The effectiveness of a sternomastoid muscle flap in preventing post-parotidectomy occurrence of the Frey syndrome

Effectiveness of the Fibrinogen-Thrombin-Impregnated Collagen Patch in the Prevention of Postoperative Complications after Parotidectomy: A Single-Blinded, Randomized Controlled Study

We investigated whether a fibrinogen-thrombin collagen sponge patch reduces postoperative complications of parotid gland surgery. This single-blinded, randomized controlled study included 165 patients who underwent parotid surgery for benign tumors (2018–2019) at a tertiary center. Primary outcomes were postoperative drain amount, days until drain removal, and discharge. Patients were scheduled for follow-up at 1 and 4 weeks, and 3 months after surgery. Complications including surgical site infection, pain, seroma, sialocele, salivary fistula, facial nerve palsy, Frey’s syndrome with subjective symptoms, and facial asymmetry were analyzed. After identifying confounding variables, multivariate approaches were used. Histologic analysis was performed in a mouse model of salivary gland surgery. In total, 162 patients (77, fibrinogen-thrombin collagen patch group; 85, controls) were included, with no significant between-group differences other than resected tissue. Among postoperative total drain amount and days until drain removal and discharge, the only postoperative total drain was significantly lower in the patch group than in the control group in the adjusted model. Additionally, although validation through robust trials with longer follow-up is needed, we found the potential benefit of the fibrinogen patch on Frey’s syndrome and facial asymmetry. In conclusion, fibrinogen-thrombin-impregnated collagen patches in parotidectomy can reduce postoperative drainage and improve outcomes.

Sternocleidomastoid flap for pedicled reconstruction in head & neck surgery- revisiting the anatomy and technique

Background

Previous studies on sternocleidomastoid flaps, have defined the importance of preserving sternocleidomastoid (SCM) branch of superior thyroid artery (STA). This theory drew criticism, as this muscle is known to be a type II muscle, i.e., the muscle has one dominant pedicle (branches from the occipital artery at the superior pole) and smaller vascular pedicles entering the belly of muscle (branches from STA and thyrocervical trunk) at the middle and lower pole respectively. It was unlikely for the SCM branch of STA to supply the upper and lower thirds of the muscle. We undertook a cadaveric angiographic study to investigate distribution of STA supply to SCM muscle.

Methods

It is a cross-sectional descriptive study on 10 cadaveric SCM muscles along with ipsilateral STA which were evaluated with angiography using diatrizoate (urograffin) dye. Radiographic films were interpreted looking at the opacification of the muscle. Results were analyzed using frequency distribution and percentage.

Results

Out of ten specimens, near complete opacification was observed in eight SCM muscle specimens. While one showed poor uptake in the lower third of the muscle, the other showed poor uptake in the upper third segment of muscle.

Conclusion

Based on the above findings we suggest to further investigate sternocleidomastoid muscle as a type III flap, as the STA branch also supplies the whole muscle along with previously described pedicle from occipital artery. However, this needs to be further corroborated intra-operatively using scanning laser doppler. This also explains better survival rates of superior thyroid artery based sternomastoid flaps.

Frey's Syndrome: A Review of Aetiology and Treatment

First described by Polish Neurologist Łucja Frey in 1923, Frey's syndrome (FS), or auriculotemporal syndrome, is a rare condition characterised by gustatory sweating, typically encountered as sequelae following invasive head and neck surgery. The pathophysiology of FS can be described by aberrant reinnervation of postganglionic parasympathetic neurons to the surrounding denervated sweat glands and cutaneous blood vessels. Multiple invasive procedures have been associated with FS ranging from salivary gland surgery to burn reconstruction and thoracoscopic sympathectomies. Rarely, FS can be secondary to trauma or non-surgical aetiologies, including diabetes and infection. Physical symptoms vary based on the severity and surface area affected by FS and range from mild symptoms to severe psychosocial morbidity for patients. Surgeons operating in the head and neck, including otolaryngologists, maxillofacial surgeons, and plastic surgeons, should be aware of this potential complication and be up to date with diagnosis and treatment strategies for FS. This review article summarises the literature relating to FS focusing on its aetiologies, symptomatology, prevention, and available treatments, aiming to provide an up-to-date review of this condition for surgeons operating in the head and neck region. Although various treatment options have been suggested, these are often limited to topical agents that require life-long administration for symptom control. Further research is recommended to identify the optimal treatment for this condition and the role of surgery as a treatment for severe or refractory cases.

Acellular dermal matrix for prevention of Frey's syndrome after superficial parotidectomy of benign tumors

PURPOSE

To evaluate: 1) the efficacy of acellular dermal matrix (ADM) to prevent Frey's syndrome (FS) after superficial parotidectomy of benign tumors. 2) the effect of different follow-up intervals on the incidence of FS.

METHODS

Fifty-five patients with benign parotid gland tumors underwent superficial parotidectomy were divided into two groups: Non-ADM group (n = 31, 56.3%) and ADM group (n = 24, 43.6%). The primary outcomes measure was the incidence of FS. The secondary outcomes were surgical site depression, infection, salivary sialocele, and salivary fistula. Subjective FS was evaluated using a clinical questionnaire submitted via WeChat at 3, 6, 12, 18, 24, and 32 months postoperatively. Objective FS was evaluated using Minor starch-iodine test at 6 and 12 months postoperatively.

