An update on extracapsular dissection for the management of parotid gland pleomorphic adenoma.

Superficial parotidectomy has been the gold standard for surgical removal of benign mobile parotid gland tumours. The comparatively newer technique of extracapsular dissection, which involves careful dissection of the tumour itself without the need for formal gland excision, has gained popularity in recent years. Tumours can be removed via smaller incision, and the technique reduces the risk of Frey's syndrome (gustatory sweating) and hollowing at the site of surgery. The risk of facial nerve damage can also be lower with extracapsular dissection. If done carefully, the incidence of tumour recurrence, particularly for pleomorphic adenomas, is comparable with formal parotidectomy. We provide a brief update overview of the current evidence for extracapsular dissection in the treatment of benign parotid tumours and include several meta-analyses which provide evidence for the safety of the technique. We have also included our audited results of over 100 recent extracapsular dissections, with 0% incidence of permanent facial nerve weakness, reported Frey's syndrome and recurrence rates over the last 5 years.

[Complications in the surgery of the parotid salivary glands. Causes, mechanisms of development, methods of prevention]. / Oslozhneniya v khirurgii okoloushnykh slyunnykh zhelez. Prichiny, mekhanizmy razvitiya, sposoby profilaktiki.

Operations for neoplasms of the parotid salivary gland require from the surgeon a deep knowledge of the anatomical and topographic features of this area and technical skill, which puts it in a number of «jewelry¼ operations that require patience and concentration. The review is devoted to the topic of specific postoperative complications after parotidectomy or subtotal resection of the gland. These include relapses of tumors, paralysis or paresis of facial muscles, Frey syndrome, salivary fistulas or sialocele, violation of skin sensitivity, soft tissue deformity. The review presents the frequency and causes of complications, mechanisms of their development, methods of prevention and elimination.

Frey Syndrome, First Bite Syndrome, great auricular nerve morbidity, and quality of life following parotidectomy.

PURPOSE: Parotidectomy may be burdened by numerous complications that may worsen subjects' quality of life (QoL). These include paresis or paralysis of the facial nerve, face profile asymmetry, keloids, salivary fistula, Frey Syndrome (FS), First Bite Syndrome (FBS), and hypo-anaesthesia of the skin. This study is an effort to assess the incidence of complications following parotidectomy and their impact on subjects' QoL. METHODS: Subjects undergoing parotidectomy for benign neoplasms from 2012 to 2015 were selected and invited to attend our outpatient clinic. After a brief anamnesis, the medical examiners tested their tactile perception and performed the Minor test for FS. Depending on the complications showed, subjects were asked to complete from 1 to 4 questionnaires about their QoL. RESULTS: 76 subjects completed the medical examination. The most frequent complication was the hypo-anaesthesia of the skin (71%). 21 subjects (28%) were positive to the Minor test, while 8 subjects (11%) reported FBS-compatible symptoms. Two subjects (3%) showed a facial nerve paralysis. Free abdominal fat graft was used in 16 subjects (21%) and it was associated with a lower incidence of FS. Surgery of the deep lobe of the parotid was associated with FBS. CONCLUSIONS: FBS appears to have a greater influence on subjects' QoL than FS and hypo-anaesthesia of the skin. Moreover, this work confirms that surgery of the deep lobe of the parotid is a risk factor for developing FBS and the free abdominal fat graft is a reliable technique to prevent FS.

Reconstructive techniques of the parotid region.

