10.14639/0392-100X-N2231
Objective. Parotidectomy is the main treatment for parotid tumours, but its functional and aesthetic sequelae can be very disturbing for patients.Methods. 15 patients underwent total conservative parotidectomy, harvesting of a superficial musculoaponeurotic system (SMAS) flap and lipofilling between May 2014 and June 2020 for a benign parotid tumour. Aesthetic, functional sequelae and cosmetic results were assessed with the House-Brackmann scale, Luna-Ortiz’s classification and a semiquantitative questionnaire. Lipofilling resorption was analysed by maxillofacial and neck MRI imaging at 2 years after surgery. The results were compared to a group of 21 patients who underwent total parotidectomy without harvesting a SMAS flap and lipofilling.Results. No complications were observed. No facial defects were seen during follow-up. Post-operative MRI showed fat resorption was less than 20% in 12 patients and from 20 to 30% in 3 patients. Cosmetic satisfaction was 100% in all cases. Only 1 patient (6%) complained of Frey’s syndrome.Conclusions. Lipofilling is an excellent solution considering its efficacy, safety, simplicity, duration over time and economic costs. Donor site invasiveness is minimal, and reintervention is always possible. Face-lift incision and SMAS flap can improve aesthetic results and minimise the disfiguring impact of the surgical scar.
text/xml
1827-675X
2231
en
Giovanni Succo
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
parotid gland tumours
Lipofilling after total parotidectomy: a useful option to prevent functional and aesthetic sequelae
Text.Serial.Journal
https://www.actaitalica.it/
42
Head and neck
2022-12-29
2022-07-18
2022-12-29
2023-01-16
516-524
1
Giovanni Succo
2022/12/29
10.14639/0392-100X-N2231
516
ENT Unit, San Giovanni Bosco Hospital, Turin, Italy
1827-675X
parotid gland tumours
en
524
Lipofilling after total parotidectomy: a useful option to prevent functional and aesthetic sequelae
https://www.actaitalica.it/article/download/2231/890
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:516-524; doi: 10.14639/0392-100X-N2231




Head and neck


Lipofilling after total parotidectomy: a useful option
to prevent functional and aesthetic sequelae
Il lipofilling dopo parotidectomia totale:
valida tecnica per prevenire sequele estetiche e funzionali
Erika Crosetti1,2, Giulia Arrigoni3, Marco Fantini4, Gabriele Fondello5, Diego Moniaci6, Riccardo Carnino7, Giovanni Succo4
1
 ENT Unit, San Luigi Gonzaga Hospital, Orbassano (TO), Italy; 2 Department of Oncology, University of Turin, Orbassano (TO), Italy;
3
 ENT Unit, Chivasso Hospital, ASLTO4, Chivasso (TO), Italy; 4 ENT Unit, San Giovanni Bosco Hospital, Turin, Italy; 5 Radiology
Service, Mauriziano Hospital, Turin, Italy; 6 Vascular Surgery Unit, San Giovanni Bosco Hospital, Turin, Italy; 7 Plastic Surgery Unit,
Candiolo Cancer Institute FPO-IRCCS, Candiolo (TO), Italy


