Surgical Excision Of Sublingual Gland
Surgical Excision Of Submandibular Gland
An extraoral submandibular incision is used. The incision should follow the course of
the diagastric muscle. To determine the course of the diagastric an imaginary curved line is drawn to connect the mastoid process, the lateral surface of the hyoid bone and the genial tubercle. A 5 cm long incision is made along the middle segment of this
curved line. The incision well be directly over the inferior pole of the gland. The incision is made through the skin, superficial fascia and platysma muscle. (Fig. 7-6)
• Skin and superficial fascia
are reflected inferiorly exposing the anterior facial vein crossing the submandibular gland. The vein is isolated, ligated and cut between the ligations.
• The upper flap is raised close to the surface of the gland using scissors.
The plane of dissection should pass deep to the remnants of the anterior facial vein to ensure that all branches of the facial nerve will be raised with the flap. The cervical branch of the facial nerve is usually encountered at this level and can usually
can be retracted. However, cutting this branch presents no serious loss of function as it supplies, only partially the platysma muscle.
• By blunt disection the gland is freed anteriorly and inferiorly. The gland is then retracted
upward and backward. The posterior belly of diagastric and the stylohyoid muscle anterior to it are identified. The muscles are retracted downward to expose the facial artery as it lies between the gland and the muscles. The facial artery is clamped and ligated.
• The upper flap, with the anterior facial vein, is retracted and the interval between the gland and the inferior border of the mandible is defined. At the sametime, the gland is reflected up and backward exposing the posterior border
of the mylohyoid muscle. Using finger dissection the gland is further freed. Care should be taken to protect the hypoglossal nerve which lies medial to the gland as it crosses over the underlying hupoglossus muscle.
• The gland is
then retracted downword and detached from its attachments with the submandibular ganglion. The lingual nerve can be idenbtified at this point and avoided.
• The mylohyoid muscle is retracted anteriorly and the submandibular duct
retracted posteriorly. The duct is ligated by two sutures anterior to the ductal pathosis, if exist, and cut between the ligations. This is to prevent the sepage of infected material into the wound from either the residual duct or the gland. The gland
is then removed.
The resulted dead space must be closed or drained. Drainage is indicated whenever there is doupt that the field is infected. Wound clousre is performed as follows:
• The fascia
of the diagastric, mylohyoid, hyoglossus and stylohyoid muscles are approximated and sutured using absorbable catgut.
• The subcutaneous tissues are sutered using resorbaple catgut.
• Skin is sutured
using 4-0 black silk and the sutures are removed 5-7 days postoperatively.
• The wound should alawys be covered with heavy pressure dressing. This will help to eleminate any dead space
and help drainage.
• The draine should emerge from the most dependent point, which is usually the posterior aspect of the wound. The draine is removed 24-48 hours postoperatively, if no wound suppuration is present.
Five days postoperatively the dressing may be discontinoued and half the sutures are removed. Adhesive tabe should pridge the incision line.
• The remmining sutures are removed 7 days postoperatively but the wound should continue
to have adhesive tabe bridging support for at least two weeks.
Surgical Excision Of Parotid Gland
Because of the possibility of permenant damage to the facial nerve and its branches removal of the parotid gland is only performed
when stronge indications are present and after faliure of all conservative methods of treatment. The presence of tumors or suspected malignancy are the primary reasons for removal of the parotid gland. (Fig. 7-7)
for removal of the parotid gland runs from the superior attachment of the auricle downwards, turns anteriorly at the angle of the mandible to the submandibular region to stop at the hyoid bone. A second incision is made posterior to the pinna and join the
first one anterior to it. By blunt dissection the ear is retracted from the field and a skin flap is developed over the cheek side of the incision. (Fig. 7-8)
Localization of the facial nerve
The facial nerve can be located by
one of the two following ways:
• Locate the peripheral portion of the branches of the facial nerve as they emege from the anterior border of the gland and dissect backwards.
• Locate the main trunk
of the facial nerve by dissecting between the posterior border of the gland and the stylomastoid foramen and dissected anteriorly. A nerve stimulator is very helpful during localization of the facial nerve and its branches.
and wound closure
• The superficial lobe (Suprafacial part) of the gland is then dissected out and removed. The duct is ligated and cut in the same way as the submandibular duct.
• Disection of the
deep lobe is facilitatated by posterior and superior retraction of the ear. Care should be taken to protect the external carotid artery and the retromandibular vein which pass through the gland..
• The wound is then closed in layers
and a draine is inserted to be removed ater 48 hours.