Parotidectomy and Plastic Reconstruction

 

Figure 5 show the preoperative location of the tumor (the round circle) and the standard incision (upper left).  Again, note the high and anterior location of the tumor.  In upper right, the actual incision line is seen.  In the middle left, the SMAS is seen being held by the forceps.  In the middle right, the dissected facial nerve is seen after the tumor removal.  In the lower left, the SMAS is seen laid back to fill the defect.  In the lower right, the closed incision is seen.

 
Figure 5a
 
Figure 5b
 
Figure 5c
 
Figure 5d
   
Figure 5e
   

By extending the incision to the hairline in front and behind the ear, one converts the incision into a standard facelift incision. At the Facial Institute, we combine our training as Facial Plastic Surgeons and Head and Neck Surgeons (the senior surgeon trained with the famed Head and Neck Surgeon, Paul Ward, MD, FACS who is now retired).  By applying both disciplines, a parotidectomy can be safely performed at the same time as a facial rejuvenation procedure.  It is with the superior knowledge of head and neck anatomy that excellent cosmetic results can be achieved with a stand alone facelift or one combined with head and neck tumor removals.  Let us explain.

As the individual ages, not only does the skin lose elasticity and sags, but so do the facial muscles and fat pads.  The gravity dependent downward shift of the tissues deep to the skin are largely responsible for jowling, loss of the jaw line, and deep nasolabial folds (the groove from the corner of the nose to the corner of the lip).  In the frequently-done skin only facelift only the skin is being pulled back.  This does not correct the deeper changes associated with aging.   This technique will lead to the classic poor result- the old Hollywood actress with a “windswept” look.  If the deeper structures are addressed, the result will be superior.  All the major changes of aging are addressed, not just the skin.  Even without simultaneous combined surgery, a facelift at the Facial Institute combines a well developed SMAS flap with reposition of deeper structures as needed.  You may see some of these results in the before and after section at FacialInstitute.com.  A combined patient is seen in Figure 6.

 
Figure 6a
 
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Figure 6e
   

Figure 6. The top 2 photos show the preoperative appearance.  She has a benign tumor of the left parotid.  The bottom 2 show the postoperative appearance after a simultaneous facelift, parotidectomy and SMAS flap.  The arrow to the left shows the intact facial nerve.  She is recurrence free 7 years later and has normal facial function without Frey’s syndrome.

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Besides parotid tumors, the combined procedure approach has been used for other benign head and neck tumors.  The patients in figure 7, 8 and 9 had tumors in various locations under and around the jaw that typically would have required an uncamouflaged incision under the angle of the mandible.  We were able to approach both with a small submental incision (in the line under the chin that is used for most facelifts) and the facelift incision.  With this approach, all the import nerve and vascular structures were identified and saved.

 
Figure 7a
 
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Figure 7d

Figure 7. Patient had a mass in her submandibular gland that was benign requiring removal of the entire gland (the salivary gland under her jaw). She had a simultaneous facelift.

 
Before
 
After

Figure 8. 45 year old only 6 days after a facelift (see the neck bruising on the right) and also after a simultaneous removal of a neck tumor through the same incision.  The tumor is see pushing out the tissues under the chin (arrow).  Patient is from out of the country and later photos are not available.

 
Figure 9a
 
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Figure 9d

Figure 9.  Patient with large submandibular tumor (see arrow) removed enitirely using facelift incisions.  All nerve and vascular structures were preserved.  She had a simultaneous facelift.

 


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David M. Alessi, MD, FACS  

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