Eur J Plast Surg (1994) 17:243-246 European " ~ 1 ,,I a Journa, of I~II#JIIQII' I I£~

© Springer-Verlag 1994

The gracilis free flap for reconstruction of parotidectomy defects M. J. I. Braam, 1 N. B. M e l a n d 2 and K. D. Olsen 3

1 Visiting Medical Student, Section of Plastic and Reconstructive Surgery, Mayo Clinic and Mayo Foundation, University of Nijmegen, The Netherlands 2 Section of Plastic and Reconstructive Surgery, Mayo Clinic and Mayo Foundation 3 Section of Otorhinolaryngology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Summary. Tota l p a r o t i d e c t o m y causes a significant pos t - opera t ive concave deformi ty in the r e t r o m a n d i b u l a r , p reaur icu la r , and in f ra -aur icu la r regions of the face; m a n y pa t ien ts are concerned a b o u t this defect. Frey ' s s y n d r o m e (gus ta to ry sweating) is also a wel l - recognized pos tope ra t i ve ent i ty fo l lowing p a r o t i d surgery. The inci- dence of Frey ' s s y n d r o m e ranges f rom 10-90%, depend- ing on the type and complex i ty of the inves t iga t ion used to d iagnose it [5, 11]. N u m e r o u s m e t h o d s have been de- scr ibed to correc t these p rob lems . Pa t ien ts requi r ing to ta l p a r o t i d e c t o m y were recent ly offered the op t i on of imme- dia te r econs t ruc t ion of the con tou r defect wi th mic rovas - cu lar t ransfer of a t a i l o red gracil is muscle flap. F o u r pa- t ients are inc luded in this p r e l im ina ry series; all are ex- t remely satisfied with the pos tope ra t i ve result. The defect fol lowing to ta l p a r o t i d e c t o m y can be r econs t ruc ted im- med ia t e ly wi th grat i fying cosmet ic results, a h idden d o n o r site scar, and to da te no opera t ive morb id i ty .

Key words: Grac i l i s P a r o t i d e c t o m y

Correspondence ~o: N.B. Meland, MD, Mayo Clinic/Scottsdale, 13400 East Shea Boulevard, Scottsdale, Arizona 85259, USA

Materials and methods

Four consecutive patients were included in this report. The ages ranged from 51-72. There were two males and two females. The diagnosis of parotid mass was made with needle biopsy.

Two patients had high grade adenocarcinomas, and the others had a terminal duct carcinoma and a high grade, dedifferentiated acinic adenocarcinoma. The surgical procedures are noted in Table 1. All patients underwent a total parotidectomy, and one patient had removal of the deep musculature of the parotid bed. The mandible was preserved in all cases as was the external skin.

The gracilis muscle was harvested through a linear incision high on the thigh. The incision started 5 cm below the inferior pubic ramus and ended 12 cm distally. The muscle was harvested through this 7 cm incision with careful isolation of the vascular pedicle. A small drain was placed and the donor site closed with a subcuticular suture. Postoperatively, the whole leg was wrapped with an Ace bandage for three weeks. Microvascular anastomosis was carried out to the remaining stumps of the facial artery and vein in two patients and directly into the external carotid artery and common facial vein in two patients. All free flaps were done with loop mag- nification and 9-0 nylon suture. The muscle flaps were sutured into position and trimmed and contoured so that an over-correction of approximately 20-30% was present in the immediate postoperative period. In two patients who required facial nerve grafting, the gra- cilis muscle was folded upon itself, sandwiching the facial nerve

Table 1

Age Sex PA diagnosis Surgical procedure Satisfaction Complications Would do cosmetic result flap again

72 F High-grade Total parotidectomy, preservation facial nerve, Very satisfied Postop hematoma Yes adenocarcinoma modified neck dissection, lateral tarsorraphy (grade 4)

M High-grade None Yes adenocarcinoma (grade 4)

M Adenoid cystic Yes carcinoma

F High-grade Yes adenocarcinoma (dedifferentiated acinic type)

51

62

69

Total parotidectomy, removal facial nerve, modified neck dissection, greater auricular nerve graft to facial nerve

Total parotidectomy, preservation facial nerve, modified neck dissection

Total parotidectomy, sacrifice facial nerve, radical neck dissection, deep muscle removal, parapharyngeal dissection, sural nerve graft, lateral tarsorraphy

Very satisfied

Very satisfied Skin necrosis Rd Rx

Very satisfied Facial palsy, exposure keratitis

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Fig. 1 a--e. Patient ~ 3 : a, b Preoperative views of a 62-year-old male with a right parotid mass. e Following resection, the tailored gracilis flap is revascularized by the facial vessels. The facial nerve was covered with the gracilis free flap. d Postoperative appearance, e

Lateral view of the early postoperative defect. Despite skin necrosis following radiation therapy, patient's incisions healed with little scarring

grafts between a vascularized tissue bed, since there was to be post- operative radiation. The skin was closed directly.

The two patients with facial nerve sacrifice underwent tarsor- rhaphy to protect their corneas. Average operative time for the completed surgical procedure ranged from 3.5-6 h with a mean time for free tissue transfer of 90 rain. The free tissue transfers did not prolong the postoperative stay. Hospitalization ranged from 4-9 days. All patients received radiation therapy within six weeks of surgery.

Results

The gracilis survived in all cases; the flaps were buried, the pedicles were dopplered th rough the skin and all re- mained patent. One pat ient developed a postoperat ive h e m a t o m a that was evacuated on the third postopera t ive day with delayed closure of the facial skin. The 72-year-

old female had poor return of her facial nerve function after grafting and radiat ion therapy and developed a mild exposure keratitis. The 62-year-old male developed some skin necrosis during the radiat ion therapy.

