Chapter 55
55
in the aged neck, previously undetected ptotic or en- larged submandibular glands can appear as a promi- nent bulge and can be more noticeable, to both the patient and the physician (Figs. 55.1, 55.2).
Partial resection of the submandibular glands is an effective means of improving contours and aesthetic outcomes in neck lifts (Fig. 55.3). Knowledge of neck anatomy and sound surgical technique are critical when considering partial resection of the subman- dibular glands.
55.1 Introduction
As our skills at facial rejuvenation have advanced, so has our attention to the submental area in our aes- thetic assessment and surgical approach [1, 3]. Despite thorough preparation and the best surgical efforts, the rejuvenating results of a neck lift and platysma- plasty can be marred by ptotic or enlarged subman- dibular glands. Unnoticed preoperatively, following the effects of skin/muscle tightening and fat resection
Partial Resection of the Submandibular Gland
Farzad R Nahai, Foad Nahai
Fig. 55.1. Preoperative lateral view demonstrating an oblique cervicomental angle, fatty neck, redundant and hanging skin, platysmal bands, and a witch’s chin
Fig. 55.2. Postoperative lateral view after face and neck lift including submental access for platysmaplasty. The subman- dibular glands were not addressed. Note their prominence after defatting and tightening of the neck. Their presence de- tracts from the aesthetic result and demonstrates poor neck contours
411 55 Partial Resection of the Submandibular Gland
55.2 Anatomy
Singer and Sullivan [4] published an excellent ana- tomical description of the submandibular gland, its blood supply and location relative to critical struc- tures in the neck. The submandibular gland is a bi- lobed structure located within the digastric triangle of the neck deep to the platysma muscle. It rests on the caudal surface of the mylohyoid muscle, behind the mandible (although it descends beyond its inferior border with age), with its lower border nestled against the tendinous portion of the digastric muscles. The smaller deep lobe rests behind the mylohyoid muscle.
The gland is enveloped by its own fascial covering and is one of the multiple glandular structures within the head and neck which produce saliva.
The submandibular gland derives its blood supply from branches of both the superior thyroid and the facial arteries. Two branches enter it medially and a separate deep perforating branch enters from its deep border. While the function of the gland is dictated by its autonomic input, four critical nerves, the lingual, hypoglossal, marginal mandibular, and cervical, course close to it. The hypoglossal nerve is located posterior to the tendinous junction of the digastric deeper within the neck. The lingual nerve is also deep, protected by the medial border of the mandible,
and rests cephalad and medial to the deep lobe. The marginal mandibular nerve is located approximately 3–4 cm cephalad to the inferior border of the sub- mandibular gland and travels deep to the platysma, temporarily dipping below the level of the inferior border of the mandible as it courses medially towards the mentum. The cervical branch also runs deep to the platysma and is caudal to the marginal mandibu- lar nerve. From a submental approach to the subman- dibular glands, the terminal branches of the cervical nerve are not seen.
55.3
Surgical Decision Making and Technique
A preoperative examination of the nonfatty neck can identify enlarged or ptotic submandibular glands.
These can then be marked before surgery. Clear knowledge of the anatomy and adequate comfort level operating in this area is a prerequisite for partial re- section of the submandibular glands. Typically the submandibular glands are encountered when the de- cision has been made to perform a platysmaplasty through a submental approach. At the time of mobi- lizing the platymsa muscles on either side by dissect- ing and freeing up its undersurface to facilitate mid- line plication, the submandibular glands may be noted as being ptotic or enlarged. If you see that the glands, if left alone, will create an unwanted bulge in the neck, you have three choices: (1) accept the bulge, (2) suspend the glands, or (3) partially resect them. If the glands are minimally ptotic or enlarged, you have the option of resuspending them using sutures be- tween the mylohyoid muscle and the mandibular periostem. Suspension will be successful if the gland can be repositioned above the level of the lower man- dibular border without undue tension. The suspen- sion technique forgoes any further dissection deep to the platysma and minimizes the risks of bleeding and local structure injury.