RESULTS

There was a statistically significant difference in the incidence of subjective and objective FS when ADM compared with Non-ADM groups (P<0.05). The respective incidence of subjective FS at 3, 6, 12, 18, 24, and 32 months was 4.2%, 8.3%,20.8%, 20.8%, 20.8%, 20.8% in ADM group and 3.2%, 9.7%, 29%, 38.7%, 45.2% in Non-ADM group. The incidence of objective FS after 6 and 12 months was 4.2%, 8.3% in ADM group and 8.3% (2/24), 38.7% (12/31) in Non-ADM group respectively. Five patients in ADM group and 1 patient in Non-ADM group developed sialocele, and all patients resolved with conservative management. Surgical site depression was significantly higher in the Non-ADM group (15/31) compared with (5/24) in ADM (P=0.049). No cases of immune rejection, infection, hematoma, or salivary fistula were observed in ADM group.

CONCLUSIONS

The current study demonstrated that 1) ADM could reduce the incidence of FS in the patients undergoing superficial parotidectomy. 2) the peak onset of about 18 months appear to be acceptable follow-up for the development of FS.

Different Surgical Strategies in the Prevention of Frey Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE/HYPOTHESIS

To define the best surgical technique able to reduce Frey syndrome (FS) incidence after parotidectomy.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were the incidence of subjective (clinical) and objective (positive starch-iodine test result) FS, respectively.

RESULTS

A total of 3830 patients with a median age of 50.35 years (n = 2323; IQR 44.25-54.18) were included for six interventions [temporoparietal fascia (TPFF), free fat graft (FFG), acellular dermal matrix (ADM), sternocleidomastoid muscle (SCM) flap, and superficial musculoaponeurotic system (SMAS) flap]. If compared to no treatment, the greatest reduction of subjective (clinical) FS incidence was measured for the TPFF (OR: 0.07, CI: 0.004-0.57), the ADM (OR: 0.09, CI: 0.02-0.35), and the FFG (OR: 0.11, CI: 0.03-0.42) techniques. However, a significant difference was measured also for the SCM flap (OR: 0.38, CI: 0.18-0.73) and for the SMAS flap (OR: 0.42, CI: 0.19-0.97). All treatments showed a significant reduction of the objective FS incidence if compared to no treatment (FFG, OR: 0.06, CI: 0.002-0.62; TPFF, OR: 0.07, CI: 0.01-0.33; ADM, OR: 0.11, CI: 0.03-0.44; SMAS, OR: 0.36, CI: 0.17-0.71; SCM, OR: 0.40, CI: 0.19-0.74).

CONCLUSIONS

TPFF, ADM, and FFG seem to be the best treatment strategies to prevent FS after parotidectomy. Further randomized controlled trials comparing these techniques should be conducted to define specific indications. Laryngoscope, 131:1761-1768, 2021.

What is the best method for prevention of postparotidectomy Frey syndrome? Network meta-analysis

BACKGROUND

Prevention of Frey syndrome (FS) after parotidectomy using an interposition barrier has long been gaining a wide popularity; however, there is no clear evidence regarding which preventive technique is more effective. The aim of this network meta-analysis (NMA) is to answer the question: What is the best method for prevention of FS after parotidectomy?

METHODS

A comprehensive search of the PubMed, Embase, SCOPUS, and Cochrane library was conducted to identify the eligible studies. The outcome was the incidence of subjective Frey syndrome (SFS) and objective Frey syndrome (OFS). The Bayesian NMA accompanied with a random effects model and 95% credible intervals (CrIs) were calculated using GeMTC R package.

RESULTS

Thirty-four studies (n = 2987 patients) with five interventions, namely Alloderm (ADM), temporoparietal fascia (TPF), sternocleidomastoid muscle (SCM), superficial musculoaponeurotic system (SMAS), and free fat graft (FFG), were compared together and with no interposition barrier (NB). The results of NMA showed a statistically significant reduction in both SFS and OFS when ADM, TPF, SMAS, FFG, and SCM were compared with NB. No statistical differences were observed when comparing ADM, SCM, SMAS, FFG, and TPF. TPF ranked the best of all treatments (59.4%) and was associated with the least incidence of SFS; whereas ADM ranked the best of all treatments (61.1%) and was associated with the least incidence of OFS.

CONCLUSIONS

All interventions (TPF flap, ADM, FFG, SMAS, and SCM) were associated with a significant reduction in the incidence of FS when compared with NB. TPF and ADM showed the best outcome with the least incidence of SFS and OFS, respectively.

Prospective outcomes following drainless superficial parotidectomy with sternocleidomastoid flap reconstruction

Background

Patients undergoing superficial parotidectomy for benign parotid lesions are at risk of postoperative complications, most notably cosmetic complications such as facial paralysis and contour defects, and functional complications including Frey’s syndrome. Traditionally, surgical drains have been placed at the end of surgery to prevent hematoma and sialocele formation. However, this can increase the risk of postoperative complications and contribute to a prolonged course in hospital. To try and prevent these risks and complications, we introduced a novel technique of a drainless parotidectomy by reconstructing the resulting parotid bed defect with a superiorly based sternocleidomastoid (SCM) rotational flap and by placement of gelfoam into the wound bed and a facelift dressing postoperatively to provide additional hemostasis and avoid drain placement.

