Neck Lift after having a Parotidectomy?

Question

I'm 60 yrs. old, and I just hate the way my neck is becoming. I had a benign tumor removed from my left parotid gland, which resulted in the complete removal. I assume the surgery went deep, because there's a noticeable depression. I suspect the facial nerve is close to the surface, because when I chew, that side sweats! I just have mild numbness in the earlobe and this has been 8 yrs. ago. I've been told to leave my face alone. But my neck is bothering me with noticeable bands and crepiness; no sagging.

Dilip D. Madnani, MD, FACS · Answer

A neck lift or face lift after parotidectomy does put you at higher risk for facial nerve damage, but in experienced hands the risk is lower. I have done a few of these cases which have turned out well,  and the elevation of the skin flap is usually the most tenuous part of the procedure. At 60, you probably would benefit from more than just a neck lift, so get an consultation with a plastic surgeon with experience in facelifts after parotidectomy and have them discuss your options.

Babak Azizzadeh, MD, FACS · Answer

Hi Elaine - I am sorry to hear about the complications you have experienced after your parotidectomy 8 years ago. My partner (Dr. Babak Larian) and I perform minimally invasive parotid removal surgeries very regularly and I specialize in monitoring and preserving the facial nerve, as well as reconstructing the face after the tumor has been removed. In many cases I will actually perform a neck lift and/or facelift at the same time as the parotid removal for best results. Although your surgery was 8 years ago, it is possible to have a neck lift and perhaps some facial reconstruction to make your face more symmetrical at this time. But I would need to examine you to determine if you are in fact a candidate for surgery right now. Our top priority will be to make sure that no more damage is done to your facial nerve. Therefore, I cannot stress enough how important it is for you to see a true specialist who has extensive experience in working with patients post-parotidectomy so that your results are positive and not damaging. Although you are in North Carolina, I offer Skype consults. Please call my office if you would like to set one up. Also, the sweating that you are getting when you eat is called "Frey's Syndrome." After surgery, your nerve reattached to sweat glands instead of your salivary glands. So now when your body wants to salivate, you sweat.

Elizabeth Whitaker, MD, FACS · Answer

Great question with a complicated answer.  Parotidectomy reduces the amount of tissue between the skin flap that is elevated with a face or neck lift and the facial nerve, so the nerve is more vulnerable to injury which can be permanent.  When I perform facelifts post-parotidectomy, I always counsel patients about the increased risk.  I would recommend consulting with an experienced facial plastic surgeon to determine if the potential benefit outweighs the additional risk in your case and discuss your options.In addressing the other symptoms you mention, I need to describe a little about parotid surgery.  The facial nerve runs through the parotid gland, and is usually dissected out and exposed during surgery to protect it.   One of the sensation nerves may be divided to better expose and protect the facial nerve which can result in permanent numbness.  Sweating when eating results from "Frey's syndrome", when nerve fibers (from the auriculotemporal nerve not the facial nerve) reconnect inappropriately and rather than triggering saliva secretion as they did originally, they now trigger sweating.  This is called "gustatory sweating" since it is triggered by eating.  Confusing, isn't it?I hope this helps :)

Sirius K. Yoo, MD · Answer

Thank you for your question.  The size and location of the parotidectomy are important because the layer of tissue that normally supports a facelift called the SMAS (not the skin) lies directly over the parotid and is usually removed during parotidectomy surgery.  That mean, there could be a large gap between the ends that would be difficult to safely find and mend together.  As an aside, if you don't like the divot you have been left with, it could be filled with a fat graft.  You would need a consultation with a talented surgeon who is trained in parotidectomy surgery as well as facelift surgery to evaluate your case and specific anatomy.  You may be fine with a face/necklift, but it may be the case that caution is the better part of valor and an alternative neck rejuvenation procedure would be better.  The sweating when you eat is a well known complication of parotid surgery called Frey Syndrome.  It happens when the nerves that go to the parotid gland (salivary gland) that tell the gland to secrete saliva are cut.  These nerves can then grow back and innervate the sweat glands of the face skin rather than the parotid which they were intended for.  Afterwards, when your brain tells your salivary glands to secrete saliva, those aberrant nerves tell the sweat glands to sweat and you know the results.  This can be treated with Botox or lifting up the skin that sweats (also cutting the aberrant nerves in the process) and placing tissue between them and the skin so they can't grow back into the sweat glands.  All the best!

