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 Textbook of Plastic, Reconstructive,

Agrawal
and Aesthetic Surgery
Volume III

Head and Neck

Textbook of Plastic, Reconstructive, and Aesthetic Surgery is a comprehensive and illustrated work for students,

Reconstruction
Head and Neck
teachers, and practicing surgeons. It is a six-volume set with the topics of the volumes based on the clinical needs
of plastic surgeons in developing countries. Along with latest developments, these volumes incorporate landmark

Reconstruction
contributions, innovations, and techniques used by Indian clinicians who regularly deal with unique and complicated
conditions. While a majority of authors have been chosen from the Indian subcontinent, a few international authors
whose work is considered indispensable for understanding the subject have also been included.

The six volumes seek to incorporate in one work issues relevant to the developing world as well as insights from
national and international plastic surgery practices which highlight newer management techniques along with
traditional methods. This makes these volumes a “must-have” resource for students and practitioners of plastic
surgery across the globe.

This ‘Head and Neck Reconstruction’ volume covers a wide spectrum of topics. It covers surgery techniques
for reconstructions of clefts, treatment of craniofacial anomalies, onco-reconstruction, occuloplasty, and
reconstruction of ear and nose. The team of authors has been carefully selected and they are highly experienced
in their respective fields. The book is divided into three sections. The cleft section covers the entire gamut of clefts
in detail, including operative steps and clinical photographs. The second and the third sections cover the recent
advances in craniofacial anomalies and reconstruction techniques of head and neck section, respectively. Each topic
of the book is a must read for any plastic surgeon. Editor-in-Chief
Salient features: Karoon Agrawal
• Includes important chapters on topics like “approach to the patients of cleft” and “aesthetic onco-
reconstruction”.
• Provides historical background of each topic along with recent advances and clinically relevant information.
• Untangles the mysteries of decision making in many areas of head and neck reconstruction.
Volume Editor

Volume III
• Adequate emphasis is given to the basic sciences relevant to each chapter.

Surajit Bhattacharya
Karoon Agrawal is currently Director Professor of Burns, Plastic, and Maxillofacial Surgery at Safdarjung Hospital
and Vardhman Mahavir Medical College, New Delhi, India. He was the President of the Association of Plastic
Surgeons of India (2016); President of the National Academy of Burns-India (2010); and President of the Indian
Society of Cleft Lip Palate and Craniofacial Anomalies (2009). Section Editors
Surajit Bhattacharya is currently the President of Association of Plastic Surgeons of India and Senior Consultant in
Plastic, Reconstructive, and Aesthetic Surgery at Sahara Hospital, Lucknow, Uttar Pradesh, India. He is trained at
Rajesh Powar
King George Medical University, Lucknow and has undergone fellowship in Micro-, Hand, and Craniofacial Surgeries
from Australia.
Alok Sharma
Rajesh Powar is currently working as Professor and Head of Plastic Surgery and Project Director of KLES Smile Train Gautam Biswas
Project at Jawaharlal Nehru Medical College, Belgaum, Karnataka, India.

Alok Sharma retired as commandant of a multi-speciality Military Hospital at Jabalpur, Madhya Pradesh, India.

Gautam Biswas is presently working as a Consultant at Tata Medical Centre, Kolkata, West Bengal, India, a tertiary
care oncology centre, established in 2012.

ISBN 978-93-88257-15-2

9 789388 257152 www.thieme.in

Agrawal_Textbook Plastic Surgery_Vol III_k6_spine42.indd 1 30.10.2018 09:43:51

35
Congenital Torticollis, Salivary Gland
Tumors, and Reconstruction of Facial
Deformities in Leprosy

e
Rupnarayan Bhattacharya, Goutam Guha, and Ramanuj Mukherjee

Salivary Gland Tumors •• Approach to a Patient with Salivary Neoplasm

m
¾¾ Classification of Salivary Gland Tumor

¾¾ Anatomical Peculiarity of Parotid Gland

¾¾ Anatomical Peculiarity of Submandibular Salivary Gland

¾¾ Histological Feature

•• Secretory Acinus
◊ History

◊ Examination

◊ Differential Diagnosis

◊ Investigation

¾¾ Treatment Outline
ie
•• Mucous Acinus •• Principles of Surgical Management

•• Myoepithelial Cells •• Surgical Management of Benign Tumors

¾¾ Etiology ◊ Parotid Gland Tumors

•• Viruses ◊ Submandibular Salivary Gland Tumors

•• Radiation ◊ Minor Salivary Gland Tumors

•• Genetic Basis •• Surgical Management of Malignant Tumors
Th

¾¾ Malignant Nonepithelial Tumor ◊ Principle of Surgical Management

¾¾ Pleomorphic Adenoma ◊ Parotid Gland Tumors

¾¾ Papillary Cyst Adenoma (Warthin’s Tumor) ◊ Submandibular Gland

•• Prognosis ◊ Rare Tumors of Salivary Gland

¾¾ Oxyphil Cell Adenoma ¾¾ Complications of Parotidectomy

¾¾ Adenoid Cystic Carcinoma (Cylindroma) •• Facial Nerve Damage

¾¾ Adenocarcinoma •• Frey’s Syndrome

¾¾ Squamous Cell Carcinoma ¾¾ Minor Salivary Gland

¾¾ Pleomorphic Adenocarcinoma •• Clinical Features

¾¾ Mucoepidermoid Carcinoma •• Surgical Principle

¾¾ Metastatic Tumors ¾¾ Cystic Lesions of Salivary Glands

•• TNM Classification •• Introduction

•• Stage Grouping •• Clinical Classification of Cysts

816  Head and Neck Reconstruction

•• Clinical Features ◊ Limitation of This Operation

•• Diagnostic Workup •• Conclusion
◊ Imaging ¾¾ Johnsons Modification
◊ Aspiration Cytology ¾¾ Surgical Procedure for Nasal Deformity
◊ Treatment •• Augmentation of Dorsum of Nose
•• Ranula ◊ Route for Insertion of Graft
◊ Classification ◊ Preparation of the Pocket for Graft
◊ Origin ◊ Stabilization of the Graft
◊ Presentation
◊ Postoperative Care

e
◊ Treatment
•• Postnasal Epithelial Inlay (PNEI)
◊ Complications
◊ Anesthesia
◊ Prognosis
◊ Dissection and Creation of Postnasal Space
◊ Conclusion

Facial Leprosy

¾¾ Introduction

¾¾ History

m
¾¾ Pathology of Facial Involvement in Leprosy

•• Nonparalytic Complications
◊ Fabrication of the Stent

◊ Postoperative Care

•• Crockett’s Operation

•• Nasolabial Flaps

•• Forehead Flap

¾¾ Wrinkled and Lax Facial Skin

ie
◊ Skin and Subcutaneous Tissue
¾¾ Reconstruction of Eyebrow
◊ Ear
¾¾ Conclusion
◊ Nose
Torticollis
•• Paralytic Deformity
¾¾ Definition
¾¾ Classification
¾¾ Epidemiology
¾¾ Treatment
Th

¾¾ Anatomical Variation in Sternomastoid

•• Conservative Treatment
¾¾ Classification
¾¾ Surgical Correction of Lagophthalmos

•• Lateral Tarsorrhaphy (Mc Laughlin) ¾¾ Secondary Torticollis

•• Medial Tarsorrhaphy (Fritschi) ¾¾ Etiology of Primary (Congenital) Torticollis

•• Upper Lid Loading ¾¾ Pathology

•• Dynamic Procedures ¾¾ Clinical Feature

◊ Basis of Muscle Transfer ¾¾ Other Associated Anomaly

•• Operation Procedure (Anderson Modification of ¾¾ Management

Gillies Method) ¾¾ Complications of Surgery

◊ Complications ¾¾ Different Nomenclatures of Torticollis

 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  817

Salivary Gland Tumors ganglion, and hypoglossal nerve. The mandibular branch of
facial nerve lies on the surface of the gland and damage to
it causes deviation of angle of mouth. The facial artery is in
close relation with the gland.
Classification of Salivary Gland Tumor
Salivary glands are classified into:
••Major salivary gland (parotid—2, submandibular—2,
Histological Feature
sublingual—2).
The major components of salivary glands are secretory
••Minor salivary gland (multiple).
acinus, mucinar acinus, and myoepithelial cells.
Minor salivary glands are situated in the lips, oral mucosa,
tongue, hard and soft palate, floor of mouth, entire upper
respiratory tract, and lateral pharyngeal wall. Secretory Acinus
Salivary gland neoplasms are commonly seen in fifth and
The functional unit of salivary glands is the secretory acinus

e
sixth decade. Patients with malignant neoplasm typically
and related ducts, and myoepithelial cells. Acini may be
present after 65 years, whereas those with benign tumors
serous, mucous, or mixed. Serous acini are formed by
usually present in younger years. Benign neoplasms are seen
commonly in women, whereas malignant neoplasms are secretory cells with basal nuclei. They surround a lumen that
seen equally in both sexes. becomes the origin of the intercalated duct. The cytoplasm
of serous cells contains zymogen granules and they secrete

Parotid Gland

m
Anatomical Peculiarity of

••The parotid gland is the largest salivary gland.