Methods

All patients with benign parotid disease undergoing a drainless superficial parotidectomy and reconstruction with a superiorly based SCM rotational flap at our center were identified within a prospective cohort database between July 2010–2018. Primary outcomes included postoperative cosmetic and functional outcomes, complications and length of hospital stay. A secondary cost analysis was done to compare this novel technique to traditional superficial parotidectomy with surgical drain placement.

Results

Fifty patients were identified within the database and were included in the final analysis. The average length of hospital stay was 1.02 days. All patients were satisfied with their aesthetic outcome at 1 year. During long term follow-up, 63% of patients reported normal appearance of the operated side. Seven patient’s (14%) developed temporary facial paresis following surgery. All patients had resultant normal facial function at follow-up in 1 year. No patients developed subjective Frey’s Syndrome. Two patients (4%) developed a postoperative sialocele requiring drainage and one patient (2%) developed a hematoma on extubation requiring evacuation and drain placement. Cost analysis demonstrated a cost savings of approximately $975 per person following surgery.

Conclusion

In the current study, we introduced a novel approach of a drainless superficial parotidectomy using a superiorly based SCM flap, gelfoam and placement of a post-operative facelift dressing. This drainless approach was associated with good long-term cosmetic and functional outcomes with few postoperative complications. This new technique may also offer the potential for long-term savings to the health care system.

Use of the SMAS flap for reconstruction of the parotid lodge

The purpose of our study was to evaluate the benefits of the SMAS flap in patients with benign tumours of the parotid gland treated by superficial parotidectomy. We carried out a retrospective chart review on 123 patients suffering from benign tumours of the parotid gland admitted to our Institution between March 1997 and March 2010. A superficial parotidectomy was performed in all the cases reported. Our sample was divided in two groups basing SMAS flap reconstruction done (Group 2) or not (Group 1) after superficial parotidectomy. Reconstruction using SMAS flap was accomplished in 64 patients. Chi-square test was used to assess statistical difference between the two groups. The level of statistical significance was P < 0.05. No significant differences concerning hematoma, wound infection and facial paralysis were observed between the first and second group (3.38 vs 1.56% [P > 0.05], 8.47% vs 4.68% [P > 0.05], 5.08% vs 0.00% [P > 0.05]). Transient facial nerve weakness, fistula, dip skin and Frey's syndrome were significantly more frequent without SMAS flap reconstruction (10.16% vs 3.125% [P < 0.05], 13.55% vs 3.125% [P < 0.05], 13.55% vs 3.125% [P < 0.05], 20.33% vs 0% [P < 0.05] respectively). The use of the SMAS flap is able to reduce the cosmetic and functional complications that occur after the removal of a benign tumour of the parotid through the superficial parotidectomy technique, above all, it reduces the occurrence of Frey's syndrome.

The Effects of Superficial Musculoaponeurotic System Flap on the Development of Frey's Syndrome and Cosmetic Outcomes After Superficial Parotidectomy

Objective

To investigate the outcomes of superficial musculoaponeurotic system (SMAS) flap and classic techniques in superficial parotidectomy in terms of Frey's syndrome (FS) and cosmetic satisfaction.

Methods

In this study, a retrospective chart review of patients that underwent superficial parotidectomy was performed. These patients were divided into two subgroups: group 1 included patients in which the SMAS flap was harvested and group 2 comprised the remaining patients on whom classic superficial parotidectomy was performed. All the patients were evaluated clinically and with Minor's starch-iodine test for FS. For the evaluation of the cosmetic results, the patient's satisfaction was queried according to the incision scar and surgical field skin retraction/facial symmetry. Both groups were compared in terms of complications and numbness of surgical area.

Results

Fifty-five patients (31 male and 24 female) with a mean age of 50.19 years were included in the study. Thirty-two patients were in group 1 and 23 in group 2. Thirteen patients (23.7%) described as having FS and six of them were in group 1, while seven were in group 2. Minor's starch-iodine test was positive in nine patients in group 1 (28.1%) and six patients in group 2 (26.1%) (p=1.000). With regard to cosmetic satisfaction, eight patients (25%) stated mild discomfort from the incision scar and two patients (6.3%) stated cosmetic dissatisfaction for facial asymmetry in group 1. In group 2 for the same factors the number of patients were 11 (47.8%) and 2 two (8.7%), respectively (p=0.027). There were no statistically significant differences in means of complication and numbness (p>0.05).

Conclusion

According to our study results, there was no superiority between both the groups in terms of FS and incision scar satisfaction. We determined that there was a significant benefit of SMAS flap application in the prevention of volume loss and surgical area retraction.

