . Two patients reconstlUcted with tempoparietal flap develop subcutaneous hematoma.

Il

Discussion

The reconstlUctive surgery of the parotid gland is still an open issue, acrually in literature different soluResults tions are preferred to find the best way to rebuild the area and to a\'oid the depression skin and Frey's synThe sample was formed by 24 female and 2l male drome . After parotidectomy, depression skin is often aged between 18 and 72 years, mean age 45 years; 38 the reason of dissatisfaction among patients, espepatients were treated for pleomorfic adenoma and 7 cially among young people. Frey's syndrome is a frefor Warthin Tumor. An analysis of Table IV shows quent complication due to inadequate regeneration of that one of patients reconstructed with SMAStec- parasympathetic fibers of auricolotemporal nerve.3 In

74

ITALIA.'\ )OCR'\Al

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PAROTID SURGERY

Figure 6.-Incision processo TABLE

SMAS

V-Parotid Rappaport

DEMARlA

of the seNI muscle

TPF

Kornblut

6 cm from the mastoid

20 18

Bonann

5

H6nigl5

:-'leningaud

2005

2006

Sood 23

Filhol2

1999

Sultan 24

Ahmed

1995

1999

Rubinstei 1999

21

tecbl1iqu

S:-'lAS

Defecl ,;3 cm

Facial asymmeuy, deficiency '11 c.rI... skin depression

SC\1

Defect ,;3 cm

Deficiency Xl c.n., Lalerocervical hematomas

TPF

Defect >3 cm

Cestele\,8 2002

literature the frequency of Frey's syndrome is estimated to be Up to a maximum of 50% of patients.2. ~ Both of these complications, aesthetic and functional, can be reduced through the interposition of tissue in the cavity left by parotidectomy. O"er the years, several authors have proposed various kinds of technical reconstruction after parotidectomy. Among these, the fascia lata 3 and skin-fat grafts,~despite the grafts give good resu1ts, are not frequentIy used due to the high risk of resorption and infectionr Other techniques proposed,6 that took mO,stsuccessfui are the Iocai flaps, such as the Si\1AS,FTP flap and the flap of SCM. From the review of the Iiterature and our clinicai experience we have gained the indications and complications for each of the three techniques \\'e proposed (Tabies V,VI). The SMASis quickly set and

Val. 21 - NO.2

of the flap lO co"e:-

19

2004

l

7.-Rotation

T.-illLE

2000

1974

Figure

VI.- Type reconstructice tive surgical complication .

reconstructive literature reuiew.

1985

SCM

about

ITAllA.'\J ]OUR.'Al

Total parotidectomy

Alopecia, fromal branch deficiency of VII c.n.; Unsightly scar, hematomas

has excellent cosmetic resuIts. Agreement with CesteIeyn,8 SMASis preferabie for defects that do not exceed 3 cm in diameter. The limit of this technique is represented by cases of totai parotidectomy and in patients with littie subcutaneous tissue. The major complications are possibie residuai depression and the involvement of the VII crani c nerve.20 Another technique that \\'e use in preneurai parotidectomy and in patients \\'ith thin subcutaneous tissue is the

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PAROTID

DE MARIA

Figure 8.-A.

B) Excellenr esthetic anel fllnctional resllirs.

SCM flap, easy to set with minimum increase in surgical time. Common complication are the latero cervie al hematoma, atrophy of muscle and accessory nerve injuries.16 Another surgical procedure is the TPF flap, whose execution is more complex and surgical time are extended. This technique is preferred in cases of total parotidectomy, the aesthetic results are not velY satisfact01Y because the scar is stretched in temporal regionI" In our school we prefer the use of these local flaps for the reconstruction of post-surgical defects parotidectomy in cases of benign tumors, usually set up with face lift access type. Analysis of the results (Table N) obtained using the three techniques proposed, show that the post-surgical Frey"s syndrome incidence in rebuilt patiems (4.4% in our case) is lower than in not rebuilr population2--! In few cases we foune! complications such as depression skin or post surgical hematomas. \Y!enoticed that the use of SMAS flap, not only reduces the surgical rime due to easy implememation. bur rhere ,,-ere not any complications that we believed effective in the reconsrruction after preneural parotidectomy. The esthetic ane! functional results are excellent (Figure 8A. B). Alternati\-ely. in patients with thin subcutaneous rissue. ,,-e prefer the use of SCM flap, while in patients ,,-ith total parotidectomy we prefer the TPF flap.

