Research Article
Strategies for Submandibular Gland Management in Rhytidectomy
Logan Bond1, Thomas J Lee2 and Thomas Gerald O’Daniel2*
1University of Louisville, USA
2Deprtment of Plastic Surgery, University of Louisville, USA
*Corresponding author: Thomas Gerald O'Daniel, Department of Plastic Surgery, University of Louisville, Louisville Kentucky, USA
Published: 28 Apr, 2017
Cite this article as: Bond L, Lee TJ, O’Daniel TG.
Strategies for Submandibular Gland
Management in Rhytidectomy. Clin
Surg. 2017; 2: 1446.
Abstract
Submandibular gland excision is a described, yet less commonly used technique in operative
neck rejuvenation, because of the misconception that this technique carries too high a risk for its
potential benefit. The following is a detailed description of the key anatomy regarding the glands
and surrounding structures, the senior surgeon’s technique, and an assessment of ten years of
outcomes and complications.
Keywords: Submandibular gland; Rhytidectomy; Neck rejuvenation
Introduction
Ellenbogen and Karlin [1] Described five criteria for a youthful appearing neck: a distinct
inferior mandibular, subhyoid depression, visible thyroid cartilage bulge, visible anterior border
of the sternocleidomastoid muscle distinct in its entire course from mastoid to sternum and a
cervicomental angle of between 105 and 120 degrees. Appropriate management of the submandibular
glands during neck lift can help achieve this ideal and lead to both better outcomes but also higher
patient satisfaction. Despite numerous descriptions of the improvement that can be expected from
management of the submandibular gland during neck rejuvenation surgery [2,3], there has not been
wide acceptance among surgeons due to the unfamiliarity of the anatomy, the complexity of the
procedure and the potential for significant complications [4].
Skin excision and platysma manipulation are the main stays in neck rejuvenation. However,
ptotic submandibular glands can mar an otherwise excellent result by creating contour deformities
in the superior neck. Other described methods to manage ptotic submandibular glands include
resuspension or plication of the glands up to the level of the mandible. Our approach involves
partial resection of the bulkiness in the underlying tissue deep to the platysma in order to better
control the contour of the submental area of the neck. A thorough understanding of the anatomy,
utilization of appropriate instrumentation and a systematic approach can allow one to safely and
predictably recontour the submandibular gland when necessary.
Anatomy
Careful attention and mastery of the anatomy of the neck is critical. The neck superior to the
hyoid is divided into the submental triangle medially and submandibular triangle laterally, with
the anterior belly of the digastric dividing the two. The submandibular triangle is bound by the two
bellies of the digastric muscle and the mandible. It is bound superficially by skin, superficial fascia,
platysma and investing fascia. Deep to the triangle are the mylohyoid, hypoglossus and middle
constrictor of the pharynx. The contents of the submandibular triangle are the submandibular
salivary gland, facial artery and hypoglossal nerve running deep to the gland and the facial vein and
submandibular lymph nodes which are superficial to the gland.
The anatomy pertinent to the submandibular glands consists of its capsule, vascular supply and
proximity of nearby nerves. The capsule is derived from the superficial layer of the deep cervical
fascia and creates a dense, tight closed space beneath the platysma. Bleeding can become contained
within the capsule and expansion will be along the path of least resistance in the direction of the
airway. The gland itself is divided into a deep lobe and a superficial lobe. The duct comes off the deep
lobe and leads into the mouth. The deep lobe lies deep to the mylohyoid and extends around the
mylohyoid muscle laterally. The superficial lobe begins after the gland turns inferomedially and runs
superficial to the mylohyoid muscle.
The vascular supply to the submandibular gland consists of
superficial, intermediate and deep supply. The superficial supply
consists of one to two vessels that enter the medial aspect of the
superficial lobe. The intermediate vessel enters the medial aspect
of the capsule to supply both the superficial and the deep lobe. The
deep perforator courses through the central aspect of the deep lobe to
pierce the posterior aspect of the superficial lobe. The facial vein often
runs between the deep and superficial lobes at the lateral extent of the
capsule, however its course may vary, where it can run superficially or
laterally to the superficial lobe of the submandibular gland.
Nerves surrounding the submandibular gland include the
marginal mandibular, lingual, hypoglossal and mylohyoid nerves.
The marginal mandibular nerve is often 3 cm to 4 cm superior to the
superficial lobe of the gland. The lingual, hypoglossal and mylohyoid
nerves are all posterior to the mylohyoid and are essentially protected
underneath the mandible border.
Figure 1
Figure 2
Figure 3
Technique
From 2006-2016, the senior surgeon performed 830 neck lift with
and without a facelift. Of these, 170 included submandibular resection
and reduction as a component of the neck lift. The percentage of
patients having the submandibular reduction increased over the
course of time, related to the comfort level with the procedure and
lower threshold for removal, from an early rate of less than 5% of
cases to a current rate of over 60.