Anteriorly Based Partial Thickness Sternocleidomastoid Muscle Flap Following Parotidectomy

The anteriorly based partial thickness sternocleidomastoid (SCM) muscle flap is among the various methods described to correct parotidectomy defects, but its indications and limitations are not clearly demonstrated in several reports. This study was done to test the aesthetic outcome of this method, its indications and limitations. At Dr. Babasaheb Ambedkar Memorial hospital, Mumbai, 20 patients presenting with benign parotid tumors underwent parotidectomy. 16 underwent superficial parotidectomy and 3 underwent adequate parotidectomy, 1 had total parotidectomy. The anteriorly based partial thickness SCM muscle flap was used to correct the contour deformity and to prevent Frey syndrome. The aesthetic result was evaluated by assessing and scoring the overall appearance of the scar, the degree of symmetry of the reconstructed parotid region and the site of the donor muscle in comparison to their contralateral normal sides. The overall aesthetic appearance was good in 17 patients, and moderate in 3 patients. 17/20 patients had an overall deep satisfaction with the result. The residual hollowness following total parotidectomy defect and the poor quality of scars were the main reasons affecting the aesthetic outcome. Superficial parotidectomy through modified Blair's incision with immediate reconstruction with anteriorly based partial thickness SCM flap allows a satisfactory aesthetic outcome and minimal donor site morbidity. Scores of the above two parameters were accessed. Patients' satisfaction was assessed by patients questionnaire.

Effectiveness of platysma muscle flap in preventing Frey syndrome and depressive deformities after parotidectomy

BACKGROUND

Frey syndrome (FS) or depressive deformity (DD) occurring after parotidectomy significantly reduces a patient's quality of life. However, there seems to be no effective treatment strategy against these complications. In this study, we report our experience of using platysma muscle flap (PMF) to prevent the development of FS and DD after parotidectomy, and evaluate its effect subjectively and objectively.

METHODS

Superficial parotidectomy was performed for eight cases of parotid gland tumor, and a PMF was transferred to cover the site. The incidence of FS and DD were evaluated subjectively, using a questionnaire to the patients and board-certified reconstructive surgeons, and objectively, using Minor's starch-iodine test.

RESULTS

In seven patients, the defect could be completely covered with PMF, and none of them developed FS or obvious DD. However, in one patient, the defect could be only partially covered, and the patient developed complications in the exact site that the flap did not cover. Overall scores from the questionnaire were high in relation to both cosmetic and functional perspectives from most of the patients and all the surgeons. No patients had major postoperative complications requiring revision.

CONCLUSIONS

PMF can be useful to cover the defect and prevent complications after parotidectomy. PMF is relatively easy to perform with fewer complications; however, a complete coverage of the defect should be ensured to obtain optimal results.

Sternocleidomastoid Muscle Flap after Parotidectomy

Introduction Most patients after either superficial or total parotidectomy develop facial deformity and Frey syndrome, which leads to a significant degree of patient dissatisfaction.

Objective Assess the functional outcome and esthetic results of the superiorly based sternocleidomastoid muscle (SCM) flap after superficial or total parotidectomy.

Methods A prospective cohort study for 11 patients subjected to parotidectomy using a partial-thickness superiorly based SCM flap. The functional outcome (Frey syndrome, facial nerve involvement, and ear lobule sensation) and the esthetic results were evaluated subjectively and objectively.

Results Facial nerve palsy occurred in 5 cases (45%), and all of them recovered completely within 6 months. The Minor starch iodine test was positive in 3 patients (27%), although only 1 (9%) subjectively complained of gustatory sweating. The designed visual analog score completed by the patients themselves ranged from 0 to 3 with a mean of 1.55 ± 0.93; the scores from the blinded evaluators ranged from 1 to 3 with a mean 1.64 ± 0.67.

Conclusion The partial-thickness superiorly based SCM flap offers a reasonable cosmetic option for reconstruction following either superficial or total parotidectomy by improving the facial deformity. The flap also lowers the incidence of Frey syndrome objectively and subjectively with no reported hazard of the spinal accessory nerve.

[Quality of life after primary parotidectomy for benign tumor]

INTRODUCTION

Parotidectomy is commonly performed for various indications, including benign tumors of the parotid region. Esthetic or functional sequels of various importance and lasting effects may occur, as after any surgical procedure. These disorders may impact the patient's quality of life. The authors retrospectively evaluated the long-term outcome of patients having undergone conservative primary parotidectomy for a benign tumor, with a minimum follow-up of 10 years.

PATIENTS AND METHODS

A hundred and twenty-six superficial conservative primary or secondary parotidectomies were performed during 5 years, 94 (74.6%) of which for benign tumors. A flap of the sternocleidomastoid muscle (SCM) was inserted between the skin and facial nerve branches to prevent Frey's syndrome and alleviate surgical site depression according to some criteria. Questionnaires were completed at least 10 years after surgery.

RESULTS

The data of 53 patients was analyzed. 88.7% of patients had undergone a superficial parotidectomy and 11.3% a total one. The average histological tumor size was 3.3 cm (2.6 to 6.3 cm). The tumors were distributed as follows: pleomorphic adenoma in 79.4% of patients, cystadenolymphoma in 15.1%, oncocytoma in 3.7%, and basal cell adenoma in 1.8%. Twenty-six SCM flaps (49.1%) were performed. No patient presented with facial paresis or facial paralysis at the end of the study. The average follow-up was 10.4 years (10-11 years). Overall, social, psychological, and professional implications were reported by 7.5% of patients, and in 1.8% of cases the impact was significant. The use of a SCM flap seemed to prevent Frey's syndrome (Fischer test P=0.00001) and improved cosmetic results (Fisher test P<0.00001).

