- Email: [email protected]
Local Rhomboid Flap Reconstruction for Skin Defects After Excising Large Parotid Gland Tumors
Accepted Manuscript Local Rhomboid Flap Reconstruction for Skin Defects after Excising Large Parotid Gland Tumors Min-Hui Hung, M.D., Chun-Ta Liao, M.D., Chung-Jan Kang, M.D., Shiang-Fu Huang, M.D., Ph.D. PII:
S0278-2391(16)30834-5
DOI:
10.1016/j.joms.2016.09.021
Reference:
YJOMS 57456
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 12 July 2016 Revised Date:
30 August 2016
Accepted Date: 13 September 2016
Please cite this article as: Hung M-H, Liao C-T, Kang C-J, Huang S-F, Local Rhomboid Flap Reconstruction for Skin Defects after Excising Large Parotid Gland Tumors, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.09.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Local Rhomboid Flap Reconstruction for Skin Defects after Excising Large Parotid Gland Tumors
RI PT
Min-Hui Hung, M.D. Resident, Department of Otolaryngology, Chang Gung Memorial Hospital, Keelung, Taiwan Chun-Ta Liao, M.D. Professor, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taiwan
M AN U
SC
Chung-Jan Kang, M.D. Associate professor, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taiwan
TE D
Shiang-Fu Huang, M.D., Ph.D. 1 Associate professor, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taiwan 2 Department of Public Health, Chang Gung University, Taoyuan, Taiwan
*Send correspondence to Dr. Shiang-Fu Huang, Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.
EP
No. 5, Fu-Shin Street, Kwei-Shan, Taoyuan 333, Taiwan. Tel: 886-3-3281200 ext. 3968 ; Fax:
886-3-3979361
AC C
E-mail: [email protected] Running Title: Rhomboid Flap in Large Parotid Gland Tumor Key Words: parotid gland tumor, pleomorphic adenoma, Warthin’s tumor, skin defect, rhomboid flap Word count: 1576 Conflict of interest statement
ACCEPTED MANUSCRIPT
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M AN U
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None declared.
ACCEPTED MANUSCRIPT Abstract Most parotid tumors grow slowly, and, sometimes, these patients do not request
RI PT
surgical treatment until the tumors become large and affect their appearances. The surgical treatment of these large tumors is usually accompanied by large skin defects after the excision, and it is challenging for surgeons to close the defect primarily. We
SC
present case reports of 2 patients: one was a 68-year-old man with a left parotid gland
M AN U
tumor (110 mm in the greatest dimension), and the other patient was a 79-year-old man with a left parotid gland tumor measuring approximately 77 mm that had existed for decades. Both of the patients received facial nerve dissection and parotidectomy with skin sacrifice. The large skin defects following the parotidectomy were
TE D
successfully reconstructed with local rhomboid flaps. No facial palsy, wound disruption, flap edge loss or major complications occurred after the surgeries. Except
EP
for the scars, the color of the cheek flap was unapparent from the periphery. In
AC C
conclusion, local rhomboid flap reconstruction is a rapid and practical technique for reconstructing medium to large skin defects in the cheek and upper neck regions after tumor excisions. The flap was reliable in both blood supply and cosmetic outcome.
ACCEPTED MANUSCRIPT INTRODUCTION Parotid tumors are common in head and neck neoplasms, with an average
RI PT
incidence of 4.7 per 100,000 people for benign tumors and 0.9 for malignant tumors.1 Benign tumors account for approximately 60–80% of parotid neoplasms and comprise a heterogeneous group with distinct clinical and histological features and biological
SC
behaviors. The most common benign parotid gland tumor is pleomorphic adenoma
M AN U
(PA). Among such tumors, Warthin’s tumor, also known as adenolymphoma or papillary lymphomatous cystadenoma, is the second-most common benign neoplasm, accounting for approximately 15% of parotid epithelial tumors.2 However, most parotid tumors grow slowly, and parotidectomy with tumor
TE D
excision is the main treatment. Some patients prefer observation instead of surgery when the tumor initially presents. Occasionally, patients can have parotid gland
EP
tumors for decades, which can develop into a large parotid mass.3, 4 Such cases
AC C
present a challenge for surgeons when performing a parotidectomy and preserving the facial nerves. Moreover, the surgeries for large parotid gland tumors typically involve skin sacrifice, and closing the defect primarily can be difficult. Free flap reconstruction or rotation flaps are generally adopted in this situation, but the demands of the technique, the reliability of the flap and the color difference between the flap and the nearby cheek skin are the major concerns for these patients. We
ACCEPTED MANUSCRIPT attempted to solve these problems by developing a local rhomboid flap to reconstruct the skin defect after the excision of a large parotid tumor. In this paper, we report our
AC C
EP
TE D
M AN U
SC
RI PT
experiences with 2 of our patients.