PURPOSE: The aim of our study was to evaluate and check (analyze and compare the results) the complications of patients with benign parotid disease reconstructed with the 3 reconstructive techniques used after the removal of benign tumors of the parotid gland treated at our institution. The reconstruction of this anatomical region may include the use of superficial musculoaponeurotic system (SMAS) flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap to prevent aesthetic and functional complications. PATIENTS AND METHODS: We carried out a retrospective review of 224 patients operated on between February 2002 and March 2009 with benign primary parotid tumors. Extracapsular dissection or superficial parotidectomy was performed and then these patients were reconstructed with the 3 techniques that we used to apply at the Department of Maxillofacial Surgery in the University Federico 2 of Naples: the SMAS flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap. The statistical difference between the extracapsular dissection versus superficial parotidectomy and the statistical difference between the 3 types of flaps as concerns evaluated recurrence rate and complications were measured with the χ test. The chosen level of statistical significance was P less than 0.05. RESULTS: Out of the 224 enrolled patients, 103 were women and 121 men, with an average age of 54 years. After histopathological examination, 136 adenomas and 88 cystadenoma lymphomas were diagnosed. Enucleoresection was the surgical technique adopted in 169 cases while superficial parotidectomy was used in the remaining 55 cases. The reconstruction was performed with SMAS flap in 122 patients, with muscle flap SMC in 66 patients and temporoparietal fascia flap in 36 patients. Table 1 shows that no significant differences as concerns hematoma and wound infection were observed after extracapsular dissection and superficial parotidectomy(1.8% vs.1.8% [P > 0.05] and 1.8% vs. 5.5% [P > 0.05]). Transient facial nerve weakness, fistula, dip skin, Frey syndrome, spinal nerve injury, and facial paralysis were significantly more frequent after superficial parotidectomy than after extracapsular dissection (4.1% vs. 27.3% [P < 0.001], 1.8% vs. 10.9% [P < 0.001], 3% vs. 12.7% [P < 0.001], 0% vs. 5.5% [P < 0.001], 0% vs. 3.6% [P < 0.001], and 0% vs. 9.1% [P < 0.001], respectively). Table 3 shows that the presence of Frey syndrome is statistically significant in the first 2 comparisons, group I against group IV and group II against group V, respectively (P < 0.05 and P < 0.01). And in the first comparison between group I and IV, there was a statistically significant presence of transient facial nerve weakness (P < 0.001), fistula (P < 0.001), dip skin (P < 0.05), and facial paralysis (P < 0.001). In the second comparison between group II and group V besides the presence of Frey syndrome, there is also a statistically significant presence of transient facial nerve weakness (P < 0.05), skin depression (P < 0.05), accessory spinal nerve injury (P < 0. 01), and facial paralysis (P < 0.01). In the comparison between the third and the sixth group, there is a statistically significant presence of transient facial nerve weakness (P < 0.05), fistula (P < 0.01), and facial paralysis(P < 0.05). CONCLUSIONS: Extracapsular dissection showed similar effectiveness and fewer side effects than superficial parotidectomy, and the 3 reconstruction techniques used in this trial drastically reduce the occurrence of post-parotidectomy Frey syndrome and greatly reduce functional and aesthetic complications.

Evaluation of functional and aesthetic outcomes of free dermal fat graft versus superficial musculoaponeurotic system flap after superficial parotidectomy: randomized clinical trial.

BACKGROUND: Parotidectomy is the standard procedure for treatment of many parotid lesions; however, it has several drawbacks. Facial asymmetry and Frey's syndrome are the most annoying complications to patients. Insertion of interpositioning grafts into the parotidectomy bed can decrease these complications significantly. Free dermal fat graft (FDFG) and superficial musculoaponeurotic system (SMAS) flap have very promising results. This RCT aimed to compare these two techniques regarding functional and aesthetic outcomes. METHODS: Between February 2016 and October 2021, adult patients undergoing superficial conservative parotidectomy in a single centre for a benign indication were randomized into two equal groups using a closed envelope method. In one group, FDFG was inserted at the parotidectomy bed, whereas, in the other group, SMAS flap was performed. Preoperative, operative, and postoperative data were recorded and analysed. The primary outcome was the development of Frey's syndrome. RESULTS: Seventy-eight patients were randomized into two equal groups of 39 patients. There was no significant difference between the two groups regarding development of Frey's syndrome. There was no significant statistical difference between study groups regarding demographic data, co-morbidities, parotid pathologies, specimen volumes, total operating time, and postoperative complications. A tendency for over correction was observed in FDFG and under correction in SMAS flap. There was no statistically significant difference between the study groups regarding the patients' aesthetic satisfaction with the majority displaying excellent satisfaction with no poor results. CONCLUSION: FDFG and SMAS flap are simple, rapid, and reliable procedures and are effective in improving both functional and aesthetic outcomes post-parotidectomy. They have comparable results; however, selection of either procedure can be determined according to patient and tumour characteristics. Registration number: NCT05452837 (http://www.clinicaltrials.gov).

Two-stage surgical approach with dermofat graft and lipofilling for the treatment of established Frey syndrome and facial depression deformity.

Frey syndrome and facial contour deformity commonly occur after parotid surgery. Although the treatment of established Frey syndrome has focused on medical solutions, surgical solutions to established Frey syndrome have been less reported. Moreover, these methods may not resolve the facial depression. In the presented case here, we used 2-stage surgical approach with dermofat graft and lipofilling for the treatment of established Frey syndrome and facial depression deformity. We considered that this technique provides the easiest, most practical, satisfying, and effective solution for Frey syndrome that develops in the late follow-up period after superficial parotidectomy.

