OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

SUBMANDIBULAR SALIVARY GLAND EXCISION Johan Fagan

The submandibular salivary gland (SMG) The digastric muscle forms the antero-
may be excised for chronic sialadenitis, inferior and posteroinferior boundaries of
sialectasis, sialolithiasis, benign and malig- the submandibular triangle (Figure 2). It is
nant tumours, and as part of a neck dissect- an important surgical landmark as there are
tion. The use of sialendoscopy is likely to no important structures lateral to the mus-
reduce the frequency of SMG excision for cle. The facial artery emerges from imme-
sialolithiasis. diately medial to the posterior belly, and
the XIIn runs immediately deep to the
The key concerns for the patient are the digastric tendon.
surgical scar, and injury to the marginal
mandibular, lingual and hypoglossal ner- The mylohyoid muscle is a flat muscle
ves. attached to the mylohyoid line on the inner
aspect of the mandible, the body of the
Surgical anatomy hyoid bone, and by a midline raphe to the
opposite muscle (Figures 1, 2, 4, 8). It is a
The SMG has both an oral and cervical key structure when excising the SMG, as it
component. It passes around the posterior forms the floor of the mouth, and separates
free margin of the mylohyoid muscle, the cervical from the oral part of the SMG.
which forms the “diaphragm” of the mouth Of importance to the surgeon is that there
and separates the cervical and oral com- are no important vascular or neurological
ponents of the gland. The SMG is situated structures superficial to the mylohyoid; the
mainly in the submandibular triangle lingual and XIIn are both deep to the
(Level 1b) of the neck. The oral com- muscle.
ponent extends some distance along the
submandibular duct immediately deep to
the mucosa of the floor of the mouth
(Figure 1). The duct opens close to the
midline in the anterior floor of mouth.
Posterior belly digastric

Lingual nerve Stylohyoid

Sublingual gland Anterior belly digastric

Submandibular duct Mylohyoid

Submandibular gland Hyoglossus

Mylohyoid muscle

Geniohyoid muscle Figure 2: Muscles encountered with SMG

excision

Figure 1: Superior, intraoral view of SMG, The marginal mandibular nerve is at risk
duct, lingual nerve and mylohyoid and of injury as it runs within the investing
geniohyoid muscles layers of deep cervical fascia overlying the
gland, and may loop up to 3cms below the
The cervical part of the gland is imme- ramus of the mandible. It comprises up to
diately deep to the platysma, and is encap- 4 parallel running branches. It crosses over
sulated by the investing layer of the deep the facial artery and vein before ascending
cervical fascia. to innervate the depressor anguli oris
muscle of the lower lip (Figure 3). In order
to minimise the risk of injury to the nerve,
one should incise skin and platysma at
least 3cms below the mandible, and incise
Lingual nerve
the fascial covering of the SMG just above
the hyoid and do a subcapsular resection of Submandibular ganglion

the SMG. Submandibular duct

Nerve to mylohyoid

Mylohyoid muscle

Submandibular gland

Figure 4: Note the submandibular

ganglion, nerve to mylohyoid and how the
lingual nerve swerves around the duct

The XIIn is covered by a thin layer of

fascia, distinct from the SMG capsule, and
is accompanied by thin walled ranine
veins that are easily torn at surgery (Figure
5).
Figure 3: The marginal mandibular nerve
(yellow arrow) is seen crossing the facial
artery (red arrow) and the ligated vein
(blue arrow)

The lingual nerve is a large, flat nerve, and

runs in the lateral floor of mouth above the
SMG, and sends secretomotor nerve fibres
to the submandibular ganglion which in-
nervate the SMG (Figures 1 & 4). It comes
into view during SMG excision when the
SMG is retracted inferiorly, and the mylo-
hyoid is retracted anteriorly. Figure 5: XIIn crossing the hyoglossus
muscle, accompanied by ranine veins
The hypoglossal nerve (XIIn) enters the
submandibular triangle posteroinferiorly The nerve to mylohyoid is a branch of V3
and medial to the hyoid bone, crosses the (Figures 4 & 6), and innervates the mylo-
submandibular triangle in an anterosupe- hyoid and anterior belly of digastric. It is
rior direction, and exits into the mouth generally not looked for or preserved at
behind the mylohyoid muscle. It traverses surgery. However when diathermy is used
the medial wall of the submandibular train- to mobilise the SMG off the mylohyoid
gle, where it is applied to the hyoglossus muscle, contraction of the mylohyoid and
muscle (Figure 5). anterior belly of digastric is usually noted
due to stimulation of this nerve.

