Reconstruction of Complex Total Parotidectomy Defects Using the Free Anterolateral Thigh Flap with Adjacent Nerve and Fascia Grafts
River M. Elliott, MD, Gregory S. Weinstein, MD, David W. Low, MD, Liza C. Wu, MD.
University of Pennsylvania Health System, Philadelphia, PA, USA.
BACKGROUND: Defects resulting from total parotidectomy present unique challenges for reconstructive surgeons. Skin, subcutaneous tissue, bone and the facial nerve are often resected, resulting in severe contour deformity and facial paralysis. Advantages of the free ALT flap include versatility, a large skin and soft tissue paddle, long pedicle length, and access to adjacent nerves and fascia lata for facial reanimation. The purpose of this study is to report our experience and outcomes using the ALT flap and neighboring fascia and nerve grafts to reconstruct complex parotidectomy defects.
METHODS: The records of all patients treated by the senior authors between July 2005 and November 2009 who underwent parotidectomy, neck dissection, and reconstruction with free ALT flap were retrospectively reviewed. Surveys were conducted to assess patient satisfaction, functional outcome, and complications.
RESULTS: Twenty-two patients were enrolled. Of these, 14 participated in surveys. All patients underwent parotidectomy and neck dissection. Additionally, five patients had resection of the temporal or mastoid bones, six had partial or complete sacrifice of the facial nerve, and 11 had both bone and nerve resection. Three patients had parotidectomy alone. Nine patients had immediate reconstruction with free ALT alone; four underwent free ALT with fascia lata sling; five underwent free ALT with nerve grafting, and four underwent free ALT with fascia lata sling and nerve grafting. Mean operative time was 7 hours 14 minutes. Mean EBL was 365 cc. There was one flap loss. At a mean follow-up of 17.4 months, there were no wound infections, and no patients experienced lasting leg weakness. Four (29%) experienced numbness, and one (7%) developed a seroma. Recipient site morbidity included: two patients (14%) reported symptoms of Frey’s syndrome, three (21%) patients experienced delayed wound healing, and five (36%) reported facial numbness. All patients were able to eat solid food, however five reported problems with drooling. Smile asymmetry persisted in seven patients (50%), and five had difficulty closing the ipsilateral eye. Ten patients (71%) reported being “very happy” with their aesthetic result and two reported being “somewhat happy.”
CONCLUSIONS: The free ALT flap, used in conjunction with adjacent nerve and fascia, offers a versatile option for the reconstruction of complex parotidectomy defects. The procedure involves minimal donor site morbidity, and results in modest functional outcomes and high degrees of patient satisfaction.
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