An 80-year-old male was referred to us with squamous cell carcinoma of the left pre-auricular area that was confirmed through incisional biopsy (). The patient was suffering from occasional bleeding, discharge, and repeated ulceration of the lesion. We performed computed tomography of the head and neck region before surgery, which showed no evidence of invasion. We performed wide excision of the tumor with a 0.5 cm lateral margin throughout. We obtained a safe margin of depth without parotid gland injury even though the tumor bed was close to the parotid gland fascia (). However, we could not completely rule out micro-injuries to the parotid gland fascia although we reserved parotid gland fascia. After wide excision, the skin defect was covered with a 5×6 cm full thickness skin graft from the left inguinal area. The usual compression dressing with a tie-over suture was applied to maintain the skin graft.\nOn the fifth postoperative day, we discovered exudate from the base of the skin graft through the slit incision site (). The dressing materials were wet and the discharge from the operative site increased during meals. The amount of discharge was approximately 50 mL, and its amylase level was 200,000 unit/L. Accordingly, we confirmed the exudate was salivary discharge and he was diagnosed with a sialo-cutaneous fistula.\nWe decided to use botulinum toxin type A injection because of concern for graft failure due to increased sialorrhea that was not controlled by conventional compression dressings. Using a tuberculin syringe, we administered a transcutaneous injection of 25 IU of the toxin at a point 0.5 cm above the site of the fistula at the surgical incision line and administered another 25 IU injection 0.5 cm anterior from that point. The injections were performed only for the superficial parotid gland in order to avoid post injection facial nerve paralysis. The discharge draining from the sialo-cutaneous fistula was considerably reduced after the second day of injection. The patient fully recovered within a week without any complications such as graft shearing or failure ().
A 35-year-old male, carpenter by profession, reported to us following a RTA. He was diagnosed with a panfacial fracture which included a LeFort 3, ZMC, naso-orbital-ethmoid, bilateral condylar, and symphysis fractures [Figures and ]. The right subcondylar-ramus fracture was approached through a periangular incision. The left dislocated condyle was then reduced and fixed through a preauricular approach. This was followed by the symphysis fracture reduction and fixation through an intraoral vestibular approach. The midface was finally reduced and fixed. This was followed by a postoperative orthopantomogram for assessment [].