SUMMARY
Objective. Parotidectomy is the main treatment for parotid tumours, but its functional and
aesthetic sequelae can be very disturbing for patients.
Methods. 15 patients underwent total conservative parotidectomy, harvesting of a superfi-
cial musculoaponeurotic system (SMAS) flap and lipofilling between May 2014 and June
2020 for a benign parotid tumour. Aesthetic, functional sequelae and cosmetic results were
assessed with the House-Brackmann scale, Luna-Ortiz’s classification and a semiquanti-
tative questionnaire. Lipofilling resorption was analysed by maxillofacial and neck MRI
imaging at 2 years after surgery. The results were compared to a group of 21 patients who
underwent total parotidectomy without harvesting a SMAS flap and lipofilling.
Results. No complications were observed. No facial defects were seen during follow-up.
Post-operative MRI showed fat resorption was less than 20% in 12 patients and from 20 to
30% in 3 patients. Cosmetic satisfaction was 100% in all cases. Only 1 patient (6%) com-
plained of Frey’s syndrome.
                                                                                                  Received: July 18, 2022
Conclusions. Lipofilling is an excellent solution considering its efficacy, safety, simplicity,
                                                                                                  Accepted: October 3, 2022
duration over time and economic costs. Donor site invasiveness is minimal, and reinterven-
tion is always possible. Face-lift incision and SMAS flap can improve aesthetic results and
                                                                                                  Correspondence
minimise the disfiguring impact of the surgical scar.                                             Erika Crosetti
KEY WORDS: parotidectomy, lipofilling, Frey’s syndrome, parotid gland tumours                     ENT Unit, Department of Oncology, University
                                                                                                  of Turin, San Luigi Gonzaga Hospital, Orbassano
                                                                                                  (TO), Italy, Regione Gonzole 10, 10043 Orbassano,
RIASSUNTO                                                                                         Turin, Italy
Obiettivo. La parotidectomia è il trattamento di scelta per i tumori parotidei; tuttavia, può     Tel. +39 011 9026463
associarsi a disturbi funzionali ed estetici per il paziente.                                     E-mail: erikacro73@yahoo.com
Metodi. 15 pazienti sono stati sottoposti a parotidectomia totale conservativa per tumore
parotideo, con allestimento di lembo di SMAS e lipofilling, nel periodo tra maggio 2014 e           How to cite this article: Crosetti E, Arrigoni
giugno 2020. I risultati estetici e funzionali sono stati valutati mediante la scala di House-      G, Fantini M, et al. Lipofilling after total pa-
Brackmann, la classificazione di Luna-Ortiz e questionari semiquantitativi. Il riassorbi-           rotidectomy: a useful option to prevent func-
mento del lipofilling è stato valutato mediante una RM del massiccio facciale a 2 anni              tional and aesthetic sequelae. Acta Otorhi-
                                                                                                    nolaryngol Ital 2022;42:516-524. https://doi.
dall’intervento.
                                                                                                    org/10.14639/0392-100X-N2231
Risultati. Non vi sono state complicanze intra e post-operatorie. Nessun paziente ha pre-
sentato deficit del nervo faciale. La RM post-operatoria ha mostrato un riassorbimento di         © Società Italiana di Otorinolaringoiatria
tessuto adiposo < 20% in 12 pazienti e tra 20-30% in 3 pazienti. Solo un paziente ha pre-         e Chirurgia Cervico-Facciale
sentato la syndrome di Frey. Il 100% dei pazienti è stato soddisfatto del risultato estetico.
Conclusioni. Il lipofilling è una tecnica valida, efficace, semplice, sicura e durevole. Pre-                    OPEN ACCESS
senta minima invasività sul sito donatore ed è ripetibile. Un’incisione tipo lifting, combi-
                                                                                                  This is an open access article distributed in accordance with
nata con l’allestimento del lembo di SMAS, può migliorare i risultati estetici e minimizzare      the CC-BY-NC-ND (Creative Commons Attribution-Non-
l’impatto della ferita chirurgica.                                                                Commercial-NoDerivatives 4.0 International) license. The
                                                                                                  article can be used by giving appropriate credit and mentio-
PAROLE CHIAVE: parotidectomia, lipofilling, sindrome di Frey, tumore parotideo                    ning the license, but only for non-commercial purposes and
                                                                                                  only in the original version. For further information: https://
                                                                                                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                                         Lipofilling after total parotidectomy




