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Published on January 23, 2023 by Mark Wax

Reconstruction of the parotid bed following resection for metastatic skin cancer

blog article from the ASN Cutaneous Cancer Section

When large metastases are present in the parotid bed, surgical excision is the preferred modality of treatment.  Depending on the extent of the disease, either a classic superficial parotidectomy or a near total parotidectomy with excision of the deep lobe may be required for complete clearance of the nodal tissue. A comprehensive or limited neck dissection may also be concurrently performed.

This resection of the parotid gland can lead to significant concavity deformities (Figure 1).

Figure 1: This young woman demonstrates the concavity defect from a parotidectomy

Historically, the volume defect had not been reconstructed.  Over time, the soft tissue defect may have less abrupt edges and soften, but the concavity will always be present. The concavity imparts no functional deficits but may result in cosmetic dissatisfaction. In the setting of malignancy, the cosmetic deformity is often considered by most surgeons to be a minor issue in the post-operative period as concern for facial nerve function predominates.

Patients, however, can have differing opinions on the cosmetic outcome of an extensive parotidectomy with concavity deformity1. Ciuman et al demonstrated that parotidectomy for benign disease did not impact overall quality of life, but cosmetic discontent with the facial contour deformity was quite high with 70% reporting a change in appearance.2 Greater than half reported noticeable depression as a result of the cosmetic deformity. Casual observers were also able to notice the contour defect. A review of 274 patients by Bianchi et al discovered that the most essential factor impacting aesthetic outcome was the amount of parotid tissue removal.3 However, the full impact of the contour defect on patient’s quality of life has not been fully elucidated due to the lack of symptom specific questions on quality-of-life instruments1.

Minimal parotidectomy with neck dissection may yield smaller volume defects and spare involvement of the overlying cutaneous tissue. Surgical reconstruction of the facial skin in this situation is not required and the volume defect may be addressed with a range of reconstructive options. The reconstructive paradigm to address soft tissue defects ranges from sternocleidomastoid (SCM) muscle flaps, acellular dermal implants, superficial musculoaponeurotic system (SMAS) plication, fat graft, and free tissue transfer.4,5 Both the SMAS plication and SCM muscle flap have been shown to be equivalent to soft tissue fillers and result in improved patient satisfaction with their final appearance4. Acellular dermal implants like Alloderm and fat grafting are ideal for smaller volume parotid defects (Figure 2).

a) A small superficial parotidectomy defect that will create a divot in the cheek is present.
b) The defect has been reconstructed with layered AlloDerm to provide adequate cosmesis

Reconstructive options are primarily volume-driven and often imparts no alterations in overall functional status.  It is our preference to consider reconstruction in the majority of parotidectomy defects.  Small contour defects are easily reconstructed by the ablative team at the time of the initial surgery.  Larger defects are approached and a 2-team fashion with involvement of our facial plastics colleagues.  When malignancy surveillance is required, it is often done with radiologic imaging so the reconstructive modality used does not impact surveillance or outcome.  All reconstructive tissues will atrophy or shrink over time.  if adjuvant radiation is expected; fat grafting may atrophy significantly.  In our experience it is rare to have patients unhappy with too much bulk in the reconstruction.  As with most fat grafting and other parts of the head and neck up to 50% greater volume should be utilized depending on what the next course of treatment is.  When there is cutaneous involvement and the defect is not extensive, cervicofacial advancement flaps are ideal for functional and cosmetic reconstruction.

Soft tissue defects greater than 70 cm3 are more common in the setting of advanced metastatic skin cancer to the parotid bed since extensive parotidectomy with concurrent neck dissection is usually necessary, and local constructive modalities are not adequate in these situations.6 There is an increased risk of facial skin involvement with aggressive disease, resulting in another layer of complexity in the reconstruction. Scenarios where local tissue may not be ideal include the large size of the defect, previous rotational flaps disrupting the facial skin or soft tissue blood supply, prior radiation history, heavy smoker, or poor prognostic indicators for wound healing. When defects are of a more significant nature or the wound bed is a more hostile environment, then regional or free tissue transfer should be considered (Figure 3 a,b).5

a) This gentleman had a parotidectomy neck dissection with a small skin defect.
b) A supraclavicular flap was utilized for reconstruction of the soft tissue and skin.