ACCEPTED MANUSCRIPT Methods and Materials In 2004 and 2015, 2 patients with a large parotid tumor underwent a scheduled
RI PT
parotidectomy with facial nerve preservation and local rhomboid flap reconstruction at our institution. The follow-up times were 1 year and 6 months. No facial palsy, wound disruption, or major complications occurred. Each patient opted for an
SC
operation under general anesthesia and provided informed consent for the procedure.
Review Board, Taiwan, R.O.C.
M AN U
This case report was approved by the Chang Gung Medical Foundation Institutional
Surgical Technique of the Rhomboid Flap
After the parotidectomy and excision of the overlying skin, we developed a rhomboid
TE D
flap as described by Tamborini.5 Briefly, the flap was harvested in a diamond shape, following the geometric design of the classic rhomboid flap. The corner of the
EP
rhomboid excision was preserved as much as possible, giving the defect a near
AC C
diamond shape. A parallelogram was drawn around the lesion to be excised. Imaginary lines were extended from the longitudinal diagonal and one adjacent defect side of the parallelogram. These imaginary lines became the superior–medial side of the rotation flap. A line parallel to the long diagonal of the defect was drawn, which was equal in length to the defect side. Horizontal incisions were made in the preexisting creases as much as possible. The scars from the closure of the excision
ACCEPTED MANUSCRIPT and the flap’s donor site were hidden in the skin creases. After the diamond defect was created, the flap and surrounding tissue were undermined in the subplatysmal
RI PT
plane. The diamond flaps were rotated to fit the neighboring tissue to close the primary surgical defect, whereas the donor site was closed using primary closure. RESULTS AND REPRESENTATIVE CASES
SC
Case 1:
M AN U
A 68-year-old man had a left parotid gland tumor for several years (Figure 1a). Head and neck computed tomography (CT) revealed a large mass from the left parotid gland (92 mm in the greatest dimension). Initially, the patient was hesitant about the surgery. Two years later, a repeated CT was arranged and revealed an even larger
TE D
mass in the left parotid gland with marked interior cystic/necrotic content (110 mm in the greatest dimension). Sonography-guided needle aspiration was arranged, and the
EP
cytology was suggestive of PA. A scheduled parotidectomy with skin sacrifice and
AC C
local rhomboid flap reconstruction was performed (Figures 1b, 1c and 1d). The final pathology revealed a noninvasive carcinoma ex-PA with a closed margin and no metastasis. The wound healed well, and no facial palsy or other complications occurred. Adjuvant chemo-radiotherapy was suggested, but the patient refused. Regular follow-up of the patient was arranged, and no evidence of recurrence was noted.
ACCEPTED MANUSCRIPT Case 2: A 79-year-old man had a left infra-auricular mass lesion without pain for more than
RI PT
10 years (Figure 2a). Head and neck CT revealed a very large mass in the superficial lobe of the left parotid gland, with a lesion size of approximately 77 mm and
heterogeneous components. Sonography-guided fine needle aspiration was arranged
SC
and revealed complex solid and fluid contents. The aspiration cytology was negative
M AN U
for malignancy, with macrophages and neutrophils in the specimen. The favored diagnosis was Warthin’s tumor. The patient decided to undergo surgery because the tumor was too large and interfered with his social activities. A scheduled parotidectomy with skin sacrifice (Figure 2b) and local rhomboid flap reconstruction
TE D
was performed (Figure 2c). The postoperative follow-up revealed that the wound healed well; no facial palsy or other complication occurred (Figure 2d). The final
AC C
EP
pathology confirmed the initial diagnosis of Warthin’s tumor.
