Submandibular gland flap for reconstruction after parotidectomy

Submandibular Gland Flap Reconstruction for Oropharyngeal Defects After Transoral Robotic Surgery (TORS)

BACKGROUND

To describe utilization and outcomes of submandibular gland flap (SGF) reconstruction after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

A multi-institutional retrospective case series of patients who underwent TORS for OPSCC followed by SGF reconstruction with harvest via transcervical approach from 1/1/2016 to 4/1/2023.

RESULTS

In total, 14 patients underwent SGF reconstruction after TORS for OPSCC. All patients had HPV-positive disease, predominantly in early local (N = 10 with pT1/pT2 disease, 71%) and regional stages (N = 11 with pN0/pN1 disease, 79%). Most patients received adjuvant radiation treatment (N = 9, 64%). Median hospital LOS after surgery was 4 days (IQR 2 days) with median functional oral intake scale (FOIS) score of 5 (IQR 0.8) at 1-3 weeks after surgery.

CONCLUSIONS

SGF reconstruction is a useful technique for closure of appropriately selected TORS defects requiring reconstruction beyond healing by secondary intention and mobilization of adjacent tissue but not large enough to warrant free flap reconstruction.

Functional reconstruction of tissue defects after total parotidectomy using a modified submandibular gland flap

OBJECTIVE

Reconstruction of soft tissue defects after total parotidectomy requires a feasible and effective pedicled flap with sufficient volume. In this study, we introduce a modified submandibular gland flap (SMGF) for functional reconstruction of soft tissue defects resulting from total parotidectomy.

MATERIALS AND METHODS

This study included 12 patients diagnosed with parotid gland carcinoma undergoing total parotidectomy and ipsilateral selective neck dissection. The modified SMGF was harvested and transferred to the parotid bed. This procedure was coupled with anastomosis between the parotid gland duct and Wharton's duct. The feasibility of the surgery, postoperative complications, facial profile restoration, and salivary secretion were assessed.

RESULTS

All SMGFs pedicled only over the proximal facial artery survived without major complications. Facial profiles were well-restored, and salivary secretion was partially reserved. During the postoperative follow-up, no tumor recurrence was observed in any of the cases, and the volume of the SMGFs did not show obvious atrophy.

CONCLUSIONS

The modified SMGF is a viable solution for volume restoration and functional reconstruction after total parotidectomy.

CLINICAL RELEVANCE

This modified technique is simple and feasible for the functional reconstruction of soft tissue defects after total parotidectomy compared to other flaps and is worthy of clinical promotion.

Reverse submandibular gland flap: An alternative for reconstruction of medium-sized oral defects

Despite the development of microsurgery, local flaps still play an essential role in the reconstruction of head and neck defects. The submandibular gland flap (SMGF) has proven to be a reliable method for repairing medium-sized defects. It requires a shorter duration of general anesthesia and has fewer donor site complications compared to the free flap. However, the restricted vascular pedicle length limits its application. Retrograde flow is one solution. The authors describe a novel technique of using reverse submandibular gland flap (RSMGF) for the reconstruction of oral cavity defects. Additional vascular pedicle length was obtained by ligating the proximal end and dissecting the distal end of the facial vessels, thus extending its application range. The RSMGF is technically feasible and suitable for repairing medium-sized defects of the oral cavity (cT2 stage tumor) like buccal mucosa, especially for the elderly in poor general condition, for whom free flaps are not applicable.

CT and MR Imaging Appearance of the Pedicled Submandibular Gland Flap: A Potential Imaging Pitfall in the Posttreatment Head and Neck

Pedicled locoregional submandibular gland reconstruction flaps are increasingly used in oncologic head and neck surgery and have unique imaging characteristics that can mimic locally recurrent tumor. In this clinical report, 23 posttreatment imaging studies were evaluated in 19 patients who had undergone submandibular gland flap reconstructions after resection of a primary head and neck tumor. Submandibular gland flaps were most commonly mobilized into the parapharyngeal space or parotid bed, with others located inferior to the mandibular body and within marginal mandibulectomy defects. The original shape of the gland was typically not preserved. Identifying the submandibular gland hilum, vascular pedicle, glandular texture, and absence of submandibular gland in the orthotopic location was most useful in recognizing a flap. The interpreting radiologist must be familiar with the unique submandibular gland flap imaging characteristics to accurately differentiate normal postoperative appearance and recurrent tumor.

