The parotid gland, the largest salivary gland, is the most common gland harboring tumors, with a reported incidence of 75% in the United States [1]. Both malignant and benign tumors are removed through different parotidectomy types, depending on the extent of the tumor. Postoperatively, 70% patients exhibit facial contour defects in the form of concave deformities, which are negatively correlated, esthetically, with the resection depth of the parotid gland [1]. Reconstructive options such as local and regional flaps, vascularized tissue flap transfer, acellular dermal matrix, filler, and abdominal dermal fat have been reported [1].

Recently, facelift incision is being used for the excision of benign parotid tumors [2]. It provides esthetic satisfaction to the patient as the scars are hidden, a wide surgical field, and access to the superior aspect of the sternocleidomastoid muscle (SCM) and the lateral part of the face, including the superficial musculoaponeurotic system (SMAS) [2]. Additionally, it helps in the reconstruction of the excised parotid gland with SCM and SMAS transposition flaps without additional incisions [2].

Facial harmony and appearance are important aspects of quality of life, and deformities of the face impact a person’s social life and social interaction considerably by both self-perception and observer-perception [3]. Parotidectomy alters facial appearance, particularly leading to facial deformities and scars. Thus, reconstruction after parotidectomy should be aimed to restore the patient to a normal state with the lowest morbidity.

Herein, we report a case of a malignant parotid tumor with a skin defect that was surgically removed via a modified Blair incision and reconstruction with SMAS transposition flap and partial-thickness SCM myocutaneous flap.

A 38-year-old male visited our otolaryngology-head and neck department with a slowly growing and painless mass in the right parotid region since 2 years. The patient had not experienced facial palsy in the past. His medical and surgical histories were unremarkable. He was not a smoker, but he occasionally consumed alcohol every month.

Physical examination of the head and neck showed a large, firm, and painless mass measuring approximately 7 cm×7 cm over the parotid region (Fig. 1). No abnormal findings were found in the oral cavity or larynx, except for the mass in the parotid gland. Gross cranial nerve examination, including that of the facial nerve, revealed no abnormal findings. Contrast-enhanced computed tomography (CT) showed a large mass with inhomogeneous enhancement in the right parotid gland, approximately 7 cm in maximum dimension (Fig. 2). The fine needle aspiration cytology report indicated a malignant parotid tumor such as myoepithelial carcinoma.

Figure 1. (A) Preoperative view of the protruding right parotid mass, which led to facial disfigurement. (B) Preoperative status of the mass occupying the parotid region.

Figure 2. (A) Preoperative contrast-enhanced axial computed tomography scan showing a large right parotid mass with heterogeneous enhancement. (B) Coronal computed tomography showing mass protrusion from the parotid gland.

Enhanced magnetic resonance imaging of the head and neck revealed a large mass with mixed diffusion restriction in the right parotid gland and strong inhomogeneous enhancement (Fig. 3) extending into the right masticator, pterygoid, and parapharyngeal spaces.

Figure 3. Preoperative gadolinium-enhanced magnetic resonance imaging delineating the soft tissue border of the right parotid mass and showing the facial disfigurement caused by the large parotid tumor. (A) Axial view, (B) coronal view.

Staging work-up using positron emission tomography and thoracic CT showed no significant nodule or mass in either lung, no pleural or pericardial fluid collection, and no significantly enlarged lymph nodes in the mediastinum and both hila. Some abnormal metabolic findings such as small metastatic lymphadenopathies in the right cervical levels II and III, but no significant hypermetabolic evidence of other distant metastases were observed.

The patient underwent right total parotidectomy with right supra-omohyoid neck dissection, and a superiorly based partial-thickness SCM flap with an SMAS flap was used for reconstruction (Fig. 4). We designed our reconstruction to cover the lower part of the defect using a superiorly based partial-thickness myocutaneous SCM transposition flap and reinforced it with the posterior margin of the platysma for a tension-free skin closure. The SMAS flap was elevated and used to cover the smaller upper part of the defect. Lastly, after skin undermining, we closed the primary skin defect without tension and used Z-plasty to overcome and correct the standing-cone deformity.