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.

[Application of retroauricular sulcus incision in surgery of parotid gland tumor].

Objective: To investigate the application of retroauricular sulcus incision in surgery for benign tumor in superficial lobe of parotid gland. Methods: A total of 20 patients were reviewed who underwent the resection of benign tumor in the superficial lobe of parotid gland with retroauricular sulcus incision at the Department of Otorhinolaryngology, the Linyi City People Hospital between May 2015 and March 2017. There were 12 males and 8 females with an age range of 12-66 years old, including 15 cases with mixed tumor and 5 cases with adenolymphoma. Surgical procedure included facial never dissection from the main trunk to facial never cervical trunk, temporal trunk and peripheral branches. After resection of tumor and superficial lobe of parotid gland, and sternocleidomastoid muscle flap was used to fill the defect in parotid area. All patients were postoperatively followed up after surgery. Results: Surgeries were successfully operated in all patients. Follow-up for 2 years showed there was no presence of recurrence, salivary fistula, Frey syndrome, scar affecting facial appearance, or significant deformity in the surgical area. Conclusion: Surgery for superficial lobe of parotid gland and facial nerve dissection through retroauricular sulcus incision have some advantages such as incision concealment, simple procedure for facial nerve dissection, simultaneous repair of tissue defects with sternocleidomastoid muscle flap, and less complications.

[Functional modified periauricular incision in parotidectomya].

Objective:The purpose of this study was to present the usefulness of modified periauricular incision in parotid surgical procedures. Method:Sixteen consecutive partial superfacial parotidectomies were performed using modified periauricular incision. Clinical evaluation of cosmetic satisfaction, incidence of complications such as Frey's syndrome, facial nerve palsy, earlobe numbness and salivary fistula were observed. Result:The parotid tumors were removed in all cases with need for any further skin procedures, as the incisions produced a good aesthetic result. The average scale of cosmetic satisfaction are 9.2. Temporary paralysis of the facial nerve were found in two patients, and six patients felt numbness around earlobe after operation. Hey all recovered in 1 to 3 months after surgery. All patient healed without salivary fistula and Frey's syndrome. No recurrence was happened during follow-up in 6 to 30 months (median follow-up period was 22 months). Conclusion:The results of the present study indicate that modified periauricular incision have a high-quality and highly aesthetic option for surgical procedures concerning benign conditions of the parotid gland.

Treatment of postparotidectomy Frey syndrome with the interposition of temporalis fascia and sternocleidomastoid flaps.

OBJECTIVES: This study was performed to evaluate the effectiveness of overlapping the temporalis fascia flaps (TFFs) and the sternocleidomastoid muscle flaps (SCMFs) as physical barriers to treat established Frey syndrome and concavity after parotidectomy. STUDY DESIGN: We retrospectively reviewed 17 patients who underwent corrective procedures with simultaneous TFF and SCMF interposition for the treatment of Frey syndrome. The affected areas of the cheek skin were identified with starch-iodine tests. The facial contours of the patients were classified as bilaterally symmetric (BS), with a slightly shallow (SS) contour on the surgical side, or with a conspicuously shallow (CS) contour on the surgical side. RESULTS: The sample was followed up for a mean of 22 months. The average area of gustatory-sweating positive skin was reduced from 12.80 to 1.32 square centimeters postoperatively. The facial asymmetry secondary to parotidectomy was greatly improved. CONCLUSIONS: The authors concluded that this technique was efficacious in ameliorating Frey syndrome and facial concavity secondary to parotidectomy.

Prevention of Frey's syndrome with superficial musculoaponeurotic system interposition.

Frey's syndrome after parotidectomy has an incidence generally reported to be 50% to 60% and is thought to be due to aberrant reinnervation of sweat glands by postganglionic parasympathetic fibers normally supplying the parotid gland. One hundred twelve patients had interposition of a flap of the superficial musculoaponeurotic system between the parotid bed and the overlying skin. Only one patient developed symptomatic Frey's syndrome, and one other patient had positive results on starch iodine testing. In patients not having the interposition, the incidence of symptomatic Frey's syndrome and positive starch iodine testing was 83% and 87%, respectively.

