Parotidectomy is used for the treatment of a variety of parotid and nonparotid pathologies. Three common complications associated with traditional parotidectomy are a visible neck scar, facial contour deformity, and Frey syndrome (gustatory sweating). Sialocele and salivary fistula are also relatively common complications following parotidectomy, occurring in 4–14% of cases,1,2 but these complications were not a primary focus of our study, given that are usually self-limited and can be treated conservatively.
The standard parotidectomy approach is via a preauricular incision with an extension into the neck (Blair incision). Although the preauricular part of the incision is inconspicuous, the neck incision is visible. Facelift incisions have been shown to provide excellent parotidectomy access while obviating the need for a neck incision.3–11 Parotid gland resection results in cheek volume loss leading to facial asymmetry. Multiple methods have been described to fill the parotidectomy defect and restore this volume.12–14 These include the sternocleidomastoid flap, SMAS flap, temporoparietal fascia flap (TPFF), temporalis muscle flap, free abdominal fat transfer/fat grafting, to name a few. The TPFF is a good source of thin, pliable, durable, and well-vascularized tissue that can be elevated through the parotidectomy incision and is based on the superficial temporal vessels.
Frey syndrome is a condition in which the act of mastication causes sweating, erythema, and pain in the cheek at the parotidectomy site.15 In 1923, Frey described a case of gustatory sweating following a parotid gland bullet injury. The condition is thought to occur due to aberrant regeneration of transected neurons.16 The auriculotemporal nerve carries both sympathetic nerve fibers to the sweat glands of the face and parasympathetic fibers to the parotid gland. During parotidectomy, both types of fibers are transected. As the nerves regenerate, the parasympathetic fibers join the distal transected ends of the sympathetic fibers. Thus, stimulation of the parasympathetic fibers of the parotid gland, as occurs during mastication, results in activation of sympathetic fibers of the facial skin causing gustatory sweating. Various methods have been described to treat Frey syndrome. Topical anticholinergics like glycopyrolate17 and scopolamine18 control symptoms, but their use is limited by side effects and development of tolerance. Botox injected locally has also shown to be effective, but injections have to be repeated periodically.19 Surgical techniques aim to place a barrier between the parotid bed and overlying skin to prevent aberrant neuronal regeneration. Innumerable vascularized and nonvascularized tissues and biomaterials have been used for this purpose.20–28 These interposition techniques not only decrease the incidence of Frey syndrome, they also decrease the postparotidectomy contour deformity. We endeavored to study the effectiveness of using a TPFF in conjunction with a facelift incision in reducing scar visibility, cheek contour deformity and the incidence of Frey syndrome following parotidectomy.
Eleven consecutive patients underwent parotidectomy for various tumors (Table 1). Fine needle aspiration (FNA) was performed preoperatively in any patient in whom there was suspicion for carcinoma. Facelift incisions and TPFFs were used in all patients. A concomitant facelift was performed in 3 patients. Postoperatively, patients were followed for up to 7 years. All patients gave written consent to be included in this study.
A facelift incision with temporal extension is made in the following manner: starting in the temporal hair-bearing area extending down to the ear and then around the root of the helix before turning to form a small V-flap between the root of helix and tragus and then extending along the tragal edge to the lobule. The incision is then taken around the lobule staying 2 mm below the lobule. The incision is then carried up behind the ear to the helical-occipital junction obliquely before making a right angle and coming back down just inside the occipital hairline. The incision along the occipital hairline is done in a sharply beveled “trichophytic” manner to allow hair to eventually grow through the scar. We used this incision technique in all patients without compromising surgical exposure (Fig. 1). Concomitant facelift was only performed in patients with proven benign tumors, and in these patients the operation was started on the side without parotid pathology and closed before switching sides to avoid contamination of the contralateral surgical field.
In the preauricular area, the skin flap was raised at the sub-SMAS level. The parotidectomy was done with standard technique, identifying all the facial nerve branches in an antegrade fashion.29 In all the patients, the TPFF was used to restore volume loss and help to prevent Frey syndrome. In the temporal region, a full-thickness flap was elevated anteriorly and posteriorly such that an adequately sized TPFF was raised. If the contour requires increased volume, a larger flap can be taken and enfolded to increase volume correction. Care was taken to raise any hair-bearing skin just deep to the follicles to avoid alopecia. Flap dissection was limited anteriorly to 1 cm behind Pitanguy’s line, which indicates the position of the frontal branch of the facial nerve.30 In all cases, the flap easily covered the whole parotid bed including the retromandibular area where the postparotidectomy deformity commonly occurs.
TESTING FOR FREY SYNDROME
Six patients were tested for objective evidence of Frey syndrome with the Minor Starch Iodine test.31 In this method, iodine solution is applied to the parotidectomy-sided cheek and allowed to dry before being powdered with corn starch. The patient is then asked to chew on a lemon candy. A positive result occurs when the brown iodine color turns dark purple as an iodine-starch complex forms in the aqueous medium of sweat (see figure, Supplemental Digital Content 1, which displays the Positive Minor Starch Iodine test in a patient with traditional parotidectomy but no TPFF. (a) before sucking on lemon candy; (b) after sucking on lemon candy, https://links.lww.com/PRSGO/A958).
Good cheek contour and facial symmetry were achieved in 10 of the 11 patients. One patient underwent total parotidectomy and postoperative radiation therapy for acinic cell carcinoma. Although this patient had good cheek contour postoperatively, at long-term follow-up there was a slight depression. Patients who undergo larger resections or radiation therapy could benefit from a TPFF combined with other flaps. The skin incisions were inconspicuous in all patients. None of the patients complained of gustatory sweating or had objective evidence of subclinical Frey syndrome by Minor Starch Iodine test. None of the patients developed sialocele or salivary fistula. Three of our patients desired a formal facelift at the time of parotid surgery and all were extremely pleased with their result (Fig. 2). Combining a formal facelift is thus another way to improve facial symmetry and the aesthetic outcome in patients with proven benign parotid masses.
Patient satisfaction following parotidectomy can be improved by the use of facelift incisions and interposition of TPFFs.
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