Reconstruction of Radical Parotidectomy Defects

Daniel C. Baker, MD, New York, New York

William W. Shaw, MD,* New York, New York
John Conley, MD,t New York, New York

Reconstruction
of contour defects after radical parotidectomy with or without mandibulectomy
is a
difficult challenge. Although the facial and cervical
skin is usually preserved, the underlying soft tissue
and bone are deficient. Traditional methods of reconstruction include buried dermis-fat flaps from the
chest or posterior cervical region, sternocleidomastoid muscle flaps, and dermis-fat grafts. These
methods, however, are associated with many undesirable problems such as unsightly donor site defects,
the need for multiple stages, and unpredictable atrophy and resorption. The challenge is, therefore, to
be able to reliably restore facial contour while preserving the overlying skin in one predictable operation with minimal donor site deformity.
Reconstructive surgery of the head and neck with
microvascular free flaps is now a well established and
acceptable method. The first reported use of a microvascular free dermis-fat flap for facial reconstruction was by Fujino et al [I] in 1975. They successfully reconstructed
large facial defects in one
patient after trauma and in another patient with
hemifacial atrophy. A de-epithelized microvascular
deltopectoral flap was placed beneath the facial skin.
Subsequently,
de-epithelized groin flaps were employed for reconstruction in patients with hemifacial
atrophy by Wells and Edgerton [2] and Harashina
et al [3]. With this background we decided to use
microvascular free dermis-fat flaps to reconstruct
large facial defects secondary to radical parotidectomy and other ablative head and neck surgery.
From the New York University School of Medicine and the Institute of
Reconstructive Plastic Surgery, New York University Medical Center:* the
Department of Clinical Ctolaryngology, Columbia College of Physicians and
Surgeons;+ and the Head and Neck Service. St. Vincents Hospital and
Medical Center,+ New York, New York.
Reprint requests should be addressed to Daniel C. Baker, MD, Institute
of Reconstructive Plastic Surgery, 580 First Avenue, New York, New York
10016.
Presented at the Twenty-Fifth Annual Meeting of The Society of Head and
Neck Surgeons, Pittsburgh, Pennsylvania, April 1-4. 1979.

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Surgical Technique

Two operative teams are preferable: one working

at the recipient site and the second elevating the flap.
Donor and recipient vessels are mapped preoperatively with the Doppler instrument. Arteriography
is rarely used as it may cause transient damage to the
endothelium; preoperative Doppler examination and
intraoperative evaluation of flow and vessel condition
are more reliable.
Initially the reliability of recipient vessels is confirmed: normal, brisk, pulsatile arterial flow must be
demonstrated.
The recipient vessels are usually
chosen from the proximal side of the defect; however,
the simplest and most convenient vessels should be
chosen, and the rich vascular architecture of the head
and neck usually allows for a choice of vessels. Occasionally, as in bilateral radical neck dissection
where both external carotid arteries have been ligated (case 41, retrograde flow with or without a vein
graft has been used.
While the recipient vessels are being dissected, the
second team isolates the flap vessels and completes
elevation of the flap as an island. The size of the flap
is estimated from the defect, and a template from the
recipient site is often useful in planning. If the defect
is deeper than the thickness of the flap, the design
may be lengthened to permit folding of the flap on
itself to double the thickness (this was done in five
of our reported cases with no compromise in vascular
supply to the flap).
The recipient site is prepared by carefully elevating the facial and cervical skin several centimeters
beyond the borders of the defect. Often this skin flap
is extremely thin and fragile secondary to irradiation;
structures such as the facial nerve and carotid artery
may lie directly beneath the skin.
The flap vessels are divided and the flap is placed
beneath the defect to determine the most comfort-

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Microvascular

Free Dermis-Fat

Flaps

Figure 1. Left, detached free flap placed on dermatome for de-epithelization. Right, de-epithelized flap with bridge of epithelium for
postoperative monitoring and relief of tension,

able vessel position and the area to be de-epithelized.

Routinely we leave a several centimeter border of
epithelium on the flap for postoperative monitoring
and to relieve tension. The Reese dermatome is used
to remove a 0.016 inch thickness of epidermis on the
completely detached free flap (Figure 1).
We have found that vessel anastomosis is most
easily performed with the flap in an upside down
position. Standard microvascular
techniques are
utilized employing 10-O or 9-O nylon interrupted
sutures. After completion of the anastomoses (usually
one artery and two veins), the flap is placed beneath
the skin to fill the defect. It is important to suture the
dermis of the flap to the borders of the defect to
prevent settling of the flap into a bulky mass [2].
The flap may be tailored and trimmed to fit the defect as long as respect for the vascular pattern is observed. The skin bridge for monitoring is usually
placed along the posterior wound margin; it also