ACCEPTED MANUSCRIPT DISCUSSION The tumors in our study, Warthin’s tumor and PA, are the most common neoplasms in the salivary gland.6 Treatment of these tumors consists of a partial, subtotal, or total
RI PT
parotidectomy with preservation of the facial nerve.2 Recurrence after surgical
treatment is extremely rare.6 However, PAs have a risk of malignant change in
SC
patients who have had a tumor that has grown for a long period of time.7, 8 A previous
M AN U
study reported that the risk of malignancy is only approximately 1.5% up to 5 years but increases to 9.5% after more than 15 years.9 This condition we observed in our first patient. For parotid gland tumors, the skin can be preserved in a routinely performed parotidectomy except in conditions such as tumors that invade the skin,
TE D
margins that are close to the skin and concerns regarding the safety margin. In both of our cases, we attempted to preserve the skin overlying the tumors. However, both of
EP
the tumors in our study were so large that caution had to be taken to avoid rupture of
AC C
the tumor capsules. Inadvertent injury of the integrity of the tumor will ultimately cause tumor seedling and tumor recurrence. More specifically, in PA, tumor recurrence carries a high risk of malignant change, which is why we sacrificed a large area of the cheek skin. The follow-up of both patients revealed no tumor recurrence and proved that sacrificing the nearby skin can benefit the patients in disease eradication.
ACCEPTED MANUSCRIPT Rhomboid flaps were used in the facial reconstruction to repair the rhomboid defects.10 Limberg first described a transposition flap for closing a rhomboid defect in 1946. This flap was used to repair a defect with the configuration of a rhombus with
RI PT
60° and 120° interior angles.11 Rhomboid flaps are full-thickness cutaneous local
flaps with a random blood supply; they rely on the dermal–subdermal plexus of blood
SC
vessels. The aesthetic and mechanical properties of these flaps render them
M AN U
particularly useful for reconstructing defects on the cheek, temple, lips, nose, and eyelids. In both our cases, the blood supply of the flap edge was reliable, even for large defects and chronic smokers as our patients were. No flap-edge necrosis was noted, possibly because of the laxity of the neck skin of elderly adults, as was the case
TE D
with both of our patients. Comparing the rhomboid flap with a platysmal flap, the vascularity of the platysmal flap was unreliable and could not be used after neck
EP
dissection.12 By contrast, the rhomboid flap was more flexible than a cervicopectoral
AC C
flap or cervicodeltoid flap because of the smaller surgical extent and suits for medium check and neck skin defects. The other benefit of taking a rhomboid flap from the neck is the closely matching skin color. Except for the scars, the color of the cheek flap was unremarkable from the periphery. From our experience, the rhomboid flap is a straightforward to perform technique, has a high success rate and provides a good option for post-parotidectomy or cheek skin defects in addition to cervicopectoral
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
rotation flaps and plastysmal flaps.12, 13
ACCEPTED MANUSCRIPT CONCLUSION Surgical treatment of large parotid gland tumors is seldom encountered in clinical
RI PT
practice. From our experience, local rhomboid flap reconstruction is a practical tool for reconstructing medium skin defects and for patients requiring a parotidectomy for large skin areas. The flap was straightforward to perform and reliable in both blood
SC
supply and cosmetic outcome, and it provides a good option for cheek and upper neck
M AN U
skin defects. Acknowledgement
This work was supported by grants CMRPG3F0671 and BMRPB53 from Chang Gung Memorial Hospital, Linkou, and MOST 103-2314-B-182A-057-MY2 from the
AC C
EP
TE D
National Science Council, Executive Yuan, Taiwan, ROC.
ACCEPTED MANUSCRIPT REFERENCES 1.
Pinkston JA, Cole P: Incidence rates of salivary gland tumors: results from a population-based study. Otolaryngol Head Neck Surg 120:834, 1999 Bussu F, Parrilla C, Rizzo D, Almadori G, Paludetti G, Galli J: Clinical approach and treatment of benign and malignant parotid masses, personal
2.
RI PT
experience. Acta Otorhinolaryngol Ital 31:135, 2011 Phillips JS, Premachandra DJ: Giant parotid mass. Can J Surg 52:E21, 2009 Sajid M, Rehman S, Misbah J: Giant Pleomorphic Adenoma of the Parotid Gland. J Coll Physicians Surg Pak 25 Suppl 2:S110, 2015
3. 4.