Introduction                                                   salivary gland ultrasound, fine needle biopsy (FNAB) with
                                                               pathological examination and maxillofacial and neck MRI/
Parotidectomy is the mainstay of treatment for benign          CT scan.
and malignant parotid gland tumours. At present, many          Inclusion criteria was a fine-needle aspiration (FNAB)-
surgical options exist for parotid tumours and include         proven benignant neoplasm not involving the parotid cap-
(following the European Salivary Gland Society classi-
                                                               sule demonstrated by pre-operative imaging. Exclusion
fication from the least to the greatest volume resected):
                                                               criteria was a FNAB-proven tumour involving the parotid
parotidectomy (I or II, tumour arising in the boundaries
                                                               capsule demonstrated by pre-operative imaging.
of the superficial lobe), complete superficial parotidecto-
my (I-II, tumour involving the entire superficial lobe) and
                                                               Surgical procedure
total conservative parotidectomy (I-IV, tumour involving
                                                               All patients in Group A underwent total parotidectomy
both the superficial and deep lobe or arising in the deep
                                                               (I  IV) with preservation of the facial nerve, followed
lobe) 1. Radical removal, avoiding rupture of the tumour
                                                               by lipofilling. A face-lift skin incision was made and the
capsule and preservation of the facial nerve, are the main
                                                               SMAS plane was dissected off the glandular capsule and
goals of parotid surgery. Minor importance is paid on
                                                               preserved as a flap in continuity with the platysma, deep to
prevention of Frey’s syndrome (or auriculotemporal syn-
                                                               the subcutaneous layer (Fig. 1). The SMAS flap was iso-
drome) 2 and minimising aesthetic defects (concave de-
                                                               lated on both sides to then reposition and stretch it at the
formities, facial contour deformity, prominent scar), that
                                                               end of the resection in order to allow for lipofilling even
may result from parotidectomy. Several approaches have
                                                               superficially to it. The posterior branch of the great auricu-
been developed to prevent or secondarily treat neurologi-
                                                               lar nerve was mobilised and preserved whenever possible.
cal syndromes and cosmetic facial depression including
                                                               Simultaneously, a second surgical team harvested the fat
flaps (sternocleidomastoid flap, temporoparietal fascial
                                                               graft from the sub-umbilical abdominal region using Cole-
flap, superficial musculoaponeurotic system [SMAS]
                                                               man’s technique 6. The donor site was infiltrated through
flap), autologous tissue grafts, implants, allogenic der-
                                                               a 3 mm horizontal incision with a 1:400,000 solution of
mis, dermal fat grafts and free fat grafts 3, in addition to
                                                               epinephrine in Ringer’s lactate. Fat was aspirated by exert-
topical therapies (anticholinergics) 4 and multiple intra-
                                                               ing a low negative pressure using a 10 ml Luer-Lok syringe
cutaneous botulinum toxin A injections 5. Lipofilling has
                                                               attached to a blunt tip cannula to minimise mechanical
been described as an efficient, quick, safe, and inexpen-
                                                               trauma to adipocytes. The material was centrifuged for 3
sive surgical procedure. Based on the injection of autolo-
                                                               minutes at 3,000 rpm and the semi-liquid phase contain-
gous semiliquid fat graft, the technique is widely used in
                                                               ing vital adipose tissue was stored. After total conserva-
cosmetic surgery.
                                                               tive parotidectomy, the SMAS flap was approximated and
The main aim of this study is to present the outcomes fol-
                                                               sutured to the tragal plane (Fig. 2A-B). Lipofilling was
lowing harvesting of SMAS flap and lipofilling after total
                                                               performed using multi-layer injections under and over the
conservative parotidectomy in patients treated for a benign
                                                               SMAS flap, obtaining approximately 30% overcorrection
parotid tumour.
                                                               of the anatomical deficit by observing the convexity of the

Materials and methods
Study population
A retrospective study was carried out on the use of lipo-
filling after total conservative parotidectomy and harvest-
ing SMAS flap. The study cohort (Group A) included 15
consecutive patients treated between May 2014 and June
2020 for a benign parotid tumour (mostly arising in the
deep parotid lobe). All patients underwent total conserva-
tive parotidectomy, SMAS flap harvesting and lipofilling.
The control group (Group B) included 21 consecutive pa-
tients treated between January 2007 and December 2013
who underwent parotidectomy without harvesting SMAS
flap and lipofilling.
All patients underwent the same clinical assessment during
the 3 weeks before surgery including clinical examination,     Figure 1. Face-lift skin incision and SMAS flap harvesting (PG: parotid gland).



                                                                                                                                        517
E. Crosetti et al.




Figure 2. (A) Total conservative parotidectomy. (B) Approximation of the SMAS flap and suture to the tragal plane. (C) Precise marking of the injected area on the
skin of the patient to avoid dressing compression at that site. (D) Post-operative compressive dressing: a head bandage is wrapped over the top of the head and
brought down in front of the ear, under the chin and around the neck.