2
 Submental artery

Mylohyoid muscle

Myohyoid artery

Facial artery

Figure 8: The facial artery emerges from

behind the posterior belly of digastric
Figure 6: Diathermy tip points to the nerve (removed), and gives rise to a few
to mylohyoid crossing the mylohyoid mus- branches including the submental artery
cle
The submental artery island flap is based
The common facial, (anterior) facial and on the submental branch of the facial
ranine veins are encountered during SMG artery which courses along the inferior,
excision (Figures 5 & 7). inner margin of the mandible (Figures 8).

The mylohyoid artery and vein are encoun-

Anterior facial vein
tered when the surgeon elevates the SMG
Anterior branch of from the lateral surface of the mylohyoid
retromandibular vein (Figures 8 & 9). It branches from the
Common facial vein inferior alveolar artery just before it enters
Lingual vein
the mandibular foramen, crosses the mylo-
hyoid, and disappears anteriorly behind the
Internal jugular vein
digastric. It has connections with the
External jugular vein
submental artery and via a defect in the
mylohyoid, with the sublingual artery in
Figure 7: Veins of head and neck
the floor of the mouth.
The facial artery is identified during
excision of the SMG. It enters the subman-
dibular triangle posteroinferiorly from be-
hind the posterior belly of digastric and
hyoid, courses across the posteromedial
surface of the SMG, and reappears at the
superior aspect of the SMG where it joins
the facial vein to cross the mandible
(Figures 3 & 8). A few anterior branches
enter the SMG and have to be divided if
the surgeon elects to preserve the artery
during resection of the SMG e.g. when a
buccinator myomucosal flap is planned Figure 9: Mylohyoid artery
(Figures 8 & 9).

3
Operative steps

Anaesthesia

The anaesthetist should avoid muscle para-

lysis as it is useful to monitor the move-
ment of the lower lip should the marginal
mandibular nerve be surgically irritated.
EJV

Positioning and draping

The patient is placed in a supine position

with neck extended and the head rotated to
the opposite side. The skin of the anterior Figure 9: Incision through skin, fat and
neck and lower face is sterilised. Draping platysma to expose facial vein crossing
is done in such a way that the lower lip, over SMG and external jugular vein (EJV)
lower margin of the mandible, and upper
neck are exposed. The facial vein is ligated and divided
where it crosses the SMG (Figure 10).
Incision of skin and platysma

A horizontal incision is placed in a skin

crease at least 3cms below the mandible or
at the level of the hyoid bone, extending
anteriorly from the anterior border of the
sternocleidomastoid muscle (Figure 8).

Figure 10: Division and ligation of facial

vein inferiorly

The fascial capsule of the SMG is incised

with cautery or a knife parallel to and just
above the hyoid bone to expose the SMG.
By applying inferiorly directed traction to
Figure 8: Placement of incision the SMG, a subcapsular dissection with
exposure of the SMG is done with cautery
The incision is carried through skin, subcu- (Figure 11). Contraction of the angle of the
taneous tissue and platysma to expose the mouth alerts the surgeon to the proximity
capsule of the SMG, the facial vein and of the marginal mandibular nerve.
posteriorly, the external jugular vein
(Figure 9).

4
 so as to avoid injury to marginal mandibu-
lar nerve.

