The Laryngoscope Lippincott Williams & Wilkins, Inc., Philadelphia © 2001 The American Laryngological, Rhinological and Otological Society, Inc. The Use of Acellular Dermis in the Prevention of Frey’s Syndrome Satish Govindaraj, MD; Michael Cohen, MD; Eric M. Genden, MD; Peter D. Costantino, MD, FACS; Mark L. Urken, MD, FACS Educational Objective: At the conclusion of this presentation, the participant should be able to discuss the indications and advantages of using acellular der- mis in the prevention of post-parotidectomy gustatory sweating (Frey’s Syndrome). Introduction: Gustatory sweating is a common postoperative problem and a challenge to treat. The purpose of this study was to evaluate the role of acellular dermis in preventing post- parotidectomy gustatory sweating. Methods: Sixty-four patients were randomly assigned to two groups. Group I consisted of 32 patients who underwent a superficial lobe parotidectomy. Group II consisted of 32 patients who underwent a superficial lobe parotidectomy and underwent intraoperative placement of acellular der- mis within the parotid bed, between the skin flap and the remaining parotid tissue. The implanted volume of acellular dermis was determined by the amount re- quired to aesthetically restore lateral facial contour. All 64 patients were evaluated for gustatory sweating by identical phone and mail questionnaires. Thirty ran- domly chosen patients (group I  15, group II  15) were evaluated using a modified Minor’s Starch-Iodine Test (MSIT). In all 30 patients, the MSIT was administered to both sides of the face. Results: The responses to ques- tionnaires (N  64) demonstrated the subjective pres- ence of gustatory sweating in 3 of 32 patients (9.3%) in group I, whereas group II demonstrated a subjective incidence in 1 of 32 patients (3.1%). The objective inci- dence determined by those who underwent the MSIT (n  30) revealed a 40% (6) and 0% incidence of Frey’s Syndrome in groups I and II, respectively. The compli- cation rate in group I was 9% (3 seromas) and in group II it was 25% (7 seromas and 1 wound infection). Con- clusions: Acellular dermis appears to be an effective method for preventing post-parotidectomy gustatory sweating, despite its higher complication rate. Key Words: Frey’s Syndrome, acellular dermis, gustatory sweating. Laryngoscope, 111:1993–1998, 2001 INTRODUCTION Frey’s Syndrome is a long-term complication of pa- rotid excision that is characterized by two main symp- toms: gustatory sweating and gustatory flushing. Diag- nostic testing and clinical familiarity have traditionally focused on the “sweating” component of the syndrome; however, clinicians need to be cognizant of difficulties with gustatory flushing as well, which can result in sig- nificant discomfort from cosmetic embarrassment and pain from local vascular engorgement. The incidence of Frey’s Syndrome has been studied in numerous articles with variable percentages (Table I). Some reasons for this variability are that incidence rates are reported based on the presence of clinical symptoms, whereas others report results obtained from objective test- ing (i.e., starch-iodine test). Perhaps the first article to bring Frey’s Syndrome to the forefront as a common post- parotidectomy entity was Laage-Hellman’s in 1957. 1 In his study of 123 patients, he used the Minor’s Starch- Iodine Test to determine an objective incidence of Frey’s Syndrome in nearly 100% of patients. This number has been difficult to duplicate in subse- quent studies; however, the overall average is 38% for subjective (clinical symptoms) presence of Frey’s Syn- drome and 86% when objective testing is performed with Minor’s Starch-Iodine Test. 2 Ten percent of patients re- port having distressing symptoms. Botulinum toxin A has been used in the treatment of Frey’s Syndrome with reported success 3,4 ; however, ther- apeutic modalities are rarely permanent in efficacy and those that are surgical in nature place the facial nerve at significant risk as a result of prior excision of the overlying superficial parotid lobe. Because of the limited efficacy of therapeutic modalities, preventive measures that protect against the future development of Frey’s Syndrome and add minimal risk and operative time are needed. A recent study by Dulguerov et al. reviewed the effi- cacy of synthetic and semisynthetic barriers in the pre- vention of Frey’s Syndrome. 2 It is thought that by the interposition of a barrier (i.e., dermal graft, synthetic ma- terials, adipose tissue), the severed postganglionic auto- nomic fibers of the parotid gland will be prevented from aberrant outgrowth to the overlying sweat glands. In ad- dition, the interposition techniques have the added benefit From the Departments of Otolaryngology (S.G., M.C., E.M.G., M.L.U.) and Otolaryngology (M.L.U.), Mount Sinai Medical Center, New York, NY; and the Center for Cranial Base Surgery, Department of Otolaryngology (P.D.C.), St. Luke’s-Roosevelt Hospital Center, New York, NY, U.S.A. Editor’s Note: This Manuscript was accepted for publication July 16, 2001. Send Correspondence to Satish Govindaraj, MD, Department of Oto- laryngology, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1189, New York, NY 10029, U.S.A. Laryngoscope 111: November 2001 Govindaraj et al.: Frey’s Syndrome 1993