Tamborini F, Cherubino M, Scamoni S, Frigo C, Valdatta L: A modified rhomboid flap: the "diamond flap". Dermatol Surg 38:1851, 2012 Yoo GH, Eisele DW, Askin FB, Driben JS, Johns ME: Warthin's tumor: a 40-year experience at The Johns Hopkins Hospital. Laryngoscope 104:799,
SC
5.
M AN U
6.
1994 Buenting JE, Smith TL, Holmes DK: Giant pleomorphic adenoma of the parotid gland: case report and review of the literature. Ear Nose Throat J 77:634, 1998
7.
10. 11. 12.
Oral Oncol 28B:49, 1992 Borges AF: The rhombic flap. Plast Reconstr Surg 67:458, 1981 Limberg AA: Design of local flaps. Mod Trends Plast Surg 2:38, 1966 Shestak KC, Roth AG, Jones NF, Myers EN: The cervicopectoral rotation flap--a valuable technique for facial reconstruction. Br J Plast Surg 46:375, 1993 Eckardt AM: Platysma myocutaneous flap - its current role in reconstructive surgery of oral soft tissue defects. J Korean Assoc Oral Maxillofac Surg 39:3, 2013
AC C
13.
TE D
9.
Mizui T, Ishimaru JI, Miyamoto K, Toida M: Malignant transformation of a gigantic pleomorphic adenoma of the submandibular gland: a case report. J Oral Maxillofac Surg 58:1422, 2000 Seifert G: Histopathology of malignant salivary gland tumours. Eur J Cancer B
EP
8.
ACCEPTED MANUSCRIPT FIGURE LEGENDS: Figure 1.
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(a) A large parotid tumor (largest diameter, 11.0 cm). (b) Skin defect after parotidectomy and facial nerve dissection. The design of the rhomboid flap is indicated by the white dashed line.
SC
(c) Rhomboid flap used for covering the whole skin defect.
sacrificed skin (10 x 10 cm). Figure 2.
M AN U
(d) Excised parotid tumor (size, 13 x 13 cm) with the intact capsule and overlying
(a) Large tumor in the left parotid gland with very thin overlying skin. The design of
TE D
the rhomboid flap is indicated by the white dashed line. (b) Excised parotid tumor (size, 9 x 8 cm) with the intact capsule and overlying
EP
sacrificed skin (8 x 8 cm).
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(c) Rhomboid flap was developed and used for covering the whole skin defect. (d) Three months after excision of the tumor and rhomboid flap reconstruction. Fair scar condition with no difference in skin color.
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SC
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
S0278-2391(16)30834-5
DOI:
10.1016/j.joms.2016.09.021
Reference:
YJOMS 57456
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 12 July 2016 Revised Date:
30 August 2016
Accepted Date: 13 September 2016
Please cite this article as: Hung M-H, Liao C-T, Kang C-J, Huang S-F, Local Rhomboid Flap Reconstruction for Skin Defects after Excising Large Parotid Gland Tumors, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.09.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Local Rhomboid Flap Reconstruction for Skin Defects after Excising Large Parotid Gland Tumors
RI PT
Min-Hui Hung, M.D. Resident, Department of Otolaryngology, Chang Gung Memorial Hospital, Keelung, Taiwan Chun-Ta Liao, M.D. Professor, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taiwan
M AN U
SC
Chung-Jan Kang, M.D. Associate professor, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taiwan
TE D
Shiang-Fu Huang, M.D., Ph.D. 1 Associate professor, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taiwan 2 Department of Public Health, Chang Gung University, Taoyuan, Taiwan
*Send correspondence to Dr. Shiang-Fu Huang, Department of Otorhinolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.
EP
No. 5, Fu-Shin Street, Kwei-Shan, Taoyuan 333, Taiwan. Tel: 886-3-3281200 ext. 3968 ; Fax:
886-3-3979361
AC C
E-mail: [email protected] Running Title: Rhomboid Flap in Large Parotid Gland Tumor Key Words: parotid gland tumor, pleomorphic adenoma, Warthin’s tumor, skin defect, rhomboid flap Word count: 1576 Conflict of interest statement
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
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None declared.
