A case is presented of a young female with parotid recurrent pleomorphic adenoma and skin infiltration treated with subtotal parotidectomy combined with a bilateral superficial muscular aponeurotic system rhytidectomy

BAJ, A.

BELTRAMINI, G.A.

COMBI, V.A.

DEMARCHI, M.

GIANNÌ, A.B.

English

PubMed

A. Baj

G.A. Beltramini

V.A. Combi

A. Giannì

M. Demarchi

AIR Universita degli studi di Milano

256Case reportBilateral SMAS rhytidectomy in parotid recurrent pleomorphic adenomaRitidectomia bilaterale nel trattamento di un adenoma pleomorfo parotideo ricorrenteA. BAj, G.A. BeltrAmini, m. DemArchi, V.A. comBi, A.B. GiAnnìDepartment of maxillo-Facial Surgery, Fondazione irccS ospedale maggiore Policlinico regina elena e mangiagalli, milan, italySummarya  case is presented of a young female with parotid recurrent pleomorphic adenoma and skin infiltration treated with subtotal parotidectomy combined with a bilateral superficial muscular aponeurotic system rhytidectomy.Key wordS: Pleomorphic adenoma • Parotidectomy • Rhytidectomy • Tumour recurrence • Skin infiltrationRiaSSunToGli autori descrivono il caso di una giovane donna affetta da adenoma pleomorfo parotideo ricorrente ed infiltrazione cutanea trattato mediante parotidectomia subtotale in associazione a ritidectomia bilaterale.parole chiave: Adenoma pleomorfo • Parotidectomia • Ritidectomia • Recidiva tumorale • Infiltrazione cutaneaActa Otorhinolaryngol Ital 2011;31:256-258IntroductionThe parotid gland is the most common site of salivary glands tumours; 50-74% of all parotid lesions are benign pleomorphic adenomas. The recurrence rate of pleomor-phic adenoma has been dramatically reduced from 20-45% to less than 4% over the last few decades 1.nevertheless, the management of recurrent pleomorphic adenomas of the parotid gland is a major challenge for the clinician 2. with surgical treatment there is a con-siderable risk of facial nerve injury and a high recur-rence rate. Moreover, on account of the high incidence in healthy young people, the aesthetic issues are not neg-ligible. Surgeons can use a rhytidectomy incision, for a parotidectomy, to avoid a visible scar 3 and use a superfi-cial musculo-aponeurotic system (SmaS) flap 4 5 or fat 6 grafts to fill any hollow or recess in the retro-mandibular region 7. Nodular dissemination with skin infiltration re-quires parotidectomy and excision of a huge skin paddle over the tumour. Direct closure of a unilateral excision can leave an asymmetric “pulled appearance” to one side of the face. in order to preserve facial contour and sym-metry, we suggest to balance the skin paddle sacrifice of the tumour affected side with a contralateral SmaS rhytidectomy 8.Case reporta 32-year-old female (Fig. 1a) with a 10-year history of multiple residual pleomorphic adenomas underwent su-perficial parotidectomy three times, which resulted in a facial nerve deficiency (Fig. 1B). She was referred to our Department following recurrence involving a right parotid mass with cutaneous infiltration that had grown over the last two years.after performing magnetic resonance imaging (mri) (Fig. 2) and considering the patient’s age, it was decided to perform a subtotal parotidectomy with facial nerve preservation and skin resection (Fig. 3a-B).an intra-operative frozen section confirmed the clinical diagnosis and excluded malignant transformation. The residual parotid gland was raised together with the skin and SMaS over the neoplasm (Fig. 3C-D). Subcutaneous and sub-SmaS flaps were prepared on the affected side in order to close the skin defect, with SMaS plication to fill the parotid defect. Then, to balance the facial symmetry, a SmaS and skin rhytidectomy were performed on the non-affected left side. The patient recovered very well, without any additional facial nerve dysfunction. The final pathology report confirmed that the mass was a benign pleomorphic adenoma. one month post-operatively, a sat-aCTa oToRhinolaRyngologiCa iTaliCa 2011;31:256-258Bilateral SMaS rhytidectomy in parotid recurrent pleomorphic adenoma257isfactory aesthetic result was achieved with perfect sym-metry of the face and facial rejuvenation (Fig. 4a-B-C). one year post-operatively, there is no evidence of either disease recurrence or Frey’s syndrome.Discussionrecurrent pleomorphic adenoma presents an increased risk of malignant transformation and facial nerve damage. Skin infiltration is another of the main problems of re-sidual adenomas, often requiring sacrifice of the skin and SMaS over the tumour with poor aesthetic results. The aims of surgical treatment of recurrent pleomorphic ad-enomas are wide excision of the lesions (total or subtotal parotidectomy with facial nerve preservation, whenever possible, and skin excisions, when necessary), preven-tion of gustatory sweating, and restoration of the facial symmetry. Surgical options should be tailored to the in-dividual patient.Defects of the parotid region, that include the gland and 4-5 cm of skin, can be reconstructed using non-vascular-ized dermal fat grafts, local skin or muscle flaps, regional myocutaneous flaps, and