DISCUSSION

Conservative parotidectomy for primary benign tumors has a limited impact on the quality of life in the long run. This impact concerned 7.4% of patients. There was a significant impact in 2% of patients. We recommend filling the surgical site to improve functional and esthetic results and decrease long-term effects on the patient's quality of life.

Autologous fat transfer: an aesthetic and functional refinement for parotidectomy

Parotidectomy is a surgical procedure associated to functional (Frey's syndrome) as well as aesthetic (facial asymmetry) complications that can be very disturbing for the patient. Several procedures have been described to primarily avoid or secondarily reconstruct the facial defect and treat the neurological iatrogenic syndrome. Autologous fat transfer was primarily used in 10 cases to avoid such complications. It is an easy technique widely used in cosmetic and reconstructive surgery. This technique gives very satisfying long-term results on the cosmetic as well as on the physiological point of view.

The Efficiacy of Sternocleidomastoid Muscle Flap on Frey's Syndrome via a Novel Test: Galvanic Skin Response

The aim of this study was to evaluate the effects of sternocleidomastoid (SCM) muscle flap on preventing Frey's syndrome by using, Galvanic skin responses (GSR). Fourty-three patients who underwent superficial parotidectomy were randomly divided into two groups and their GSR were recorded. SCM muscle flap was applied over the surgical area only in one group. Six months after the surgery, GSRs were remeasured. In addition, the patients completed a questionnaire regarding their complaints about clinical Frey's syndrome. Four patients had symptoms of clinical Frey's syndrome. Postoperative GSR measurements revealed no significant difference between two sides in flap group (p = 0.426) but higher in without flap group (p = 0.003). The patients with clinical Frey syndrome had significantly higher GSR values than the remaining patients. The SCM muscle flap was an effective method in preventing Frey's syndrome. Moreover, GSR test was highly sensitive and specific for diagnosis.

Role of medical thermography in treatment of Frey's syndrome with botulinum toxin A

Frey syndrome classically causes gustatory sweating and facial flushing. We describe 2 cases in which medical thermography was used to investigate the symptoms. Images were taken after patients chewed a sialagogue and 2 weeks later they were given injections of botulinum toxin A. Images taken 4 weeks after treatment showed a considerable reduction in sweating and facial flushing, which was supported by the results of quality of life questionnaires completed before and after treatment. Medical thermography is much cleaner than the Minor's starch iodine test. It identifies areas of gustatory sweating, changes in temperature, and vascular changes, which potentially enable treatment to be targeted accurately.

Graft for prevention of Frey syndrome after parotidectomy: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To detect the effect and safety of different types of grafts for the prevention of Frey syndrome after parotidectomy.

MATERIALS AND METHODS

The following data bases were searched electronically: MEDLINE (using OVID, from 1948 to July 2011), Cochrane Central Register of Controlled Trials (CENTRAL, issue 2, 2011), EMBASE (available from: http://embase.com, 1984 to July 2011), World Health Organization International Clinical Trials Registry Platform (July 2011), Chinese BioMedical Literature Database (1978 to July 2011), and the China National Knowledge Infrastructure (1994 to July 2011). The relevant journals and reference lists of the included studies were manually searched for randomized controlled trials studying the effect and safety of different types of grafts for preventing Frey syndrome after parotidectomy. The risk of bias assessment using Cochrane Collaboration's tool and data extraction was independently performed by 2 reviewers. The meta-analysis was performed using Review Manager, version 5.1.

RESULTS

A total of 14 randomized clinical trials and 1,098 participants were included. All had an unclear risk of bias. The meta-analysis results showed that the use of an acellular dermis matrix can reduce by 82% the risk of Frey syndrome compared with the no-graft group using an objective assessment (relative risk [RR] 0.18, 95% confidence interval [CI] 0.12 to 0.26; P < .00001; Grading of Recommendations, Assessment, Development, and Evaluation [GRADE] quality of evidence: high). The acellular dermis matrix can also reduce by 90% the risk of Frey syndrome compared with the no-graft group using a subjective assessment (RR 0.10, 95% CI 0.05 to 0.22; P < .00001; GRADE quality of evidence: high). The muscle flaps can reduce by 81% the risk of Frey syndrome compared with the no-graft group (RR 0.19, 95% CI 0.13 to 0.27; P < .00001; GRADE quality of evidence: high). No statistically significant difference was found between the acellular dermal matrix and muscle flap groups (RR 0.73, 95% CI 0.15 to 3.53, P = .70; GRADE quality of evidence: low). No serious adverse events were reported.

CONCLUSIONS

The present clinical evidence suggests that grafts are effective in preventing Frey syndrome after parotidectomy. More randomized clinical trials are needed to confirm our conclusions and prove the safety of the grafts.