ACCEPTED MANUSCRIPT Abstract Most parotid tumors grow slowly, and, sometimes, these patients do not request
RI PT
surgical treatment until the tumors become large and affect their appearances. The surgical treatment of these large tumors is usually accompanied by large skin defects after the excision, and it is challenging for surgeons to close the defect primarily. We
SC
present case reports of 2 patients: one was a 68-year-old man with a left parotid gland
M AN U
tumor (110 mm in the greatest dimension), and the other patient was a 79-year-old man with a left parotid gland tumor measuring approximately 77 mm that had existed for decades. Both of the patients received facial nerve dissection and parotidectomy with skin sacrifice. The large skin defects following the parotidectomy were
TE D
successfully reconstructed with local rhomboid flaps. No facial palsy, wound disruption, flap edge loss or major complications occurred after the surgeries. Except
EP
for the scars, the color of the cheek flap was unapparent from the periphery. In
AC C
conclusion, local rhomboid flap reconstruction is a rapid and practical technique for reconstructing medium to large skin defects in the cheek and upper neck regions after tumor excisions. The flap was reliable in both blood supply and cosmetic outcome.
ACCEPTED MANUSCRIPT INTRODUCTION Parotid tumors are common in head and neck neoplasms, with an average
RI PT
incidence of 4.7 per 100,000 people for benign tumors and 0.9 for malignant tumors.1 Benign tumors account for approximately 60–80% of parotid neoplasms and comprise a heterogeneous group with distinct clinical and histological features and biological
SC
behaviors. The most common benign parotid gland tumor is pleomorphic adenoma
M AN U
(PA). Among such tumors, Warthin’s tumor, also known as adenolymphoma or papillary lymphomatous cystadenoma, is the second-most common benign neoplasm, accounting for approximately 15% of parotid epithelial tumors.2 However, most parotid tumors grow slowly, and parotidectomy with tumor
TE D
excision is the main treatment. Some patients prefer observation instead of surgery when the tumor initially presents. Occasionally, patients can have parotid gland
EP
tumors for decades, which can develop into a large parotid mass.3, 4 Such cases
AC C
present a challenge for surgeons when performing a parotidectomy and preserving the facial nerves. Moreover, the surgeries for large parotid gland tumors typically involve skin sacrifice, and closing the defect primarily can be difficult. Free flap reconstruction or rotation flaps are generally adopted in this situation, but the demands of the technique, the reliability of the flap and the color difference between the flap and the nearby cheek skin are the major concerns for these patients. We
ACCEPTED MANUSCRIPT attempted to solve these problems by developing a local rhomboid flap to reconstruct the skin defect after the excision of a large parotid tumor. In this paper, we report our
AC C
EP
TE D
M AN U
SC
RI PT
experiences with 2 of our patients.
ACCEPTED MANUSCRIPT Methods and Materials In 2004 and 2015, 2 patients with a large parotid tumor underwent a scheduled
RI PT
parotidectomy with facial nerve preservation and local rhomboid flap reconstruction at our institution. The follow-up times were 1 year and 6 months. No facial palsy, wound disruption, or major complications occurred. Each patient opted for an
SC
operation under general anesthesia and provided informed consent for the procedure.
Review Board, Taiwan, R.O.C.
M AN U
This case report was approved by the Chang Gung Medical Foundation Institutional
Surgical Technique of the Rhomboid Flap
After the parotidectomy and excision of the overlying skin, we developed a rhomboid
TE D
flap as described by Tamborini.5 Briefly, the flap was harvested in a diamond shape, following the geometric design of the classic rhomboid flap. The corner of the
EP
rhomboid excision was preserved as much as possible, giving the defect a near
AC C
diamond shape. A parallelogram was drawn around the lesion to be excised. Imaginary lines were extended from the longitudinal diagonal and one adjacent defect side of the parallelogram. These imaginary lines became the superior–medial side of the rotation flap. A line parallel to the long diagonal of the defect was drawn, which was equal in length to the defect side. Horizontal incisions were made in the preexisting creases as much as possible. The scars from the closure of the excision
ACCEPTED MANUSCRIPT and the flap’s donor site were hidden in the skin creases. After the diamond defect was created, the flap and surrounding tissue were undermined in the subplatysmal
RI PT
plane. The diamond flaps were rotated to fit the neighboring tissue to close the primary surgical defect, whereas the donor site was closed using primary closure. RESULTS AND REPRESENTATIVE CASES
SC
Case 1:
M AN U
A 68-year-old man had a left parotid gland tumor for several years (Figure 1a). Head and neck computed tomography (CT) revealed a large mass from the left parotid gland (92 mm in the greatest dimension). Initially, the patient was hesitant about the surgery. Two years later, a repeated CT was arranged and revealed an even larger
TE D
mass in the left parotid gland with marked interior cystic/necrotic content (110 mm in the greatest dimension). Sonography-guided needle aspiration was arranged, and the
EP
cytology was suggestive of PA. A scheduled parotidectomy with skin sacrifice and
AC C
local rhomboid flap reconstruction was performed (Figures 1b, 1c and 1d). The final pathology revealed a noninvasive carcinoma ex-PA with a closed margin and no metastasis. The wound healed well, and no facial palsy or other complications occurred. Adjuvant chemo-radiotherapy was suggested, but the patient refused. Regular follow-up of the patient was arranged, and no evidence of recurrence was noted.