Figure 4. Intra-operative photographs. (A) Significant soft tissue hollowness in the right parotid region after total parotidectomy with an intact but exposed facial nerve (black arrow). Superficial musculoaponeurotic system (SMAS) layer (white arrow) and sternocleidomastoid muscle (SCM) (blue arrow) can be identified. (B) Closure and reconstruction of the defect with the combined use of an SMAS flap and a superiorly based partial-thickness myocutaneous SCM flap. The resultant standing-cone deformity was corrected using Z-plasty to hide the scar behind the right auricle.

Histologic analysis and immunohistochemistry revealed the lesion as low-grade mucoepidermoid carcinoma with a negative surgical margin. Postoperative radiotherapy was performed because of a lack of confidence in the achievement of excision with safe margins.

During the first month of follow-up, there were no complications, such as delayed facial paralysis, Frey’s syndrome, soft tissue depression, significant facial contour deformity, or pain at the surgical site. To date, the patient has had no evidence of recurrence after the operation (Fig. 5).

Figure 5. (A) One-month postoperative frontal view of the patient clearly showing more harmonious facial contouring and negligible lower facial-third asymmetry formed by the bones of the lower face. (B) Postoperative lateral view showing hidden facial scars and smooth contouring and transition between the face and neck region.

Traditionally, a parotid gland tumor is approached by the bayonet-shaped incision described by Blair. Surgical techniques for parotidectomy have evolved over time, with several techniques being advocated today. Regardless of the type of parotidectomy, a few temporary or permanent complications may occur that may have a significant negative effect on patient quality of life [4]. Generally, two major complications should be considered during and after parotidectomy. Functional complications include facial nerve morbidity and Frey’s syndrome. Esthetic complications include pre-auricular and cervical scars and the formation of a hollow and depressed space over the parotid region, which may have significant negative effects on patient quality of life [2].

Malignant parotid tumors are considered a contraindication for facelift incision and SMAS flap because of an increased risk of recurrence and residual disease [5]. Nevertheless, as long as the plane of dissection is normal and the tumor can be excised with a safe margin and without affecting the SMAS layer, its use to reconstruct the parotid region is reasonable [5].

Surgical techniques to restore the facial contour after parotidectomy include fat grafting, fascia lata graft, acellular dermal matrix, dermofat graft, SMAS flap, SCM flap (superiorly or inferiorly based), platysma muscle flap, and temporoparietal fascia flap through free tissue transfer [1,6,7]. Although reconstruction is important, the optimal modality for parotid region reconstruction remains controversial. Surgeons should consider the interdependence between function protection and esthetic outcome, and consider facial contour symmetry, defect coverage, auricular shape and position, and facial nerve protection before opting for a treatment modality [8].

The SCM muscle is highly vascular, receiving blood supply from the occipital artery in the superior portion, superior thyroid artery in the midportion, and transverse cervical artery in the lower portion. Therefore, the SCM flap can be designed using several methods; partial-thickness superiorly based flap is the most described variant [7,9]. Possible complications reported with the SCM flap are depression in the neck, particularly in individuals with a thin neck, and injury to the cervical accessory and great auricular nerves [9]. Additionally, the SMAS flap is considered a biological barrier of the face that also shows the ability to fill the defect [10]. The muscle fibers of the SMAS layer run extensively in the face, which provides the surgeon with various flap designs to cover the defect in the parotid region [10]. However, the SMAS layer is thin and short compared with the SCM flap, which alone may not optimally restore facial symmetry because of an insufficient tissue bulk [9].

In our case, we used a modified Blair incision to approach the large malignant parotid tumor for wide surgical field access, and the skin and subcutaneous layer were excised with a safe margin, managing skin redundancy and obtaining neck access for dissection of cervical lymph nodes. At the conclusion of surgery, the facial nerve was intact but exposed due to skin and subcutaneous and soft tissue defects in the parotid region.

Parotidectomy is a relatively safe surgical procedure that aims to remove benign and malignant tumors. However, the key negative factors of parotidectomy are facial disfigurement and disharmony due to soft tissue defects in the parotid region. Nevertheless, we combined the advantages of the SMAS and SCM flaps to reconstruct the defect with a pleasant outcome and protect the facial nerve and Frey’s syndrome.

The authors have nothing to disclose.