Free Vascularized Parascapular Fat Flap for Parotidectomy Reconstruction

Abstract

Objective

The contour defect resulting after parotidectomy can be cosmetically unappealing. Multiple reconstructive efforts have been reported to mitigate this problem. We describe a novel technique of vascularized parascapular fat reconstruction based on the circumflex scapular vessels and evaluate its outcomes.

Methods

Consecutive patients who underwent parotidectomy with or without additional resections and vascularized parascapular fat flap reconstruction in 2020 were included. Demographic, morphologic, intraoperative, and postoperative data were assessed.

Results

Eight patients (3 female) were included. Median cut-to-close time was 247 (range 209–298) minutes, including tumor ablation. None of the patients had any wound complications, and all except one was discharged on postoperative day 1. Flap monitoring was not performed. None reported any significant donor site morbidity except scar formation. At last follow up, all patients reported satisfactory facial contour.

Conclusion

Vascularized parascapular fat flap reconstruction of parotidectomy contour defects has satisfactory cosmetic outcomes with minimal morbidity and short hospitalization courses.

Introduction

Multiple techniques have been described for reconstruction of facial contour defects after parotidectomy. These techniques ascend the reconstructive ladder and include free fat grafting, local flaps, and free flaps [1–3]. The stability of tissue volume and consistent healing of free fat grafting is questionable, especially in the setting of postoperative radiation. While fat resorption, necrosis, and volume under-correction are known complications of free fat grafts in the literature, other studies have noted a consistent and predictable long-term cosmetic result [4–6]. Due to the discrepancies regarding free fat graft stability in the literature, vascularized free flaps are promising since they offer more stable and predictable volume maintenance even after postoperative radiation treatment [7]. However, free tissue transfer requires microvascular expertise, an additional donor site, longer operative times, and prolonged hospitalization for flap monitoring. The parascapular flap has low associated morbidity and provides an optimal donor site for vascularized free tissue transfer after parotidectomy to facilitate a short inpatient stay and minimal additional operative time [8]. As a result, the aim of this study was to describe our institutional experience with reconstruction of parotidectomy defects with vascularized parascapular fat, a novel technique.

Materials and Methods

We conducted a retrospective review of consecutive patients who underwent parotidectomy with or without additional resections and were reconstructed with vascularized parascapular fat for facial contouring between January 1, 2020 and December 31, 2020. Demographic, morphologic, intraoperative, and postoperative follow-up details were assessed. This study was approved by the Washington University Institutional Review Board (#202012161).

Operative Technique:

After ablative surgery was completed, a parascapular fat flap was harvested from the ipsilateral side. The arm was draped and placed on an elevated mayo stand to enable access to the surgical site. A Doppler was used to identify the circumflex scapular vessels in the triangular fossa. A 6 cm incision was made, and anterior-inferior dissection was performed to identify the proximal pedicle between the teres major and minor. After the pedicle had been identified, a generous portion of fat and fascia was incorporated in the flap, and the proximal part of the descending and horizontal perforators were incorporated to ensure vascularity. A skin paddle was not incorporated. Once the flap was isolated on the pedicle, pedicle dissection was performed. Since minimal pedicle length was needed, dissection was only continued proximally until the vessels were of decent caliber for microvascular anastomosis (1–4 cm) (Figure 1A). The flap was then harvested, and the surgical site was closed over one suction drain with two-layered skin closure using resorbable sutures (Figure 1B). We then performed the microvascular anastomosis with 8–0 nylon sutures for the artery and a coupler device for the vein (Cook Medical, Bloomington, IN) (Figure 2) The flap was contoured to reconstruct the correct volume to the face and positioned meticulously to ensure ideal vessel geometry prior to skin closure (Figure 3).

Figure 1.

A. Flap isolated on its proximal pedicle on patient 3. *teres major. B. Double layered skin closure over a suction drain on patient 1.

Figure 2.

A. Anastomosis of the flap vessels to the left external jugular vein (v, venous anastomosis) and facial artery (a, arterial anastomosis) of patient 3. B. Anastomosis of the flap vessels to the facial artery and vein of patient 4 (v, venous anastomosis, a, arterial anastomosis).

Figure 3.

A. The volume was trimmed to an ideal size and positioned for ideal vessel geometry in order to avoid kinking in patient 4. B. Ideal flap volume and vessel orientation were also achieved in patient 1.

Results

In total, 8 patients, 3 females and 5 males underwent parascapular fat flap reconstruction after parotidectomy (Table 1). All patients had facial skin coverage after the parotidectomy, either with primary closure or with advancement flaps. Median cut-to-close time was 247 (range 209–298) minutes for the entire case including ablation. All patients had uneventful postoperative courses, with all except one being discharged on post-operative day 1. Flap monitoring was not performed in these patients, which reduced the amount of postoperative care. None of the patients developed any wound complications at either the facial incision or donor site. None of patients had any donor site morbidity from their harvest site except a small hidden linear scar. At last follow-up, all patients reported satisfaction with their facial contour with median follow-up of 6 (range 4 to 9) months.

Table 1.

Summary of patients’ demographics, disease, additional surgery and postoperative course.