Utilization of free tissue transfer for parotid skin defects are relatively rare. When necessary, the ideal flap would provide not only coverage of the skin defect, but also would reconstruct the soft tissue defect from parotidectomy and neck dissection. Radial forearm free flaps and anterolateral thigh flaps are most commonly used.  The lateral arm flap has recently been proposed in the literature as another alternative option. The ultimate decision depends on the volume of tissue required and patient body habitus (Figure 4a,b,c).4

a) This gentleman had a skin cancer metastatic to the parotid region requiring skin resection parotidectomy and neck dissection.
b) An anterolateral thigh free flap was utilized to reconstruct the soft tissue as well as the skin defect.
c) At 1 year facial contour remains good

Patients seem to anecdotally report favorable outcomes after free tissue transfer. Cannady et al described a series of 18 patients with free tissue transfer for soft tissue volume reconstruction of total parotidectomy defects with acceptably cosmetic outcomes reported by patients.5 The benefits of free tissue transfer include healthy vascularized tissue in the wound bed, especially if adjunct radiation therapy is to be pursued post-operatively, adequate skin paddle for facial skin defects with no local tissue available for rotation, and adipose or muscular tissue to address the soft tissue volume loss. Unlike a fat graft, vascularized adipose tissue is less likely to atrophy to the same extent.

In terms of free tissue transfer, radial forearm flap, anterolateral thigh flap, and lateral arm flap are acceptable options when both a skin and soft tissue defect needs to be addressed. When there is no facial skin defect, an adipose fascial free flap from the thigh that results in minimal donor site morbidity may be a more suitable reconstructive modality. Described by Fritz et al, this flap can be harvested as a 2-team approach with a straightforward inset and vascular anastomosis adding an hour or two to the overall length of the surgery.7 Even though vascularized adipose tissue does not shrink like fat grafts, there is a possibility that these grafts will also atrophy to a considerable extent like other free tissue transfers.8 Long-term data is lacking, but there may be a role in overcorrection of the soft tissue volume loss at the time of reconstruction in anticipation of volume loss, especially in the setting of post-operative radiation therapy.

Reconstruction of the parotid bed volume loss may not be like other typical head and neck reconstructions since there is no functional role.  Anecdotal evidence from patients report poor cosmetic outcomes and overall dissatisfaction with contour deformities with this defect. There is very little quantitative evidence in the literature regarding its impact on the overall quality of life, but there may still be a role for parotid bed reconstruction to obtain good cosmetic outcomes. Reconstructive options are relatively straightforward and should be considered during pre-operative evaluation.  Patient morbidity from reconstruction is relatively minor.  The benefits are potentially major.

Mark K Wax MD FACS FRCS(C) 1
Professor Otolaryngology-HNS
Professor Maxillo Facial Surgery
Program Director

Sara Yang MD1
Fellow Microvascular and Reconstructive Surgery
Oregon Health Sciences University