TABLE I

relieves tension in the early postoperative

period
when some flap edema is common.
Postoperatively
the flap is monitored for color,
temperature, and capillary refill and with the Doppler instrument. Immediate reexploration is done
when vascular compromise is evident, and an otherwise doomed flap may often be salvaged (case 6).
Patients are generally discharged on the ninth
postoperative
day. After several months the skin
bridge may be excised and any excess tissue trimmed
under local anesthesia as an outpatient procedure.
The following case reports are summarized in
Table I.
Case Reports
Case 1 (Figure 2): The patient was a 19 year old white
man who had had radical parotidectomy
and partial
mandibulectomy for neuroblastoma 10 years earlier. A full
course of radiation (5,000 rads) and chemotherapy was

Summary of Six Cases

Case Age (yr)

No.
& Sex

Pathology

19M

Neuroblastoma

2
3

16F
53F

Osteogenic sarcoma
Acinic cell

68M

Squamous cell adenoma

5
6

23F
31F

Neurofibromatosis
Adenoid cystic

Surgery
Radical parotidectomy, partial
mandibulectomy
Parotidectomy, mandibulectomy
Parotidectomy, VII nerve
graft reconstruction
Laryngectomy, RND: parotidectomy,
mandibulectomy, RND
Parotidectomy, mandibulectomy
Parotldectomy, mandibulectomy,
temporal bone resection

Radiation
(rads)

Flap Size
(cm)

Vessels

11x17

5,000

Superior thyroid

10 X 18
7x 10

5,000
None

Lingual
Superior thyroid

12 x 20

6,000

Superior temporal
retrograde vein
graft
Occipital
Lingual (reexplored)

9x
9X

15
18

None
None

RND = radical neck dissection.

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Baker et al

given postoperatively. A 7 by 10 cm defect was reconstructed with an 11 by 17 cm groin flap doubled on itself.
The superficial circumflex iliac artery was anastomosed
to the superior thyroid artery. The total time required for
anesthesia and operation was 9 hours. The patient was
ambulatory on the third postoperative day and was discharged on the ninth day without complications.
Case 2 (Figure 3): The patient was a 16 year old white
girl who had had total parotidectomy and hemimandibulectomy for osteogenic sarcoma 7 years earlier. She received
radiation (5,000 rads) and chemotherapy postoperatively.
A 10 by 18 cm groin flap was de-epithelized and folded to
fill a 7 by 10 cm defect. The superficial circumflex iliac
artery was anastomosed to the lingual artery. The patient
was discharged on the ninth postoperative day with no
complications.
Case 3: The patient was a 52 year old white woman who
had had radical parotidectomy and facial nerve grafting
for acinic cell carcinoma 5 years earlier. A 7 by 10 cm groin
flap was used to fill a 5 by 7 cm defect utilizing the superior
thyroid vessels. She was discharged on the 10th postoperative day with no complications, and the flap was trimmed
3 months later.
Case 4 (Figure 4): The patient was a 68 year old white
man who had had total laryngectomy and right radical neck
dissection for squamous cell carcinoma 10 years earlier and
radical parotidectomy, partial mandibulectomy, and left
radical neck dissection for adenocarcinoma of the parotid
gland 5 years earlier. He received postoperative radiation
(6,000 rads) to the left parotid gland and neck. A 12 by 20
cm groin flap was elevated and doubled on itself to fill an
8 by 12 cm defect. Because both external carotid arteries

Figure

552

2. Case 1. Left, preoperative

had been ligated, retrograde arterial flow from the superficial temporal artery was used for anastomoses with the
superficial circumflex iliac artery; an interposition vein
graft was necessary to obtain adequate length. Venous
anastomosis was to the angular vein. The patient was discharged on the 10th postoperative day without complications.
Case 5: The patient was a 23 year old white woman with
multiple resections of neurofibromatosis of the left side of
the face and parotid gland. A 9 by 18 cm groin flap was used
to fill a 7 by 10 cm defect. Arterial anastomosis was to the
occipital artery. The patient was discharged on the 10th
postoperative day.
Case 6: The patient was a 31 year old white woman who
had had radical parotidectomy, partial mandibulectomy,
and temporal bone resection 6 years earlier for recurrent
adenoid cystic carcinoma of the parotid gland. A 12 by 20
cm groin flap was elevated to fill an 8 by 11 cm defect. The
superficial circumflex iliac artery was anastomosed to the
lingual artery, with venous anastomosis to the superior
thyroid. Twelve hours postoperatively there was evidence
of venous congestion, and the patient was returned to the
operating room where a small hematoma was evacuated,
venous thrombosis discovered, and a reanastomosis to the
external jugular vein performed. The wound healed per
primam with complete flap survival, and the patient was
discharged on the 10th postoperative day.

Comments
Dermal-fat grafts (free grafts consisting of all
layers of skin and underlying subcutaneous fat after

view. Right, postoperative

view.