Treatment of Frey's syndrome with topical 2% diphemanil methylsulfate (Prantal): a double-blind evaluation of 15 patients.

Fifteen patients with severe gustatory sweating after total parotidectomy and facial nerve preservation were asked to take part in a double-blind study. All patients were alternatively treated with topically applied placebo and topically applied 2% diphemanil methylsulfate (an anticholinergic agent). A 10-day period was allowed between applications for return of symptoms. Two-percent diphemanil methylsulfate provided partial relief in 33.3% of patients and total relief in 40% of patients. Involvement of the hairy temporal line region with gustatory sweating was the main reason for failure. Duration of relief varied from 2 to 4 days. The only side effect was dryness of the mouth noted in two patients.

Frey syndrome: treatment with temporoparietal fascia flap interposition.

There is a 10% to 48% reported incidence of clinically significant gustatory sweating after parotid surgery or injury. Various medical and surgical treatments have been used in the attempt to treat this socially embarrassing condition. These treatments are not always effective and often have unwanted risks and adverse effects. They also do not address the post-parotidectomy defect. Prevention of Frey syndrome and correction of the postoperative contour deformity after parotidectomy have recently been achieved by interposition of temporoparietal fascia flap between the parotid gland and the cheek skin flap at the time of parotidectomy. This article presents the first report (to our knowledge) of an established case of Frey syndrome being treated with temporoparietal fascia flap interposition.

Prevention of Frey syndrome during parotidectomy.

OBJECTIVE: To evaluate the incidence of Frey syndrome (auriculotemporal nerve syndrome) after parotidectomy with and without placement of a subcutaneous implant and to examine the relationship between different implants and postoperative wound complications (hematoma, seroma, salivary fistula). DESIGN: A prospective nonrandomized controlled trial. SETTING: A primary care and referral university hospital center. PATIENTS: All patients scheduled for parotidectomy from April 1994 through August 1998 were eligible. Seventy patients were enrolled (2 refused). All 70 patients were evaluated for wound complications. Sixty patients with a follow-up of more than 1 year were evaluated for Frey syndrome. INTERVENTION: The choice of implant was left to the individual surgeon: 24 patients had no implant; 7, lyophilized dura implant; 7, polyglactin 910-polydioxanone (Ethisorb) implant; and 32, expanded polytetrafluoroethylene (e-PTFE) implant. OUTCOME MEASURES: The incidence of Frey syndrome was evaluated (1) subjectively by history (clinical Frey syndrome) and (2) objectively by using 2 newly developed tests. Both hemifaces were tested, with the normal side being used as a control. RESULTS: Clinical Frey syndrome was present in 12 patients: 11 without implants (11/24 [53%]) and 1 with an implant (1/46 [2%]) (P<.001). Objective tests were positive in 24 patients: 16 (76%) of 21 without implants and 8 (20%) of 39 with implants (P<.001). In the implanted patients, the objective tests were positive in 71% (5/7) of those with lyophilized dura, 14% (1/7) of those with Ethisorb, and 8% (2/29) of those with e-PTFE implants (P<.001). Wound complications included hematoma in 5 patients (7%), seroma in 4 patients (6%), and salivary fistula in 15 (21%). Salivary fistula occurred more frequently with Ethisorb (57%) and e-PTFE (25%) implants (P = .04). CONCLUSIONS: In patients without an implant, the incidence of Frey syndrome is 50% for subjective and 80% for objective evaluation. In patients with an implant, these incidences are 3% and 10%, respectively. Some implants are associated with a higher incidence of salivary fistula.

Limited endoscopic thoracic sympathetic block for hyperhidrosis of the upper limb: reduction of compensatory sweating by clipping T4.

