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Cervicofacial Rhytidectomy After Head and Neck Tumor Removal


The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia 2001 The American Laryngological, Rhinological and Otological Society, Inc.

Cervicofacial Rhytidectomy After Head and Neck Tumor Removal
Jonathan H. Lee, MD; David A. Sherris, MD

Objective:
To compare intraoperative and postoperative complication rates of cervicofacial rhytidectomy after head and neck tumor removal with complication rates of rhytidectomy in the normal patient population. Study Design: Retrospective chart review and literature review. Methods: A sample of 11 patients treated by a single surgeon (D.A.S.) at an academic referral center who met the inclusion criteria was reviewed for previous head and neck surgical history, medical history, and surgical results and sub­sequent complications of the facial esthetic procedure. These rates were compared with the complication rates for cervicofacial rhytidectomy in normal patients as quoted in the general medical literature. Results: Patients ranged in age from 48 to 75 years (mean age, 58 y). Of the 11, no patient experienced a major complication of rhytidectomy, and two experi­enced a minor postoperative complication. Both pa­tients had received postoperative radiation for the treatment of their previous tumor, and both noted a small (< 1.5 cm) area of wound dehiscence before post-operative day 10, which required no revision and healed without sequelae. No other intraoperative or postoperative complications were found. Conclusion: Cervicofacial rhytidectomy may be safely and effec­tively performed on postoperative patients with head and neck tumors without increased incidence of ma­jor complications when compared with patients with-out a surgical tumor history. The increased incidence of minor wound dehiscence experienced by 2 of the 3 patients who received postoperative radiation in this study may indicate that small areas of skin incision dehiscence are more likely in patients who have been radiated. Surgeons performing rhytidectomy on pa­tients with head and neck tumors who were previ­ously radiated should consider more meticulous sub-dermal closure to avoid such dehiscence. Patients should be informed of the slightly higher risk of de­hiscence before surgery. Key Words: Rhytidectomy, tumor, radiation therapy.

INTRODUCTION

Patients undergoing surgery for tumors of the head and neck often experience body image problems as a result of the public display of mild to severe disfigurations.' Even among those with minimal negative cosmetic out-comes, improved adjunct treatment of and increased post-surgical survival of head and neck tumors has meant that more postoperative patients with head and neck tumors are seeking treatment for aging face syndrome. Whether it is for the treatment of postsurgical disfigurement or for cosmetic treatment of the aging face, there is a growing desire among patients with head and neck tumors to have secondary elective surgery involving esthetic cervicofacial procedures. Carefully selected patients with head and neck tumors may benefit from facial esthetic surgery ei­ther at the time of tumor surgery or at a subsequent surgery.

The current investigation was undertaken to exam­ine the rates of intra- and postoperative complications in a group of patients undergoing cervicofacial rhytidectomy after surgery for the removal of head and neck tumors. Those rates were then compared with known complication rates for people undergoing cervicofacial rhytidectomy without previous head and neck tumor surgery.

METHODS
Study Group

Patients at Mayo Clinic Rochester were identified in whom the author (D.A.S.) had performed a cervicofacial rhytidectomy after surgery for a head and neck tumor. The study group in­cluded 11 patients who underwent a total of 20 surgeries (9 patients who had tumor surgery on a date preceding the rhyti­dectomy, and 2 patients who had tumor surgery and rhytidec­tomy on the same operative date).

Clinical Information

For each case, the patient's age (at the time of rhytidecto­my), gender, and type of rhytidectomy were obtained from the medical record. With regard to the rhytidectomy. special atten­tion was paid to the number of drains placed, intraoperative complications, and postoperative complications including (but not limited to) hematoma, infection, skin flap necrosis, motor nerve injury, sensory nerve injury, and alopecia.

Pertinent medical history of the patient preceding rhytidec­tomy was also culled from the medical record. including hyper-tension, diabetes mellitus, tobacco use, and the use of medications that might affect wound healing. Finally, the date of and type of previous tumor surgery was recorded, in addition to tumor typing obtained by pathology.

TABLE I.
Rhytidectomy Technique.

Rhytidectomy Technique

No. of Patients

Postop RT

Minor Complication of Rhytidectomy

SMAS

5

2

1

Composite/deep plane

6

1

1

Total

11

3

2

SMAS = superficial musculoaponeurotic system; RT = radiation therapy.

