A 58-year old woman was referred to our department of plastic surgery 7 days after facelift surgery and neck liposuction performed at a private clinic. The patient complained of immediate post-operative salivary leakage (about 15 mL to 20 mL per day) in the right posterior auricle area, especially when chewing food, and swelling around the right parotid gland. Despite 6 days of pressure dressing and hemovac insertion, her symptoms showed no improvement prior to this visit. On physical examination, she had an asymmetric face contour, with severe swelling around the right mandible angle (Fig. 1A). Amylase concentration of the salivary leakage could not be determined as it was higher than the detection limits of the assay (>65,000 U/mL). Starch-iodine test revealed that her secretion changed from purple to light brown, indicating that the excessive secretion was mainly due to abnormality in salivary function. Sialography demonstrated that the right Stensen’s duct was not damaged. We injected intraglandular botulinum toxin type A (Botulex^®, Hugel, Chuncheon, Korea) into the right parotid gland. A total of 50 units of botulinum toxin was diluted in 3 mL of normal saline. Two units of botulinum toxin were injected for each interinjection distance of 1 cm (Fig. 1B). We also prescribed the anticholinergic drug, scopolamine, and placed a facial bandage over the patient’s face to compress the injected site. Patient was instructed to eat rice porridge and minimize temporomandibular joint motion. Follow-up was performed every 3 days. On the first follow-up visit, leakage volume had decreased significantly. Both salivary leakage and swelling of the right cheek resolved completely within 10 days (Fig. 1C). No side-effects were noted. To date, 3 months after the botulinum toxin injection, the patient is free of recurrence.

A 52-year old woman was referred to our department due to 20-25 mL salivary leakage at the right periauricular area every day. She had undergone facelift surgery 1 month prior at a private clinic, and experienced immediate post-operative salivary leakage and swelling of the right mandibular angle. No improvement was seen after hemovac insertion or pressure dressing. Her right eye and right mandible were slightly swollen and bruised (Fig. 2A). She had no symptoms of right facial nerve palsy. Amylase concentration of the salivary leakage could not be determined as it was higher than the detection limits of the assay (>65,000 U/mL). In the starch-iodine test, the sample changed color from purple to light brown, proving salivary reaction. Sialography of the right parotid gland demonstrated that Stensen’s duct was intact. We found that the patient actually had salivary leakage of 100 mL a day. Hence, we decided to maintain the hemovac drain, continue pressure dressing, and prescribed scopolamine for 2 weeks to reduce salivary secretion before injecting botulinum toxin, because the patient did not want botulinum toxin injection or a surgical procedure immediately. A total of 50 units of intraglandular botulinum toxin type A (Botulex^®, Hugel, Chuncheon, Korea) was diluted in 3 mL of normal saline and injected into the right parotid gland after 2 weeks. Two units were injected for each interinjection distance of 1 cm (Fig. 2B). The patient was instructed to continue taking scopolamine, eat rice porridge, and limit temporomandibular joint motion. Facial bandage was placed over her head and face, including the right parotid region. We checked her symptoms every 3 days. Two weeks after the injection, she was finally free of discomfort (Fig. 2C). To date, 6 months after botulinum toxin therapy, the patient is free of recurrence.