BACKGROUND: Endoscopic thoracic sympathicotomy of T2 to T4 (ETS 2-4) has evolved into an effective treatment for severe hyperhidrosis of the upper limb. Complications such as bleeding or Horner's syndrome are rare, but side effects such as compensatory and gustatory sweating occur in 30-50% of patients. Following the Lin-Telaranta classification, we aimed to reduce these side-effects by clipping T4 solely [endoscopic thoracic sympathetic block (ESB 4)]. We present our experience and clinical results using this method, with emphasis on patients' quality of life. METHODS: A total of 176 procedures (91 patients) were carried out in the ETS 2-4 group and 103 procedures (53 patients) in the ESB 4 group: 60.4 and 43.4% had palmar hyperhidrosis, 8.8 and 5.7% had isolated axillary, and 30.8 and 50.9% had combined manifestations, respectively. Follow-up was 22.1 months (obtained from 79.1% of patients) for the ETS 2-4 group and 7.5 months for the ESB 4 group (obtained from 88.7%). RESULTS: The success rate was similar for both groups: 87.9 and 64.5% had completely dry limbs, 9.9 and 35.5% ( p < 0.0002) were nearly dry, and 2.1 and 0% remained wet. (ETS 2-4 vs ESB 4). Although the armpits remained slightly humid in more patients in the ESB 4 group, 100% stated full satisfaction. Complications did not differ significantly. However, compensatory sweating (55.6 vs 8.5%, p = 0.0002) and gustatory sweating (33.3 vs 2.1%, p = 0.0019) were markedly reduced (ETS 2-4 vs ESB 4). Quality of life was assessed by a hyperhidrosis index, which significantly improved in most patients. CONCLUSIONS: ETS 2-4 and ESB 4 have similar success rates in the treatment of upper limb hyperhidrosis. The major side effects of compensatory and gustatory sweating were effectively reduced by the limited method of clipping T4, and patients' satisfaction and improvement in quality of life were remarkable.

Frey's syndrome-a technical remedy.

The symptoms of Frey's syndrome are occasionally of sufficient magnitude to warrant curative treatment. In four patients, a fascia lata graft was placed under the involved skin in an attempt to offer permanent relief from the cutaneous discomfort suffered during eating. Two of these patients have excellent long-term results. The other two patients were lost to long-term follow-up but were asymptomatic several months following grafting.

Gustatory otorrhea: Frey's syndrome of the external auditory canal.

A case of Frey's syndrome of the external auditory canal is reported. The patient presented with unilateral gustatory otorrhea and thickened external auditory canal skin. Histopathologic examination of the canal skin showed sudomotor gland hyperplasia. Symptoms were relieved with canal skin excision and skin graft.

Early results using a porcine dermal collagen implant as an interpositional barrier to prevent recurrent Frey's syndrome.

Frey's syndrome is a common complication of salivary gland surgery. Although it is usually preventable by raising the skin flap in the superficial musculoaponeurotic system layer, the treatment of the established condition often requires further surgery. There are many surgical options to treat this condition. The method described in this paper avoids the morbidity of a second operative site by using a biocompatible interpositional layer to prevent the sweat glands of the skin being inappropriately cross-innervated. The follow-up period on both patients was 12 months. This factor needs to be taken into account despite the early improvement observed.

[Treatment of facial blushing with endoscopic thoracal sympathicotomy. 85 per cent of patients are satisfied, but there are adverse effects]. / Behandling av ansiktsrodnad med endoskipisk torakal sympatikotomi. 85 procent av patienterna nöjda, men biverkningar finns.

Endoscopic transthoracic sympathicotomy, otherwise an established treatment for palmar hyperhidrosis, was used to treat patients troubled by facial blushing, one of the commonest symptoms of social phobia. The results were evaluated by means of a questionnaire answered by 90 per cent (219/244) of the patients, who rated their symptoms on a visual analogue scale (0-10) after a mean follow-up of eight months. According to the ratings, blushing was significantly reduced from a mean (+/- SEM) of 8.7 +/- 0.1 to 2.2 +/- 0.2 (p < 0.0001). Of the series as a whole, 85 per cent declared themselves satisfied with the outcome.

Superficial musculoaponeurotic system flap in partial parotidectomy and clinical and subclinical Frey's syndrome. Cosmesis and quality of life.

BACKGROUND: Frey's syndrome (FS), facial depression, and noticeable scar may have an impact on patient's quality of life after a parotidectomy. The superficial musculoaponeurotic system (SMAS) flap has been used to ameliorate those effects. METHODS: Forty-seven consecutive parotidectomies were analyzed; SMAS flap was performed in 26 of them. We investigated clinical FS, subclinical FS, and cosmetic satisfaction, and compared SMAS flap versus cases where this was not done. RESULTS: By performing the SMAS flap, the occurrence of clinical FS was reduced; however, there was no significant difference. Nonetheless, there was a significant difference in the perspiration intensity in favor of the group with SMAS flaps. In the cases we studied, the cosmetic satisfaction was high, even though facial contour-filling techniques were not used. CONCLUSIONS: Provided that the intensity of sweating is the main factor affecting the quality of life after surgery in patients, performing a SMAS flap renders the intervention worthwhile.