References

  • Nitzan D, Kronenberg J, Horowitz Z, Wolf M, Bedrin L, Chaushu G, Talmi YP: Quality of life following parotidectomy for malignant and benign disease. Plast Reconstr Surg. 2004 Oct;114(5):1060-7
  • Ciuman RR, Oels W, Jaussi R, Dost P: Outcome, general, and symptom-specific quality of life after various types of parotid resection. Laryngoscope 2012 Jun;122(6):1254-61
  • Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E: Improving esthetic results in benign parotid surgery: statistical evaluation of facelift approach, sternocleidomastoid flap, and superficial musculoaponeurotic system flap application. J Oral Maxillofac Surg 2011 Apr;69(4):1235-41
  • Militsakh ON, Sanderson JA, Lin D, Wax MK: Rehabilitation of a parotidectomy patient–a systematic approach. Head Neck 2013 Sep;35(9):1349-61
  • Cannady SB, Seth R, Fritz MA, Alam DS, Wax MK: Total parotidectomy defect reconstruction using the buried free flap. Otolaryngol Head Neck Surg 2010 Nov;143(5):637-43
  • Tamplen M, Knott PD, Fritz MA, Seth R. Controversies in Parotid Defect Reconstruction. Facial Plast Surg Clin North Am. 2016 Aug;24(3):235-43. doi: 10.1016/j.fsc.2016.03.002. Epub 2016 May 24. PMID: 27400838.
  • Ciolek PJ, Prendes BL, Fritz MA. Comprehensive approach to reestablishing form and function after radical parotidectomy. Am J Otolaryngol. 2018 Sep-Oct;39(5):542-547. doi: 10.1016/j.amjoto.2018.06.008. Epub 2018 Jun 7. PMID: 29907429.
  • Dennis SK, Masheeb Z, Abouyared M. Free flap volume changes: can we predict ideal flap size and future volume loss? Curr Opin Otolaryngol Head Neck Surg. 2022 Oct 1;30(5):375-379. doi: 10.1097/MOO.0000000000000832. Epub 2022 Jul 18. PMID: 36036533.

Published on December 12, 2022 by AHNS Webmaster

The AHNS Fellowship Match is OPEN

The AHNS currently accredits over 60 fellowship positions from 50 surgical programs in the U.S. and Canada. The application period has begun for fellowships commencing in July of 2024 – the application timeline is as follows:

For Fellowships beginning: July 1, 2024
Application Period: Monday, December 12, 2022 – Friday, March 3, 2023
Interview Period: Friday, March 3, 2023 – Monday, June 26, 2023
Ranking list opens for Programs and Applicants: Monday, June 26, 2023
Ranking list closes – Monday, July 10, 2023
Match results announced: Friday, July 14, 2023

To apply for the match, click HERE.

Instructions for Applicants completing their medical education in the US or Canada
Instructions for Applicants not eligible for an ABMS Board, or who have completed their medical education outside the US or Canada.

Published on August 23, 2022 by AHNS Webmaster

2022 AHNS/AAO Resident/Fellow Symposium – RSVP Today!

The American Head and Neck Society in conjunction with the American Academy of Otolaryngology will offer its annual head & neck surgery symposium for residents and fellows.

This day-long symposium takes place on Saturday, September 10, 2022 prior to the opening of the AAO-HNSF Annual Meeting & OTO Expo taking place in Philadelphia, Pennsylvania. The symposium will run from 11:30 am -6:00 pm.

Join us for a day of informative lectures on head and neck surgical procedures and treatments, presented by leading head and neck surgeons.

This in-person event is FREE to residents and fellows.
Lunch and refreshments will be provided.
An RSVP is required – complete the fields below to register for the event.

RSVP HERE!

Published on July 19, 2022 by AHNS Webmaster

Announcing the AHNS-Accredited Fellowships Class of 2023

The Advanced Training Council of the American Head & Neck Society is pleased to present the 2023 class of the AHNS-Accredited Fellowship programs. Congratulations to these fellows and best of luck in your 2023 Fellowship year!

