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British Journal of Oral and Maxillofacial Surgery 56 (2018) 877–880
Available online at www.sciencedirect.com
ScienceDirect
Vascularised fatty tissue: its role in prevention of the
symptoms of Frey syndrome after parotidectomy
A. Ghassemia,b,∗,1, A. Modabberc, P.O. Brzoskad, M. Sababie
a Oral and Maxillofacial Surgery, Teaching Hospital, Georg-August-University Göttingen, Klinikum-Lippe, Röntgenstr. 18, 32756 Detmold, Germany
b Medical Faculty University RWTH-Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
c Oral and Maxillofacial Surgery, University Hospital RWTH-Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
d Department of Internal Medicine, St. Marien-Hospital, Hospitalstraße 44, 52353 Düren, Germany
e Department of Hearing Disorders Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Accepted 8 June 2018
Available online 15 October 2018
Abstract
We studied 37 consecutive patients who had parotidectomies between 2008 and 2017 and who had vascular fat flaps inserted to replace the
excised parotid tissue and prevent Frey syndrome. They were followed up for 1–9 years to check for the relevant symptoms. We studied 17
female and 20 male patients, mean age 52 (range 19–78) years. The flaps took a maximum of 17 minutes to dissect. There was no donor site
morbidity, the vascular fat flap was stable in all cases for up to nine years, and none of the patients complained of symptoms of Frey syndrome.
© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Parotidectomy; concave deformity; Frey’s syndrome; vascularized fat-flap
Introduction
Parotidectomy can cause contour deformity,1,2 visible scar,1
Frey syndrome,2 and sensory disturbance.3,4
Various techniques have been suggested to reconstruct
the parotid bed and reduce both the concave deformity
and the risk of Frey syndrome. They include a sternoclei-
domastoid flap (SCM),5,6 superficial musculoaponeurotic
system flap (SMAS),7,8 temporoparietal facial flap,9,10 free
fat grafts,11,12 dermo-fat grafts,13,14 and acellular dermal
matrix materials.15,16 They should act as barrier between the
overlying skin and the facial nerve. However, all have their
∗ Corresponding author at: Oral and Maxillofacial Surgery, Teaching Hos-
pital, Klinikum Lippe, Röntgenstr. 18, 32756 Detmold, Germany. Tel.: +49
5231 35000; fax: +49 5231 300216.
E-mail addresses: aghassemi@ukaachen.de, aghassemi@icloud.com
(A. Ghassemi).
1 Alireza Ghassemi wrote the first draft of the manuscript.
limitations that include infection, complications at the donor
site, and resorption. Some have reported that secondary appli-
cation of a barrier material after symptoms have developed
can increase the risk of injury to facial nerve.
We replaced the excised parotid tissue with a vascularised
fat flap and evaluated the additional time needed to do this,
as well as the morbidity and signs of the development of Frey
syndrome in the long term.
Patients and methods
The study was approved by the institutional review board,
and complies with the Helsinki Declaration. All patients gave
their informed consent to participate in the study.
Thirty-seven consecutive patients had parotidectomies
between 2008 and 2017 after institutional approval had been
given and written informed consent obtained. In all cases we
replaced the excised parotid gland with a vascularised fat pad.
https://doi.org/10.1016/j.bjoms.2018.06.022
0266-4356/© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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-
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
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parotid surgery: statistical evaluation of facelift approach, sternocleido-
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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
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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.
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surgery to prevent Frey’s syndrome and improve aesthetic outcome. J
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of the total parotidectomy defect. Laryngoscope 2008;118:1186–90.
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14. Nosan DK, Ochi JW, Davidson TM. Preservation of facial contour during
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after parotidectomy. Ear Nose Throat J 2007;86:512–3.
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17. Curry JM, Fisher KW, Heffelfinger RN, et al. Superficial musculoaponeu-
rotic system elevation and fat graft reconstruction after superficial
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  • 1. British Journal of Oral and Maxillofacial Surgery 56 (2018) 877–880 Available online at www.sciencedirect.com ScienceDirect Vascularised fatty tissue: its role in prevention of the symptoms of Frey syndrome after parotidectomy A. Ghassemia,b,∗,1, A. Modabberc, P.O. Brzoskad, M. Sababie a Oral and Maxillofacial Surgery, Teaching Hospital, Georg-August-University Göttingen, Klinikum-Lippe, Röntgenstr. 18, 32756 Detmold, Germany b Medical Faculty University RWTH-Aachen, Pauwelsstraße 30, 52074 Aachen, Germany c Oral and Maxillofacial Surgery, University Hospital RWTH-Aachen, Pauwelsstraße 30, 52074 Aachen, Germany d Department of Internal Medicine, St. Marien-Hospital, Hospitalstraße 44, 52353 Düren, Germany e Department of Hearing Disorders Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Accepted 8 June 2018 Available online 15 October 2018 Abstract We studied 37 consecutive patients who had parotidectomies between 2008 and 2017 and who had vascular fat flaps inserted to replace the excised parotid tissue and prevent Frey syndrome. They were followed up for 1–9 years to check for the relevant symptoms. We studied 17 female and 20 male patients, mean age 52 (range 19–78) years. The flaps took a maximum of 17 minutes to dissect. There was no donor site morbidity, the vascular fat flap was stable in all cases for up to nine years, and none of the patients complained of symptoms of Frey syndrome. © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Parotidectomy; concave deformity; Frey’s syndrome; vascularized fat-flap Introduction Parotidectomy can cause contour deformity,1,2 visible scar,1 Frey syndrome,2 and sensory disturbance.3,4 Various techniques have been suggested to reconstruct the parotid bed and reduce both the concave deformity and the risk of Frey syndrome. They include a sternoclei- domastoid flap (SCM),5,6 superficial musculoaponeurotic system flap (SMAS),7,8 temporoparietal facial flap,9,10 free fat grafts,11,12 dermo-fat grafts,13,14 and acellular dermal matrix materials.15,16 They should act as barrier between the overlying skin and the facial nerve. However, all have their ∗ Corresponding author at: Oral and Maxillofacial Surgery, Teaching Hos- pital, Klinikum Lippe, Röntgenstr. 18, 32756 Detmold, Germany. Tel.: +49 5231 35000; fax: +49 5231 300216. E-mail addresses: aghassemi@ukaachen.de, aghassemi@icloud.com (A. Ghassemi). 1 Alireza Ghassemi wrote the first draft of the manuscript. limitations that include infection, complications at the donor site, and resorption. Some have reported that secondary appli- cation of a barrier material after symptoms have developed can increase the risk of injury to facial nerve. We replaced the excised parotid tissue with a vascularised fat flap and evaluated the additional time needed to do this, as well as the morbidity and signs of the development of Frey syndrome in the long term. Patients and methods The study was approved by the institutional review board, and complies with the Helsinki Declaration. All patients gave their informed consent to participate in the study. Thirty-seven consecutive patients had parotidectomies between 2008 and 2017 after institutional approval had been given and written informed consent obtained. In all cases we replaced the excised parotid gland with a vascularised fat pad. https://doi.org/10.1016/j.bjoms.2018.06.022 0266-4356/© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
  • 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. 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