Suspension sutures under undue tension will tear and can be relied upon for only a certain amount of upward repositioning of the glands; therefore, if the glands are significantly enlarged or ptotic, suspension sutures alone will not be adequate and you must con- sider resecting the superficial lobe. Paramount to a safe and controlled resection is an intracapsular ap- proach to the superficial lobe. The superficial fascia is incised and peeled back to expose the gland. Using gentle blunt dissection techniques in addition to bi- polar cautery forceps, you can excise the superficial lobe of the submandibular gland safely provided you do this in a controlled manner. Remember that two
Fig. 55.3. Same patient as in Figs. 55.1 and 55.2 after partial resection of the submandibular glands through a submental incision. Note the improvement in neck contour and enhance- ment of the aesthetic result
412
References
1. Ramirez OM, Robertson KM. Comprehensive approach to rejuvenation of the neck. Facial Plast Surg. 2001 17:129–
2. Connell BF, Shamoun JM. The significance of digastric 140.
muscle contouring for rejuvenation of the submental area of the face. Plast Reconstr Surg. 1997 99:1586–1590.
3. Martin, TJ. Submandibular Gland Resection and Rejuvena- tion of the Aging Neck. Presented at the ASAPS Meeting, 2001.
4. Singer DP, Sullivan PK. Submandibular gland I: an ana- tomic evaluation and surgical approach to submandibular gland resection for facial rejuvination. Plast Reconstr Surg.
2003 112:1150.
5. Nahai, Farzad R. Presentation of “Are Subplatysmal Pro- cedures in Facial Rejuvenation Safe and Warranted? A Re- view of 100 Cases.” Presented at the American Society for Aesthetic Plastic Surgery Meeting, Orlando, Florida, April 2006.
6. Author is Codner, Mark A., Nahai, Foad. Discussion of Submandibular Gland One and Anatomic Evaluation and Surgical Approach to Submandibular Gland Resection for Facial Rejuvenation. Plastic and Reconstructive Surgery, September 15, 2003, pp. 1155–1156.
vessels usually enter its medial surface. It is best to identify these early and cauterize them. Vascular clips can also be helpful here. Staying within the fascial en- velope of the gland minimizes the chance of damage to local structures. It is unwise to dissect above the level of the lower mandibular border as bleeding be- hind the mandible is much more difficult to control.
After the superficial lobe has been removed, ensure excellent hemostasis, then close the capsule. If sus- pension sutures are still needed, they are applied at this time. Bleeding in this area can be copious and difficult to control so it is imperative to dissect in a controlled and judicious manner. Drains are left deep to the platysma whenever a partial submandibular glad resection is performed.
55.4
Thoughts on Our Experience
The question arises as to whether complex procedures in the subplatysmal plane are worth the risk and whether or not there is added morbidity. The com- monly practiced alternative of liposuction and or di- rect lipectomy in the neck, which we employ, is effec- tive in contouring the neck; however, it is not without its own problems. Liposuction can cause streaking, skeletonization, skin adherence to the platysma, and unmask deeper problems, all of which can be difficult to remedy. Indeed resection of the submandibular gland can be risky with the potential for bleeding, nerve injury, dry mouth, and dental problems. In our hands, partial resection of the submandibular gland has been a safe and effective adjunct to contouring the neck [5, 6]. Knowledge of the neck anatomy, an intra- capsular approach, and judicious surgical technique are imperative and have made this a technique that we both advocate and employ when indicated.
The key points for the operation are listed in Ta- ble 55.1.
Table 55.1. Key points
– Having in-depth anatomical knowledge of the neck when embarking on any procedure that includes neck structures is imperative – Be aware that in the fatty neck a ptotic or enlarged
gland may not be evident during a preoperative evaluation and could potentially mar an otherwise good aesthetic result
– Consider suspending the submandibular gland if possible before resecting it
– Perform an intracapsular dissection/resection of the submandibular gland to avoid injury to surrounding critical structures
– Ligate the medial vessels early during the intracapsular dissection