Novel Local Chimeric Flap Based on Tunnelized Facial Artery Myomucosal Island Flap and Submandibular Gland Flap for Reconstructions After Oral Squamous Cell Carcinoma Surgery

The reconstruction of oral tongue and floor of mouth defects after resections of squamous cell carcinoma is a challenging task in reconstructive surgery aiming for appropriate restoration of oral function and quality of life improvement. In this study, the authors introduce the innovative reconstruction technique of medium-sized defects consisting of tunnelized facial artery myomucosal island flap and submandibular gland flap as the local chimeric flap pedicled on facial vessels. A retrospective case series evaluation of 4 patients suffering from oral cavity cancer (stages III and IVa), who underwent transoral tumor excision with neck dissection and immediate reconstruction in the time period September 2020 to July 2021, was conducted. No flap losses or flap-related complications were identified. No recurrences occurred during the follow-up at 11.0±4.5 months (range: 6-16 mo, median=11 mo). Tunnelized facial artery myomucosal island flap and submandibular gland flap local chimeric flap expands the reconstruction options of medium-sized defects after ablative oral cancer surgery in carefully selected patients primarily not suitable for free flap reconstructions.

Pedicled Cervical Lymphoadipose Tissue for Volume Reconstruction after Superficial Parotidectomy

Volume restoration is often required after parotidectomy due to the resultant facial contour deformity. Common procedures include local pedicled flaps, such as the sternocleidomastoid muscle flap, fat grafting, and even autologous free flaps, for more extensive defects. Local pedicled flaps have the advantage of a single surgical site, which spares the patient the added morbidity of a separate fat graft donor site, while simultaneously reducing the operative time. We report two cases of a novel reconstructive option using pedicled level I and II cervical lymphoadipose tissue for volume restoration after superficial parotidectomy. This reconstruction would be useful for patients with benign parotid lesions and inferior parotid defects. In addition, with maintained blood supply to this tissue, it would likely provide sustained bulk over time.

What is the best method for prevention of postparotidectomy Frey syndrome? Network meta-analysis

BACKGROUND

Prevention of Frey syndrome (FS) after parotidectomy using an interposition barrier has long been gaining a wide popularity; however, there is no clear evidence regarding which preventive technique is more effective. The aim of this network meta-analysis (NMA) is to answer the question: What is the best method for prevention of FS after parotidectomy?

METHODS

A comprehensive search of the PubMed, Embase, SCOPUS, and Cochrane library was conducted to identify the eligible studies. The outcome was the incidence of subjective Frey syndrome (SFS) and objective Frey syndrome (OFS). The Bayesian NMA accompanied with a random effects model and 95% credible intervals (CrIs) were calculated using GeMTC R package.

RESULTS

Thirty-four studies (n = 2987 patients) with five interventions, namely Alloderm (ADM), temporoparietal fascia (TPF), sternocleidomastoid muscle (SCM), superficial musculoaponeurotic system (SMAS), and free fat graft (FFG), were compared together and with no interposition barrier (NB). The results of NMA showed a statistically significant reduction in both SFS and OFS when ADM, TPF, SMAS, FFG, and SCM were compared with NB. No statistical differences were observed when comparing ADM, SCM, SMAS, FFG, and TPF. TPF ranked the best of all treatments (59.4%) and was associated with the least incidence of SFS; whereas ADM ranked the best of all treatments (61.1%) and was associated with the least incidence of OFS.

CONCLUSIONS

All interventions (TPF flap, ADM, FFG, SMAS, and SCM) were associated with a significant reduction in the incidence of FS when compared with NB. TPF and ADM showed the best outcome with the least incidence of SFS and OFS, respectively.

Different Surgical Strategies in the Prevention of Frey Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE/HYPOTHESIS

To define the best surgical technique able to reduce Frey syndrome (FS) incidence after parotidectomy.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were the incidence of subjective (clinical) and objective (positive starch-iodine test result) FS, respectively.

RESULTS

A total of 3830 patients with a median age of 50.35 years (n = 2323; IQR 44.25-54.18) were included for six interventions [temporoparietal fascia (TPFF), free fat graft (FFG), acellular dermal matrix (ADM), sternocleidomastoid muscle (SCM) flap, and superficial musculoaponeurotic system (SMAS) flap]. If compared to no treatment, the greatest reduction of subjective (clinical) FS incidence was measured for the TPFF (OR: 0.07, CI: 0.004-0.57), the ADM (OR: 0.09, CI: 0.02-0.35), and the FFG (OR: 0.11, CI: 0.03-0.42) techniques. However, a significant difference was measured also for the SCM flap (OR: 0.38, CI: 0.18-0.73) and for the SMAS flap (OR: 0.42, CI: 0.19-0.97). All treatments showed a significant reduction of the objective FS incidence if compared to no treatment (FFG, OR: 0.06, CI: 0.002-0.62; TPFF, OR: 0.07, CI: 0.01-0.33; ADM, OR: 0.11, CI: 0.03-0.44; SMAS, OR: 0.36, CI: 0.17-0.71; SCM, OR: 0.40, CI: 0.19-0.74).

CONCLUSIONS

TPFF, ADM, and FFG seem to be the best treatment strategies to prevent FS after parotidectomy. Further randomized controlled trials comparing these techniques should be conducted to define specific indications. Laryngoscope, 131:1761-1768, 2021.