revascularized free tissue trans-fer 10 11. Each reconstructive method has inherent strengths and weaknesses, and all these options may fail to provide an excellent colour match and result in donor site morbid-ity. Direct closure can leave an asymmetric “pulled ap-pearance”.in our case, we performed an aggressive unilateral face lift to obtain initial closure of the resected site and performed the same procedure on the contralateral side  to obtain fa-cial symmetry and the best aesthetic results. with SmaS Fig. 1. Frontal static view (A) of a 32-year-old female with recurrence of a pleo-morphic adenomas. Frontal dynamic view (B) showing a facial nerve deficiency, out-come of three superficial parotidectomies.Fig. 2. Pre-operative mag-netic resonance imaging showing a right parotid mass with cutaneous infiltration.Fig. 3. Intra-operative views: (A) skin paddle design; (B) facial nerve identification and preservation; (C, D) extent of surgical resection.ABA BC Da. Baj et al.258References1 Redaelli de Zinis lo, Piccioni M, antonelli aR, et al. Man-agement and prognostic factors of recurrent pleomorphic ade-noma of the parotid gland: personal experience and review of the literature. eur arch otorhinolaryngol 2008;265:447-52.2 Valentini V, Fabiani F, Perugini M, et al. Surgical techniques in the treatment of pleomorphic adenoma of the parotid gland: our experience and review of literature. J craniofac Surg 2001;12:565-8.3 lohuis PJ, Tan Ml, van den Brekel MW, et al. Superficial parotidectomy via facelift incision. ann otol rhinol laryn-gol 2009;118:276-80.4 Marchal F, Sacoun a, Pieyre JM. Advantage of lifting in parotidectomy. Schweiz Med Wochenschr 2000;125:116S-21S.5 Foustanos a, Zavrides h. Face-lift approach combined with a superficial musculoaponeurotic system advancement flap in parotidectomy. Br J oral Maxillofac Surg 2007;45:652-5.6 Curry JM, Fisher KW, heffelfinger Rn, et al. Superficial musculoaponeurotic system elevation and fat graft recon-struction after superficial parotidectomy. laryngoscope 2008;118:210-5.plicature, this procedure allowed us to avoid Frey’s Syn-drome 12 13 and obtain excellent aesthetic results in terms of colour match and symmetry.in multiple residual pleomorphic adenoma with skin infil-tration, a contralateral face lift is a good choice for obtain-ing facial balance.address for correspondence: Dr. g.a. Beltramini, Dipartimento di Chirurgia Maxillo Facciale, Fondazione iRCCS ospedale Maggio-re Policlinico, Regina Elena e Mangiagalli, via Francesco Sforza 35, 20122 Milano, italy. Fax: +39 02 55032745. E-mail: giada.bel-tramini@hotmail.itReceived: august 30, 2010 - accepted: February 8, 2011Fig. 4. Frontal (A) and profile, right (B) and left (C), views one month post-operatively, showing symmetry of the face and facial rejuvenation without any additional facial nerve dysfunction.7 nouraei Sa, al-yaghchi C, ahmed J, et al. An anatomical comparison of Blair and facelift incisions for parotid sur-gery. clin otolaryngol 2006;31:531-4.8 Boynton JF, Cohen BE, Barrera a. Rhytidectomy and paroti-dectomy combined in the same patient. aesthethic plast Surg 2006;30:125-31.9 glas aS, Vermey a, hollema h, et al. Surgical treatment of recurrent pleomorphic adenoma of the parotid gland: a clinical analiysis of 52 patients. head Neck 2001;23:311-6.10 Teknos Tn, nussenbaum B, Bradford CR, et al. Reconstruction of complex parotidectomy defects using the lateral arm free tis-sue transfer. otolaryngol head Neck Surg 2003;129:183-91.11 asal K, Köybaşioğlu a, inal E, et al. Sternocleidomastoid muscle flap reconstruction during parotidectomy to prevent Frey’s syndrome and facial contour deformity. ear Nose Throat J 2005;84:173-6.12 Cesteleyn l, helman J, King S, et al. Temporoparietal fascia flaps and superficial musculoaponeurotic system plication in parotid surgery reduces Frey’s syndrome. J oral maxillofac Surg 2002;60:1284-97.13 angspatt a, yangyuen T, Jindarak S, et al. The role of SMAS flap in preventing Frey’s syndrome following standard su-perficial parotidectomy. J Med assoc Thai 2004;87:624-7.A B C

Bilateral SMAS rhytidectomy in parotid recurrent pleomorphic adenoma

E-mail: giada.beltramini@hotmail.it Received:

Management and prognostic factors of recurrent pleomorphic adenoma of the parotid gland: personal experience and review of the literature. eur arch otorhinolaryngol

Sacoun a, Pieyre JM. Advantage of lifting in parotidectomy. Schweiz Med Wochenschr

Superficial musculoaponeurotic system elevation and fat graft reconstruction after superficial parotidectomy. laryngoscope

Superficial parotidectomy via facelift incision. ann otol rhinol laryngol

Surgical techniques in the treatment of pleomorphic adenoma of the parotid gland: our experience and review of literature.

Zavrides h. Face-lift approach combined with a superficial musculoaponeurotic system advancement flap in parotidectomy.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3203725

Bilateral SMAS rhytidectomy in parotid recurrent pleomorphic adenoma

Abstract

Similar works

Full text

Available Versions

AIR Universita degli studi di Milano