The American

Journalof Surgery

Microvascular

Free Dermis-Fat Flaps

Figure 3. Case 2. Left, preoperative view. Right, postoperative view; note the bridge of epithelium.

Figure 4. Case 4. Left, preoperative view. Right, postoperative view. The arterial supply to the microvascular dermis-fat
flap was from retrograde flow by way of the superficial temporal artery.

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Baker et al

removal of the epidermis) have been used extensively

for breast reconstruction,
hemifacial atrophy, and
other contour defects. It is believed that the major
advantage of dermis-fat grafts is that the dermis
serves as a vasoinductive agent preventing fat absorption [4]. Presumably the rich subpapillary vascular plexus of the dermis enhances early revascularization by the recipient site, thereby increasing
chances of fat survival. However, this concept has
been challenged by Sawhney et al [5], who studied
dermis-fat grafts in pigs and noted a decrease in
volume of the graft of 6.7 per cent at 1 week, 9 per
cent at 2 weeks, 20 per cent at 4 weeks, and 33.3 per
cent at 8 weeks. They concluded that there was no
evidence to suggest that vascularization of fat occurs
through the dermis in dermal fat grafts because the
growth of blood vessels was confined to the dermal
portion of the graft. This finding explains the eventual complete replacement of fat by fibrous tissue.
Clinically, the use of dermis-fat grafts has been
disappointing in breast reconstruction
as well as in
large facial defects. There is usually gradual shrinkage and resorption of fat over months to years, and
many patients require multiple repeat graftings.
Dying fat cells either rupture into liquified fat to
drain externally or are absorbed by the body.
In a recent review [6] of 33 dermal-fat-fascia grafts
to the head and neck, a 70 to 100 per cent absorption
was noted in all instances. The process of absorption
was a gradual one that was assessed over an interval
of 5 to 20 years, although the major effect was obvious
within 1 year postoperatively.
Ten per cent of patients had complete graft loss within 2 weeks from
infection or hematoma, and another 14 per cent had
apparent liquification of fat which drained spontaneously within 2 weeks after surgery. It was concluded that irradiated and scarred tissue beds did not
support free dermal-fat-fascia
grafts well, and that
the method had limited value in augmentation.
It is well known that pedicle flaps of dermis and fat
survive well due to better blood supply [7], although
this method requires multiple stages. Regional
muscle flaps have also been used, although additional
incisions, loss of donor function, and muscle atrophy
occur. As Hoopes [4] has stated, clearly dermis-fat
transferred on a vascular pedicle retains viability.

554

We believe that the microvascular free dermis-fat

flap should be the procedure of choice for large soft
tissue augmentation in the head and neck. The advantages of this flap include a high reliability with
over 90 per cent success, minimal complications, and
a cosmetically acceptable donor site. In addition,
large volumes of tissue may be transferred in one
stage independent of the vascular quality of the recipient bed, and massive overcorrection is unnecessary because survival is assured by the independent
vascular supply. Some of the disadvantages of microvascular dermis-fat flaps are the longer operating
time required and the need for two surgical teams,
which we believe are well compensated for by the
gratifying results.
Summary

The technique of microvascular free dermis-fat

flaps is an efficient method of restoring cervicofacial
contour after ablative head and neck surgery. Our
success in six consecutive patients, including three
who had received irradiation, establishes this as a
reliable technique associated with gratifying results
and minimal complications.
Acknowledgment: The authors thank Dr. Harry Bunke
for his advice and assistance in Case 4, and Dr. John Converse for his guidance.

References
1. Fujino T, Tanino R, Sugimoto C: Microvascular transfer of free
deltopectoral dermal-fat flap. Plasf Reconsfr Surg 55: 428,
1975.
2. Wells JH, Edgerton MT: Correction of severe hemifacial atrophy
with a free dermis-fat flap from the lower abdomen. Plasf
Reconstr Surg 59: 223, 1977.
3. Harashina T, Nakajima T, Yoshimura Y: A tree groin flap in
progressive facial herniatrophy. Br J Plast Surg 30: 14,
1977.
4. Hoopes JE: Dermis-fat grafts. In Symposium on Basic Science
in Plastic Surgery (Krizek TJ, Hoopes JE, eds). St. Louis, CV
Mosby, 1976.
5. Sawhney CP, Banerjee TN, Chakravarti RN: Behavior of dermal
fat transplants. Br J Plasf Surg 22: 169, 1969.
6. Conley J, Clairmont AA: Dermal-fat-fascia grafts. J Ofolaryngol,
1978.
7. Converse JM. Betson RJ: A 20 year follow-up of a patient with
hemifacial atrophy treated with a buried de-epithelized flap.
Plast Reconsfr Surg 48: 278, 1969.

The American Journal of Surgery