The surgeon next frees the anterior margin

of the SMG from the anterior belly of
digastric with electrocautery dissection,
and proceeds in a posterior direction, ele-
vating the SMG from the lateral surface of
the mylohyoid muscle. The only structures
of note that one encounters during this part
of the dissection are the mylohyoid nerve
Figure 11: Subcapsular dissection of SMG and vessels (Figure 13). By dividing these
to avoid injury to marginal mandibular vessels with electrocautery, one gains free
nerve access to the posterior part of the mylo-
hyoid muscle (Figures 13 & 14).
Once the superior margin of the SMG has
been reached, then the surgeon dissects
bluntly with a haemostat in the fatty tissue
above the gland to identify the facial artery
and vein keeping immediately above the
SMG so as to avoid injury to the marginal
mandibular nerve (Figure 12). Although
not essential to do so, the marginal
mandibular nerve may be exposed where it
crosses the facial artery and vein by careful
blunt dissection (Figures 3 & 12). Avoid
using monopolar cautery in the proximity
of the nerve.
Figure 13: Front-to-back mobilisation of
Facial vein Marginal SMG off mylohyoid muscle, and division of
mandibular
nerve mylohyoid nerve and vessels

The surgeon next skeletonises the posterior

free margin of the mylohyoid with diather-
my or scissors, with the knowledge that the
Facial
artery XIIn, ranine veins and lingual nerve are all
immediately deep to the muscle, and are
exposed and vulnerable to injury imme-
diately posterior to the muscle (Figure 14).

By retracting the mylohyoid anteriorly and

by using careful finger dissection, the
lingual nerve, submandibular ganglion, and
Figure 12: Facial artery and facial vein submandibular duct come into view
and marginal mandibular nerve (Figure 15).

The surgeon then division and ligates the

facial artery and facial vein close to SMG

5
 Marg mand n

Mylohyoid
Lingual n

SM duct

Facial a

Ant belly of
digastric SM ganglion

Figure 14: Exposing posterior part of

mylohyoid Figure 16: Finger dissection in plane
between SMG and fascia covering XIIn
and ranine veins
Mylohyoid

Once the XIIn nerve has been identified,

one may safely clamp, divide and ligate the
submandibular duct and the lingual nerve,
taking care not to place the tie across the
Lingual n main nerve (Figure 17). With surgery for
sialolithiasis one should follow and divide
SM Duct the duct more anteriorly in the floor of the
mouth so as not to leave behind a calculus.
XIIn

Marg mand n

Figure 15: Retracting mylohyoid brings

lingual nerve, XIIn and submandibular
duct into view

An index finger is passed in the well-

defined interfascial plane that exists be-
tween the SMG and submandibular gang- SM duct (Cut)
lion laterally, and the fascia covering the
XIIn and ranine veins medially (Figure
16). The finger exits posteriorly cephalad
to the facial artery where it emerges from
Figure 17: Division and ligation of sub-
behind the posterior belly of the digastric
mandibular duct and submandibular gang-
muscle.
lion

The SMG can then be reflected inferiorly,

and the facial artery is identified, ligated
and divided where if exits from behind the
posterior belly of digastric (Figure 18).

6
 Alternative technique: Preservation of
facial artery

The facial artery has to be preserved for

pedicled flaps based on the artery i.e. the
buccinator and submental flaps, the latter
which is based on the submental branch of
the facial artery (Figure 8). Preserving the
artery is quite simple, and involves divi-
ding the 1-4 anterior branches of the artery
(Figure 20).

Marg mand n

Figure 18: Ligation and division of facial

artery Facial vein

The SMG is then finally freed from the Facial artery

tendon and posterior belly of the digastric

Ant branch
and removed. The final view of the resec- facial artery
tion demonstrates the XIIn, ranine veins,
lingual nerve, and transected duct all on Post belly of
digastric
the lateral aspect of the hyoglossus muscle,
and the facial artery (Figure 19). Figure 20: Preserving the facial artery by
dividing anterior branches
SM duct

Author & Editor

Lingual n

Johan Fagan MBChB, FCORL, MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Ranine vs
Cape Town, South Africa
Facial a
johannes.fagan@uct.ac.za

XIIn
THE OPEN ACCESS ATLAS OF
Figure 19: Final view of XIIn, ranine veins OTOLARYNGOLOGY, HEAD &
and lingual nerve NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
The wound is irrigated with water, and
closed in layers with vicryl to platysma
and subcuticular suture to skin. A suction
drain is left in situ. The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
johannes.fagan@uct.ac.za is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
License

7
8