All patients were seen f rom 8-18 months following surgery and quest ioned about donor site problems and cosmesis; all were very satisfied. There were no problems with the d o n o r site scar or muscle harvest site. No patient compla ined of gus ta tory sweating, a l though starch iodine s t imulat ion testing was not performed. The facial contours were judged to be very satisfactory (Figs. 1, 2).

Discussion

Immedia te reconstruct ion of parot id defects with free tis- sue transfer could be considered as inappropr ia te and

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Fig. 2 a-f. Patient #2: a, b Preoperative views of 51-year-old pilot who was referred for radical parotidectomy, previous excision abandoned due to extent of tumor, e Radical parotidectomy, mod- ified radial neck dissection and complete removal of the sternoclei- domastoid muscle due to invasion by tumor, d The tailored gracilis

flap has been inserted; it covers the parotid fossa, to the infrafascic- ular nerve grafts to the facial nerve, and reconstructs the missing sternocleidomastoid muscle down to the clavicle, e, f Nine months postoperative appearance following radiation therapy; there is re- covery of facial nerve function

aggressive. The authors feel that with appropriate team- work, the gracilis microvascular transfer can be success- ful in 95-98% of cases. The operation time is not greatly increased, and the patients appreciate the total recon- struction.

There are several benefits in this use of gracilis to re- construct parotidectomy defects. The neuro and vascular supply have been well described [8]. The length of the donor site scar is less than 10 cms, is not visible and without contour deformity. The vascular pedicle is te- dious to dissect and short, but with dissection of the me- dial circumflex vessels into the interspace between the adductor longus and magnus muscles, a pedicle of 4 5 cm can be obtained with a vessel diameter of at least 1.5 mm. The muscle can be trimmed and manipulated to fit the surgical defect with approximately 20 30% over- correction. Utilizing a two-team approach, muscle har- vest and donor site closure is performed at the same time as tumor resection. With tumor removal completed, the microvascular anastomosis and suturing of the muscle into place should add no more than 60-90 min to the procedure.

Numerous techniques have been described to recon- struct the postoperative parotidectomy defect and pre- vent Frey's syndrome. These include: free dermal fat

grafting [9] , superficial musculoaponeurotic system (SMAS flap) [3, 10, 12], sternocleidomastoid muscle flap [4, 5], trapezius myocutaneous flap [7], and deepithelial- ized fasciocutaneous free flaps [1, 2, 6]. Although good results can be obtained with these techniques, they all have disadvantages. The use of the sternocleidomastoid muscle may produce an unsightly donor site defect in the neck. Following neck dissection, an unreliable blood sup- ply to the muscle can result in subsequent atrophy. Other regional muscle flaps can also be utilized but leave un- sightly donor site scarring. The SMAS layer is frequently unavailable, especially after resection of malignant tu- mors. Free, nonvascularized dermal fat grafts usually re- sorb with time; this is especially so with postoperative radiation. Deepithelialized scapular or groin free tissue transfer are also options, but not so satisfactory because of donor site access and potential morbidity.

The gracilis free tissue transfer through a very short, high medial thigh incision is considered to be the proce- dure of choice for immediate reconstruction of total parotidectomy defects. Contour correction has been ex- cellent, and there have been no postoperative complaints of Frey's syndrome. There is no donor site morbidity, and the procedure increases operating time by only 60- 90 min. To date, the success rate has been 100%. The

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a d a p t a t i o n of this t echn ique to superf icial p a r o t i d e c t o m y defects is be ing considered.

References

1. Baker DC, Shaw WW, Conley J (1979) Reconstruction after ablative head and neck surgery, Arch Otolaryngol 106:449-453

2. Baker DC, Shaw WW, Conley J (1980) Reconstruction of radical parotidectomy defects. Am J Surg 138:550-554

3. Bonanno PC, Casson PR (1991) Frey's syndrome: a preventable phenomenon. Plast Reconstr Surg 89:452-458

4. Bugis SP, Young JEM, Archibald SD (1990) Sternocleidomas- toid flap following parotidectomy. Head Neck 430-434

5. Casler JD, Conley J (1991) Sternocleidomastoid muscle transfer and superficial musculoaponeurotic system plication in the pre- vention of Frey's syndrome. Laryngoscope 101:95-100

6. David DJ, Tan E (1978) A de-epithelialized free groin flap for facial contour restoration. J Maxillofac Surg 6:249-252

7. Dinner MI, Guyuron B, Labandter HP (1983) The lower trapez- ius myocutaneous flap for head and neck reconstruction. Head Neck Surg 613-617

8. Manktelow RT, Zuker RM (1990) Microvascular free gracilis muscle and musculocutaneous flap to the forearm. In: Strauch B, Vasconez LO, Hall-Findlay EJ (eds) Grabb's encyclopedia of flaps. Little Brown and Company, Boston, pp 1207-1211

9. Nosan DK, Ochi JW, Davidson TM (1991) Preservation of facial contour during parotidectomy. Otolaryngol Head Neck Surg 104:293-297

10. Rappaport I, Allison GR (1985) Superficial musculoaponeurotic system amelioration of parotidectomy defects. Ann Plast Surg 14:315-323

11. Wallis KA, Gibson T (1978) Gustatory sweating following parotidectomy: correction of a fascia lata graft. Br J Plast Surg 31 : 68-71

12. Yu LR, Hamilton R (1992) Frey's syndrome: prevention with conservative parotidectomy and superficial musculoaponeurot- ic system preservation. Ann Plast Surg 29:217-222

N.B. Meland