Program Fellow
AdventHealth Orlando Mathew Biskup
Augusta University – Endocrine Josh Ziehm
Case Western Reserve University Hospitals / Cleveland Medical Center Nithin Peddireddy
Cleveland Clinic Foundation Lindsey Shehee
Emory University School of Medicine Scott Hong
Emory University School of Medicine – Endocrine Meredith Lilly
Henry Ford Health Jaishree Palanisamy
Icahn Mt Sinai School of Medicine Austin Lam
Indiana University School of Medicine Deborah Xie
Johns Hopkins University Kenneth Akakpo
Johns Hopkins University – Endocrine Max Plitt
Massachusetts Eye & Ear Omar Karadaghy
Massachusetts Eye & Ear – Endocrine Marika Russell
MD Anderson Cancer Center Jennifer Anderson
Alexandra Belcastro
Medical University of South Carolina Madelyn Stevens
Memorial Sloan-Kettering Cancer Center Ryan Instrum
Kenric Tam
Moffitt Cancer Center Jennifer Bourne
Mount Sinai Beth Israel Ricardo Ramirez
Nebraska Methodist Hospital Herschel Patel
New York University Langone Health John Stein
Northwestern University Richard Muller
Oregon Health & Science University Ryan Hellums
Pennsylvania State / Hershey Medical Center Mohamad Saltagi
Stanford University Medical Center Zipei Feng
The Ohio State University Michael Li
Lauren Miller
Thomas Jefferson University Emily Funk
University of Alabama-Birmingham William Reed
University of Alberta Hospital Wael Hasan
University of California – Davis Anthony Sanchez
University of California – San Francisco Zainab Farzal
University of Cincinnati Medical Center Tam Ramsey
University of Florida Linda Chow
University of Iowa Hospitals and Clinics Rahul Gulati
University of Kansas Medical Center Ethan Craig
University of Miami Hospital and Clinics Neeraja Konuthula
Sallie Long
University of Michigan David Forner
Carlos Green
University of North Carolina – Chapel Hill Julian Vellucci
University of Pennsylvania Health System Lukas Dumberger
Jake Lee
University of Pittsburgh Medical Center Arturo Eguia
Eric Wu
University of Washington Rocco Ferrandino
University of Wisconsin Kevin Carlson
UT Southwestern Medical Center Justin Pyne
Vanderbilt University Medical Center Ramez Philips
Pratyusha Yalamanchi
Washington University at St. Louis Zaid Al-Qurayshi
Tara Mokhtari

Published on June 24, 2022 by AHNS Webmaster

AHNS Educational Series: Presented by the AHNS Cancer Prevention and Survivorship/Supportive Care/Rehabilitation Services

HPV-Related Oropharyngeal Cancer: The Importance of Early Detection &  Prevention

AHNS Educational Series: Presented by the AHNS Cancer Prevention and Survivorship/Supportive Care/Rehabilitation Services In Partnership with the Head and Neck Cancer Alliance

Wednesday July, 20, 2022 at 7:00 PM EST
This session is an hour and complimentary for all!

The AHNS gratefully acknowledges the generous educational grant in support of this activity from Roche.

Moderator:
Ann Gillenwater, MD– AHNS Cancer Prevention Service Vice-Chair

Panelists:
Laura Dooley, MD – AHNS Cancer Prevention Service Member
Warren Swegal, MD – AHNS Survivorship/Supportive Care/Rehabilitation Service Member
Kristin Oliver, MD– Pediatrician
Michael Murphy –Survivor, Head and Neck Cancer Alliance Ambassador

At the end of this one-hour webinar, participants will be able to:
1. Identify the current trends in the epidemiology of HPV-related oropharyngeal cancer
2. Recognize the common clinical presentation of HPV-related oropharyngeal cancer
3. Distinguish the short and long-term side effects that come with head and neck cancer treatment
4. Articulate current barriers to population-based screening for HPV-related oropharyngeal cancer, thus emphasizing the importance of primary prevention
5. Outline the current indications for HPV-vaccination and the role it plays in prevention of HPV-related cancers.

Register Here Now!

 

 

 

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News and Announcements

  • Statement from the American Head and Neck Society in Support of Continued HPV Vaccination July 3, 2025
  • KN689 Infographic June 9, 2025
  • Immunotherapy in Mucosal HNSCC: Key Takeaways from the AHNS Webinar June 4, 2025
  • World No Tobacco Day May 31, 2025
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