For the total parotidectomy patient, the defect “remains a challenge…. We all know that contour defect that occurs in this patient population.”
Explore This IssueMarch 2018
“The go-to for us right now for this type of reconstruction is the submental flap,” he said. But he cautioned that it “doesn’t work for everything.” He recalled one patient with an aggressive parotid malignancy, for whom a submental flap was planned, but he ended up using an anterior lateral thigh flap because of the man’s extensive disease.
He advised against a rigid, either-or approach and emphasized choosing wisely on a patient-by-patient basis. “It’s all about doing the right thing for the patient,” Dr. Deschler said. “It’s not ‘pedicle or free.’”
Dr. Hanasono said that free flaps are a good option in parotidectomy cases, even for aesthetic reasons. “To me, it didn’t make sense when I was in training that we would do eight-hour free flap surgery for breast reconstruction, but we wouldn’t do it for facial reconstruction for what’s essentially an aesthetic defect,” he said.
In the case of a man with a parotid tumor, a flap wasn’t necessary for closure, but, after the procedure, the patient requested a revision because of his appearance. So, the next day, Dr. Hanasono used an adipofascial perforator flap for a better aesthetic result. “Free flaps are certainly warranted in the head and neck, this most visible part of the body for all of us,” Dr. Hanasono said. “For small contour deformities, you can use local pedicle flaps or fat grafting.” But he said that for more significant defects such as total parotidectomy involving the temporal bone, “I like using adipofascial flaps. And in particular I like the ALT (anterior lateral thigh) flap when you need nerve grafts and fascial grafts that can be harvested from the same donor site.”
Lateral Mandibular Defects
Dr. Khariwala pointed to a study of 59 patients with these defects who were reconstructed with soft tissue flaps and bridging plates (Otolaryngol Head Neck Surg. 2003;129:48-54). There were delayed failures in just five of the cases. “That would suggest you can use a bridging plate with soft tissue,” he said. “There is a risk of plate failure or exposure that’s present but low.” Evidence also suggests that a free tissue transfer might be a better option in patients who are dentate, but in those without teeth, a bridging plate in the soft tissue is fairly safe (Head Neck. 2008;30:709-717). This approach can also save time, he said, noting, “If you really want to focus on getting the patient off the table, maybe this is something you want to think about.”