skin flap after its closure, facial contour and by compari-                        in Group A underwent maxillofacial and neck MRI at 2
son with the contralateral side. No suction drainages were                         years after surgery, asking the radiologist to evaluate the
used, but a soft drain was inserted to prevent the build-up                        symmetry of facial contour before and after the operation,
of fluid without draining the lipofilling that was injected.                       grading fat resorption as less than 20%, between 20 and
The injected area was precisely marked on the skin to avoid                        30% or more than 30%.
dressing compression at that site (Fig. 2C). A head bandage                        MRI was performed with a 1.5 T scanner (Siemens Sym-
was wrapped over the top of the head and brought down in                           phony TIM; Siemens, Enlargen, Germany and Philips
front of the ear (on the opposite side of the wound), under                        Achieva, Philips Healthcare, Best, The Netherlands). The
the chin and up over the dressing and around the neck. This                        imaging protocol included T1-weighted images in three or-
compressive dressing was held in place for 7 days to allow                         thogonal planes, T2-weighted images with fat suppression
the fat injection to settle (Fig. 2D).                                             in axial and coronal planes, contrast-enhanced T1-weight-
All patients in Group B underwent total parotidectomy (I                          ed images with fat suppression in axial and coronal planes
IV) with preservation of the facial nerve, without the use of                      and axial diffusion-weighted images. T1-weighted images
SMAS flap and lipofilling, using a face-lift skin incision.                        were used for volume measurements of the fat graft, since
All patients were included in regular follow-up programme                          the fat tissue is best observed with this sequence.
(salivary gland assessment by ultrasound and clinical ex-                          The severity of Frey’s syndrome was evaluated using Luna-
amination every 12 months).                                                        Ortiz’s classification 7: mild (total score 1-3) or severe (total
To assess the degree of resorption of the lipofilling, patients                    score ≥ 4) on the basis of subjective (clinical manifestation,



518
                                                                                                          Lipofilling after total parotidectomy




excessive focal sweating and unpleasant smelling sweat)         Table II. Intraoperative and postoperative results.
and objective manifestations (extent of the affected area re-    Characteristic                                   Group A         Group B
vealed by Minor’s iodine starch test) 8. Facial nerve defects                                                     (N = 15)        (N = 21)
were evaluated with the House-Brackmann scale 9. Patients       Intraoperative time (minutes)
                                                                   Mean                                             140             120
were asked to evaluate postoperative cosmetic results with
                                                                   Range                                           85-260          80-170
a semiquantitative questionnaire, focusing on symmetric
                                                                Hospitalisation length (days)
appearance and change of cosmesis during follow-up. Sat-           Mean                                               3               3
isfaction was graded on a scale of 1 (strongly unsatisfied)        Range                                             2-4             2-4
to 5 (strongly satisfied).                                      Intraoperative complications
                                                                   No                                             15 (100%)      21 (100%)
                                                                   Yes                                              0 (0%)        0 (0%)
Statistical analysis
Means and standard deviations were used to report con-          Postoperative complications
                                                                   No                                             15 (100%)      21 (100%)
tinuous variables and frequencies and proportions for cat-         Yes                                              0 (0%)        0 (0%)
egorical variables. The following parameters were evalu-        Sequelae
ated with nonparametric Mann-Whitney and Fisher Tests:             No                                              14 (93%)       17 (81%)
intraoperative time, length of hospitalisation, complication       Frey’s syndrome                                  1 (6%)        4 (19%)
                                                                   Aesthetic satisfaction                         15 (100%)      20 (95.2%)
rates, facial nerve deficit, grade of lipofilling resorption
                                                                   Grade I postoperative facial nerve function*     0 (0%)         0 (0%)
(Group A), cosmetic satisfaction and Frey’s syndrome.              Grade II postoperative facial nerve function     0 (0%)        1 (4.8%)
                                                                Radiological evaluation of fat resorption
Results                                                            ≤ 20%                                          12 (80%)     Not applicable
                                                                   20-30%                                          3 (20%)     Not applicable
Group A
                                                                   ≥ 30%                                           0 (0%)      Not applicable
A total of 15 patients were treated. Demographic data for
                                                                *Grades 1 to 6 on the House-Brackmann Scale.
patients in Group A are summarised in Table I. The median
age was 45 years (range 16-72 years). Fourteen patients
were affected by pleomorphic adenoma, and one patient           Radiologist-evaluated fat resorption more than 30% was
had a multilocular lymphangioma. The mean intraoperative        not seen in any patient.
time was 140 minutes (range 85-260 minutes). The mean           When evaluated with the House-Brackmann scale, no fa-
length of hospitalisation was 3 days (range 2-4 days). The      cial defects were seen during follow-up. All patients ex-
results in this group are summarised in Table II.               pressed the highest level of cosmetic satisfaction (5/5,
No intra-operative or post-operative complications were
                                                                strongly satisfied) (Figs. 3-5). Only one patient (6%) com-
observed. The first follow-up was performed after 9-14
                                                                plained of Frey’s syndrome and had a positive Minor test
months and the second after 18-24 months. The late timing
                                                                during follow-up (7.5 cm2 of skin involved after 12 months
of the first follow-up was intentional in order to allow suf-
                                                                postoperative and 12.5 cm2 of skin after 36 months post-
ficient time for nerve regeneration.
                                                                operative; Tab. III).
Maxillo-facial and neck MRI, performed at 2 years after
surgery, showed fat resorption of < 20% in 12 patients
                                                                Group B
(80%), while 3 patients (20%) had 20-30% fat resorption.
                                                                A total of 21 patients (15 females and 6 males) were in-
                                                                cluded in Group B. Demographic data are summarised in
Table I. Demographic data of Group A.                           Table IV. The median age was 49 years (range 22-65 years).
 Characteristics                        No. of patients         Twenty patients were affected by pleomorphic adenoma,
                                            N = 15              and one patient had an oncocytoma. The mean intraopera-
Age, yo                                                         tive time was 120 minutes (range 80-173 minutes). The
  Mean, n                                    45                 mean length of hospitalisation was 3 days (range 2-4 days).
  Range                                     16-72
                                                                The results in this group are summarised in Table II.
Sex, n (%)
  Male                                      4 (27)
                                                                No intraoperative or postoperative complications were
  Female                                   11 (73)              observed. The first follow-up was performed after 9-14
Histology, n (%)                                                months and the second after 18-24 months. The late tim-
  Pleomorphic adenoma                       14 (87)             ing of the first follow-up was intentional to allow sufficient
  Multilocular lymphangioma                  1 (6)              time for nerve regeneration.