••A dense fascial sheath covers the parotid gland.
Superiorly it is attached to the zygomatic arch; post­
eriorly it blends with sternomastoid fascia, and anteri­
amylase.

ie
orly with masseteric fascia. Tightness of the fascia is
responsible for severe pain seen in acute parotitis.
••Drainage of parotid gland is via Stensen’s duct which
exits anteriorly, pierces the buccinators muscle, and
enters the oral cavity opposite the maxillary upper
molar tooth.
••Conventionally parotid is divided into superficial and
deep lobe by the facial nerve and its branches, though
Th
Mucous Acinus
Their cells also have basally placed nuclei and their cytoplasm
is clear and contains sialomucin. The secretions of these cells
pass through the intercalated ducts which are lined by a
single layer of cuboidal cells. They are communicating with
each other to form larger striated ducts.
The striated ducts join the interlobular excretory ducts,
which are lined by pseudostratified columnar epithelium
that often contains few mucous cells.
Myoepithelial Cells
Myoepithelial cells are contractile cells and contain actin,
myosin, and intermediate filaments. Myoepithelial cells

anatomically these two lobes are continuous.
••The facial nerve enters the posterior part of the
gland after it comes out of the stylomastoid foramen
and divides into five branches—temporal branch to
frontalis, zygomatic branch to orbicularis oculi, upper
and lower buccal branches to muscles of lip and cheek,
and mandibular branch to muscles of lower lip and
chin that is cervical part of platysma.
Anatomical Peculiarity of
Submandibular Salivary Gland
It lies under the mandible and on the mylohyoid muscle. The
gland is divided into superficial and deep part which extends
beneath mylohyoid muscle. Submandibular duct runs on the
floor of the mouth to open at the frenulum of the tongue.
In the deeper part lies the lingual nerve, submandibular
are present around the secretory cells and also surround
the intercalated ducts. Ultrastructurally, the cytoplasm of
myoepithelial cells contains actomyosin microfilaments
running parallel with the outer surface of the cell, glycogen
granules, lipofuscin, and pinocytotic vesicles.
Etiology
The viruses, radiation, and genetic factors have been blamed
for the occurrence of salivary gland tumors.1,2
Viruses
There is no convincing report regarding association of benign
parotid tumor and virus. However, a strong association
between Epstein–Barr virus and lymphoepithelial carcino­
mas has been reported by some.
818  Head and Neck Reconstruction

Radiation ••CD117 or c-kit is found in adenoid cystic carcinoma,

myoepithelial carcinoma, and lymphoepithelioma like
There is evidence of relation of exposure to ionizing radiation carcinoma.
and the development of salivary gland tumors especially ••Matrix metalloproteinase-1, tenascin-C, and beta-6
mucoepidermoid carcinomas and Warthin’s tumors. The risk integrin have been found to be associated with benign
was directly related to the level and duration of exposure to tumor expansion in pleomorphic adenoma and
ionizing radiation.
metastasis by malignant tumors.4
Therapeutic radiation, particularly of the head and neck
region, has been linked with a significantly increased risk of
developing salivary gland cancers especially with iodine131
Malignant Nonepithelial Tumor
used in the treatment of thyroid disease and repeated
exposure to routine dental radiographs.3
Hodgkin lymphoma
There is association of salivary gland malignancy with
••Diffuse large B-cell lymphoma
exposure to metal in the plumbing industry, nickel com­
••Metastatic tumors to the salivary glands

e
pounds, woodworking in the automobile industry. However,
••Lung, breast, kidney, colon
there is a strong association between smoking and Warthin’s
The malignant tumors of surgical importance are as follows:
tumor and adenoid cystic carcinoma.3
••Adenoid cystic carcinoma
••Adenocarcinoma
Genetic Basis ••Squamous cell carcinoma

m
The exact genetic predisposition and genetic pathway in
salivary tumors are unknown. However, a few of the common
associations known to have a therapeutic implication are
summarized below.2,4
••PLAG1 and HMGA2 encoded by gene located in 12th
chromosome is detected by RTPCR and FISH and aids
in the diagnosis of pleomorphic adenoma as this is the
signature gene motif.
••MECT1–MAML2 is a fusion protein expressed in muco­
••Malignant pleomorphic adenoma
••Metastatic tumor
••Lymphoma

Pleomorphic Adenoma
It is the commonest tumor of the parotid gland but may
involve the minor salivary glands also, especially in the
ie
epidermoid cancer. The positive fusion protein is an palate.
indicative of tumor with good prognosis and limited Pleomorphic adenoma of parotid gland is popularly
spread (Box 35.1). known as mixed parotid tumor.
It is so named because they contain both stromal and
Box 35.1  Classification of salivary neoplasm5–7 epithelial components. They are commonest benign salivary
tumor and account for 60% of all salivary gland tumor and
Benign epithelial tumors
90% of parotid tumor. This tumor is slow growing, but may
••Pleomorphic adenoma
become quite large at the time of presentation. It is usually
Th