RESULTS

Ten women and 1 man between the ages of 48 and 75 years underwent rhytidectomy (average age, 58 y). Five patients underwent superficial musculoaponeurotic sys­tem (SMAS) rhytidectomy and 6 underwent composite/ deep plane rhytidectomy (Table I). The longest period between tumor surgery and rhytidectomy was 16.5 years (average time, 3.7 y). Sixteen ancillary cosmetic proce­dures were performed simultaneously with rhytidectomy, including blepharoplasty, brow lift, temporalis muscle transfer, dermal fat graft, septorhinoplasty, and XII/VII nerve transfer (Table II). Six patients had postresection facial paralysis, 4 after removal of acoustic neuroma/ schwannoma by translabyrinthine (3) or by transtempo­ral/transmastoid resection (1), and 1 each after parotidec­tomy and suboccipital craniotomy (Table III). The other 5 patients without postoperative facial paralysis underwent parotidectomy (2), partial glossectomy (1), total maxillec­tomy (1), and partial glossectomy with ipsilateral sublin­gual gland excision and modified radical neck dissection (1) (Table III). Six different tumor types were treated with surgery. Postoperative radiation was used in 3 cases: 1 each with salivary gland malignancy, squamous cell can­cer of the tongue, and adenoid cystic cancer of the maxilla (Table IV). There were no major complications of rhytidec­tomy, and 2 patients (18%) developed minor (<1.5 cm) wound dehiscence less than 10 days after rhytidectomy

(Table V). Both patients had received postoperative radi­ation therapy as part of the treatment of their tumors, and they accounted for 2 of the 3 (66%) patients who had received such therapy in the study.

One patient developed a 1.5-cm area of wound dehis­cence at the earlobe on postoperative day 10, which re­quired no revision and healed without sequelae (Fig. 1). Fourteen months before SMAS rhytidectomy, the patient underwent partial glossectomy and sublingual gland ex­cision with ipsilateral modified radical neck dissection for treatment of a grade 4 of 4 undifferentiated carcinoma consistent with salivary gland origin. The patient was treated with postoperative radiation therapy after the tu­mor surgery. At the time of SMAS rhytidectomy, the pa­tient also underwent melolabial augmentation with a der­mal fat graft.

Another patient developed a 1-cm submental wound dehiscence on postoperative day 9, which required no re-vision and healed without sequelae. The patient had pre­viously undergone left total maxillectomy with postoper­ative radiation therapy and multiple reconstructive surgeries, including dacrocytorhinostomy, rhinoplasty, calvarial bone graft, and lower lip reduction. The compos­ite rhytidectomy was performed 70 months after maxillec­tomy, and was performed concurrently with bilateral lower lid blepharoplasty and premaxillary augmentation.

 

TABLE III.
Head and Neck Procedure.

Head and Neck Procedure

No. of Patients

Post-resection Facial Paralysis

Postop RT

Minor Complication of Rhytidectomy

Parotidectomy

3

1

0

0

Translabyrinthine resection

3

3

0

0

Partial glossectomy

0

1

0

Partial glossectomy, RSG excision,

0

1

1

RMRND

Suboccipital craniotomy

1

0

0

Total maxillectomy

0

1

1

Transtemporal, transmastoid resection

1

0

0

with facial nerve graft

Total

11

6

3

2

RSG = right sublingual gland; RMRND = right modified radical neck dissection; RT = radiation therapy.

TABLE IV. Tumor Type.

Tumor Type

No. of Patients

Post-resection Facial Paralysis

Postop RT

Major Complications
of Rhytidectomy

Minor Complications of Rhytidectomy

Acoustic neuroma/schwannoma

Pleomorphic adenoma

Salivary gland malignancy

SCC-tongue

Meningioma

Adenoid cystic CA of maxilla

Total

4

2

2

1

1

1

11

4

0

1

0

1

0

6

0

0

1

1

0

1

3

0

0

0

0

0

0

0

0

0

1

0

0

1

2

RT = radiation therapy; SCC = squamous cell carcinoma; CA = carcinoma.

The patient seen in Figure 2 underwent SMAS rhyt­idectomy with multiple concomitant esthetic surgical pro­cedures 8.5 years after parotidectomy. She developed no complications of the esthetic surgical procedures either intraoperatively or postoperatively.

DISCUSSION

While major intraoperative complications (cardiovas­cular event, anesthetic reaction, death) of rhytidectomy are exceedingly rare, there are a number of well-documented postoperative complications of rhytidectomy. In the non-tumor patient population, the reported inci­dence of these complications in the literature has re­mained relatively stable over the last 10 years. In our review of the literature, we found one paper which specif­ically addressed esthetic surgery of the face after head and neck tumor surgery, but which did not specifically address comparative complication rates.' To our knowledge, the incidence of these complications in patients with previous head and neck tumor surgery has not been previously reported. For the purposes of discussion, we divided the postoperative complications of rhytidectomy into major and minor categories. For major complications, we in­cluded hematoma, skin flap necrosis, motor nerve dam-age, and sensory nerve damage. Under minor complications , we included infection, partial wound dehiscence, and alopecia.