ACCEPTED MANUSCRIPT Case 2: A 79-year-old man had a left infra-auricular mass lesion without pain for more than
RI PT
10 years (Figure 2a). Head and neck CT revealed a very large mass in the superficial lobe of the left parotid gland, with a lesion size of approximately 77 mm and
heterogeneous components. Sonography-guided fine needle aspiration was arranged
SC
and revealed complex solid and fluid contents. The aspiration cytology was negative
M AN U
for malignancy, with macrophages and neutrophils in the specimen. The favored diagnosis was Warthin’s tumor. The patient decided to undergo surgery because the tumor was too large and interfered with his social activities. A scheduled parotidectomy with skin sacrifice (Figure 2b) and local rhomboid flap reconstruction
TE D
was performed (Figure 2c). The postoperative follow-up revealed that the wound healed well; no facial palsy or other complication occurred (Figure 2d). The final
AC C
EP
pathology confirmed the initial diagnosis of Warthin’s tumor.
ACCEPTED MANUSCRIPT DISCUSSION The tumors in our study, Warthin’s tumor and PA, are the most common neoplasms in the salivary gland.6 Treatment of these tumors consists of a partial, subtotal, or total
RI PT
parotidectomy with preservation of the facial nerve.2 Recurrence after surgical
treatment is extremely rare.6 However, PAs have a risk of malignant change in
SC
patients who have had a tumor that has grown for a long period of time.7, 8 A previous
M AN U
study reported that the risk of malignancy is only approximately 1.5% up to 5 years but increases to 9.5% after more than 15 years.9 This condition we observed in our first patient. For parotid gland tumors, the skin can be preserved in a routinely performed parotidectomy except in conditions such as tumors that invade the skin,
TE D
margins that are close to the skin and concerns regarding the safety margin. In both of our cases, we attempted to preserve the skin overlying the tumors. However, both of
EP
the tumors in our study were so large that caution had to be taken to avoid rupture of
AC C
the tumor capsules. Inadvertent injury of the integrity of the tumor will ultimately cause tumor seedling and tumor recurrence. More specifically, in PA, tumor recurrence carries a high risk of malignant change, which is why we sacrificed a large area of the cheek skin. The follow-up of both patients revealed no tumor recurrence and proved that sacrificing the nearby skin can benefit the patients in disease eradication.