••Myoepithelioma
••Papillary cyst adenolymphoma (Warthin’s tumor)
••Oxyphil adenoma (Oxyphil cell adenoma)
••Canalicular adenoma
••Ductal papillomas
••Cystadenoma
••Benign connective tissue tumor
••Hemangioma
Malignant epithelial tumors
••Acinic cell carcinoma
••Mucoepidermoid carcinoma
••Adenoid cystic carcinoma
••Adenocarcinoma
••Oncocytic carcinoma
••Salivary duct carcinoma
••Myoepithelial carcinoma
••Carcinoma ex pleomorphic adenoma
adenocarcinoma)
••Metastasizing pleomorphic adenoma
••Squamous cell carcinoma
••Lymphoepithelial carcinoma
painless at the beginning, but appearance of pain and rapid
growth with or without facial nerve involvement arises the
suspicion of malignant conversion.7
The capsule of normal parotid tissue (pseudo capsule)
varies in thickness and lobules of tumor tissue extend into
the capsule. This explains the chance of local recurrence
after enucleation of the tumor.
Mixed parotid tumor is multifocal. Commonly, the
superficial lobe is involved, but rarely both lobes or deep lobe
only may be involved. The most common site of affection of
parotid tumor is at the lower pole where it can be confused
with neck node.8
(pleomorphic
Papillary Cyst Adenoma
(Warthin’s Tumor)
It constitutes about 10% of benign salivary tumors. It
involves almost exclusively the parotid gland (frequently
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  819
the tail) occasionally separate from the main body of the
gland. About 10% is bilateral, male: female 10: 1.9
Pathology: this tumor is soft, brown in color, shows
cystic areas. Histologically, it shows salivary epithelium in
lymphoid stroma.
Prognosis
It is frequently multicentric in origin so tendency to recur
after local excision is high. Rarely malignant lymphoma or
undifferentiated carcinoma may arise in a Warthin’s tumor.9
Oxyphil Cell Adenoma
e
The tumor arises from acidophilic cells called oncocytes. It
occurs in elderly persons, is slow growing, and is usually of
small size.
There are other benign tumors such as benign lympho­
hemangioma.
m
epithelial tumor (Godwin’s tumor), lymphangioma, and
Adenoid Cystic Carcinoma
(Cylindroma)
It constitutes 31% of minor salivary tumors, 2% of parotid
ie
tumors, and 15% of submandibular gland. It usually occurs
in sixth decade of life and affects both genders.
Lymph nodes are involved directly or by contiguous
invasion. It tends to spread along nerve sheath (invasion
along nerve sheath) and counts for almost 15% incidence of
facial nerve paralysis at the time of presentation.10
Distant metastasis especially to lungs indicates vascular
dissemination
Th
a b
Adenocarcinoma
Three percent of parotid tumor and 10% of submandibular
and minor salivary glands are of this type.9 It is one of the
common salivary gland tumors in the childhood. In 23%
cases, patients present with facial nerve paralysis.10
Squamous Cell Carcinoma
It arises from the duct of major salivary glands and is very
aggressive. Showing male preponderance, usually it appears
in seventh decade of life.
It is characterized by rapid growth, pain, involvement of
skin, and facial nerve. Lymph node metastasis is common10
(Fig. 35.1a, b).
Pleomorphic Adenocarcinoma
Primary pleomorphic adenocarcinoma is rare. The com­
moner type is malignant conversion of pleomorphic
adenoma. Parotid is commonly involved, though other
minor salivary glands may be affected. It has bad prognosis,
high recurrence rate, and incidence of metastasis. Facial
nerve involvement is common8 (Fig. 35.2a, b).
Mucoepidermoid Carcinoma
It comprises of 9% of parotid carcinoma and arises from the
ducts of the gland. It occurs in two forms: low- and high-
grade tumors.
Low-grade tumors are common and seen in childhood. It
is treated by excision of parotid gland with preservation of
facial nerve.
Fig.35.1  (a, b) Recurrent
squamous cell carcinoma of
parotid gland with clinical
features of parotid tumor.
820  Head and Neck Reconstruction
a
m
High-grade tumors are unencapsulated, aggressive, and
invade the gland and surrounding tissues rapidly. There are
high incidences of involvement of neck nodes. It is treated
b
Fig. 35.2  (a, b) Rapidly growing parotid gland carcinoma with involvement of skin.
ie
by radical parotidectomy including removal of facial nerve
branches with modified radical neck dissection followed by
radiotherapy.9
Metastatic Tumors
Parotid gland may be involved by metastasis from primary
Th
lesion in face or scalp (melanoma, GI tract, or adenocarcinoma
of urogenital tract).
The presence of abundant lymphatic tissue in the
parenchyma of the glands is responsible for the profuse
metastasis in the glands.9
TNM Classification
••T—Primary tumor.5
••TX—Primary tumor cannot be assessed.
••T0—No evidence of primary tumor.
••T1—Tumor 2 cm or less in greatest dimension without
extraparenchymal extension.
••T2—Tumor more than 2 cm but not more than 4 cm
in greatest dimension without extraparenchymal
extension.
••T3—Tumor more than 4 cm and/or tumor with extra­
parenchymal extension.
••T4a—Tumor invades skin, mandible, ear canal, or facial
nerve.
e
••T4b—Tumor invades base of skull, pterygoid plates, or
encases carotid artery
Note: Extraparenchymal extension is clinical or
macroscopic evidence of invasion of soft tissues or
nerve, except those listed under T4a and 4b.
••N—Regional lymph nodes
••NX—Regional lymph nodes cannot be assessed
••N0—No regional lymph node metastasis
••N1—Metastasis in a single ipsilateral lymph node, 3
cm, or less in greatest dimension
••N2—Metastasis as specified in N2a, 2b, 2c below
••N2a—Metastasis in a single ipsilateral lymph node,
more than 3 cm but not more than 6 cm in greatest
dimension
••N2b—Metastasis in multiple ipsilateral lymph nodes,
none more than 6 cm in greatest dimension
••N2c—Metastasis in bilateral or contralateral lymph
nodes, none more than 6 cm in greatest dimension
••N3—Metastasis in a lymph node more than 6 cm in
greatest dimension
Note: Midline nodes are considered ipsilateral nodes.
••M—Distant metastasis
••MX—Distant metastasis cannot be assessed
••M0—No distant metastasis
••M1—Distant metastasis
Stage Grouping
••Stage I T1 N0 M0.
••Stage II T2 N0 M0.
••Stage III T3 N0 M0, T1, T2, T3 N1 M0.
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  821
••Stage IV A T1, T2, T3 N2 M0, T4a N0, N1, N2 M0.
••Stage IV B T4b Any N M0.
••Any T N3 M0.
••Stage IV C Any T Any N M1.
The regional lymph nodes are the cervical nodes.
Approach to a Patient with Salivary Neoplasm
History
Appearance of swelling in early childhood suggests con­
genital sialectasis.10,11 Bilateral involvement is seen in
Warthin’s tumor and Sjogren’s syndrome. If pain and
swelling are related to eating, the likely diagnosis is calculous
leading to sialectasis. Patients usually complain of swelling,
pain, xerostomia, foul taste, and sometimes sialorrhea, or
excessive salivation.
Benign tumors grow slowly, whereas the malignant
tumors grow rapidly. Rapid recent increase in size of a pre­
viously slowly growing tumor of parotid gland indicates
m
malignant conversion of a benign tumor, for example,
malignant change of pleomorphic adenoma. Appearance of
facial palsy is seen as a result of invasion of facial nerve by
malignant neoplasm of parotid.
Examination
Warthin’s tumor may present as a cystic swelling of
parotid, whereas pleomorphic adenoma may have cystic
ie
or variegated feel. Benign tumors are usually mobile and
fixation with masseteric or surrounding structures points
Th
a b
Fig. 35.3  (a, b) Squamous cell carcinoma of left parotid gland with left facial nerve palsy.
toward malignant neoplasm. Intraoral examination (bidigital
palpation) may detect a stone lodged in salivary duct.
A differential diagnosis of swelling around the mand­
ible includes a parotid tumor or a submandibular tumor.
Sublingual and minor salivary tumors present as swelling in
floor of mouth and lower lip, hard palate, respectively.
••Upward and outward elevation of the ear lobule (best
seen from posterior view as it allows comparison) is a
reliable guide (Fig. 35.1a, b).
••Obliteration of the retromandibular groove (best
seen from posterior aspect) suggests parotid gland
enlargement (Fig. 35.2b).
••Involvement of facial nerve along with a lump in the
parotid region suggests a neoplastic pathology of
e
parotid gland (Fig. 35.3a, b).
••Enlargement of deep lobe is seen as medial bulging
of the pharyngeal tonsils; a bimanual examination
is rarely useful (noncompliance form patient and
surgeon!) has been superseded by a cross-sectional
imaging.
••Bilateral enlargement (sialadenosis) is rarely due to
neoplastic disorder of systemic involvement. Systemic
causes including alcohol abuse and Sjogren’s syndrome
are common encounters.
••Unilateral causes are usually neoplastic. Involvement
of facial nerve suggests malignant transformation.
Painful lesions and facial pain with parotid lump
suggest adenoid cystic carcinoma.
••Soft cystic lesions (with fluctuation) suggest the
possibility of Warthin’s tumor.
822  Head and Neck Reconstruction
Differential Diagnosis
Salivary gland neoplasms have common differential
diagnosis with regional lymphadenopathy. Submandibular
gland is often indistinguishable with lymph nodes.
A few rare causes of clinical curiosity that are commonly
encountered are as follows:
••Hypertrophy of masseter.
••Enlarged transverse process of first cervical vertebrae.
••Enlarged mandibular process.
Benign lesions of concern are autoimmune diseases such
as Sjogren’s syndrome and cystic epithelial lesions in HIV
patients.
Investigation
Ultrasound
Ultrasound with high frequency soft tissue probe (7.5
Hz onward) have made the differential diagnosis easy.
Lymph nodes in neck that are not palpable are located thus
Technetium Scan
m
necessitating the need for Neck dissection. Ultrasound-
guided fine-needle aspiration cytology (FNAC) are useful
particularly for cystic SOL to be differentiated from adenoid
cystic cancers.
99m Technetium scan casts hot image in case of Warthin’s
tumor, whereas other salivary gland tumors cast cold shadow.
But false-positive and false-negative reports are common.
ie
Computed Tomography/Magnetic Resonance Imaging
Computed tomography (CT) scan is useful in detecting
sialolithioasis, cystic salivary lesions, extra glandular tumor
spread, and involvement of underlying bone. CT scan
accurately depicts the enlargement of deep lobe and relation
to styloid process. A CT scan of the neck is mandatory before
a radical neck surgery is undertaken.
Th
Contrast-enhanced CT images of the parotid fossa equally
show a reconstruction of the neurovascular structures
along with the mandible and are important for radical
parotidectomy.
Magnetic resonance imaging (MRI) is useful in
distinguishing high-grade from low-grade malignant tumor
by their low- and high-water content, respectively. It can
also detect solitary tumor or multifocal involvement of the
parotid gland.
FNAC and Incision Biopsy
FNAC is the mainstay of diagnostic study as preoperative
incision biopsy is not preferred due to chance of injury to
branches of facial nerve and extracapsular spread. It has
99% sensitivity and 100 to 75% specificity. To improve
the diagnostic accuracy, immunohistochemistry of the
aspirate is used—such as glial—fibrillary acidic protein for
pleomorphic adenoma.
The use of FNAC in diagnosis is to be recommended with
fine needle (23 gauge) as the chance of needle tract seedling
is high. In parotidectomy, the incision should consider the
inclusion of the needle tract also in the specimen.
FNAC as a tool is equally important in diagnosing
malignant tumors though, it is difficult to distinguish poorly
differentiated mucoepidermoid carcinoma from malignant
lesion in pleomorphic adenoma.
Tumors of minor salivary glands presenting in the oral
cavity and upper respiratory tract tend to be malignant. As
these are surface tumors, if the size is small, excision biopsy
may be done. But if the size is bigger, incision biopsy is
preferable.11–14
Treatment Outline
e
Principles of Surgical Management
Surgery is the treatment of choice for salivary gland neo­
plasms as most are radio resistant and not sensitive to
chemotherapy.
••Tumor recurrence is minimized by gentle tissue
handling, including wide margins of excision and
avoiding spillage of tumor cells in operative field.
••Major neurovascular structures are encountered and
need to be preserved.
••Lymphadenectomy for malignant disease follows the
same principles as in head neck malignancy.
••Complications (e.g., facial nerve weakness) are
common and need to be explained before surgical
procedure.
Surgical Management of Benign Tumors
Parotid Gland Tumors
Total superficial parotidectomy is the preferred operation in
most of the benign tumors. The facial nerve and its branches
are identified first and the plane between the superficial and
deep lobe of the gland is developed (Fig. 35.4). If the deep
lobe is involved, total parotidectomy with preservation of
facial nerve is preferred.
Enucleation of the tumor should be discouraged.
Anecdotal reports of enucleation of smaller pleomorphic
adenoma are usually performed with a cuff of 3 to 4 mm of
normal gland.
Submandibular Salivary Gland Tumors
In all types of neoplasm, excision of submandibular salivary
gland is done with the lymph node taking care to preserve
the marginal mandibular branch of facial nerve, lingual
nerve, and hypoglossal nerve.
Minor Salivary Gland Tumors
All the salivary gland tumors are treated by local excision.
Elsewhere the defect is closed primarily. However, in hard
palate closure of defect may not be easily possible. If the
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  823

defect is small, it is allowed to epithelialize. If the raw area is

large, it is covered with local flaps, buccal myomucosal flap
(Fig. 35.5a–d) or split-thickness skin graft. In highly cellular
pleomorphic adenoma, the recurrence rate is about high and
there may be involvement of the palatal shelf. In such cases,
removal of the involved palatal shelves and reconstruction
or use of obturator is required.