Innovative Technique to Reduce Incidence of Frey's Syndrome after Parotid Surgery

Frey's syndrome was first described by Lucia Frey, a Polish neurologist in 1923. It is well accepted that it involves injury to the branches of the auriculotemporal nerve with subsequent aberrant regeneration. Due to this abnormal communication, the skin glands and vessels are always stimulated at the same time as eating and mastication, which results in symptoms such as flushing and sweating. The incidence of Frey's syndrome in the literature has been variously described from 6 to 96 per cent. We analyzed the chart of 18 patients who had parotidectomy from March 2002 to December 2009. All procedures were performed by a single surgeon at the same facility. A total of 16 superficial and three total parotidectomies were done; one patient had bilateral parotidectomy. Oxidized regenerated cellulose (Interceed) was used after 10 surgeries (study group) and no adjuvant was used after nine surgeries (control group). All of the surgeries were done using similar technique. All the patients were followed-up with for a period of about 6 months postoperatively. The absolute risk reduction associated with the placement of an Interceed was 11 per cent. The small number of cases (n = 19) and an empty cell limits statistical analysis (a Fisher's exact test revealed a P value of 0.44). Clearly the low number of procedures restricted the power to test these differences. The development of Frey's syndrome is a very disabling but under-reported complication. The placement of a temporary barrier like Interceed may help in the prevention of Frey's syndrome without increasing any complications.

'Minor' morbidity after parotid surgery via the modified Blair incision

OBJECTIVE

To assess the 'minor' morbidities subjectively experienced by the patient after parotid surgery; these include scar cosmesis and pain, 'contour' deformity following removal of parotid bulk, numbness of the pinna and gustatory sweating.

DESIGN

Retrospective study

SETTING

Tertiary Referral Centre.

PATIENTS

28 patients were included in the study.

RESULTS

Contour deformity, scarring and paraesthesia of the pinna secondary to great auricular nerve sacrifice are the most noticeable sequelae following parotidectomy.

DISCUSSION

Although facial nerve injury is the most serious morbidity following parotidectomy, it is relatively uncommon. Other 'minor' morbidities are more likely to cause post-operative problems. Despite there being a number of different approaches to the parotidectomy, with or without reconstruction, these have not been satisfactorily compared.

Risk of facial palsy and severe Frey's syndrome after conservative parotidectomy for benign disease: analysis of 610 operations

CONCLUSIONS

Advanced age, long operation time and large specimen volume were significant risk factors for transient facial palsy after conservative parotidectomy. Revision operation was the only risk factor for development of a permanent palsy. Risk factors for Frey's syndrome were not found. The incidence of Frey's syndrome was not altered by the use of a sternocleidomastoid muscle flap or other implantation material.

OBJECTIVES

The results of studies identifying risk factors for facial palsy and Frey's syndrome after parotidectomy are contradictory. This study attempted to identify these risk factors by performing a retrospective review of a large series of patients.

PATIENTS AND METHODS

A total of 610 standardized conservative parotidectomies for benign diseases performed between 1989 and 2004 were studied retrospectively. The risk factors for facial palsy and Frey's syndrome were determined by univariate and if possible by multivariate analysis of variables related to patient demographics and operation characteristics.

RESULTS

The rates of transient facial palsies, permanent facial palsies and Frey's syndrome were 18%, 4%, and 4%, respectively. Significant univariate and multivariate risk factors for development of a transient facial palsy were age>70 years, operation time>260 min, and a specimen volume>70 cm3. The only significant risk factor for the development of a permanent palsy was prior surgery. A significant risk factor for the development of Frey's syndrome could not be estimated.

Branching patterns of the arterial branches supplying the middle vascular pedicle of the sternocleidomastoid muscle: a topographic anatomical study with surgical applications for the use of pedicles osteomuscular flaps

When making a sternocleidomastoid (SCM) osteomuscular flap to include the clavicle and determining the rotation arc of the osteomuscular flap, it is very important to know the location and the origin of the superior thyroid artery and the distribution pattern of the SCM branch. Accordingly, in this study, the 50 SCM muscles and their arteries were dissected in 26 Korean cadavers, and the results were analyzed. The average distances from the origin of the superior thyroid artery to the clavicular and sternal heads of the SCM muscle were 87.6 mm (57.7-123.8 mm) and 131.2 mm (99.7-166.8 mm), respectively. The average distance from the origin of the superior thyroid artery to the SCM branch entering the SCM muscle was 30.1 mm (16.0-37.7 mm). After entering the SCM muscle, the SCM branches of the superior thyroid artery bifurcated into the clavicular and sternal branches at a point located an average of 58.8 mm (28.4-130.4 mm) above the clavicle. The distribution patterns of the superior thyroid artery were classified into six types based on the branching order and the dual supplies to the SCM muscle. Among them, type I in which the laryngeal branch first divided from the superior thyroid artery was the most common case (36%).

Sternocleidomastoid Muscle Flap Reconstruction during Parotidectomy to Prevent Frey's Syndrome and Facial Contour Deformity

We studied the incidence of Frey's syndrome and facial contour deformity in two groups of patients who had undergone superficial parotidectomy. One group was made up of 12 patients who were randomized to undergo reconstruction of the surgical defect with a sternocleidomastoid muscle flap; the other 12 patients did not receive a flap. All 24 patients were evaluated via a short questionnaire, the starch-iodine test, and a visual examination. On the questionnaire, none of the 24 patients said they experienced abnormal facial sweating, flushing, or warmth while eating, although 6 of the 12 patients in the nonflap group had a mildly positive starch-iodine test. No patient in the flap group had a positive test. The difference between the two groups was statistically significant (p < 0.05). No statistically significant difference was seen between the two groups with respect to cosmetic results.

