Management of Parotid Duct Injury After Buccal Fat Removal
Immediate primary repair with microsurgical anastomosis over a stent is the treatment of choice when parotid duct injury is recognized intraoperatively or within 24-48 hours, as this provides the best functional outcomes and prevents chronic complications like sialocele, fistula formation, or gland atrophy. 1, 2, 3
Immediate Recognition and Initial Management
If Injury Recognized Intraoperatively:
- Stop the procedure immediately and identify both the proximal (glandular) and distal (oral) ends of the severed duct 1, 4
- Perform primary microsurgical repair using an intraductal stent (epidural catheter, silicone tube, or lacrimal probe) to maintain patency during healing 1, 3
- The stent should remain in place for 2-4 weeks to allow epithelialization of the anastomosis 1, 3
- Suture the duct ends over the stent using fine absorbable sutures (7-0 or 8-0) under magnification 1, 4
If Injury Suspected Postoperatively:
- Look for clear fluid drainage from the surgical site or progressive unilateral facial swelling in the parotid region within 24-48 hours 2, 4
- Immediate surgical exploration is warranted if duct injury is suspected, as early repair (within 48-72 hours) has significantly better outcomes than delayed management 1, 4
Anatomic Considerations Critical to Repair
- The parotid duct (Stensen's duct) runs horizontally across the masseter muscle, approximately one fingerbreadth below the zygomatic arch, and pierces the buccinator muscle to enter the oral cavity opposite the maxillary second molar 1, 2
- Injuries anterior to the masseter (distal third) can be managed by creating a new oral opening (marsupialization) if primary repair is not feasible 1, 4
- Injuries over or posterior to the masseter (proximal two-thirds) require microsurgical repair or gland ablation, as marsupialization is not anatomically possible 1, 4
Treatment Algorithm Based on Timing and Location
Early Recognition (< 48 hours):
- Primary microsurgical repair with stenting for all injuries where both duct ends can be identified 1, 3
- If distal end cannot be located and injury is anterior to masseter: create oral fistula by suturing proximal duct to buccal mucosa 1, 4
- If proximal duct is severely damaged: consider ligation of proximal duct with or without gland ablation using antisialagogues 1, 4
Delayed Recognition (> 1 week):
- Chronic sialocele or fistula formation is likely if untreated 2, 4
- Options include: repeated aspiration with pressure dressing, sclerosing agents, botulinum toxin injection to suppress gland function, or surgical intervention (duct reconstruction vs. gland excision) 1, 4
- Parotidectomy may be necessary for refractory cases with chronic infection or fistula 1, 4
Adjunctive Measures
- Antisialagogue medications (anticholinergics like glycopyrrolate) reduce saliva production and decrease pressure on the repair 1, 4
- Pressure dressings for 5-7 days help prevent fluid accumulation 1, 4
- Prophylactic antibiotics (1st or 2nd generation cephalosporins) are recommended given proximity to oral cavity 5
- Soft diet for 2 weeks to minimize mechanical stimulation of salivary flow 1
Critical Pitfalls to Avoid
- Do not attempt repair without magnification - the duct is only 2-3mm in diameter and requires microsurgical technique 1, 3
- Do not delay exploration if duct injury is suspected - outcomes deteriorate significantly after 72 hours 1, 4
- Do not confuse parotid duct injury with facial nerve injury - facial paresis can also occur after buccal fat removal but presents with motor weakness rather than swelling/drainage 6
- Do not perform blind ligation without identifying the proximal stump, as this can lead to gland necrosis and abscess formation 4