ACCEPTED MANUSCRIPT Rhomboid flaps were used in the facial reconstruction to repair the rhomboid defects.10 Limberg first described a transposition flap for closing a rhomboid defect in 1946. This flap was used to repair a defect with the configuration of a rhombus with
RI PT
60° and 120° interior angles.11 Rhomboid flaps are full-thickness cutaneous local
flaps with a random blood supply; they rely on the dermal–subdermal plexus of blood
SC
vessels. The aesthetic and mechanical properties of these flaps render them
M AN U
particularly useful for reconstructing defects on the cheek, temple, lips, nose, and eyelids. In both our cases, the blood supply of the flap edge was reliable, even for large defects and chronic smokers as our patients were. No flap-edge necrosis was noted, possibly because of the laxity of the neck skin of elderly adults, as was the case
TE D
with both of our patients. Comparing the rhomboid flap with a platysmal flap, the vascularity of the platysmal flap was unreliable and could not be used after neck
EP
dissection.12 By contrast, the rhomboid flap was more flexible than a cervicopectoral
AC C
flap or cervicodeltoid flap because of the smaller surgical extent and suits for medium check and neck skin defects. The other benefit of taking a rhomboid flap from the neck is the closely matching skin color. Except for the scars, the color of the cheek flap was unremarkable from the periphery. From our experience, the rhomboid flap is a straightforward to perform technique, has a high success rate and provides a good option for post-parotidectomy or cheek skin defects in addition to cervicopectoral
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
rotation flaps and plastysmal flaps.12, 13
ACCEPTED MANUSCRIPT CONCLUSION Surgical treatment of large parotid gland tumors is seldom encountered in clinical
RI PT
practice. From our experience, local rhomboid flap reconstruction is a practical tool for reconstructing medium skin defects and for patients requiring a parotidectomy for large skin areas. The flap was straightforward to perform and reliable in both blood
SC
supply and cosmetic outcome, and it provides a good option for cheek and upper neck
M AN U
skin defects. Acknowledgement
This work was supported by grants CMRPG3F0671 and BMRPB53 from Chang Gung Memorial Hospital, Linkou, and MOST 103-2314-B-182A-057-MY2 from the
AC C
EP
TE D
National Science Council, Executive Yuan, Taiwan, ROC.
ACCEPTED MANUSCRIPT REFERENCES 1.
Pinkston JA, Cole P: Incidence rates of salivary gland tumors: results from a population-based study. Otolaryngol Head Neck Surg 120:834, 1999 Bussu F, Parrilla C, Rizzo D, Almadori G, Paludetti G, Galli J: Clinical approach and treatment of benign and malignant parotid masses, personal
2.
RI PT
experience. Acta Otorhinolaryngol Ital 31:135, 2011 Phillips JS, Premachandra DJ: Giant parotid mass. Can J Surg 52:E21, 2009 Sajid M, Rehman S, Misbah J: Giant Pleomorphic Adenoma of the Parotid Gland. J Coll Physicians Surg Pak 25 Suppl 2:S110, 2015
3. 4.
Tamborini F, Cherubino M, Scamoni S, Frigo C, Valdatta L: A modified rhomboid flap: the "diamond flap". Dermatol Surg 38:1851, 2012 Yoo GH, Eisele DW, Askin FB, Driben JS, Johns ME: Warthin's tumor: a 40-year experience at The Johns Hopkins Hospital. Laryngoscope 104:799,
SC
5.
M AN U
6.
1994 Buenting JE, Smith TL, Holmes DK: Giant pleomorphic adenoma of the parotid gland: case report and review of the literature. Ear Nose Throat J 77:634, 1998
7.
10. 11. 12.
Oral Oncol 28B:49, 1992 Borges AF: The rhombic flap. Plast Reconstr Surg 67:458, 1981 Limberg AA: Design of local flaps. Mod Trends Plast Surg 2:38, 1966 Shestak KC, Roth AG, Jones NF, Myers EN: The cervicopectoral rotation flap--a valuable technique for facial reconstruction. Br J Plast Surg 46:375, 1993 Eckardt AM: Platysma myocutaneous flap - its current role in reconstructive surgery of oral soft tissue defects. J Korean Assoc Oral Maxillofac Surg 39:3, 2013
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13.
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Mizui T, Ishimaru JI, Miyamoto K, Toida M: Malignant transformation of a gigantic pleomorphic adenoma of the submandibular gland: a case report. J Oral Maxillofac Surg 58:1422, 2000 Seifert G: Histopathology of malignant salivary gland tumours. Eur J Cancer B
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(a) A large parotid tumor (largest diameter, 11.0 cm). (b) Skin defect after parotidectomy and facial nerve dissection. The design of the rhomboid flap is indicated by the white dashed line.
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(c) Rhomboid flap used for covering the whole skin defect.
sacrificed skin (10 x 10 cm). Figure 2.
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(d) Excised parotid tumor (size, 13 x 13 cm) with the intact capsule and overlying
(a) Large tumor in the left parotid gland with very thin overlying skin. The design of
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the rhomboid flap is indicated by the white dashed line. (b) Excised parotid tumor (size, 9 x 8 cm) with the intact capsule and overlying
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sacrificed skin (8 x 8 cm).
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(c) Rhomboid flap was developed and used for covering the whole skin defect. (d) Three months after excision of the tumor and rhomboid flap reconstruction. Fair scar condition with no difference in skin color.
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