Botulinumtoxin zur Behandlung des gustatorischen Schwitzens

BACKGROUND

Botulinum toxin A has meanwhile become a proven method for treatment of gustatory sweating (focal hyperhidrosis, Frey's syndrome). Clear-cut recommendations regarding dosage of botulinum toxin A in Frey's syndrome are currently not available. The aim of this prospective randomized study therefore was to investigate botulinum toxin A with respect to its efficacy in Frey's syndrome, the ideal dose yielding maximal duration of the effect, and patient contentedness as well as unwanted side effects in patients of the Clinic of OMF Surgery at the Ruhr-University of Bochum.

PATIENTS AND METHOD

Twenty patients suffering from severe Frey's syndrome as a result of operations of the parotid gland were examined with the starch iodine test according to Minor. The gustatory skin areas were re-examined after intracutaneous injection of botulinum toxin A for up to 1 year. The patients ( n=20) were randomly assigned to two different treatment groups (group I: 2 MU/cm(2), n=10; group II: 3 MU/cm(2), n=10).

RESULTS

Mean sweating skin areas in the two treatment groups ranged between 39+/-9 and 32+/-12 cm(2), respectively. A single injection of 3 MU botulinum toxin A resulted in a nearly complete blockade of gustatory sweating for the observation period of 1 year. In the group treated with 2 MU botulinum toxin A, 44% of the total gustatory skin areas were still sweating, thus necessitating a second injection of botulinum toxin A in these patients.

CONCLUSION

Intracutaneous injection of botulinum toxin A represents a highly effective and minimally invasive procedure for the treatment of Frey's syndrome. This study shows for the first time that a dosage of 3 MU/cm(2) of botulinum toxin A achieves a complete and reliable blockade of gustatory sweating lasting for at least 12 months. This dose may therefore be recommended for treatment of this syndrome.

Treatment of gustatory sweating (Frey's syndrome) with botulinum toxin A

BACKGROUND

Gustatory sweating is a common complication of parotid surgery. Injection of botulinum toxin A has been reported as a safe and effective treatment option for patients with Frey's syndrome.

PATIENTS AND METHODS

A total of 69 patients who had undergone superficial parotidectomy because of adenoma were evaluated with respect to the incidence of Frey's syndrome and treatment interest. Minor's iodine starch test was used to detect the affected skin area. Affected skin areas were documented using a digital camera; skin areas were evaluated morphometrically. A single injection of Botox per 1 cm(2) skin field was administered to those patients interested in treatment.

RESULTS

Of 43 patients (62%) with gustatory sweating, 33 patients requested treatment. The affected skin area varied from 16 cm(2) to 81 cm(2). The individual Botox dosage ranged from 16 to 80 IU. All relevant clinical symptoms of sweating disappeared within 1 week after a single injection. Treatment was well tolerated with no side effects.

CONCLUSION

Botox A injection is a safe and effective treatment with long-lasting effects for patients with extensive gustatory sweating.

Use of AlloDerm implant to prevent frey syndrome after parotidectomy

OBJECTIVE

To evaluate the effectiveness of AlloDerm, an acellular human dermal matrix graft, as an interpositional physical barrier to prevent the development of Frey syndrome after parotidectomy.

METHODS

The 30 patients included in the study were divided into 3 groups of 10. In group 1 (study group), patients underwent superficial parotidectomy with placement of an AlloDerm graft (LifeCell Corp, Branchburg, NJ). In group 2 (control) patients had superficial parotidectomy without placement of an interpositional barrier. In group 3 (control), patients underwent deep-plane rhytidectomy without disruption of the parotid fascia. All were evaluated after 1 year and questioned about gustatory sweating. Subjective assessment of Frey syndrome was documented when patients experienced gustatory sweating, even if they were not perturbed by the symptom. The Minor starch-iodine test was performed in each patient for objective assessment.

RESULTS

The incidence of subjective Frey syndrome was observed in 1 patient in group 1 and 5 patients in group 2. The incidence of objective Frey syndrome was noted in 2 patients in group 1 and 8 patients in group 2. Both subjective and objective differences in incidence of Frey syndrome were statistically significant. None of the group 3 patients had subjective or objective Frey syndrome. Two patients in group 1 and 3 patients in group 2 developed a transient seroma or sialocele that resolved with conservative management.

CONCLUSION

The use of AlloDerm graft as an interpositional barrier improves parotidectomy outcome by reducing the incidence of Frey syndrome.

