Total parotidectomy defect reconstruction using the buried free flap
1) Present an alternative method of total parotidectomy with or without neck dissection defect reconstruction that results in improved cosmesis. 2) Describe applications of free tissue transfer in parotidectomy defect reconstruction.
Case series with chart review.
Two tertiary-care medical centers.
A two-institution retrospective review from 2002 to 2009 was conducted for buried free flaps utilized in reconstruction of defects from total parotidectomy with or without neck dissection. Patients with temporal bone or skin resections were excluded. Demographic information, tumor characteristics, surgical interventions, flap details, and adjunctive facial reconstructive techniques were recorded. Postoperative cosmetic results were evaluated by patient and physician satisfaction.
Eighteen patients with a mean age of 57.4 years underwent flap reconstruction. Total parotidectomy was performed in all cases, 11 cases required facial nerve sacrifice, and 14 cases included neck dissection. The anterolateral thigh flap was the most often utilized free flap. Mean flap area was 65.5 cm(2). Adjunctive static facial reanimation was employed in eight patients. All flaps survived. Ten patients underwent adjuvant radiation. Free flap reconstruction resulted in cosmetic patient and surgeon satisfaction, despite adjuvant radiation therapy.
Free flap reconstruction of total parotidectomy (with or without neck dissection) defects is safe and effective. It does not preclude adjunctive facial reanimation and provides sufficient tissue bulk to match the contralateral facial contour despite radical resections and adjuvant radiation therapy in most cases.
Available from: Brett A. Miles
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ABSTRACT: To review the recent literature on the expanding use of the anterolateral thigh free flap for head and neck reconstruction.
The versatility of the anterolateral thigh free flap allows it to be raised as a subcutaneous, musculocutaneous, fasciocutaneous, or adipofascial flap. In recent years, it has been reported to reconstruct defects involving the scalp, skull base, pharynx, tracheal stoma, oral cavity, and oropharynx. Various techniques have also been described in its harvest and inset, including combination flaps in conjunction with other free flaps or bone grafts, chimeric flaps, double-paddled skin flaps, and sensate flaps. These reports confer good functional and aesthetic outcomes equal to or better than other fasciocutaneous free flaps.
The role of the anterolateral thigh free flap in reconstructing head and neck defects is ever expanding, with many novel harvesting and reconstructive techniques described in recent years. Because of the large surface area of the anterolateral thigh, as well as the ability to tailor variable amounts of skin, muscle, fat, or fascia associated with this flap, the reconstruction options are numerous. More importantly, good functional and aesthetic outcomes are achievable with an associated low morbidity of the donor site.
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Over the last several decades, reconstruction of the head and neck oncologic defect has been revolutionized by the use of microvascular free tissue transfer. The majority of these defects can be reconstructed with the ability to visually monitor the flap, to intervene as soon as vascular compromise becomes evident. Occasionally, it is necessary to use a flap that has no visual external monitor: a buried free flap. A belief has circulated within the microvascular community that buried free flaps do not do as well as visible flaps. By our review, there are no recent data in the literature to support this position. We present our data on the outcomes of buried free flaps in microvascular reconstruction. MethodsA single institutional retrospective review of 1492 flaps was performed between January 1999 and December 2011. A total of 103 free flaps (7.2%) were identified as meeting the criteria for a buried flap. It should be noted that all flaps with or without an external segment were monitored with an implantable Doppler. The flap failure and complications are defined as those failures or complications occurring within 2 weeks of surgery and related to the operation or to the flap itself. ResultsIn all, 5 of the 103 patients (4.9%) had complications requiring reoperative intervention. There were no instances of flap failure within the first 2 weeks of surgery. Conclusion
In our series, there are no differences in flap failure rates comparing buried flaps to externally monitored flaps. (c) 2012 Wiley Periodicals, Inc. Head Neck 35: 1468-1470, 2013
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ABSTRACT: Background Extirpation of aggressive parotid or cutaneous facial tumors often involves facial nerve sacrifice and the creation of a large soft-tissue defect. We describe a method for single-stage reconstruction during radical parotidectomy to restore facial form and function without additional morbidity. Methods We conducted a review of immediate reconstruction/reanimation of radical parotidectomy defects with the use of anterolateral thigh (ALT) fat and fascia flaps for facial contouring, orthodromic temporalis tendon transfer (OTTT), cable grafting of the facial nerve, and fascia lata lower lip suspension. Results Five patients (mean age, 67.4 years) underwent extirpation of malignant tumors with facial nerve sacrifice resulting in large soft-tissue deficits. All patients had ALT free tissue transfer to correct facial contour defects and OTTT to restore facial form and function. Four patients underwent cable grafting of facial nerve branches. Branches of the motor nerve to the vastus lateralis harvested from the ALT surgical site were used for cable nerve grafting in 3 patients. Fascia lata from the same ALT harvest site was used for lower lip suspension to the OTTT in 4 patients. There were no donor site complications. All patients achieved midfacial symmetry at rest, oral competence with dynamic corner-of-mouth movement, and full eye closure. Conclusions Tumor clearance, symmetric facial appearance, as well as dynamic facial rehabilitation were accomplished in a single-stage procedure using the method described herein. The ALT free flap provides versatile options for soft-tissue defects as well as access to motor nerves optimal for grafting without additional morbidity. Patients undergoing extirpation of malignant tumors requiring facial nerve sacrifice can undergo immediate free tissue contour reconstruction and facial reanimation procedures with no additional morbidity.
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