Sternocleidomastoid Flap in Parotid Surgery: A Case Series

Abstract

Superficial and deep parotidectomies are known treatments for benign and malignant neoplasms of parotid glands. Due to the gland's proximity to facial nerve and other vital structures, this surgery carries the highest risk of facial nerve palsy. Another frequently overlooked complication, which can be detrimental to patient's life style is Frey's syndrome, or gustatory sweating. Other complications include flap necrosis and various contour deformities. We conducted this study on a group of 40 patients of parotid swellings to assess usage of sternocleidomastoid flap in prevention of Frey's syndrome, contour deformities, flap necrosis, salivary fistula and drain related injuries. We divided the patients in two groups based on the usage of sternomastoid flap. In Group A, the patients underwent superficial or total parotidectomies with a partial thickness, superiorly based sternomastoid flap. In Group B, no sternomastoid flap was placed. The incidence of Frey's syndrome was seen to be 3 times in Group B, while a visible contour deformity was seen in a third of patients in Group B, with Group A reporting no incidence. Also Group A, did not see any cases of flap necrosis or salivary fistula, while Group B saw 3 and 2 cases respectively. Also, among the two revision cases done in Group A, the one with previously placed sternomastoid flap (done by us 3 years back) had an excellent plane preserved, while another revision case without sternomastoid flap saw a complete adherence of facial nerve to overlying skin, resulting in Grade II permanent facial palsy. Parotidectomy is a technically challenging surgery in regards to important structures in the vicinity. Even with ostensibly perfect technique, facial nerve injury can occur for unknown reasons. All in all, sternomastoid flap is an acceptable modality to fill the parotidectomy defect, improve the facial contour and reduce the incidences of Frey's syndrome and skin necrosis.

Minor Parotidectomy Complications: A Systematic Review

“…Flap necrosis was reported in 34 studies 16,23,27,30,38,46,48,64,67,68,73,79,82–85,96,98,105–107,111,114,115,118,125,128,130,136,147,149,213,216,217 reporting on 7,017 patients (Table I and Fig. 2E).…”

“…Salivary fistula was reported in 137 studies 6–10,12,14–16,18–24,27,28,30–34,36,38–40,43–45,47,49,51,52,55,56,58,62–65,75,76,79,84–87,89,91,93,97–99,101,103–109,112,114–119,124–127,129,131–133,136,138,139,141,144,148–150,153,154,156,164,166,170–215 reporting on 18,815 patients (Table I and Fig. 2D).…”

“…A factor possibly related to flap necrosis was the extent of surgery, being for recurrences 48 or for deep lobe tumors 217 . In two studies, no clear explanation 67,213 could be found.…”

“…Postparotidectomy depression or deformity were reported in 25 studies, 29,37,43,83,91,99,103,105,107,116,136,143,157,164,188,194,205,208,213,219,221,223,224,239,240 reporting on 2,481 patients (Table 1). The pooled incidence of depressions reported was 11.8 (95% CI: 6.9‐19.5), with a minimum of 0% and a maximum of 45% (heterogeneity I 2 = 90.4%).…”

“…The only factor from outliers is the absence of reconstruction 116,219 . Statistically significant reduction of the depression was found after various reconstruction techniques: temporoparietal fascial flap, 219 SMAS and sternocleidomastoid muscle flap, 157 sternocleidomastoid muscle flap, 213,240 or SMAS alone 83,99,143,205,224 …”