                                                                                                                                           519
E. Crosetti et al.




Figure 3. Aesthetic outcomes in a 39-year-old woman.




Figure 4. Neck MRI (T2) at 2 years postoperative and aesthetic outcomes in 16-year-old male.


Table III. Characteristics of Frey’s syndrome in Group A.
                                                                         First follow-up visit   Second follow-up visit
                                                                        (range 9-14 months)      (range 18-24 months)
                                                                            N = 15, n (%)            N = 15, n (%)
Symptomatic Frey’s syndrome                                                    1 (6%)                   1 (6%)
Positive Minor starch-iodine test                                              1 (6%)                   1 (6%)
Iodine-positive surface area, cm2                                              7.5 cm2                 12.5 cm2




520
                                                                                                                   Lipofilling after total parotidectomy




                                                                                  necessary (I-IV), Frey’s syndrome and aesthetic defects can
                                                                                  frequently occur 10. The aesthetic defect is due to the surgi-
                                                                                  cal scar and to a remarkable depressed area in the parotid
                                                                                  region, resulting in asymmetry of facial contour. Almost
                                                                                  all patients who undergo parotidectomy I-IV show a vari-
                                                                                  able degree of aesthetic defects 10. Frey’s syndrome, which
                                                                                  consists of sweating, flushing and erythema of the parotid
                                                                                  region, is triggered by mastication and other salivation
                                                                                  stimuli and has uncertain aetiology. It seems to be caused
                                                                                  by an aberrant process of reinnervation, producing atypical
                                                                                  synapsis between parasympathetic and sympathetic fibres.
Figure 5. Volumetric comparison of the contents of the parotid region at 2
years after surgery: (A) non-operated side; (B) following total parotidectomy
                                                                                  The rate of Frey’s syndrome following parotidectomy is
and immediate lipofilling.                                                        very heterogeneous in the literature (reported in 10-40%
                                                                                  of cases) and reflects discrepancies in reporting and diag-
                                                                                  nosis 3. The variability may also be related to the surgical
Table IV. Demographic data of Group B.                                            technique used, diagnostic method and length of follow-up.
 Characteristics                                 No. of patients                  However, up to 90% of patients have been reported to have
                                                     N = 21                       a positive starch iodine test (Minor’s test) 3,4,7,11.
 Age, yo                                                                          By filling the anatomic defect caused by surgery both aes-
   Mean, n                                             49                         thetic defects and Frey’s syndrome can be prevented. Re-
   Range                                              22-65
                                                                                  constructive techniques can restore normal face contour
 Sex, n (%)
   Male                                              6 (28.6)                     and symmetry, creating a physical barrier to a pathological
   Female                                           15 (71.4)                     reinnervation process 3,8,9,11-13. Moreover, the use of a face-
 Histology, n (%)                                                                 lift incision minimises the disfiguring impact of the surgi-
   Pleomorphic adenoma                              20 (95.2)                     cal scar 12-14.
   Oncocytoma                                        1 (4.8)                      Many reconstructive techniques are now available. Recon-
                                                                                  struction using SMAS flap has shown to be effective in pre-
                                                                                  venting Frey’s syndrome. However, due to its thinness it is
Using the House-Brackmann scale, no facial defect was                             not suitable to correct deep anatomic defects. A temporopa-
seen in 20 patients (95.2%) during follow-up. One patient                         rietal fascia flap allows good aesthetic results, but requires
(4.8%) complained of a grade II House-Brackmann facial                            an extended temporal incision, and has an increased risk of
nerve defect. Fifteen patients (71.4%) expressed the high-                        alopecia and nerve lesions 15. The effectiveness of a ster-
est level of cosmetic satisfaction (5/5, strongly satisfied),                     nocleidomastoid muscle flap is still debated. Overall, the
while 3 patients (14.3%) were moderately satisfied (4/5)                          use of flaps has drawbacks such as an increase in surgical
and 3 (14.3%) were satisfied (3/5). Four patients (19%)                           time, limited availability of tissue and the limited rotation
complained of Frey’s syndrome and had a positive Minor                            angle. Graft and non-autologous implants (possibly syn-
test during follow-up (Tab. V).                                                   thetic) such as acellular dermal matrix, human lyophilised
                                                                                  dura, PTFE patches and polyglactin 910 mesh are possible
                                                                                  alternatives that ensure a high rate of aesthetic satisfaction.
Discussion
                                                                                  Even if these materials could be an ideally limitless source
Parotidectomy is the treatment of choice for benign parotid                       and are quick and easy to use, their high costs represent
gland neoplasms. When total conservative parotidectomy is                         a limitation for a large-scale use. Furthermore, the non-