TABLE V.
Complication Rate for Rhytidectomy.

Complications

Incidence in Non-Tumor Literature

Incidence in This Series

Major Hematoma

0.9-8%2

0

Skin flap necrosis

1-3%2

0

Motor nerve damage

0.9%2

0

Sensory nerve damage

7%3

0

Minor Infection

Rare3

0

Partial wound dehiscence

Rare3

18%

Alopecia

1-3%2

0

Total

18%

The rates of major complications in the 11 patients we studied were comparable with those stated in the gen­eral medical literature, with no incidence of hematoma, skin flap necrosis, or nerve damage. In terms of minor complications, none of the 11 patients developed infection or alopecia, but 2 (18%) developed partial wound dehis­cence. Compared with the general medical literature for the normal patient population, in which the incidence of partial wound dehiscence is reported to be rare, the rate in our population is much higher. Although, given the size of this study population, we cannot attach statistical sig­nificance to the percentage of patients who developed this complication from rhytidectomy after head and neck tu­mor surgery, it is important to note that these complica­tions developed in 2 of the 3 patients who received post-operative radiation therapy as an adjuvant to their head and neck tumor surgery. In both cases, surgical revision was not required and the areas of dehiscence healed with-out sequelae.

CONCLUSION

Our results indicate that with the possible exception of patients who received postoperative radiation therapy, cervicofacial rhytidectomy may be safely and effectively performed on postoperative patients with head and neck tumors without increased incidence of complications when compared with patients without a surgical tumor history. Two thirds of the patients in this study who received postoperative radiation as an adjuvant to surgery for treatment of a head and neck tumor developed minor wound dehiscence. While the small number of patients in this study preclude the assignment of statistical signifi­cance to this finding, these results may indicate that small areas of skin incision dehiscence are more likely in pa­tients who have been radiated. Surgeons performing rhyt­idectomy on previously radiated patients with head and neck tumors should consider more meticulous subdermal closure to avoid such dehiscence. Patients who have un­dergone radiation therapy to the head and neck should be informed of the higher risk of skin incision dehiscence before surgery.

Before and after patient pictures
Fig. 1. A 53-year-old patient status-post right sublingual gland excision, partial glossectomy, and right modified radical neck dissection and postoperative radiation therapy for treatment of grade 4/4 undifferentiated carcinoma consistent with salivary gland origin. The patient underwent SMAS rhytidectomy and melolabial augmentation with dermal fat graft. (A) Preoperative frontal view, (B) postoperative frontal view, (C) preoperative lateral view, (D) postoperative lateral view (arrow points to small area of wound dehiscence).

Before and after patient pictures
Fig. 1. (E) preoperative oblique view, and (F) postoperative oblique view.

Before and after patient pictures
Fig. 2. A 59-year-old patient status-post left parotidectomy for treatment of a pleomorphic adenoma. The patient underwent SMAS rhytidectomy, bilateral endoscopic brow-lift, primary septal rhinoplasty, bilateral lower lid blepharoplasty, and reconstruction of the left cheek with dermal fat graft. (A) Preoperative frontal view, (B) postoperative frontal view, (C) preoperative lateral view. (D) postoperative lateral view.

Before and after patient pictures
Fig. 2. (E) preoperative oblique view, and (F) postoperative oblique view.

BIBLIOGRAPHY

  1. Graham WP, Rosillo R. Social rehabilitation of the patient with head and neck cancer. Symposium on Malignancies of the Head and Neck. St. Louis : C.V. Mosby, 1975:215-220.
  2. Thorne GHM, Aston SJ. Aesthetic surgery of the aging face. In: Aston SJ, Beasley RW, Thorne GHM, eds. Grabb & Smith's Plastic Surgery. Philadelphia : Lippincott-Raven Publishers, 1997:633-649.
  3. Adamson PA, Moran ML. Complications of cervicofacial rhyt­idectomy. Facial Plastic Surgery Clinics of North America 1993;1:257-271.
  4. Barret BM Jr, Rose FA. Aesthetic cervicofacial surgery for head and neck tumor patients. Aesthetic Plast Surg 1984; 8:123-128.

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