Microsurgery for Parotidectomy Defects: A Powerful and Versatile Tool for Aesthetic and Functional Reconstruction

Purpose:

            Surgical management of parotid pathologies may lead to heterogeneous defects with variable involvement of skin, soft tissue, and bone along with possible sacrifice of the facial nerve. Local tissues are often inadequate to address these diverse reconstructive needs. We therefore aim to evaluate the role of microsurgery in reconstruction of parotidectomy defects.

Methods:

            All microsurgical reconstructions for parotidectomy defects performed were identified and reviewed. Patient demographics, intra-operative variables including microsurgical flap characteristics, and reconstructive outcomes were analyzed.

Results:

            A total of 11 microsurgical reconstructions in ten patients were performed. Average patient age and body-mass index were 38.5 years and 25.94 kg/m². Six patients (60.0%) had a former smoking history while three (30.0%) had major medical co-morbidities. Six patients (60.0%) had prior surgical intervention with prior partial parotidectomy/enucleation (30.0%) being most common. Two patients each (20.0%) had undergone prior radiation and chemotherapy. Five (50.0%) and three (30.0%) patients underwent adjuvant radiation and chemotherapy, respectively. Average follow-up was 116.4 days.

            The most common tumor pathologies were pleomorphic adenoma, acinic cell carcinoma, and squamous cell carcinoma (20.0%, each). Primary surgical procedures included total parotidectomy (30.0%), superficial parotidectomy (30.0%), radial parotidectomy (20.0%), and revision parotidectomy (20.0%). Four (40.0%) and two (20.0%) patients underwent concurrent neck dissection and bony resections. Three patients (30.0%) had facial nerve branch sacrifice reconstructed with nerve grafts in three cases (100.0%) and nerve transfers in two cases (66.7%).

            Microsurgical free flaps utilized included medial sural artery perforator (MSAP) flaps in six patients (60.0%) and anterolateral thigh (ALT) flaps in five (50.0%) patients. Average flap and skin paddle sizes were 79.61 cm² and 5.33 cm², respectively. Two flaps (18.2%) were completely de-epithelialized and buried. Ten donor sites (90.9%) were closed primarily while one MSAP donor site (9.1%) was closed with a full-thickness skin graft. Average total operative time was 10 hours, 54 minutes. Average patient length of stay was 4.6 days.

            There was one overall complication (10.0%), representing a hematoma managed non-operatively. No patients experienced post-operative Frey syndrome. Three patients (30.0%) underwent secondary revision procedures, including flap debulking (30.0%), skin paddle excision (10.0%), and donor site revision (10.0%).

Conclusions:

            Microsurgery represents a safe and versatile tool for reconstruction of parotidectomy defects. Lower extremity flaps, notably ALT and MSAP flaps, are effective in restoring soft tissue bulk for adequate facial contour while also providing vascularized tissue to protect vital structures and mitigate aberrant nerve regeneration, assisting in prevention of Frey syndrome.