Surgical Management of Malignant Tumors

Principle of Surgical Management
The surgical excision of primary tumor with wide margins
is the treatment of choice for malignant lesions of salivary
glands.15,16

e
Palpable lymph nodes are considered malignant and
mandate a comprehensive neck dissection (MRND).
The management of the nonpalpable neck nodes in
salivary gland cancer is in favor of elective neck dissection.

Fig. 35.4  Facial nerve preserved in superficial

parotidectomy.

m Parotid Gland Tumors

Almost all of the malignant tumors of parotid gland are radio
resistant.
ie
Th

a b c

Fig. 35.5  (a) Preoperative picture of ectopic salivary gland tumor of hard palate.
(b) Excision with 5 mm wide margin. Bony palate was not intact. (c) Defect covered
with left buccal myomucosal flap. (d) Fistula free and recurrence free palate at 6 months
follow-up. (These images are provided courtesy of Prof. Karoon Agrawal, New Delhi,
d India.)
824  Head and Neck Reconstruction
Total parotidectomy including the facial nerve is the sur­
gical treatment of choice. According to clinical and radio­
logical findings, other structures, for example, ramus and
condyle of mandible, temporomandibular joint, the mastoid,
external auditory meatus, surrounding soft tissues and skin,
may be included with the resected specimen (Figs. 35.6
and 35.7).
If only the superficial lobe of the parotid gland is
involved, attempt to preserve the facial nerve may be made.
Facial nerve is sacrificed if deep lobe or whole of parotid is
involved, or in case of recurrence (Fig. 35.8).
m
ie
a b
Fig. 35.6  (a) Parotid gland adenocarcinoma fungated through skin. Planned to excise and cover with large Limberg flap.
(b) Postexcision defect covered using Limberg rhomboid flap. Facial nerve was sacrificed.
Th
Fig. 35.7  Parotid gland malignant tumor was fungating
through skin—postexcision defect covered with free radial
artery forearm flap.
If the nerve is sacrificed, attempt should be made to bridge
the gap with a nerve graft using great auricular nerve. If this
fails, then delayed cross face anastomosis of facial nerve
may be tried provided the patient is free of recurrence. If the
main trunk of facial nerve is removed, facial–hypoglossal
nerve anastomosis is not possible.
In adenoid cystic carcinoma, the facial nerve involvement
is extensive. Due to perineural spread of the tumor cells, the
infiltration may be intracranial. The facial nerve should be
removed by drilling deep into the mastoid. The great auri­
cular and auriculotemporal nerve should also be removed.
e
Fig. 35.8  Facial nerve involved in parotid carcinoma hence
sacrificed.
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  825
Radical neck dissection is indicated in clinically positive
neck, otherwise elective neck dissection is performed.
Submandibular Gland
The components of resected specimen depend on the extent
of involvement. Usually, the operation is wide excision of
submandibular salivary gland and duct, digastric muscle, tail
of parotid, and submental fat, and in selected cases adjoining
skin and mandible (marginal or segmental mandibulectomy)
along with radical neck dissection.
Similar to parotid, if the tumor is adenoid cystic carcinoma,
the lingual and hypoglossal nerves should be excised.
Rare Tumors of Salivary Gland
Hemangioma
Though it is a rare tumor, among all the salivary glands,
parotid is involved most frequently. The lesions are capillary,
cavernous, or mixed vascular malformations.
The capillary malformations grow rapidly for first 6 to
m
8 months of life and they undergo spontaneous resolution
within 6 to 8 years. Other two types of lesion continue to
grow. Radiation and laser therapy are tried but with unpre­
dictable result. A course of oral prednisolone may arrest the
growth of the tumor.
Surgical intervention with proper preoperative workup is
indicated in resistant cases. Proper precaution is taken if the
tumor extends up to infratemporal fossa.
ie
Complications of Parotidectomy
Facial Nerve Damage
This can be avoided by using the landmarks for the identi­
fication of facial nerve and carefully preserving it. Accidental
Th
cut of the nerve can be repaired immediately. In other cases,
the options are described earlier.17,18
In selected cases, other surgical rehabilitative procedures
like temporalis muscle transfer, tarsorrhaphy, and unilateral
facelift may be tried.
Frey’s Syndrome
Frey’s syndrome or gustatory sweating is a common long-
term complication of parotid surgery particularly super­ficial
parotidectomy. The proposed hypothesis is the result of
regen­eration of nerve fibers from the postgangli­onic secreto­
motor parasympathetic innervations (auriculotemporal
nerve) of the parotid gland to the severed postganglionic
sympa­ thetic fibers that supply the sweat glands of the
skin of the face and are delivered via the arterial branches
supplying the gland.
Frey’s syndrome is reported to be common in the
frequency of 40 to 70% of patients undergoing parotid
surgery. Symptomatic Frey’s syndrome is seen only in 15%
patients and in this subset the symptoms are transient and
usually self-limiting.
Majority of patients with symptomatic Frey’s syndrome
do not seek medical consultation as the disease is self-
limiting within a few months. Conservative treatment of
sympt­ omatic Frey’s syndrome is done by topical appli­
cation of antiperspirant, topical anticholinergics, and
injections of botulinum toxin, which provides excellent
control for prolonged periods. Surgical techniques during
parotidectomy that can reduce the risk of Frey’s syndrome
include elevation of a thick skin flap and performance of
partial parotidectomy. In addition, interposition barriers
such as fat, acellular dermal grafts, and muscle flaps have
e
been used with success in the prevention of Frey’s syndrome.
These surgical methods are uncommonly utilized presently
due to the effectiveness of botulinum toxin therapy.
Minor Salivary Gland
Tumors of minor salivary and ectopic salivary glands are not
as common as tumors of the parotid gland. These tumors in
every way identical to those occurring in the major salivary
gland and are minor in name only.
••The labial salivary gland line the upper and the lower
lips.
••The buccal salivary glands include aggregate of larger
molar and retromolar glands.
••The palatine salivary glands, a complex of
approximately 230 minor salivary gland, which are
situated in the mucosa of soft palate and posterior part
of hard palate.
••Lingual salivary glands which involve glands situated
in the floor of mouth and tongue.
Heterotopias of salivary gland are where salivary gland
cells without any duct system are present in an abnormal
location. The most common location is the cervical lymph
nodes. Other reported sites of heterotopic salivary gland
tissue are the nose and paranasal sinuses, parathyroid glands,
thyroid, middle ear pituitary gland, and cerebellopon­
tine angle, subcutaneous tissue of neck, stomach, rectum,
and vulva.
Clinical Features
••Usually a firm, slowly growing submucosal mass.
••Tumors of hard palate are firmly fixed.
••Tumors of tongue are indurated and fixed to overlying
mucosa.
••Intraoral tumors mostly appear well circumscribed
and usually of 1 to 2 cm in size.
••Usually painless but may be painful due to ulceration
and secondary infection. Spontaneous ulceration should
be viewed with greater suspicious of malignancy.
826  Head and Neck Reconstruction
Surgical Principle
In most of the cases, the tumor is adenoid cystic carcinoma.
The treatment is wide excision with reconstruction. The
extent of excision depends on the area of involvement and
histology of the tumor. If it is the oral cavity, the postexcision
defect may need three-dimensional reconstruction by
composite microvascular flaps.
Salivary gland tumors are notoriously chemoresistant
and radioresistant. There is very little role of adjuvant
therapy.18 The mainstay is thus a wide surgical excision with
clear margins.
Surgical excision is considered to be the primary
treatment modality.
All benign tumors are treated by excision of all tumors
with 0.5 cm cuff of normal tissues.
For malignant tumors, clinically clear margin of not less
than 1 to 1, 5 cm and the exclusion of perineural infiltrate are
recommended. The extent of excision depends on the area of
involvement. If it is the oral cavity, the postexcision defect
m
may need three-dimensional reconstruction by composite
microvascular flaps.
Long-term follow-up is recommended since 5 year is
not adequate period of supervision and many authors had
experienced recurrence after 10 to 13 years.19
Cystic Lesions of Salivary Glands
ie
Introduction
The diagnosis and management of cystic lesions in the salivary
glands have been discussed extensively in the pathology
literature. The controversy has largely concentrated on
the pathogenesis and classification of salivary cysts, most
frequently involving the parotid gland, and this in turn is
Th
because experts disagree about the embryological origin of
the cysts and the varied components of the morphological
features of the cyst wall.20
Clinical Classification of Cysts
Cysts involving the salivary glands can be classified as
congenital, acquired, or parasitic.
••Congenital cysts
Sequestration dermoid is due to dermal cells being
buried along the lines of closure of embryonic clefts
and sinuses by skin fusion. The cyst is therefore lined
with epidermis and contains paste-like, desquamated
material.
Branchial cleft cysts occur in the parotid region.
••Acquired cysts
There are different types of acquired cysts.
¾¾Retention cysts are due to the accumulated
secretions of a gland following obstruction of the
duct. These are commonly found in the major and
minor salivary glands and are known as ranula.
¾¾Duct ectasia may be part of a chronic inflam­
matory process (sialadenitis) or metabolic process
(sialadenosis).
¾¾Chronic sialectasis may lead to cysts—Sjogren’s
syndrome and human immunodeficiency virus.
¾¾Degenerative cysts are associated with tumors—
Warthin’s tumor, pleomorphic adenoma,
adenolymphoma.
¾¾Cysts with malignancy of salivary glands—
mucoepidermoid tumor, acinic cell carcinoma,
adenocarcinoma.
••Parasitic cysts
e
Hydatid disease of the Taenia echinococcus has been
reported to affect the parotid gland.
Clinical Features
In parotid gland, majority of the cystic swelling presents
with painless cystic mass, the swelling varies in size, and
location (upper or lower pole). Sometimes the patient may
present with an acutely swollen and inflamed major salivary
gland, and after the acute phase is over, the residual nodule
may lead to diagnosis of a salivary cystic lesion.
Cystic lesions of other salivary glands may present as
raised submucosal swellings when located in the mouth.
Diagnostic Workup
Imaging
In most clinics, the methods of investigation include imaging
studies such as ultrasonography with or without FNAC and
CT with or without FNAC.
Aspiration Cytology
The aspirated fluid may also be a guide to the possible
diagnosis.
When FNAC is being used in cystic lesions, it is important
to aspirate the liquid and from the cyst wall, both preferably
under ultrasound and CT guidance. Analyzing both the
content and the wall of the cyst improves the likelihood of
receiving a significant result from the cytologist.
Treatment
Surgical intervention according to the nature of disease is
the treatment of choice.
Ranula
A ranula is a type of mucocele, and therefore could be
classified as retention cyst of salivary gland. The nomencla­
ture came from the Latin word rana which means “frog”
(ranula = “little frog”).21
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  827

