Farzad R Nahai, Foad Nahai
As our skills at facial rejuvenation have advanced, so has our attention to the submental area in our aesthetic 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 in the aged neck, previously undetected ptotic or enlarged submandibular glands can appear as a prominent 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.
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 detracts from the aesthetic result and demonstrates poor neck contours
Singer and Sullivan  published an excellent anatomical description of the submandibular gland, its blood supply and location relative to critical structures 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,
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 resection of the submandibular glands. Typically the submandibular glands are encountered when the decision has been made to perform a platysmaplasty through a submental approach. At the time of mobilizing the platymsa muscles on either side by dissecting 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 between the mylohyoid muscle and the mandibular periostem. Suspension will be successful if the gland can be repositioned above the level of the lower mandibular border without undue tension. The suspension 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 consider resecting the superficial lobe. Paramount to a safe and controlled resection is an intracapsular approach to the superficial lobe. The superficial fascia is incised and peeled back to expose the gland. Using gentle blunt dissection techniques in addition to bipolar cautery forceps, you can excise the superficial lobe of the submandibular gland safely provided you do this in a controlled manner. Remember that two 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 envelope 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 behind the mandible is much more difficult to control. After the superficial lobe has been removed, ensure excellent hemostasis, then close the capsule. If suspension 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.
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 commonly practiced alternative of liposuction and or direct lipectomy in the neck, which we employ, is effective 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 Table 55.1.
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