ID	Age	Sex	BMI (kg/m2)	Pathology	Tumor diameter (cm)	Additional surgery	Other therapy	Artery	Vein, coupler size (mm)	D/C POD	Cut to close (min)	Follow-up (mo)
1	31	F	24.5	Low grade mucoepidermoid carcinoma	1.9	SND 2–4	None	Facial	Ranine 2.0	1	229	9
2	63	F	29.3	Pleomorphic adenoma	1.1	None	None	External carotid	EJ, 3.5	1	215	6
3	63	M	20.8	Salivary gland tumor of unknown malignant potential	2.8	SND 2–3	None	Facial	EJ, 2.5	1	209	6
4	48	M	29.8	Recurrent pleomorphic adenoma	1.6	Advancement flap, Nerve graft	None	Facial	Facial 4.0	1	294	6
5	66	M	36.0	Cutaneous SCC	2.7	WLE temple, advancement flap, SND 2–4	XRT	Superior thyroid	Facial, 3.0	1	298	6
6	82	M	30.0	Pleomorphic adenoma	3.1	None	None	Facial	Facial 3.0	2	245	9
7	78	M	27.8	Carcinoma ex-pleomorphic	2.5	WLE, MRND3	XRT	Facial	Ranine 3.0	1	249	5
8	60	F	28.5	Pleomorphic adenoma	3.7	None	None	Occipital	EJ, 3.0	1	265	4

Abbreviations: ID, identification number; BMI, body mass index; D/C, discharge; POD, post-operative day; mo, months; F, female; M, male; SCC, squamous cell carcinoma; SND, selective neck dissection; WLE, wide local excision; MRND3, modified radical neck dissection type 3; XRT, radiation therapy; EJ, external jugular vein.

Discussion

The contour defect that results from parotidectomy can be cosmetically displeasing. As a result, multiple reconstructive techniques have been described. Each technique has its own set of drawbacks in terms of donor site morbidity, operative time, long-term stability, and resource utilization. Non-vascularized options including autologous fat grafts can improve concave deformities with minimally increased operative times, but these grafts are prone to resorption, fat necrosis, and fluid collection, which is especially troublesome in patients with larger defects [9, 10]. The most popular option for vascularized reconstruction, a more reliable method for maintaining long-term bulk, is the anterolateral thigh (ALT) free flap, which is dependable for large parotidectomy defects but is difficult to tailor to smaller defects [11]. In addition, harvesting a vascularized ALT fat flap requires a larger incision and likely carries more donor site morbidity than harvesting a vascularized parascapular fat flap of the same size. As a result in this study, we assessed and demonstrated the feasibility of performing vascularized parascapular fat flaps for defect coverage. All patients reported satisfaction with the appearance of their facial contour at their most recent follow-up visit, and no patients reported any donor site morbidity.

The use of vascularized parascapular flaps to correct facial contour deformities has been previously described [12]. A case series of 22 patients in India describes the use of fasciocutaneous parascapular free flap reconstruction in patients with progressive hemifacial atrophy and hemifacial microsomia [13]. Unlike our study’s sample, these defects were congenital rather than iatrogenic and involved de-epithelialization of the donor site at the start of flap harvest. Inevitably, de-epithelialization results in larger donor site defects and the potential for more donor site morbidity. Our technique involves only a small 6 cm incision, which is closed primarily. In addition, all 22 patients in the above case series underwent debulking and recontouring after 6 months while none of the 8 patients in this series required a second stage procedure.

The main limitation with using parascapular fat for facial contouring is the need for sequential surgery during extirpation and reconstruction. Although simultaneous harvest has been described for subscapular system flaps, the compromised position while performing delicate dissection on the facial nerve does not justify the relatively small time gain in our minds. Although other adipofascial flaps have been described, the parascapular fat flaps have arguably the lowest donor site morbidity [8]. In addition, while harvesting this flap as a purely adipofascial flap, minimal dissection on the pedicle is required, thereby further minimizing morbidity as neurovascular structures in the triangular fossa are undisturbed.

Postoperatively these flaps were not monitored. Prior studies of ALT, lateral arm, and other parascapular free flap reconstruction of parotidectomy defects involved frequent postoperative monitoring and lengthy postoperative hospitalizations [2, 11, 14]. While the possibility of microvascular compromise upon leaving the operating room remains, that probability is quite low based on our previous institutional experience. In addition, with post-procedural arterial compromise, there would be minimal detrimental consequences beyond losing the potential benefits of a vascularized flap as a non-vascularized autologous fat graft would still remain. As for avoidance of venous compromise, we believe that a majority of venous compromise arises due to technical geometrical error. Thus, meticulous care was taken as to make sure geometry of the vein was safe throughout the full range of head positions prior to skin closure.

There are several limitations to this study. The small sample size and single surgeon experience limits the ability to draw significant conclusions and its applicability in a different setting. In addition, there are no validated outcomes for post-parotidectomy facial symmetry. Despite these shortcomings, safety and feasibility of this technique appear promising based on our preliminary experience. Future directions include prospective cohort studies of parotidectomy patients undergoing reconstruction with non-vascularized abdominal fat graft versus vascularized parascapular fat flap in order to compare short-term and long-term cosmetic outcomes. Validated patient-reported outcome measures, such as the FACE-Q Head & Neck Cancer ©, should be utilized for such future studies.

Conclusions

Vascularized parascapular fat flap is a cosmetically reliable and minimally morbid reconstructive method for restoring parotidectomy contour volume when microvascular expertise and familiarity of parascapular flaps are readily available.