Prospective randomised trial of the benefits of a sternocleidomastoid flap after superficial parotidectomy

Parotid surgery can cause postoperative facial nerve dysfunction, cosmetic impairment, and Frey's syndrome. Thirty-six patients listed for superficial parotidectomy were entered into a prospective randomised trial to find out if the use of a sternocleidomastoid flap could reduce the incidence of these complications. Partial facial nerve paresis was seen at 3 months in five patients in whom flaps were raised compared with six among those who did not have flaps (P=0.025). There was no difference between the two groups at 1 year. The flap was not associated with an improvement in either subjective (P=0.13) or objective (P=0.12) appearance measured on visual analogue scales. Eight patients in whom flaps were raised described symptoms suggestive of Frey's syndrome, compared with nine patients in whom a flap was not raised (P=0.31). Overall 19 of those who had a flap and 11 of those who did not had a positive starch-iodine test (P=0.21).

Frey syndrome: treatment with type A botulinum toxin

BACKGROUND

Frey syndrome was first described by Baillarger in 1853. Frey provided a detailed analysis and description as "auriculotemporal syndrome" in 1923. According to the literature, even the most recent therapeutic measures described for the treatment of patients with Frey syndrome have little chance of success and a high incidence of side effects. Thus, a type of treatment is desirable that can suppress the symptoms of Frey syndrome and can offer a good success rate, minimum invasiveness, and few side effects.

METHODS

The experience of the authors and data from the literature confirmed the efficacy of type A botulinum toxin treatment for patients with Frey syndrome up to a maximum observation period of 3 years.

RESULTS

In the current study, seven patients with severe, symptomatic Frey syndrome after parotidectomy were treated successfully with type A botulinum toxin.

CONCLUSIONS

The method of local, intracutaneous treatment with type A botulinum toxin for patients with Frey syndrome is effective, virtually side-effect free, and minimally invasive.

Frey's syndrome and parotidectomy flaps: A retrospective cohort study

Gustatory sweating, also known as Frey's syndrome, is a recognized phenomenon after parotidectomy. The incidence of clinically significant gustatory sweating may be dependent on the thickness of the skin flap that is elevated at the time of surgery. Dissection in the subcutaneous level or the deeper sub-superficial musculoaponeurotic system level are 2 commonly used techniques in the operation. Twenty-eight patients were prospectively evaluated for Frey's syndrome after superficial parotidectomy. Thirteen patients underwent subcutaneous and 15 patients sub-superficial musculoaponeurotic system flap elevation. The overall incidence of gustatory sweating was determined, and a comparison of the two surgical techniques was assessed subjectively by patient interview-questionnaire and objectively evaluated with starch-iodine testing.

Botulinum toxin treatment for symptomatic Frey's syndrome

Gustatory sweating, or Frey's syndrome, usually occurs after surgery or trauma to the parotid gland as a result of inappropriate parasympathetic cholinergic innervation of cutaneous sympathetic receptors. Numerous medical and surgical treatments have been proposed to prevent or treat this condition. The results, overall, have been unsatisfactory. Botulinum toxin is a relatively new treatment modality for Frey's syndrome. We review the literature and present our experience with 7 patients successfully treated with intradermal injections of botulinum toxin (Botox). Our technique and dosing are described. In all treated patients gustatory sweating ceased in the area injected with botulinum toxin. In 6 patients, symptoms reappeared, and additional injections were needed up to 4 times, at 6- to 8-month intervals. All patients now have been free of symptoms for a long period of time (mean 12.1 months). We strongly recommend intradermal injections of botulinum toxin as a safe, efficacious treatment for gustatory sweating.

Traumatic Neuromas of the Head and Neck

An interesting case of a traumatic neuroma of the greater auricular nerve provides the impetus for a discussion of head and neck neuromas. Traumatic neuromas of the head and neck are relatively rare. Division of the greater auricular nerve during parotidectomy occasionally results in a traumatic neuroma. We report a case of a 73-year-old woman who presented with a traumatic neuroma nine years after undergoing superficial parotidectomy with dissection of the facial nerve for a mixed tumor. The patient had a 1.5 cm x 1.0 cm mass located below the old surgical site over the anteromedial border of the sternocleidomastoid muscle. The patient's past history was significant for Frey's syndrome, which is the result of abnormal neurologic growth. On first impression, the tumor was thought to be a recurrence of neoplastic disease; however, because of the evaluation, traumatic neuroma was suspected. An attempt at fine-needle aspiration of the mass was too painful to be carried out. At surgery, a whitish tumor was excised which, on final pathologic examination, revealed traumatic neuroma.

The surgical literature is reviewed and the subject of head and neck neuromas, including their evaluation and management, is thoroughly discussed. Knowledge of this possible diagnosis may spare the patient and the surgeon needless worry, as well as unnecessary procedures, once tumor recurrence has been ruled out.

Frey's syndrome after parotidectomy: a retrospective and prospective analysis

Gustatory sweating is a well-known sequela after parotid surgery. In a retrospective and prospective study of patients undergoing parotid surgery, the onset, time course, extent, and treatment modalities of Frey's syndrome were analyzed. Twenty-two percent of the patients evaluated by questionnaires and 43% of the patients followed prospectively within 1 year were found to be symptomatic. Although the Minor starch-iodine test was positive in 38% of patients at 3 months, none of these patients experienced symptoms. Up to 12 months after surgery the rate of patients who tested positive increased to 96% and the total area of sweating expanded to a mean value of 18 cm2. Whereas most of the patients are not markedly disturbed, few patients (5% to 10%) suffer from severe gustatory sweating. These patients present a therapeutic challenge.