Challenging reconstruction of oncologic defects of the parotid region: a single-institution experience and decision-making framework proposal

Reconstruction of the parotid region presents challenges due to the area’s complex anatomy. A classification of defects from ablative surgery can simplify and systematize the reconstructive approach. This study aims to propose a structured decision-making framework to guide reconstructive planning. A retrospective study was conducted on patients with malignant parotid tumors treated at Policlinico Umberto I between 2013 and 2023. Non-malignant tumors were excluded. The analysis focused on the involvement of skin, soft tissue, bone, and nerves, the type of parotidectomy (superficial, total, extended), whether neck dissection was performed, and the type of reconstruction used. Sixty-seven patients (mean age 55 ± 16 years) were included. Primary closure was performed in 42 cases (62.7%). Thirteen patients (19.4%) required reconstruction of soft tissue and/or bony defects, including local cervicofacial flaps (n = 2), pedicled locoregional flaps (n = 4), free flaps (n = 2), deep circumflex iliac artery free flaps (n = 2), and pectoralis major myocutaneous flaps (n = 3), with one secondary free scapular flap after iliac crest failure. Facial nerve resection was necessary in 25 patients (37%). Immediate facial nerve reconstruction was achieved with direct neurorrhaphy or interposition grafting in 11 cases and with nerve transfers (masseteric-to-facial or hypoglossal-to-facial) in 5 cases. Static facial reanimation procedures were performed in 9 patients, either alone or in combination. Successful parotid reconstruction focuses on minimizing skin tension, addressing color mismatch, restoring volume, and preserving nerve function. Based on this experience, we propose a practical decision-making framework tailored to defect volume and functional loss involving skin/soft tissue, bone, and nerve.