Abstract
Following parotidectomy, patients develop retromandibular hollowing. A case series of patients for whom a free paraumbilical graft was used to reconstruct the parotid bed defect is presented here. This graft is harvested through a supra/sub-umbilical or suprapubic incision. Over-correction of approximately 50% is required due to atrophy and resorption with time. The graft is harvested with the overlying dermis and the graft should not be filleted, as this can cause necrosis. An antibiotic membrane is placed between the graft and the underlying bed and the graft is secured with Vicryl sutures. Since 1997, 130 patients have been treated successfully with this method. Regarding complications, nine patients developed a seroma, four developed a haematoma, two suffered graft liquefaction, and one suffered an infection with frank suppuration and loss of the graft. However, no complications have been noted in the most recent 70 patients. The incidence of Frey syndrome also appeared to be reduced. The paraumbilical fat graft appears to be a successful and reliable method of correcting facial defects after a superficial or total parotidectomy. The graft can also be used to correct temporal defects and has the added advantage of reducing Frey syndrome.
In 1823 Bernard first described parotid tumour resection. Since then, techniques have evolved to include extracapsular dissection and superficial parotidectomy for benign disease, and total parotidectomy for cases in which the deep lobe is involved or there is malignant disease.
Functional complications of parotid surgery include facial nerve damage, scar, loss of ear lobe sensation, Frey syndrome, and pre-auricular/retromandibular hollowing. The use of sternocleidomastoid, temporoparietal fascia, fascia lata, lateral arm, and superficial musculoaponeurotic system flaps has been described for the correction of the contour deformity. These space-filling techniques also have the benefit of preventing Frey syndrome. However, there are disadvantages, including the resulting significant donor site defect and donor site morbidity and the procedures are time-consuming and in some cases complex to perform. The free fat graft has been described in the literature as a simple method of correcting the contour defect after parotidectomy. The aim of this study was to describe the use of the free paraumbilical fat graft to correct the contour deformity following parotidectomy in a case series of 130 patients treated since 1997.
Patients and methods
This case series describes the results obtained by a single surgeon (N.A.N.) since 1997. Patients who underwent a superficial or total parotidectomy and received the fat graft at the time of initial surgery, or as a secondary procedure, were included. Standard preoperative measures included 5000 U subcutaneous heparin, and thromboembolic deterrent stockings were used as prophylaxis against deep vein thrombosis. Antibiotics were given preoperatively if there was suspicion of gland infection.
The graft is harvested through a supra/sub-umbilical or suprapubic incision if there is adequate fat, and it is usually performed at the time of initial surgery ( Fig. 1 a) . Harvesting grafts from previously scarred areas should be avoided as this can affect quality. Over-correction of approximately 30–50% is required to compensate for resorption and atrophy. The graft site is de-epithelialized keeping the overlying dermis ( Fig. 1 b). The graft is then harvested with the overlying dermis ( Fig. 1 c). The graft should not be filleted as this can cause necrosis. An antibiotic membrane (Collatamp G; Tribute Pharmaceuticals, Canada) is placed between the graft and the underlying bed and the graft is secured with Vicryl sutures ( Fig. 1 d). A redivac drain is used for 72 h to reduce the risk of seroma and haematoma formation.
Results
The free paraumbilical fat graft after superficial/total parotidectomy has been used in 130 patients since 1997. Regarding complications, nine patients developed a seroma at the surgical site, four developed a haematoma, two suffered graft liquefaction, and one patient suffered infection with frank suppuration resulting in graft loss. The incidence of Frey syndrome was assessed purely clinically, by patient history and clinical examination. Only one patient reported gustatory sweating anterior to the graft. This patient was referred for further treatment of their symptoms, but was lost to follow-up. Importantly, no complications have been noted in the most recent 70 patients. Figure 2 shows a patient 1 year post superficial parotidectomy who received a paraumbilical fat graft at the time of initial surgery.
