Posterior platysmal elevation

Anterior platysmal plication

Fig. 24.24 Posterior platysmal and superficial musculoaponeurotic system (SMAS) plication during facelift surgery may have some restrictions when anterior platysmal plication is also performed. While this “hammock” effect may be beneficial overall, elevation particularly in the jowl region may be hampered from the opposing vector effect. Note posterior platysmal elevation

24.11Dealing with the Visible Submandibular Gland

A visible submandibular bulge after submentoplasty, neck liposuction, or facelift can detract from what would have been an outstanding surgical outcome. One can hopefully anticipate this problem during the preoperative workup. Unfortunately, it is often missed or neglected and not noticed until a few months postoperatively when the patient asks what is this bulge?

b

Numerous techniques have been described to deal with this situation including Gore-Tex slings used by Conrad et al. [30], Gore-Tex sutures by Ramirez [31], and suspension sutures by Giampapa et al. [32]. More recently, Guyuron and Jackowe [33] described a basket suspension technique for ptotic submandibular glands. The authors have tried many of these techniques including the use of an Alloderm® neck sling and found them not to be durable in our hands. The preferred approach for treating the bulging or ptotic submandibular gland is partial resection of the superficial lobe.

When a submandibular bulge is identified on the preoperative physical exam, one must remember that there are many reasons for a submandibular bulge besides ptosis and benign involutional enlargement. Rarely, bilateral submandibular bulges are due to sialosis (also known as sialadenosis). This is a rare cause of benign, non-neoplastic enlargement of the submandibular glands. It more commonly affects the parotid gland and is most often seen in patients with alcoholic cirrhosis. Also patients with various endocrine disorders such as diabetes and hypothyroidism can develop sialadenosis. One should also remember that a bulge in the submandibular region may represent a malignant process. Although ptotic submandibular glands are often asymmetric, various clues in the patient’s history and physical exam should prompt one to proceed with a workup prior to submentoplasty and resection. The typical benign submandibular gland is somewhat moveable, smooth, and firm to touch. A history of rapid change in size or swelling, the presence of pain and changes noted with eating may be helpful. When one is suspicious as to the etiology of the bulge, a fine needle aspiration biopsy may be helpful. The etiology

of submandibular lymphadenopathy can also be determined with this technique.

Partial submandibular gland resection is performed through a submental incision after the submentoplasty skin flap has been elevated with facelift scissors. The platysma is elevated laterally beginning at the midline. Excellent visualization with a lighted retractor and a dry operative field are essential. Once an appropriate amount of subplatysmal fat has been removed, the gland is located just lateral to the lateral edge of the anterior digastric muscle. True submandibular gland excess will be obvious at this time and allows for easy location. The submandibular gland should be left alone if no obvious fullness is noted. The gland is covered with a thin layer of cervical fascia and an extended Colorado tip electrocautery is used to incise the fascia. Once the fascia is incised, the pink tissue of the gland is seen. The anatomy of the bilobed submandibular gland as seen through a submental incision is that the superficial lobe wraps around the posterior border of the mylohyoid muscle (Fig. 24.25). During resection, the deep lobe is not seen and only subtotal excision of the superficial lobe is carried out (Fig. 24.26). Typically, the submandibular gland produces only 20% of the saliva in the oral cavity but leaving much of the gland above the mylohyoid helps limit saliva production losses. Long forceps are used to grasp the gland as it is slowly

Fig. 24.25 Mylohyoid and superficial lobe of submandibular gland

a

Fig. 24.26 (a) Partial resection of the superficial lobe of the submandibular gland after elevating the platysma laterally. The gland must be approached from the inferior and medial edge to avoid damage to unwanted nerves and vessels. (b) Excised superficial lobe submandibular gland

teased and dissected from its pocket. Resection takes place at the level of the cervical fascia and not within the capsule to protect the surrounding nerves. They include the more superficial marginal mandibular nerve and the deeper hypoglossal and lingual nerves. In a cadaver study by Singer, all nerves were found to be external to the submandibular gland capsule with the exception of the autonomic plexus. The hypoglossal nerve is found posterior to the tendinous junction of the anterior and posterior digastric muscle deep within the visceral layer of the neck. The lingual nerve is located cephalad and medial to the deep lobe. The marginal mandibular nerve is identified approximately 3.7 cm (range 3–4.2 cm) cephalad to the inferior limit of the submandibular gland [34, 35]. The cautery is used to slowly excise the bulging anterior portion of the gland. As one proceeds with resection, the surgeon must remember that the posterolateral portion of the superficial lobe has perforating branches of the submental artery and vein (which arise from the facial artery) that may cause troublesome bleeding. Once the gland is resected, the overlying fascia is closed with a 2–0 Vicryl suture. This may prevent recurrent ptosis and decrease the chance for postoperative hematoma and sialocele. Clearly, one should have expert knowledge of the anatomy and be very comfortable working through a 3 cm incision (Fig. 24.27). Submandibular gland resection is not for the novice submentoplasty surgeon. The potential problems are as follows: