2. 878 A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 877–880
Fig. 1. Vascularised fat flap with a superior pedicle.
We recorded the time required for dissection of the fat pad,
and followed up the patients for 1–9 years to look for symp-
toms of Frey syndrome such as flushing, and sensations of
heat or sweating, while eating.
Surgical technique
We dissected superficial to the SCM and than changed to the
subcutaneous layer to leave fatty tissue on the middle of the
muscle. After dissection and removal of the parotid gland
we dissected a superiorly pedicled, thin layer of the SCM
with the fatty part attached to its caudal part (Fig. 1). The
fatty part was dissected according to the size of the removed
parotid tissue. The flap was positioned, free of tension, into
the parotid region, and sutured to the residual edges of the
SMAS, the remaining dense edges of parotid fascia, and the
tragal perichondrium (Fig. 2). We dissected a piece of fatty
tissue that was larger than the removed tissue to compensate
for the partial resorption; it was folded if necessary.
Results
Seventeen women (mean age 44 (range 19–65) years) and 20
men (mean age 58 (range 23–78) years), with benign tumours
of the parotid gland (17 on the right-hand side, and 20 on the
left) were treated with parotidectomy.
The vascular fat flaps replaced the excised tissue ade-
quately. We harvested about 15% more fatty tissue than
the size of the gland to compensate for partial long-term
fatty resorption. The time needed to dissect and adapt the
Fig. 2. The fatty part of the flap adapted into the defect and sutured free of
tension to the edges of the superficial musculoaponeurotic system and the
tragal perichondrium.
flap did not exceed 17 minutes (10–17), and the mean dura-
tion of parotidectomy was 112 minutes (range 90–150). The
mean (range) postoperative stay in hospital was 4 (3–5) days.
There was no permanent impairment of the facial nerve,
and only slight reduction in its function for 4–8 weeks. The
parotidectomy side was slightly thicker than the other side
for 6–12 months. None of the patients complained of gusta-
tory sweating, cutaneous flushing, or similar complications
of parotidectomy. All patients were satisfied with their facial
symmetry. The reduced sensation in the preauricular region
and auricle persisted for up to three years (n = 9) and was the
only complaint. We saw no evidence of injury to the acces-
sory nerve, hollowness in the region of the SCM, or other
donor site morbidity.
Discussion
The most concerning impact of parotidectomy is postoper-
ative Frey syndrome.2,17 We removed the parotid from 37
patients and refilled the defect site with a vascularised fat
flap, after which we followed up the patients for 1–9 years
to see if they developed symptoms of Frey syndrome. The
technique was easy, but had to be planned in the beginning of
the operation, as we needed an extra 10–17 minutes to dissect
the flap. We dissected a thin part of the SCM to give us suffi-
cient blood supply to the fatty part, but avoided damage to the
accessory nerve. We saw no uncomfortable sequelae such as
muscular weakness or a hollow deformity at the donor site.
The fatty tissue was sufficient to fill the defect in all cases.
Numerous techniques and barrier materials including
autologous and allogeneic grafts have been reported, but
their long-term results are controversial. The key procedure
is to separate the skin from the para-sympathetic nerve by
replacing the lost parotid tissue. Other autogenous barriers
include free and regional flaps including fat,11,12 dermo-
3. A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 877–880 879
fat grafts,13,14 temporoparietal fascia rotational flaps,9,10 and
SMAS7,8 and SCM flaps.5,6
Some prefer to replace the lost tissue directly after
parotidectomy, and others prefer to wait until Frey syndrome
develops. However, secondary application of barrier tissue
requires an additional operation, and can increase the risk
of injury to the facial nerve. Free flaps require advanced
infrastructure and additional expertise, take a long time to
recover, and carry a risk of morbidity at the donor site.18,19
Thetemporoparietalflaphasthedisadvantagesthatitrequires
wider dissection, and there is a risk of injury to the frontal
branch of the facial nerve, alopecia, and atrophy of the tem-
poralis region.9,10 Using SMAS provides little bulk to fill a
defect, but may suspend the facial musculature and provide
subtle improvement in contour. However, it is not suitable
to replace a larger defect.17 Although the SCM provides a
larger,well-vascularisedamountoftissue,itcarriesthepoten-
tial of causing a cosmetic defect in the neck and functional
discomfort. Additionally there are the risk of injury to the
accessory or the great auricular nerves.5,20 The free fat graft
provides similar consistency and texture as the parotid gland
but can resorb.11,21 Non-autologous implants are unlimited,
and available with no additional morbidity at the donor site.
They are, however, expensive and carry the potential for
infection, formation of a salivary fistula, and rejection.22,23
In both autologous and allografts the long-term maintenance
is unpredictable.
In most reports, the interval between operation and occur-
rence of symptoms of Frey syndrome ranges from two weeks
to two years, but a rare case was reported after eight years.
However, most patients develop symptoms of Frey syndrome
by 12 months postoperatively, which can include gusta-
tory sweating in 80%, skin erythema in 40%, and reported
increases in the temperature of the skin in 20%. Studies have
shown that the clinical severity of Frey syndrome correlates
with the surface area involved and the extent of the parotid
resection.24 We dissected a larger area of fatty tissue and
folded it if necessary to gain sufficient volume. None of our
patients complained of symptoms of Frey syndrome. The
interposed fatty tissue seemed to prevent or at least slow
down the regeneration and ingrowth of nerves. In addition,
the dimension remained stable because it was adequately
vascularised. All the patients were satisfied with the outcome.
The fatty part could be harvested according to need,
allowing tension-free positioning into the site of the defect.
We observed some asymmetry as a result of postoperative
swelling on the operated side, but this was undetectable after
ayear.Allfacialnervesfunctionednormally,andtheaesthetic
outcome was pleasant with no buckle deformity.
In conclusion, we inserted vascular fat flaps after
parotidectomy (to prevent facial depression and minimise the
risk of Frey syndrome) by replacing the excised parotid tis-
sue with vascularised fatty tissue. Patients were followed up
for up to nine years, and none complained of symptoms of
Frey syndrome or donor-site morbidity. The maximum time
for dissection of the flap was 17 minutes. In thin patients we
dissected a larger fatty flap to replace the removed tissue by
folding. However, larger multicentre case series are needed
to validate the benefit of this technique over a longer time
period. Its use for malignant tumours should be considered
carefully.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
The study was approved by the institutional review board in
compliance with the Helsinki Declaration. All patients gave
their signed informed consent to participate in the study.
Disclosure
The authors do not have any financial interests or commercial
associations to disclose.
References
1. Bianchi B, Ferri A, Ferrari S, et al. Improving esthetic results in benign
parotid surgery: statistical evaluation of facelift approach, sternocleido-
mastoid flap, and superficial musculoaponeurotic system flap application.
J Oral Maxillofac Surg 2011;69:1235–41.
2. Curry JM, King N, Reiter D, et al. Meta-analysis of surgical tech-
niques for preventing parotidectomy sequelae. Arch Facial Plast Surg
2009;11:327–31.
3. Laccourreye H, Laccourreye O, Cauchois R, et al. Total conserva-
tive parotidectomy for primary benign pleomorphic adenoma of the
parotid gland: a 25-year experience with 229 patients. Laryngoscope
1994;104:1487–94.
4. Guntinas-Lichius O, Klussmann JP, Schroeder U, et al. Primary parotid
malignoma surgery in patients with normal preoperative facial nerve
function: outcome and long-term postoperative facial nerve function.
Laryngoscope 2004;114:949–56.
5. Asal K, Köybas¸io˘glu A, Inal E, et al. Sternocleidomastoid muscle flap
reconstruction during parotidectomy to prevent Frey’s syndrome and
facial contour deformity. Ear Nose Throat J 2005;84:173–6.