Table V. Characteristics of Frey’s syndrome in Group B.
                                                                            First follow-up visit                  Second follow-up visit
                                                                           (range 9-14 months)                     (range 18-24 months)
                                                                               N = 21, n (%)                           N = 21, n (%)
Symptomatic Frey’s syndrome                                                       4 (19%)                                 4 (19%)
Positive Minor starch-iodine test                                                 4 (19%)                                 4 (19%)
Iodine-positive surface area, cm2 (median)                                         8 cm2                                  13 cm2




                                                                                                                                                  521
E. Crosetti et al.




negligible risk of infection, rejection and extrusion reduces       and the patient’s age. Long-term dysfunction has been re-
their safety 16. Good aesthetic results and effectiveness in        ported in 0 to 19% of patients 22,23.
preventing Frey’s syndrome have been described using der-           In this study, none of the patients in Group A presented
mal or dermal-fat grafts (autologous or allogenic) and FAT          facial nerve deficit during follow-up (12 months after
(Free Abdominal Fat Transfer, a solid fat graft). Though            surgery); with the House-Brackmann grading scale, all
these options represent a good compromise in terms of               patients had a score of I (100%), or normal facial nerve
costs, rapidity and simplicity, the surgical invasiveness on        function. In Group B, only 1 patient had a grade II House-
the donor site is still a limitation since it can cause further     Brackmann facial nerve deficit during follow-up.
complications and aesthetic defects 3,14,15. In some cases,         These excellent outcomes regarding facial nerve dysfunc-
the techniques listed above have been combined or applied           tion may in part be justified by lipofilling that encases the
in a second step to treat but not prevent aesthetic issues and      facial nerve in fatty tissue. Mature adipocytes account for
Frey’s syndrome.                                                    approximately 20-30% of all adipocytes. The remainder
Cosmetic surgery has employed lipofilling for decades and           are the so-called DFAT cells (de-differentiated fat cells),
is associated with excellent safety. The procedures for fat         which are characterized by a high proliferative potential
grafting and applying a semi-liquid fat graft have been de-         and pluripotency. DFAT cells can differentiate into vari-
scribed in detail 6.                                                ous types of cells (adipocytes, smooth muscle cells, car-
The main debates regarding the use of lipofilling to cor-           diomyocytes, osteoblasts, chondrocytes) and significantly
rect the aesthetic defect after parotidectomy concern physi-        improve nerve-regeneration capability since they release
ological resorption of the graft and its long-term efficacy.        large amounts of VEGF. Moreover, immunohistochemical
Volume loss and graft resorption remain a major challenge           studies show that neural stem cell markers, such as nes-
in the long-term that can lead to unpredictable results. The        tin and SOX2, are found in DFAT cells, suggesting that
volume of fat transferred in the parotidectomy region has           these cells can differentiate into peripheral nerve cells
not been clearly identified. Moreover, the percentage of fat        (Schwann cells); they thus appear to play a central role in
graft resorption in parotid bed reconstruction is unknown,          nerve regeneration by releasing nerve growth factor and
and most studies have been based on the rates of fat graft          by forming myelin, which is important for axonal struc-
resorption at other sites of the face or body 17.                   ture 24,25.
Generally, fat resorption occurs during the first three             For these reasons, it is important to underline that lipofill-
months after lipofilling 18. In the literature, it has been de-     ing is contraindicated in patients with a malignant parotid