Classification midline. Large intraoral ranula may cause swallowing and

••Simple ranula—ranula arising from sublingual salivary
gland, confined to floor of mouth.
••Plunging ranula—this type of ranula extends
from floor of mouth into neck through mylohyoid
(Fig. 35.8a–c).
••Cervical ranula—when the main presentation of the
lesion is on the neck. It is rare.
••Pseudo ranula—sometimes this term is used for
other similar swellings of the floor of mouth such
as true salivary duct cysts, dermoid cysts, and cystic
hygroma.22
Origin
speech difficulty.
In plunging ranula, there is an additional swelling at
the neck. On squeezing the neck, swelling the oral lesion
increases in size. They mostly occur in young individuals.
A plunging ranula can produce additional symptoms, such
as difficulty swallowing, difficulty speaking, and tracheal
compression.22
Treatment
Sclerotherapy
••Excision and enucleation: As it is a pseudocyst and
there is no epithelial lining, it is very difficult for

e
Classically, it arises from sublingual salivary glands at the
floor of mouth. The most common cause is trauma and
rupture of the duct of the salivary gland and extravasation of
saliva into the surrounding tissue. This accumulation lacks a
true epithelial capsule; hence, it may be called a pseudocyst.
complete enucleation with intact wall.
In recurrent cases, the sublingual gland may have to
be excised.
••Marsupialization: The entire roof of the ranula
is excised and marsupialized. This allows

m
This fluid contains protein and amylase.

Presentation
It usually present as a painless bluish translucent swelling
at the floor of the mouth under the tongue, on one side of
re-epithelization of the cavity.
••Cervical or plunging ranula: It may need both intra­
oral and extraoral approach and may need splitting of
mylohyoid muscle. The external incision is given at
the submental region (Fig. 35.9a–c).
ie
Th

a b

Fig. 35.9  Plunging Ranula—right side. (a, b). Preoperative

picture. (c) Ranula delivered through submental incision. (These
images are provided courtesy of Prof. Karoon Agrawal, New Delhi,
c India.)
828  Head and Neck Reconstruction

Complications Interpretations of the presence of leprosy have been made

on the basis of descriptions in ancient Indian (Atharva Verda
••As the submandibular duct is located deep to the
and Kausika Sutra), Greek, and Middle Eastern documentary
mucosa on the anterior and lateral floor of the mouth,
sources that describe skin afflictions.
and it opens into the oral cavity on either side of
The causative agent of leprosy, M. leprae, was discovered
the frenulum; there is high chance of injury to the
by G. H. Armauer Hansen in Norway in 1873, making it
submandibular duct leading to stenosis, obstructive
the first bacterium to be identified as causing disease in
sialadenitis.
human.25 The first effective treatment (promin) became
••As the lingual nerve lies in close relation to sub­
available in the 1940s. In the 1950s, Dapsone was introduced.
mandibular duct, there is a possibility of injury to this
The search for further effective antileprosy drugs led to
nerve.
the use of clofazimine and rifampicin in the 1960s and
••Incomplete removal of oral ranula may lead to the
1970s. Later, Indian scientist Shantaram Yawalkar and his
development of plunging ranula.
colleagues formulated a combined therapy using rifampicin
Prognosis and dapsone, intended to mitigate bacterial resistance.

Chance of recurrence is high.
Conclusion
The role of reconstructive surgery in surgical management of
salivary gland neoplasm is immense. The excised specimen
e
Multidrug therapy (MDT) combining all three drugs was first
recommended by the WHO in 1981. These three antileprosy
drugs are still used in the standard MDT regimens.26,27

m
may include skin, facial nerve, mandible, leading to three
dimensional defects which must be corrected by different
flaps, facial nerve grafts, mandibular reconstruction by
different techniques—to achieve a satisfactory result from
functional and aesthetic point of view.

Facial Leprosy
ie
Introduction
Leprosy has affected humanity for thousands of years. The
disease takes its name from the Latin word lepra, which
means “scaly,” while the term “Hansen’s disease” is named
after the physician Gerhard Armauer Hansen (Fig. 35.10).
The involvement of facial nerve leads to varying degree of
Th

paralysis of muscles of facial expression.

The involvement of facial skin, nose, ear collectively
adds to the morbidity of the patients and is responsible
to the stigma of leprosy. The pathology and treatment are
discussed below.

History
Although it is difficult to retrospectively identify descriptions
of leprosy-like symptoms, what appears to be leprosy was
discussed by Hippocrates in 460 BC. In 1846, Francis Adams
produced The Seven Books of Paulus Aegineta which included
a commentary on all medical and surgical knowledge and
descriptions and remedies to do with leprosy from the
Romans, Greeks, and Arabs.23,24 Fig. 35.10  Gerhard Armauer Hansen.
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  829

Pathology of Facial Involvement in Besides this, other ocular lesions, such as chalazion,
lower lid ectropion, and punctal stenosis, may occur38,39
Leprosy (Fig. 35.11).

The complications arising out of leprosy are of two types—

nonparalytic and paralytic.28–30
Nonparalytic Complications
Skin and Subcutaneous Tissue
There is atrophy of the subcutaneous tissue, destruction
of the sweat, and sebaceous glands.28,29 In patients with
lepromatous leprosy, the skin lesions are healed with
marked fibrosis and result in disruption of normal blood
Classification
••Extent of involvement—Partial/complete.
••Side of involvement—Unilateral/bilateral.
••Area of involvement—Upper, presents with only
lagophthalmos (Fig. 35.12).
••Lower, presents with only deviation of angle of mouth.
••Total, presents with both (Fig. 35.13).38,39

e
flow to the skin resulting in the following:28,31
••The skin looks much older. Treatment
••Reduced vascularity of the skin, resulting in poor
survival of local flaps.32 In case of early involvement with history less than 6 months,
••There is loss of facial hairs like eyebrow, mustache, systemic steroid is indicated. Usually a patient who has

Ear

m
and beard.

Enlarged ear lobe may be due to tubercle formation in pati­

ents with LL. The cartilage frame work may be destroyed.33,34

Nose
It shows following changes:
••Dried up and inflamed nasal mucosa.
completed MDT is a candidate for surgical treatment, except
lagophthalmos where the operative intervention is indicated
early to save the eye from exposure keratitis.
ie
••Encrustation and ulceration of the mucosa.
••Loss of nasal mucosa.
••Partial or complete destruction of nasal septum may
lead to septal perforation.35
••Destruction of nasal bone and anterior nasal spine.35
••The collapse of nose resulting in saddle nose deformity
of various degree.
Th

Paralytic Deformity Fig. 35.11  Typical features of left ocular leprosy.