Bhupendra C.K. Patel, MD, FRCS · Answer

Remember the adage: complications always occur in retrospect. Not prospectively! Therefore, your options are as follows:1. If you want to take no risk of having injury to your facial nerve on the side the parotidectomy was performed: have one of the several different direct neck lifts. It will give you a moderate to good improvement. if one had to put a percentage to it, I say to patients that they will get about a 50% improvement: not bad, not brilliant, but safe. The scars can be camouflaged but there will be scars. 2. If you want to take a small risk, then a limited dissection of the face and a largely subcutaneous facelift will give you a moderate improvement. The neck can be treated at the same time to improve any neck laxity. There is a risk, however, as the SMAS on the parotidectomy side will be missing and there is still a small risk of injuring a branch of the facial nerve during the dissection. 3. Performing a "full-blown" SMAS-lift or deep-plane lift would carry the most risk. In a world where everyone is trying to protect their surgical turf, there are times when facts must be stated: if you had the procedure by someone who is an excellent reconstructive facial surgeon (does parotidectomies) and an excellent facial cosmetic surgeon (there are many general as well as facial plastic surgeons who fall into this category), then that is who I would choose.4. After a surgical dissection of your skin, your aberrant nerve regeneration which is causing the Frey's syndrome with sweating may or may not be much better. Botox is useful for this. 5. I tell all our patients: if you want zero risks, do not have surgery!You are getting excellent advice on this forum: digest it carefully and interview one or two appropriate surgeons. A smart surgeon will turn you down if he does not have on-going experience of the reconstructive and cosmetic aspects of facial surgery.Good luck!Prof. Bhupendra C. K. Patel MD, FRCS

Raymond E. Lee, MD · Answer

It sounds like you had a total parotidectony. This procedure exposes your facial nerve and is now very vulnerable. A facelift in my opinion would be risky and I caution it may not be worth the reward. A direct cervical excision would be a good option. Consult with an experienced facial plastic surgeon to review your options.

Oliver Pope Simmons, MD, FACS · Answer

You are very correct in your observations.   The nerve is often just under the skin after parotid surgery. Also the condition you are complaining of is called frey's syndrome and points to the fact that there was nothing placed between the free edges of the resected parotid and the skin.  More concerning regarding lifts are the fact that there is no SMAS in that area to base a lift off of.  You can have a neck lift.  Face lifts would be tricky, but doable .  I would defitnely recommend someone with duel or triple expertise. Facial plastics and head and neck. Or plastics and head and neck.  Thanks

Stephen Prendiville, MD · Answer

Generally at age 60, a facelift would be a better choice than a neck lift alone. Although facelift after parotidectomy is feasible, it requires an abundance of caution to ensure safety with the more superficial facial nerve.  The condition you describe is a well known post-parotidectomy phenomenon known as Frey syndrome.  It is caused by cholinergic nerves that previously connected to the parotid gland forming aberrant connections with cutaneous sweat glands.  The second major issue in a post-parotidectomy scenario is the condition of any remaining SMAS.  The SMAS, which is a fibrofatty layer which sits on top of the facial muscles, is used as the tension bearing layer in facelift, is often partially resected in parotidectomy. I recommend a consultation with an experienced facial plastic surgeon for further guidance.  Sometimes direct excisional approaches such as a submental Z-pasty are more appropriate.

Mark Glasgold, MD, FACS · Answer

Neck and facelifts can be performed after parotidectomy but require extreme caution.  I would recommend using a facial plastic surgeon who has trained in head and neck surgery and the surgeon should discuss the extent of the parotidectomy with the primary surgeon if possible.The sweating in your face is not related to the facial nerve.  It occurs as a result of a sensory nerve that is cut and has branches which regrow into the the facial sweat glands.  It is easily treated with botox.I would strongly suggest that you consider a direct neck excision where the incision is placed down the center of the neck.  There is no facial nerve injury risk in this surgery.  We have performed this operation on ,many woman as well as men with excellent results.

Danny Soares, MD · Answer

Lifting the neck and face requires lifting the muscle layer (SMAS), which can typically expose the capsule of the parotid gland. Because a portion of the parotid gland has been removed, there can be scarring of the parotid to the overlying SMAS, forcing the facial nerve into a more superficial and precarious location. Although performing a surgical lift is still possible, you should understand that there is a higher chance of temporary or permanent facial paralysis. You should carefully review the details of your prior surgery and the type of facelift procedure that you will be having with your surgeon. It might be wise to use a facial nerve monitor during the surgery, which will help alert the surgeon if the dissection is too close to a nerve branch. Ultimately the decision should be made by you in conjunction with your surgeon. You have also reported gustatory sweating of the affected side of the face during eating. This condition, known as Frey's syndrome is actually unrelated to the facial nerve and is instead due to the fact that the salivary nerves to the parotid gland can erroneously connect to the skin following parotidectomy. This results in stimulation of the sweat glands of the skin (instead of the normal stimulation of the parotid gland to produce saliva). Frey's syndrome can be very effectively treated with botulinum (botox) injections on a 3-6 month period. Consider discussing this with your surgeon. Best of luck!

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