scribed that the resorption phenomenon is more prominent            tumour. Nevertheless, the presence of fat in the parotid re-
(around 50%) if the harvested fat is very oily (the propor-         gion after lipofilling does not affect the need for revision
tion of oil in the centrifugated fat is high) 18. Once stabilised   surgery for recurrent pleomorphic adenoma or the need for
in situ, the fat tissue permanently remains in the recipient        adjuvant treatments (radiotherapy, chemoradiotherapy) in
bed. Eto et al. 19 noted that some adipocytes die immedi-           the case of an unexpected malignant tumour at the final his-
ately after surgery during the immediate, post-lipofilling          topathological report.
ischaemic period. However, other cells survive due to the           The results of this study are significant in terms of clinical
process of plasmatic imbibition. This biological phenome-           and economic performance. The combination of face-lift
non precedes the growth of neo-capillaries that will nourish        skin incision, SMAS flap harvesting and lipofilling was
the fat, establishing a long-term homeostatic equilibrium.          shown to be effective in limiting aesthetic defects after pa-
Both the fat and the surgical recipient bed contribute to the       rotidectomy I-IV and to reduce the rate of Frey’s syndrome.
process of revascularisation 20.                                    All patients in group A expressed the maximum cosmetic
In 2013, Vico et al. described their experience in the use of       satisfaction score, while only 71.4% of patients were high-
lipofilling after parotidectomy I-IV to treat benign parotid        ly satisfied in group B, demonstrating that lipofilling is not
neoplasms and reported that the procedure was associated            inferior in efficacy to any of the other employable options.
with good long-term efficacy 21.                                    Rigorous application of Coleman’s technique and overcor-
In the literature, the incidence of facial nerve dysfunction        rection (of about 30%) allowed maintaining long-term suc-
after surgery is variable, and the diverse populations stud-        cess without deterioration during follow-up.
ied, and type of surgical procedures used makes it difficult        Although the number of patients was small overall, the in-
to compare different studies. Postoperative facial nerve            cidence of Frey’s syndrome in Group A was low. Only one
dysfunction also depends upon the surgeon’s experience,             patient (6.6%) had a positive Minor’s test during follow-up
surgical technique employed, size and site of the tumour,           (12.5 cm2 of skin involved), suggesting that the technique
histopathological type, comorbid inflammatory conditions,           is also effective in preventing Frey’s syndrome. In group



522
                                                                                                        Lipofilling after total parotidectomy




B, four patients (19%) complained of Frey’s syndrome and         Ethical consideration
had a positive Minor test.                                       All procedures were considered to be conventional in terms
The absence of intra- or post-operative complications or         of technique and indications, in accordance with current
sequelae, in both the donor and the recipient sites, dem-        guidelines, the ethical standards of the institutional and/or
onstrates that the methods are associated with an excellent      National Research Committee and the 1964 Helsinki dec-
safety profile. Intraoperative surgical time is not substan-     laration and its later amendments. Ethical review and ap-
tially increased (140 minutes in group A vs 120 minutes          proval were not required for this study in accordance with
of group B), since the simultaneous work of two surgical         national and local institutional requirements. Before sur-
teams allows harvesting the graft while tumour removal           gery, all patients signed a consent form for disclosure of
is ongoing. At the end of the resection, graft application       anonymised data for scientific purposes. Written informed
can be easily performed in 10-15 minutes. Additionally,          consent was obtained from all patients.
the technical skills required, and extra costs are negligible.
Moreover, in the case of a poor aesthetic result in the long-    References
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