Adequate visualization is critical in safe and adequate resection
of the submandibular glands. In our practice, the key instruments
include a short, narrow, reverse angle lighted retractor with a suction
adapter to evacuate smoke and electrocautery with an extended
needle tip for precise dissection. A bone hook is used for added
retraction by lifting the mandible superiorly. For hemostasis clips
are used for larger vessels. Surgicel (Ethicon) is closely available to be
utilized for raw surface bleeding, and Tisseel (Baxter) is commonly
used to seal capillaries and for prevention of sialocele on the raw
gland bed (Figure 1). A submental incision posterior to the mental
crease is utilized to access the middle neck. The central neck skin is
elevated with at least 5 mm of subcutaneous fat retained on the under
surface. The remaining supraplatysmal fat is then removed leaving
the superficial cervical fascia intact. The platysma is elevated along
its medial border identifying the anterior insertion of the anterior
digastric muscle with the dissection continued along the digastric
muscle. The medial extension of the subplatysmal fat is identified
above the digastric tendon. Resection of the subplatysmal fat can then
be performed when necessary prior to accessing the submandibular
triangle. The medial capsule overlying the submandibular gland is
found just lateral and anterior to the digastric tendon. The capsule is
opened with careful electrocautery dissection and the submandibular
gland is then identified and completely mobilized from the capsular
attachments of the superficial lobe (Figure 2). The superficial vessels
(Figure 3) and the intermediate vessels (Figure 4) to the superficial
gland are commonly encountered and are ligated with clips or
electrocautery (Figure 5). The dissection of the gland is started
medially to laterally, with cautery being used along the well-defined
septations found within the gland. Because of the significant friability
of the gland, care must be taken when handling it as it tends to bleed
when grasped with toothed forceps. In instances where bleeding
occurs and greater visualization is needed a percutaneous suture
is used to retract the gland further into the operative field. The gland
is often excised in a piecemeal fashion to always allow for optimal
visualization of the gland being resected. As the dissection proceeds
more laterally, the central perforator (Figure 6) from the deep gland
into the superficial gland is often encountered and must be controlled
with clips or cautery. The facial vein is often seen superiorly and
laterally to the superficial gland, and can be dissected free from the
gland without sacrificing it. The marginal mandibular nerve is far
from the dissection field and is not commonly visualized. The lingual,
hypoglossal, and mylohyoid nerves are posterior to the mylohyoid
and are essentially protected underneath the border formed by the
mandible and also not commonly visualized. Typically only the
superficial gland is excised, leaving the remaining gland flush with the
mylohyoid muscle. The remaining exposed gland is then cauterized as
needed for hemostasis. Injury to the gland vessels can be difficult to
control so preventative hemostasis is critical during this dissection.
After irrigation and adequate hemostasis, we spray an aerosolized
layer of Tisseel on the raw surfaces of the gland to minimize sialocele
formation. The platysma is then managed with platysmaplasty,
and the final contour of the submental neck smoothed with suture
plication of the superficial cervical fascia. Drains are placed bilaterally
in the subcutaneous space, and the incisions are closed in two layers.
Figure 4
Figure 5
Figure 6
Figure 7
Complications
In this review, mean follow up postoperatively was 6 months. There were no cases of hematoma or complaints of xerostomia. One sialocele (Figure 7) was encountered that required operative exploration and drainage. This was treated with percutaneous drain placement and intra glandular Botox injections. The drains were left for one week and removed without recurrence. Seven patients experience asymmetrical depressor function of the lower lip, that all resolved spontaneously. Three patients had persistent/recurrent bulging of the lateral neck that was attributed to inadequate resection and progressive glandular ptosis.
Figure 8
Figure 9
Figure 9
Left immediately postop, middle 10 year postop, right one year
postop necklift with sub-mandibular gland resection.
Discussion
Submandibular gland prominence can significantly contribute
to contour irregularity of the neck and has multiple etiologies.
Congenital or developmental size discrepancy can make normal
sized glands create a noticeable bulge if the surrounding structures
are relatively smaller. Congenital malposition caused by weak intra
capsular attachments hold the superficial lobe in a lower and more
medial position that increases their visibility. Acquired ptosis, more
common with the aging neck, is caused by a laxity of the neck fascial
layers that allow the gland to drop. This ptosis is often accompanied
by enlargement, hypertrophy, or chronic inflammation of the glands
can obviously distort neck contour, and the glands may harden and
fixate to the fascial planes. Primary neck lift patients can present
with detectable prominence of the glands that contribute to neck
fullness. Secondary patients are those that are dissatisfied with the
neck contour following a previous face/neck lift (Figure 8). In these
cases, submandibular gland enlargement was overlooked or not
fully appreciated preoperatively. Correction of the neck skin laxity
may also reveal the effect ptotic or hypertrophic glands on neck
contour. Postoperatively, they become evident as patients desire
additional surgery to correct these deformities [5]. Figure 9 is an
example of a patient following facial and neck rejuvenation surgery
immediately postoperatively on the left, ten years later in the middle
with prominent submandibular gland, and following secondary neck
surgery with submandibular gland resection.
There are two general approaches for the management of enlarged
submandibular glands: suspension and resection. Suspension is the
most common method used and is often considered the safest since
there is less trauma to the gland itself. However, in our experience
and as confirmed by other authors, time [6], gravity, and tension
has significant potential for recurrence. Resection of submandibular
glands allows for more direct control of neck contour with a definitive
and predictable for correction of prominence, but there is are
significant risks that have been described [1]: the potential disruption
of local neurovasculature, most notably the marginal mandibular
branch of the facial nerve [7]; postoperative hematoma or infection;
sialocele [2] or xerostomia [4,8-13].
The details of the resection technique and associated
complications presented in this series may alleviate some of the
uncertainty associated with submandibular gland resection. Sialocele
was the worst complication, needing further surgical intervention,
but it was not life threatening and resolved with simply incision and
drainage. Issues related to bleeding and therefore the most feared
complication, airway compromising hematoma [4] was not seen. In
contrast to the observations made by Feldman [2,6] in his series, we
felt that he impaired lower lip depressor function was related to direct
platysma muscle trauma from the plication of the superficial cervical
fascia, muscle retraction or from the accompanying fat injection
to the lower mandibular border rather than injury to the marginal
mandibular nerve.
Conclusion
Submandibular gland resection is a critical component for acceptable long term results in neck rejuvenation, and full understanding of the involved anatomy can lead to safe and predictable outcomes.
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