6. Sanabria A, Kowalski LP, Bradley PJ, et al. Sternocleidomastoid muscle
flap in preventing Frey’s syndrome after parotidectomy: a systematic
review. Head Neck 2012;34:589–98.
7. Bonanno PC, Palaia D, Rosenberg M, et al. Prophylaxis against Frey’s
syndrome in parotid surgery. Ann Plast Surg 2000;44:498–501.
8. Taylor SM, Yoo J. Prospective cohort study comparing subcutaneous and
sub-superficial musculoaponeurotic system flaps in superficial parotidec-
tomy. J Otolaryngol 2003;32:71–6.
9. Ahmed OA, Kolhe PS. Prevention of Frey’s syndrome and volume deficit
after parotidectomy using the superficial temporal artery fascial flap. Br
J Plast Surg 1999;52:256–60.
10. Cesteleyn L, Helman J, King S, et al. Temporoparietal fascia flaps
and superficial musculoaponeurotic system plication in parotid surgery
reduces Frey’s syndrome. J Oral Maxillofac Surg 2002;60:1284–97.
4. 880 A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 877–880
11. Chan LS, Barakate MS, Havas TE. Free fat grafting in superficial parotid
surgery to prevent Frey’s syndrome and improve aesthetic outcome. J
Laryngol Otol 2014;128(Suppl 1):S44–9.
12. Conger BT, Gourin CG. Free abdominal fat transfer for reconstruction
of the total parotidectomy defect. Laryngoscope 2008;118:1186–90.
13. HaradaT,InoueT,HarashinaT,etal.Dermis-fatgraftafterparotidectomy
to prevent Frey’s syndrome and the concave deformity. Ann Plast Surg
1993;31:450–2.
14. Nosan DK, Ochi JW, Davidson TM. Preservation of facial contour during
parotidectomy. Otolaryngol Head Neck Surg 1991;104:293–8.
15. Sachsman SM, Rice DH. Use of AlloDerm implant to improve cosmesis
after parotidectomy. Ear Nose Throat J 2007;86:512–3.
16. Sinha UK, Saadat D, Doherty CM, et al. Use of AlloDerm implant
to prevent Frey syndrome after parotidectomy. Arch Facial Plast Surg
2003;5:109–12.
17. Curry JM, Fisher KW, Heffelfinger RN, et al. Superficial musculoaponeu-
rotic system elevation and fat graft reconstruction after superficial
parotidectomy. Laryngoscope 2008;118:210–5.
18. Epps MT, Cannon CL, Wright MJ, et al. Aesthetic restoration of
parotidectomy contour deformity using the supraclavicular artery island
flap. Plast Reconstr Surg 2011;127:1925–31.
19. Teknos TN, Nussenbaum B, Bradford CR, et al. Reconstruction of com-
plex parotidectomy defects using the lateral arm free tissue transfer.
Otolaryngol Head Neck Surg 2003;129:183–91.
20. Casler JD, Conley J. Sternocleidomastoid muscle transfer and super-
ficial musculoaponeurotic system plication in the prevention of Frey’s
syndrome. Laryngoscope 1991;101:95–100.
21. Coleman SR. Long-term survival of fat transplants: controlled demon-
strations. Aesthetic Plast Surg 1995;19:421–5.
22. Athavale SM, Phillips S, Mangus B, et al. Complications of allo-
derm and dermamatrix for parotidectomy reconstruction. Head Neck
2012;34:88–93.
23. Dulguerov P, Quinodoz D, Cosendai G, et al. Prevention of Frey
syndrome during parotidectomy. Arch Otolaryngol Head Neck Surg
1999;125:833–9.
24. Sood S, Quraishi M, Bradley PJ. Frey’s syndrome and parotid surgery.
Clin Otolaryngol 1998;23:291–301.