References l. Ahmeel OA. Kolhe ps. Pre"ention of Fre"'s snldrome anel "oll1me eleficit after Br parotielecrom,' lIsing the sllperficial temporal anery J Plast Sllrg 1999:52:256-60. fasciaI flap. 2. Allen RJ. Kaplan l- reconstrllction of a parotidecrolm' elefect lIsing

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a parallmbilical perforator flap "'ithollt eleep inferior epigastric ,·essels. J Reconstr i\Iicrosurg 2000:16:449-53. 3. Baker DC. Sha'" \\\\1. Conle)' l- .\Iicro,·asclllar free elennis-fat flaps for reconstrllction after ablati\'e heael anel neck surgely. Arch Orolaryngol 1980:106:449-53. 4. Biglioli E AlItelitano L. Reconstruction after toral parotidecromy using a ele-epithelializeel free flap. J of Cranio-Maxillofacial Surg 200-:35:36-!-8. , 5. Bonanno Pc. Palaia D. Rosenberg.\1. Casson P. Prophylaxis against Frey's s"nelrome in parotiel surgery. Ann Plast Sllrg 2000;44: -198-501. 6. Bozzeni A. Biglioli E Salvaro G. Brusati R. Technical refinemenrs in sllrgical treatment of benign parotiel rumollrs . .I Craniomaxillofac lIrg 1999:27:289-93. - BlIgis SP.Young.IE.\1. Archibalel SD. Sternocleielomasroiel flap fol!o"'ing parotielecromy. Heael :\eck 1990:12:430-5. 8. Cesteleyen L. Helman l- King S. Temporoparietal fascia flaps anel sllperficial muscllloaponellratic system plication in parotid sllrgelY redllces Fre"'s syndrome . .I Oral.v/axillofac Sllrg 2002;60:1284-97. 9. Ceste/e"n L. Smith RG. Akuamoa-Boateng E. Km'acs B. Peiffer R. Cunenr diagnosis and therapy of paratiel rumours. Acta Stomatol Belg 1991:-1:15-. lO. ConleY.Il- Clairmonr AA. Dermal-fat-fascia grafts. Otolalyngology 1978:86:641-9. 11. Falahat E Manin-Granizo R, Berguer A, De Pedro NI. Alonso A. Dominguez L. Empleo elel colgano ele sistema muscolo-aponellratico superficial (S.\lAS) an la cirugia ele parotiela. Rey Esp Cirug Oral y .\laxilofac 2002:24:129-35 12. Filho' \\7Q. Dedivitis RA, Rapopon A, Guimaràes AV. Sternocleidomastoiel muscle flap prevenring Frey synelrome following parotielecrolm·. \'(lorlel.I SlIrg 2004:28:361-4. 13. Garda 01. Gil HS. Gil F.\1.Hen'ero CP. Colgajo de SMASen la pre"enciòn elel synelrome ele Fre,·. Re" Esp Cir Oral y maxillofac 2006:28.3: 182-1-1. Hadlock T: Yarvares .\1.1\. Hair-bearing temporoparietal fasciaI flap reconstruction of upper lip anel scalp elefects. Arch Facial Plast Surg 2001:3:rO-7.

.

15. Hònig .IE Omega incision face-lift approach anel SMAS rotation ad"ancement flap in parotidecrom,' far pre"enrion of contati l' eleficienC\' anel conspicuous scars affecting the neck. Inr .I Oral .\laxillofac Surg 2005:3-1:612-8. 16. JOSt G. Legent E Baudelot S Filling of resielual depressions after parotidecromy by a sterno-cleido-masroid flap Ann Chir Plast 1968:13:18--91. Kim Sì". .\lathog RH. Plal\-sma muscle-cer\'ical fascia-sternocleidomasroid mllscle (PC5) flap for parotidecromy Head Keck 1999; 21:-128-33. 18. Kornblllt AD. \\estphal P. .\liehlke A. The effectiveness of a sternomasroid mllscle flap in pre"enring post-parotidectomy occurrence of the Fre,' s,·ndrome. Acta Orolaryngol 1974:77:368-73. 19. .\leningaud .IP.13ertolus C. Beruand .Ic. Paratidecromy: assessment of a surgical rechnique inclueling facelift incision anel SJ'.lASadvancemenr . .I Craniomaxillofac Surg. 2006;34:34-7. 20. Rappapon I. Allison GR. Superficial I11usculoaponeurotic system amelioration of parotidectolm' defects. Ann Plast Surg 1985;14: 315-23. 21. Rubinstein Rì". Rosen A. Leeman D. Frey symelrome treatmenr "'ith temporoparietal fascia flap inrerposition. Arch Otolaryngol Heael :\eck SlIrg 1999:125:808-11. 22. Roscic Z. ConselTatiye parotielecromv: a ne,,- surgical concept. .I .\laxillofac Surg 1980:8:23-1. 23. Sood S. Quraishi .\15.Jennings CR. Bradley Pl- Frey's syndrome fol10"'ing parotielectom,': pre"enrion using a ratation sternocleielomastoiel muscle flap. Clin Otolaryngol Allieel Sci 1999;24:365-8. 24. SlIltan .vIR. Wider T.\-I. Hugo NE. Frey's synelrome: prevenrion with temporoparietal fasciai flap inrerposition. Ann Plast Surg 1995;3-1:292-6: eliscussion 296--. 25. Willarel EE L\'l1l1ET. FlInctional olltcome after total parotielectomy reconstrucrion. Laf\'ngoscope 2004:114:223-6.

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