Parotid gland surgery is related to various complications, some due to the pathology characteristics and some due to iatrogenic damages. Prevention is possible thanks to technology innovations, such the use of NIM, and the filling of surgical gap using ADMs or local flaps. In our study patients were divided in Group A (patients which surgery technique included the use of SurgiMend ®) and Group B (patients which surgery technique didn’t include the use of SurgiMend ®).

In group A 2 cases (10%) of hematoma, 1 case (5%) of seroma, 1 case (5%) of Frey Syndrome, 1 case (5%) of contour deformity and 2 cases (10%) of hypertrophic scar occurred. In group B 3 cases (15%) oh hematoma occurred, 4 cases (20%) of contour deformity, 2 cases (10%) of seroma, 3 cases (15%) of Frey Syndrome, 1 case (5%) of wound infection, 2 cases (10%) of salivary fistula, 8 cases (40%) of hypertrophic scar and 2 (10%) keloids.

No cases of immune rejection and abscess were highlighted in both groups.

Salivary fistula after total parotidectomy can be explained with the presence of a gland residue. Frey Syndrome in group A can be explained by displacement or unproper positioning of SurgiMend ®. We attributed the possible displacement during the first cases treated since we did not use to stitch the SurgiMend ® to surrounding tissues.

Frey Syndrome was treated during follow up by the injection of botulinum toxin.

Hematoma cases resolved in 7 days. Corticosteroids therapy was performed in these patients to reduce inflammation.

Patients who had facial contour deformities were proposed to lipofilling treatment, but no one of them accepted the treatment.

Hypertrophic scars and keloids were treated with corticosteroid infiltrations.

Wound infection was treated with antibiotic therapy. Seromas and salivary fistulas required a frequent follow up and pressuring dressings.

The study results revealed a significant difference of VSS in the two groups, representation as vascularity and pigmentation improvement, changing scar color, scar height reduction, and increased pliability. In particular we performed ANOVA test (Significatively level: p = 0.05) between group A and B wit p < 0.05 and data show a statistically significative difference among the two groups, thus validating the hypothesis that the results obtained using SurgiMend ® are better if compared to the classic procedure.

Frey's syndrome and infra-auricular depressed deformities are most common complications that can occur after total parotidectomy. For the prevention of above-mentioned two complications, a number of scholars have proposed different techniques. Sternocleidomastoid muscle flap, the superficial musculoaponeurotic system flap, temporoparietal fascia flap, the free or vascularized dermal fat graft [7,8,9,10,11,12,13,14,15].

Cesteleyn L et al. in their study they demonstrated that incidence of Frey’s syndrome was reduced from 33 to 4% with the use of the musculoaponeurotic layer [15].

Free fat graft as an effective reconstructive technique to prevent FS was already pointed out by other authors [11,12,13].

Balasundaram I et al. used a free fat paraumbilical graft to reconstruct the parotid bed defect. This graft is harvested through a supra/sub-umbilical or suprapubic incision. Over-correction of approximately 50% is required due to atrophy and resorption with time. However, the incidence of Frey syndrome also appeared to be reduced and reliable method of correcting facial defects after a superficial or total parotidectomy [11].

Each of these methods described seems to present some problems.

For cases treated as autologous tissue transfer, a donor site, consequent scars, double surgical access and consequent lengthening of surgical times was required.

Noteworthy is the fact that fat transplantation will be subjected to a certain degree of reabsorption and therefore the long-term postoperative results are doubtful.

To overcome the limits of these techniques, in recent times, it has been proposed its ADM devices to prevent the most common complications of parotidectomy [16].

As regards non-autologous implant there are many non-crosslinked meshes available on the market, which are derived from numerous sources (human, porcine, bovine, etc.) and tissue (dermis, intestine or bladder submucosa, pericardium, etc.) are decellularized by distinct proprietary methods, and are sterilized by one of several techniques (gamma irradiation, electron, beam irradiation, ethylene oxide, etc.) [16,17,18,19].

They are xenogeneic ADMs, inert, non-crosslinked matrices reinforce soft tissue and are a framework for cellular repopulation and neovascularization, and will support fibroblast infiltration, neovascularization [16,17,18,19].

Non-autologous implants have several advantages: an unlimited and readily available supply, ease of positioning and contouring, shorter operative times, and no donor-site morbidity. Their disadvantages are lower patient acceptability due to greater risks of infection, rejection, and/or extrusion [16,17,18,19].

Selecting the optimum matrix remains difficult, including Strattice TM (Lifecell, Branchburg, NJ, US) and SurgiMend ® TM (TEI Biosciences; Boston, MA, US) [16,17,18,19].

Adelman et al. in their study compared the mechanical properties of the both ADMs, Settice and SurgiMend ®, using a series of in vitro preimplantation tests. They found SurgiMend ® had increased mechanical strength compared with Strattice of equal thickness [20].

Therefore, we decided to introduce in our clinical practice the use of SurgiMend ® [20].

SurgiMend ® is an acellular dermal matrix of type I and II collagen that over the years has provided excellent results in applications such as breast surgery, burns treatment, hernia repair, muscle flap reinforcement, plastic and reconstructive surgery [20,21,22].

SurgiMend ® helps to prevent facial contour deformities caused by the surgical gap filling the empty space and reduce the possibility to develop seroma. Furthermore, it acts like a mechanical barrier avoiding unconventional nerve junctions, known to be the cause of Frey Syndrome.

From our study, it has emerged that the use of SurgiMend ® reduces the incidence of typical complications of parotidectomy, according to the results of the most recent literature [16].

Moreover, it improves the facial profile, reduces the infra-auricular depressed deformities and therefore the esthetic results are more satisfactory, this was objectified by a reduction in the VSS score.

VSS was first introduced in 1990 and it has been widely described in the literature. In this study, VSS was used to assess vascularity, pigmentation, thickness and pliability of hypertrophic post burn scar formation pre and post treatment to detect the difference between both groups. A limitation of our study is due to the fact that a scar scaling is used as a subjective tool, other methods described in the literature have varying degrees of reliability and validity and most of them are expensive, time-consuming, highly technological and often non-portable, making them clinically impractical. VSS is the first validated scar assessment scale and remains the most widely used scale in the clinical setting. Furthermore, a previous study found that VSS is a suitable substitute for Cutometer, Mexameter and DermaScan C, in terms of discrimination of the characteristics of the scar [23,24,25].

Extracellular matrix bio-scaffolds are an innovative solution to aid surgeons, improving cosmetics outcomes and reducing the rate of complication.

It has proved to be free of side effects, which makes this method indicated.

What emerged from our study is that in the group of patients with the SurgiMend ® we found a lower score for each parameter, which corresponds to a greater degree of satisfaction of the wounds, better perceived appearance and a better consciousness of these. Results were confirmed by the ANOVA test; indeed a statistically significant difference between group A and B emerged from the test, using a pvalue < 0.05.