Lagophthalmos, conjunctival chemosis, corneal ulcer,
In leprosy, there is involvement of facial nerve leading to
eversion of lower eyelid (left).
paralysis of facial muscles.29
The involvement of seventh cranial nerve is extracranial,
but some suggests intracranial involvement too. There are
various grades of paralysis of facial nerve.
The process may involve:
••Selectively as zygomatic branch (most frequently), or
other branches.
••Whole trunk of facial nerve.
••Intracranial involvement of facial nerve has been
described.30
The nerve involvement is due to neuritic thickening and
friction over the zygomatic arch. This leads to paralysis of
orbicularis oculi and loss of complete eye closure, exposure
keratitis, corneal ulcer, corneal perforation, and ultimately
blindness.36,37 Fig. 35.12  Right upper facial palsy—right-sided lagoph­
thalmos, sparing orbicularis oris.
830  Head and Neck Reconstruction
Fig. 35.13  Left complete facial palsy.
Conservative Treatment
••Local and systemic steroid.
m
••Use of eye drops (steroid, antibiotic) and/or methyl
cellulose drops.
••Protection of eye with sunglass/eye pads.
••Active and passive exercises to close the eyes to
improve eyelid movements.
Surgical Correction of Lagophthalmos
ie
The operations are broadly categorized into two types—
static and dynamic procedures.40
••Static procedures:
¾¾Tarsorrhaphy
¾¾Canthoplasty
¾¾Canthopexy
¾¾Upper lid loading—with gold (0.6—1.6 g)
(Disadvantages—can’t close the eye when the patient
Th
is supine/infection and extrusion of the implant).
••Dynamic procedures:
¾¾Muscle transfers
Lateral Tarsorrhaphy (Mc Laughlin)
Incisions are made along the lateral 5 mm of lower and
upper eyelid. The inter marginal line of upper and lower lids
is split. A part of anterior lamella of lower lid and tarsal plate
of conjunctiva is excised. The two raw areas are sutured
together.40
Medial Tarsorrhaphy (Fritschi)
Incisions are made in the upper and lower lids medial to
punctal raising two full-thickness triangular flaps, one
based superiorly and the other based inferiorly. The exposed
edges of tarsal plates are sutured together. The skin flaps are
sutured together in the shape of Z plasty.41
Upper Lid Loading
Implantation of a weight (0.6–1.6 g of gold) in the submus­
cular plane of upper eyelid helps in gravity assisted closure.
Dynamic Procedures
Principle: In leprosy, muscles of mastication which are
supplied by cranial nerve V are spared. These muscles are
used for the reanimation of eyelid closing muscles to protect
the eye and improve facial expression.42
Aim of surgery:
••Voluntary closure of eyelids with contraction of
temporalis muscle.
e
••Correction of lower lid ectropion.
••Narrowing of the palpebral fissure.
••Proper positioning of the lacrimal puncta for the
prevention of epiphora.
••Cosmetic improvement.
Choice of operation:
If lid gap on light closure of eye is more than 5 mm, a
dynamic procedure is preferred. If it less than 5 mm, a static
procedure is preferred. In old patients with long-standing
lagophthalmos associated with laxity of lower lid with
ectropion, a static and dynamic procedure is combined.
Basis of Muscle Transfer
The basis of regional muscle transposition is to transfer new
muscle innervated by a different cranial nerve which can
furnish pull in desired directions, but it needs re-education
in the use of this voluntary muscle. The anterior and middle
fibers of temporalis muscle cause upward rotation of
mandible. When the muscle is applied to the lids, simul­
taneous clenching of the teeth produces contraction of
the transferred part of temporalis, and thereby closure of
eyelids.
As the nerve and arterial supply to the temporalis
muscle is on the deeper surface of the muscle and run
distal to proximal; after the transfer, the supply remains
intact (Fig. 35.14a). The deep temporal fascia is attached
superiorly to the temporal line of the scalp, and below up
to zygomatic arch, so a good length of it can be procured as
per requirement.
Posterior fibers of temporalis are more horizontal, so the
pull of these fibers applies better closing force to the lids
(Table 35.1).
Operation Procedure (Anderson Modification
of Gillies Method)
••Anesthesia: General or local anesthesia.43
••Position: Patient is placed supine, with head rotated
slightly toward the opposite side.
••Infiltration: Proposed incision sites over the temporal
area of scalp, the eyelids, and the canthi are infiltrated
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  831

with 2% xylocaine with adrenaline (4cc diluted to
15 cc). This will provide hemostasis and relatively
avascular dissection.
••Incision: Many incisions have been described.
Preauricular, straight, sickle-shaped, and S-shaped
inci­
sions are used to expose the area from zygo­
matic arch below to superior temporal line above
(Fig. 35.14b).
••Dissection: The deep temporal fascia is exposed
which can be identified by its shiny tough texture.
The dissection is carried to the level of zygomatic arch
distally and the area where the deep temporal fascia
blends with pericranium superiorly. The fascia is
cleared off the soft tissue.
••Isolation of the fascial strip: Two vertical parallel
incisions are made over temporal fascia, about 1 cm

Table 35.1  Different methods of temporalis myofascial sling operations

Name of operation Motor source—temporalis Extension of muscle by

Gillies (Antia) operation Anterior and middle fibers Tensor fascia lata graft

e
Anderson modification Anterior and middle fibers Temporalis fascia
Johnson’s method Posterior fibers Tensor fascia lata graft

m
ie
Th

a b

Fig. 35.14  (a) Artery and nerve supply to temporalis muscle.

(b) Incisions for the operation (modified Gillies temporalis
c transfer). (c) Elevation of temporoparietal fascial flap.
832  Head and Neck Reconstruction
d e
m Fig. 35.14  (Continued) (d, e) Division
ie
f g
apart, distally extending up to zygomatic arch and
Th
superiorly about 5 mm short of the area where the
fascia blends with pericranium. A third incision,
trans­versely made near zygomatic arch, connecting
these two and a tongue shaped flap is raised with the
base superiorly placed. The flap is dissected off the
temporalis muscle starting inferiorly proceeding
superiorly and ending about 1.5 cm short of the sup­
erior margin (Fig. 35.14c). The fascial strip and the
muscle are fixed with two or three horizontal mattress
sutures—in order to prevent accidental stripping of the
fascia off the muscle during the course of transfer. A
stay suture is applied to the tip of the fascial strip.
••Isolation of muscle: About 1 to 1.5 cm wide strip of
temporalis muscle is isolated which is continuous
cranially with the facial strip and proceeding distally
toward zygomatic arch, and having its neurovascular
pedicle entering from caudal aspect. The musculofascial
strip should be of adequate length so as to reach the
inner canthus of eye (Fig. 35.14d, e).
e
of facial strip into two striplets and
rerouting it along the upper and lower
eyelids. (f, g) Position of two strips in the
upper and lower eyelids and fixation with
the medial canthal ligament.
••Tunneling: The myofascial unit is brought up to the
lateral margin of orbit by making a tunnel which
should be adequate enough so that the muscle tendon
unit plays through it comfortably. The fascial strip is
divided into two striplets. Two incisions are made on
middle of the eyelids, about 1.5 to 2 mm from and
parallel to their margins. With the help of a fine iris
scissors, two narrow tunnels are created from the
previously made incisions, remaining as close to the
lid margins as possible. The tunnels are extended
medially to the medial canthus where it exits through
an incision over lateral wall of nose near medial
canthus. The split strips are now passed through the
tunnels—one through upper and another through
lower lids—remaining very close to the margin till both
the strips exit near medial canthus (Fig. 35.14f, g).
The medial canthal ligament is dissected for anchorage
of facial strip.
••Adjustment of tension and anchoring of strips:
With the help of the hemostats, traction is applied
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  833

to the fascial strips with both the strips in apposition
(Fig. 35.14f). The amount of tension should be such
that the upper lid overlaps the lower lid by about
2 mm. In this slightly overcorrected position, the fascial
strips are anchored to the medial canthal ligament
and the periosteum over the nasal bone. In addition,
the strips are sutured to the tarsal plates where the
incisions were made previously. The suture used is 5/0
monofilament nylon. The wounds are closed carefully
after hemostasis. The eye is covered with eye pad and
pressure bandage is applied over the scalp.
••Postoperative care and physiotherapy: The patient is
put on liquid diet for 2 weeks. Stitches were removed
on 7th postoperative day. After 10th postoperative
very much in nature regarding speed, power, and amplitude
of contraction.
The regional masticatory muscle transfer improves
the stigmata of facial nerve paralysis, but do not restore
the capacity to produce involuntary or spontaneous lid
closure.44,45
Conclusion
For correction of lagophthalmos, temporalis myofascial sling
operation is a very effective dynamic procedure. Technically,
it is easy and reproducible, can be performed with simple
instruments and in a simple setup. The secondary correction,
if required, is also easy. Though the fine and intricate

e
day, the patient is allowed to have semisolid diet and movement of eyelid can’t be restored, this operation can
3 weeks postoperative normal diet. definitely augment eye closure and protect it.
Three weeks after the operation, the patient is asked to
perform exercise that is closure of eye and clinching the teeth
together. After a certain period, patient will develop this Johnsons Modification

Complications

m
reflex (conditioned reflex). With proper training, patients
are able to dissociate these two actions (Fig. 35.15a–e).

