Facelift incision and superficial musculoaponeurotic system advancement in parotidectomy: case reports
© Kim et al. 2015
Received: 26 August 2015
Accepted: 21 October 2015
Published: 2 November 2015
Surgical procedures for parotidectomy had been developed to gain adequate approach, prevent morbidity of nerve, and give esthetic satisfaction.
We performed two cases of parotidectomy through facelift incision. One case was reconstructed with superficial musculoaponeurotic system (SMAS) flap and sternocleidomastoid (SCM) muscle rotated flap at the parotid bed. In second case, same procedures were performed, but collagen membrane was additionally implanted for prevention of Frey’s syndrome. After surgery, two cases showed esthetic results without neck scar and hollow defect on parotid bed area.
Recently, facelift incisions have often been used for surgery of the benign parotid tumor [2, 3]. It gives patients an esthetic satisfaction because the incision line can be hidden naturally in the auriculomastoid groove and hair line. This incision generally used in rhytidectomy also offers a large field of operation including a superior portion of sternocleidomastoid (SCM) muscle and lateral head and neck, as well as the parotid bed. This is helpful in reconstructing the parotid bed after partial or total parotidectomy. Unless the parotid bed is reconstructed, hollow space can be seen in the mandibular angle region which causes unaesthetic asymmetry (Fig. 1b).
The most common late complication after the parotidectomy is Frey’s syndrome. It is considered to be a misdirected growth of sectioned auriculotemporal nerve fibers and/or parasympathetic nerve fibers to the sweat glands of the skin overlying the parotid gland. The reported incidence of this syndrome is 2 to 80 % depending on the methods of reconstruction on the hollow parotid bed and the time-interval from the surgery .
The two cases of parotidectomy with facelift incision and reconstruction of superficial musculoaponeurotic system (SMAS) and SCM flap were performed and evaluated the esthetic and functional results.
Parotidectomy was conventionally performed with the dissection of the facial nerve trunk located around the mastoid process. During this procedure, meticulous blunt dissection was needed. The great auricular nerve was not preserved.
After the superficial and deep lobe of the parotid gland was successfully resected, a hollow space was covered with two layers. A superficial layer of SCM muscle was stripped off from the mastoid process and rotated anteriorly to the parotid bed. Then, the SMAS flap was advanced to the mandible angle and sutured with SCM muscle flap (Fig. 4b).
There are two major complications in dealing with the parotidectomy. There are the functional problems which are associated with morbidity of the facial nerve and Frey’s syndrome. Another is esthetic problems such as neck scarring and hollow space of the parotid region which affects the post-operative social life of the patient.
In an esthetic point of view, visible scars on the face and neck after surgery can negatively impact on an individual’s quality of life. There were many attempts to modify the Blair incision in order to avoid scarring on the neck. Nouraei et al.  showed in an anatomical study that facelift incisions provide generous access to all regions of the parotid gland, which was similar to Blair’s incision. Lee et al.  compared facelift incision with modified Blair incision in parotidectomy of benign lesion without reconstruction. The mean scar satisfaction score was significantly higher in facelift incision group. Bianchi et al.  reported that facelift incision alone in partial parotidectomy led to a high statistically significant improvement in the esthetic outcome. Facelift incisions allow the incision lines to be hidden in the postauricular region and hairline which provide improved satisfaction for the patient. It can also provide easier approach to SCM muscle .
Cesteleyn et al.  reported that the incidence of Frey’s syndrome was reduced from 33 to 4 % in cases using musculoaponeurotic layer. Allison and Rappaport  reported only two cases of Frey’s syndrome in 112 patients who had undergone operation with a SMAS flap. This SMAS flap is also useful to augment hollow defect [3, 9, 10]. The dissection of SMAS flap is easy and rapid and was conducted on the parotid region which is time-saving. It functions as a membrane for guided tissue regeneration. The hematoma below the SMAS flap may become to scar tissue and fill the parotid bed.
Sood et al.  reported that SCM muscle flap reduced the incidence of Frey’s syndrome. Two of 11(18.2 %) patients from the group which had a SCM rotation flap showed evidence of gustatory sweating. However, Gooden et al.  reported no statistical difference in incidence rate of Frey’s syndrome between the group reconstructed with SCM rotation flap and control group which had not undergone reconstruction. Effectiveness of SCM muscle flap in preventing Frey’s syndrome is controversial . Nevertheless, SCM muscle flap have other benefits unlike other procedures such as the temporoparietal or platysma muscle flap. The SCM muscle flap is easy to rotate without an additional incision into the parotid bed. And SCM muscle flap provides an adequate volume to fill the hollow space [11, 12]. Also, there is a low risk of flap necrosis because of abundant vascularization.
After parotidectomy, SMAS flap is too small to cover all defects of the parotid bed. This may lead to unsatisfactory esthetic results to patients. Combinations of various procedures with SMAS flap can be performed to increase an esthetic satisfaction. Zhao et al.  reported that the sub-SMAS flap combined with the SCM muscle flap provided more improved esthetic results than the sub-SMAS flap alone. Chen et al.  used SMAS fold flap with allograft dermal matrix (ADM) to repair the parotid bed. This showed a statistical difference in rates of satisfaction of facial contour between SMAS only group (91.9 %) and SMAS with ADM group (100 %).
In this study, we performed two cases of parotidectomy through facelift incision. One case was reconstructed with superficial musculoaponeurotic system (SMAS) flap and Sternocleidomastoid (SCM) muscle rotated flap at the parotid bed. In second case, same procedures were performed, but collagen membrane was additionally implanted for prevention of Frey’s syndrome. After surgery, two cases showed esthetic results without neck scar and hollow defect on parotid bed area.
Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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