Free Adipose Graft

Fat is usually removed from the periumbilical area. Fat removal in one piece is preferable to multiple pieces to minimize trauma and preserve vascularization. Although the resorption rate is not predictable, an overcorrection of 15–30% is suggested. The application of autologous platelet adhesive significantly reduces the resorption rate but adds complexity to the method. However, the combination of a SMAS flap with the application of autologous fat improves the symmetry and contour of the mandibular angle. The SMAS flap is sutured to the SCM muscle and prevents depression below the mandibular angle, even in case of fat resorption. Our experience shows that the combination of these two techniques enhance the cosmetic results. In addition, it has the advantage of preventing Frey syndrome. Fat grafting does not interfere with postoperative tumor monitoring because its signal on imaging is different from that of pathologic tissues. Partial resorption of the graft and the need for a donor site are the only disadvantages of the technique. Patient satisfaction rate is high.

Dermis fat graft does not seem to have a lower resorption rate than fat grafts, with the disadvantage of adding a scar, usually on the lower abdomen. Acellular dermis has no advantage over fat grafting except to avoid a donor site. On the other hand, it does not add volume, increases the cost and the infection risk, and is associated with inferior cosmetic results. With a limited risk of infection, hematoma, or fistula, fat grafting is a safe, simple, effective, and an inexpensive technique to consider for reconstruction after superficial parotidectomy. Combined with SMAS, fat grafting is the preferred technique for benign lesions.

SMAS, SCM, and TPF Flaps

Locoregional tissues are used to restore facial contour after superficial parotidectomy. The most frequently described flaps are SMAS and SCM. Few studies compare the results obtained by these flaps. In a series of 224 patients, Dell’aversana Orabona et al. evaluated SMAS, TPF, and SCM reconstructions after removal of a benign tumor. The three techniques have similar results in terms of facial contour and Frey syndrome. Bianchi et al. compared the results obtained without reconstruction, with the SCM, and with SMAS. The addition of reconstruction significantly improved facial contour without any differences between the techniques.

SMAS is a frequently used technique. Combined with a face lift incision and fat graft, there is a cosmetic improvement and a decrease in Frey syndrome. However, it cannot fill large volumes (>3 cm). It is not appropriate when the SMAS is infiltrated by tumor and in patients with thin subcutaneous tissue. The rapidity of its elevation and the absence of morbidity make it a flap of choice in reconstructions after superficial parotidectomy. In combination with fat or an SCM flap, studies also report good results.

The SCM muscle is easily accessible through the same incision. Only the anterior part of the muscle is separated, higher- or lower-based. Its indication is limited to reconstructions of the parotid tail, the anterior and upper regions being more difficult to reach by the muscle without compromising the symmetry of the neck. Long-term results are lacking with atrophy over time. Its harvest is associated with a potential risk of damage to the spinal nerve and great auricular nerve, hematoma, and neck asymmetry. The TPF flap is harvested by extending the incision hidden in the scalp. It is vascularized by the superficial temporal artery, which must be preserved during parotidectomy. Dell’aversana Orabona et al. report its use in defects of >3 cm. Complications at the donor site are alopecia on the incision borders and a lesion of the temporal branch of the facial nerve. Its delicate elevation increases significantly the operating time.