••Hemorrhage—mainly from the scalp incision and

medial canthal wound due to injury to angular vein.
••Injury to lacrimal canaliculi and sac.
••Detachment of temporalis fascial strip from the
muscle.
In this technique, the posterior fibers of temporalis muscle
are used for the reanimation of eyelids. Tensor fascia lata
graft is taken and attached to the musculoaponeurotic part
of posterior fibers of temporalis. 43,46 According to the author,
as the posterior muscle fibers are horizontal, the direction of
pull of the muscle will be more physiological.
ie
••Short length of the myofascial sling.
••Inadequate fixation to the medial canthal ligament.
Surgical Procedure for Nasal
••Under or overcorrection of lagophthalmos due to Deformity
faulty adjustment of tension.
••Ectropion—if the fascial strips are placed away from Augmentation of Dorsum of Nose
the lid margins.
Augmentation rhinoplasty is indicated in mild-to-moderate
Limitation of This Operation nasal deformity.
Th

The ideal, synchronized, complete eyelid movement is Previously autogenous bone grafts taken from rib, iliac
very difficult to achieve through any of the replacement crest, or calvarium were used to augment the dorsum of
surgeries. The orbicularis oculi and temporalis muscle differ nose. But nowadays cartilage graft, harvested from ear,

a b c d e
Fig. 35.15  (a, b) Lagophthalmos of left eye (preoperative). (c) Two months after temporalis transfer, patient can close left
eye with clenching the teeth and facial grimace. (d, e) Six months after operation patient can close left eye effortlessly.
834  Head and Neck Reconstruction
or ribs are popular. Due to frequent association of septal
mucosal inflammation, harvesting graft from septal cartilage
should be avoided.44,45,47
Silicone nasal implant has high rate of infection and
extrusion, hence not preferred.
This surgery is performed under general anesthesia with
oral midline endotracheal tube. But if cartilage is harvested
from ear, local anesthesia can be used. Nose and donor sites
are infiltrated with local anesthetics and adrenaline.
Route for Insertion of Graft
••Mid columellar incision.
••Through one nostril—by inter cartilaginous incision.
••Intraoral route—making incision in the upper gingivo
labial sulcus.
••Incision over root of nose—especially when bone graft
is used. This approach allows fixation of the bone graft
with the nasal bone by wire or a mini screw. It ensures
union with the nasal bone and thereby minimizes
resorption.
m
Preparation of the Pocket for Graft
With the help of a sharp scissors, a snugly fitting pocket is
made over the dorsum of nose and the graft is inserted up
to the frontonasal angle. Some surgeons prefer to make a
notch in the nasal bone and hinge the graft in it to secure its
position.47
Stabilization of the Graft
ie
Most of the surgeons prefer to stabilize the graft with sutures
and by application of a conforming nasal plaster along with
insertion of a nasal pack.
If bone graft is used and inserted by columellar or
intercartilaginous route, it can be fixed with the nasal
bone by a percutaneous screw inserted by making a stab
incision.47,48
Th
Postoperative Care
••Nasal packing: it is kept for 3 to 5 days.
••The conforming plaster of Paris splint is kept for 2 to 3
weeks. But the POP splint made on the operation table
is changed after 4 to 5 days when edema subsides.
••Patient is advised to take semisolid diet for 2 to 3 days.
••Antibiotic and analgesic are used asper preference of
the surgeon.
Postnasal Epithelial Inlay (PNEI)
This method is applied in patients with severe saddle
nose deformity. There is destruction of the nasal septum
and severe scarring of the nasal mucosa. The skin over the
dorsum is adhered to the anterior aspect of maxilla and
there is no space for insertion of bone graft for the purpose
of augmentation rhinoplasty. A space is created in between
the anterior aspect of maxilla and skin and it is lined by
skin graft to replace the whole mucosa. The key steps of the
operation are as follows:
Anesthesia
Preferably general anesthesia with midline flexometallic
tube. Some surgeons prefer to do the operation under local
anesthesia. The upper gingivobuccal sulcus is infiltrated
with hemostatic solution.
Dissection and Creation of Postnasal Space
Postnasal space is approached through a transverse incision
through upper gingivolabial sulcus. The tissues from the
e
anterior surface of maxilla are dissected and released by
sharp dissection. The dissection is continued till the whole
of the nose (except the columella) is lifted off the maxilla.
Fabrication of the Stent
After adequate hemostasis, a stent is made of Gutta Percha
according to the shape of the space created. Spilt skin graft is
applied over the stent with dermal surface outside and then
the whole thing that is the stent lined by split skin graft is
inserted in the postnasal space.
Postoperative Care
The postnasal stent draped with skin graft is kept in place for
about 8 to 10 days after which the stent is removed, washed,
and reapplied. This process is continued at an interval of 4
to 5 days for 3 weeks till the postnasal space is lined by the
skin graft.
Antia recommended permanent use of the postnasal stent
fabricated by acrylic fitted to the denture so as to provide
good nasal shape and projection.49
Crockett’s Operation
In this method, postnasal epithelial inlay is combined with
bone and cartilage graft over dorsum of nose. Though this
technique achieves good nasal projection, there is more
chance of infection and subsequent graft loss. Some surgeons
prefer to do it in two stages—the PNEI first, followed by
application of the graft.
Nasolabial Flaps
This flap is used in patients with moderate-to-severe nasal
collapse and mucosal contracture.
After creation of postnasal space as described above,
superiorly based bilateral nasolabial flaps are used for lining.
This avoids necessity of using permanent acrylic stent. Nasal
projection is achieved with insertion of bone graft in the
plane between nasal dorsal skin and the nasolabial flaps.50
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  835

Forehead Flap
In long-standing cases of severe nasal collapse, not only
the postnasal space is contracted due to mucosal scarring,
but also there is contracture and deficiency of the skin over
the dorsum of nose. To get an acceptable nasal profile, a
paramedian or median forehead flap is performed. The lining
of the postnasal space is provided by skin graft or flap.50
A scheme of nasal reconstruction in long-standing severe
nasal collapse has been suggested, where there is deficiency
of dorsal nasal skin, cartilage frame work, and postnasal
mucosa.
••Mucosal lining:
¾¾Over the proximal part of nose—by dermal turnover
(usually the lateral part). There are various methods of
restoration of eye brow.
••Free scalp graft
Narrow strips of postauricular hair bearing skin over
mastoid are taken and applied over the eyebrow area.
••Superficial temporal artery island flap
Small hair bearing skin islanded over the posterior
branch of superficial temporal artery is taken and
tunneled subcutaneously to the area of eyebrow.
The distance from the external ear to the midpoint of
the forehead is the length of the pedicle.45
••Scalp transposition flap (Antia)
This procedure overcomes the difficulty and the danger
of dissecting a long narrow pedicle and unpredictable

e
flap. venous drainage of the previous one.
  It is a two-stage procedure.
¾¾Over the nasal vault—by bilateral nasolabial turn­
  An inferiorly based narrow strip of skin flap is
over flap.
elevated based on superficial temporal artery and its
••Cartilage frame work—by costal cartilage or conchal
posterior branch is transposed to the eyebrow area.
cartilage.

m
••Skin deficit over the dorsum of nose, tip, columella—by
median or paramedical flap.

Wrinkled and Lax Facial Skin

The laxity of skin is marked in the lower eyelid area and
perioral area. The patient looks much older than the actual
After 3 weeks, the intervening pedicle overlying the
temporal area is excised, and final insetting of the
lateral part of the flap is done.40
••Hair transplant
Restoration of eyebrow can be achieved by hair
transplantation by either FUG or FUE technique.49,51

ie
age due to atrophy and laxity of facial skin. Conventional
facelift is not preferred in such cases. A list of deformity and
corrective surgery is mentioned in Table 35.2.
Reconstruction of Eyebrow
Loss of eyebrow is a late sign of leprosy, usually seen in
Th
Conclusion
The corrective surgeries for lagophthalmos if done in
proper time can save the eyes of the patients. Though other
facial surgeries are usually done after the completion of
MDT, surgical correction of lagophthalmos may be done
at any point of treatment to save the vision. Other surgical
procedures help in improving the facial appearance,
thereby imparting self-esteem of the patient and removes

lepromatous type. This may involve total or partial eyebrow social stigma.

Table 35.2  A list of deformity and corrective surgery

Deformity
Redundancy of upper eyelid
Redundancy of forehead skin
Lower lid sagging and ectropion
Perioral skin laxity
Procedure
Upper lid blepharoplasty
Forehead lift with or without brow lift
Lower lid blepharoplasty
In selected cases wedge excision of lower lid and tightening done
Nasolabial rhitidectomy48
Procedure:
Curved incision is made along the nasolabial fold and mobilization of skin is done on
both sides of incision, medially just short of the philtral bar
The dissection is extended up to the chin
Crescent shaped skin is excised and tightening of the remaining skin is achieved
836  Head and Neck Reconstruction
Torticollis
Definition
Torticollis (Latin—twisted neck) is a condition in which the
sternocleidomastoid (SCM) muscle is effectively shortened in
the involved side, leading to ipsilateral tilt and contralateral
rotation of face and chin. Congenital muscular torticollis is
the better terminology as far as the clinical, histological, and
MRI features are concerned showing muscular atrophy and
intramuscular fibrosis.
Epidemiology
Overall incidence of torticollis is 1:250 live births. The
male:female ratio is 3:2 and right SCM is more often affected
than the left one.52,53
m
Anatomical Variation in
Sternomastoid
The SCM muscle divides the neck into anterior and posterior
triangles, and is intimately related to many neurovascular
structures.
ie
Classically, its inferior attachment has a medial (sternal)
head and a lateral (clavicular) head. The sternal head is
tendinous and originates from the anterior surface of the
manubrium sterni, whereas the clavicular head is muscular
and originates from the superior surface of the medial
third of the clavicle. Both of these heads are separated by
a triangular gap, termed the lesser supraclavicular fossa. As
they ascend, the clavicular head spirals behind the sternal
Th
head and blends in with its deep surface, forming a thick,
rounded belly prior to its insertion into the lateral surface
of the mastoid process and the lateral half of the superior
nuchal line.
According to Sanli et al, SCM muscle has five parts based
on their attachment (namely the superficial sternomastoid,
sternooccipital, cleido-occipital, deep sternomastoid, and
cleidomastoid).54 Detailed knowledge of the variations
present in the SCM muscle is essential for surgeons and
anesthetists in order to avoid related complications.
Some studies have reported a 33% incidence of cleido-
occipital belly of the SCM muscle. The functional advantage
afforded by an extra head of the SCM muscle is not clear.
However, in view of the fact that an extra head implies
additional muscle fibers, it is important from the point of
surgical release of torticollis.
Classification
The torticollis may be primary due to pathology in the
sternomastoid muscle since birth or secondary due to
acquired causes.55,56
There are three subtypes of primary or muscular torticollis:
••Group1: Sternomastoid tumor consists of torticollis
with a palpable swelling, firm, and tender, and appears
2 to 3 weeks after birth. It spontaneously regresses
within first year.
••Group2: Muscular torticollis is with tight sterno­
mastoid but without any tumor. It does not regress
spontaneously.
••Group3: Postural torticollis is without a mass or
e
tightness of the muscle. This is seen in patients with
scoliosis of dorsal spine.
Secondary Torticollis
••Paralysis of sternomastoid muscle on one side with
over action of the same of opposite side.
••Congenital deformity of the cervical vertebra.
••Subluxation of cervical vertebra usually spontaneous.
••Cervical lymphadenitis.
••Caries of cervical spine.
••Myositis or soft tissue infection.55
Etiology of Primary (Congenital)
Torticollis
The exact etiology is unknown. Among many theories,
following are most important:
••Intrauterine malposition—(compression of vascular
supply leads to ischemia and fibrosis of the
sternomastoid).54
••Thrombosis or hemorrhage in the terminal artery or
vein to the said muscle during labor.
••Tumor formation in the sternomastoid.
Pathology
At birth or within the first 2 weeks, a firm fusiform swelling
appears within the SCM muscle and the head is tilted toward
the same side. Though the swelling or “Sternomastoid tumor”
occupies the lower or middle third, it may involve the whole
sternomastoid. The mass is composed of immature fibrous
tissue and is well demarcated from the surrounding normal
muscle. Subsequently the “tumor” is replaced by a short,
fibrotic, and contracted sternomastoid.55
 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  837

Clinical Feature schedule may produce good result if the treatment is started
early. Stretching exercise should be done by an experience
There is prominence of one sternomastoid. The head is therapist who aims at gradual stretching of the affected
muscle and strengthening of the contralateral muscle.
tilted to same side and drawn toward the shoulder of the
Botulinum toxin, ultrasound therapy, and microcurrent
affected side. The face and chin are turned to the opposite
therapy are adjunct to the stretching exercise to increase its
side (Fig. 35.16). The ipsilateral shoulder is at a higher level
effectivity.58
than its counterpart.57
Surgical treatment is required if the torticollis persists
In long-standing case, following may be present:
after 1 year of age.59–61
••Facial asymmetry—the distance between the outer
••Closed tenotomy: This is usually done at the clavicular
canthus of eye and the angle of mouth is less on the
end. But this procedure could be dangerous due to
affected side.
chance of injury to the anomalous external jugular or
••The eyes are at different level and secondary scoliosis
subclavian vein and sometimes phrenic nerve.
may develop to maintain a horizontal gaze.
••Open tenotomy—unipolar release (Fig. 35.17):

e
••Some patients may develop squint. Release of the two clavicular heads is done under
••Short and contracted cervical fascia and scalene direct vision. The ideal age of operation is 1 to 4
muscles. years of age. The complications are tethering of scar
••Early degenerative and/or scoliotic changes in the to deeper structure, loss of contour of muscle, and
cervical spine. inadequate correction.
••Cranial asymmetry.57

m
Other Associated Anomaly
••Cervical hemi vertebra.
••Congenital dislocation of hip or acetabular dysplasia in
7 to 20% of the patients with torticollis.57
¾¾Procedure: Transverse incision is made close and
parallel to clavicle and the two lower heads are
isolated and tenotomy done. If platysma and deep
cervical fascia are found to be tight, these structures
are also cut. If still the release is unsatisfactory, then
bipolar release, that is, tenotomy of sternomastoid
by a small incision at submastoid region, may be
done.
••Open tenotomy—bipolar release: In severe cases, both
ie
mastoid and clavicular heads are released (Fig. 35.18).
Management ••Z-lengthening: In mild torticollis, correction may be
achieved by performing Z-lengthening of sternoma­
Careful screening and roentgenographic examination should stoid in coronal plane.
be done before selecting the line of management. ••Endoscopic release: As conventional surgical pro­
Conservative treatment can be started at 3 to 9 months cedures leave visible scars, endoscopic release is used
of age. Use of cervical collar, splinting by brace, and exercise by some surgeons.
Th

Fig. 35.16  Torticollis. Left sternocleidomastoid is involved Fig. 35.17  Unipolar release. Lower end of
and stands prominent. There is tilting of occiput to left, chin sternocleidomastoid is exposed.
to right, elevation of left shoulder.
838  Head and Neck Reconstruction
a
m b
Burstein and Cohen reported a large series of subcut­
aneous endoscopic release of torticollis through a hairline
approach.62 Sasaki et al described an endoscopic approach
Fig. 35.18  (a) Bipolar release. (b) Outline of right sternocleidomastoid. (c) Release of lower and upper pole.
ie
using two small incisions, one at the posterior auricular fold
lateral to the auriculotemporal sulcus and another with in
the hairline.63
A technique of transaxillary subcutaneous endoscopy for
the release of the SCM muscle in congenital muscular torti­
collis is also described. This procedure provides direct access
to the fibrous bands; enables release without risk of damage
to the spinal accessory nerve, external jugular vein, or
Th
greater auricular nerve; and leaves no visible neck scars.64-66
Postoperative rehabilitation: Physiotherapy is started
after 7 days with passive stretching and splintage with
and without cervical traction and to be continued till 6 to 8
months. Patient is advised to use the cervical collar for next
6 to 8 months (if necessary more) along with exercise to
strengthen the neck muscle. Exercise in front of a mirror may
be helpful to correct the positional residual deformity.58,67
Complications of Surgery
Complications of surgery are67,68:
••Hematoma.68,69
••Injury to spinal accessory nerve, while releasing the
upper pole of sternomastoid in bipolar release.
••Hypertrophic scar.
••Unacceptable contour of neck.
••Post-correction nystagmus or diplopia in late cases
where gaze is already fixed.17
e
c
Different Nomenclatures of Torticollis
Tortus (Latin) means twisted and collum (Latin) means neck.
Different terms are used to describe abnormal movements or
position of neck. Some of the terminologies are mentioned
in Table 35.3.
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 Congenital Torticollis, Salivary Gland Tumors, and Reconstruction of Facial Deformities in Leprosy  839

Table 35.3  Terminologies used to describe abnormal movements or position of neck

Dystonic torticollis Abnormal posturing of head in any direction due to neuromuscular imbalance. Head tilt in
different directions occurs from tonic contraction of specific muscle(s)
Laterocollis—The head is displaced with the ear moved toward the shoulder from increased tone
in the ipsilateral cervical muscles
Rotational torticollis—Partial rotation or torsion of the head occurs along the longitudinal axis
due to tonic contraction of sternocleidomastoid of one side
Anterocollis—The head and neck are held in forward flexion with increased tone of anterior
cervical muscles
Retrocollis—The head and neck are held in hyperextension with increased tone in the posterior
cervical muscles
Static torticollis Fixed positioning of the head and neck in any direction, as seen in Atlanto-axial dislocation
Dynamic torticollis Dynamic posturing of the head and neck in tilt, rotation, and flexion. There is periodic spasm of
the sternocleidomastoid, trapezius, and other neck muscles, with abnormal movements, as seen

Acute traumatic torticollis
Spasmodic torticollis
e
in Parkinsonism
Acute onset of torticollis due to trauma, as in Atlanto-axial subluxation
Spasmodic torticollis is a form of focal dystonia which is a neuromuscular disorder that consists
of sustained muscle contractions causing repetitive and twisting movements and abnormal
postures in a single body region. The disorder is categorized as early onset if the patient is

m
Acute spasmodic torticollis

Benign paroxysmal torticollis

Central dystonic torticollis

diagnosed before the age of 27, and late onset thereafter
Acute spasm of unilateral neck muscles, as seen in acute retropharyngeal abscess, cervical
lymphadenitis, caries spine
It is characterized by repetitive episodes of head tilting with vomiting, pallor, irritability, ataxia,
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involved and is self-limiting
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phenothiazines, metoclopramide, haloperidol, carbamazepine, phenytoin, and L-dopa therapy
ie
Torticollis may be associated with trismus, fixed upper gaze, grimace, and speech difficulty
It is treated with diphenhydramine or benzodiazepines

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