International Journal of Surgery 7 (2009) 503–509

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.theijs.com

Review

Surgical approaches to the submandibular gland: A review of literatureq

David D. Beahm a, Laura Peleaz a, Daniel W. Nuss a, b, c, Barry Schaitkin b, Jayc C. Sedlmayr c,
Carlos Mario Rivera-Serrano b, Adam M. Zanation d, Rohan R. Walvekar a, *
a
Department of Otolaryngology Head and Neck Surgery, LSU Health Science Center, 533 Bolivar Street, Suite 566 New Orleans, LA 70112, United States
b
Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh, Pittsburgh, PA, United States
c
Department of Cell Biology and Anatomy, LSU Health Sciences Center, New Orleans, LA, United States
d
Department of Otolaryngology Head Neck Surgery, UNC School of Medicine, Chapel Hill, NC

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Surgical excision of the submandibular gland (SMG) is commonly indicated in patients with
Received 4 July 2009 neoplasms, and non-neoplastic conditions such as chronic sialadenitis, sialolithiasis, ranula and drooling.
Received in revised form Traditional SMG surgery involves a direct transcervical approach. In the recent past, alternative approaches to
4 September 2009
SMG excision have been described in effort to offer minimally invasive options or better cosmetic results. The
Accepted 12 September 2009
Available online 24 September 2009
purpose of this article is to describe the surgical approaches to the SMG and present relevant surgical anatomy
via cadaveric dissection and a systematic review of literature to compare and contrast each technique.
Study design: Cadaveric dissection with fresh human cadaver heads followed by a review of the literature.
Keywords:
Submandibular gland Methods: Cadaver heads were dissected via both the transcervical and transoral approaches to the
Cadaveric dissection submandibular gland with the use of endoscopic assistance when indicated. Key landmarks and
Surgical approaches anatomic relationships were recorded via photo documentation. A review of the literature was con-
Salivary glands ducted using a Medline search for approaches to SMG excision, including indications, results and
complications.
Results: While the traditional SMG excision remains a direct transcervical approach, many other methods
of excision are described that include open, endoscopic, and robot assisted resections. The approaches
vary from being transcervical, submental, transoral or retroauricular.
Conclusions: Alternative approaches to the SMG are feasible but should be tailored to the individual
patient based on factors such as pathology, patient preferences, availability of technology, and the
experience and skill of the surgeon.
Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Surgical incisions to access to head neck lesions have rapidly
evolved from traditional incisions along natural skin creases or
aesthetic units to more cosmetically acceptable incisions in the local
region or from remote locations that permit comprehensive surgery.
These access incisions are often smaller and complemented by
endoscopy, robotic instrumentation, and laparoscopic techniques
that allow the surgeon to achieve and maintain an excellent oper-
ative exposure and view. The impetus to move to more minimally
invasive techniques has been that these procedures are associated
with better cosmesis, less scarring, diminished blood loss, shorter
hospital stay, and lower morbidity.
In the recent past, there have been several articles discussing
novel approaches to excise the submandibular gland (SMG). Surgical
excision of the SMG is commonly indicated in patients with
neoplasms, chronic sialadenitis, sialolithiasis, and to manage chronic
drooling (sialorrhea) not responsive to conservative treatment.
While the classic SMG surgery has involved a transcervical approach,
several other approaches have recently been described that can be
classified as ‘open’ or ‘endoscopic’ approaches (see Table 1).
The purpose of this article is to review the surgical approaches
to the SMG in order to provide a comprehensive review of the
various surgical approaches to the SMG. The various approaches
will be compared and contrasted in order to highlight the advan-
tages and disadvantages of each technique.

2. Relevant anatomy
q Grant support: None.
* Corresponding author. Assistant Professor, Department of Otolaryngology Head
Neck Surgery, LSU Health Sciences Center, 533 Bolivar Street, Suite 566, New
The submandibular triangle is delineated by the anterior and
Orleans, LA 70112. Tel.: þ1 504 568 4785; fax: þ1 504 568 4460. posterior bellies of the digastric muscle and the mandible. Anteriorly,
E-mail address: rwalve@lsuhsc.edu (R.R. Walvekar). the floor of the triangle is the mylohyoid muscle; posteriorly it is the

1743-9191/$ – see front matter Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2009.09.006
504 D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509
Table 1
Classification of approaches to the submandibular gland.
Open Endoscopic
Transoral approach Endoscopy assisted
External approach Transoral
Lateral transcervical Submental
Retroauricular Lateral transcervical
Submental Completely endoscopic
Robot-assisted approach
hyoglossus muscle.1 The SMG occupies most of this triangle, below
the mylohyoid muscle.2 A part of the gland extends around the free
edge of the mylohyoid muscle that divides the gland into a smaller
anterior and larger posterior part. The mylohyoid muscle must be
retracted in order to gain access to the both parts of the gland.3 The
submandibular duct, or ’’Wharton’s duct’’, is approximately 5 cm in
length and arises from the anterior portion of the gland. It traverses
the floor of mouth between the mylohyoid and genioglossus muscles
alongside the tongue. Its opening is found at the base of the frenulum
of the tongue just posterior to the inferior incisors on the subman-
dibular caruncle via one to three orifaces.1,2
The sublingual space is an important anatomical region that lies
between the tongue and the mandibular ramus containing the deep
portion of the sublingual gland, the anterior portion of the Wharton’s
duct, and the lingual nerve which carries parasympathetic nerve
fibers to the gland. During its course, the lingual nerve loops under
the duct running a lateral to medial course and travels deep and
superior to the SMG (Fig. 1); it is most easily identified by reflecting
the posterior portion of the mylohyoid muscle.2 Also relevant is the
hypoglossal nerve, which lies inferior and medial to the lower third
of the gland under the posterior belly of the digastric muscle.3
The SMG is enclosed within a sheath formed by the investing
fascia of the neck that is attached superiorly to the mandible. The
marginal mandibular nerve forms an important external landmark as
it passes just superficial to the fascia of the SMG and deep to the plane
Fig. 1. Lateral Transcervical approach. The lingual nerve loops under the duct running
a lateral to medial course and the travels deep and superior to the submandibular
gland. The hypoglossal nerve lies inferior and medial to the lower third of the gland
under the posterior belly of the digastric muscle.
Fig. 2. Arterial Supply to the Submandibular gland. (SMG: Submandibular gland; FA:
Facial artery with branches to the submandibular gland; DG: Anterior belly of digastric
muscle).
of the platysma.4 Consequently, surgical dissection within the fascia
of the SMG poses the least risk to the marginal mandibular nerve.
The vascular pole of the gland is formed by the facial artery and vein
(Fig. 2). Identification and ligation of these vessels permits complete
liberation of the gland in any approach. The facial vessels traverse
vertically through the submandibular triangle across the mandible.2
3. Methods
A review of the literature was conducted using a Medline search
for approaches, indications, results, and complications of SMG
excision. Relevant anatomy was further illustrated through cadav-
eric dissection and photo documentation. A synopsis of the various
surgical approaches to the SMG is provided. Fig. 3 (A, B, and C)
illustrate the postauricular, lateral transcervical, and submental
surgical incisions used to access the SMG in frontal, lateral, and
submental views.
4. Results
Twenty seven articles were identified for review. Each article was
assigned a rating of the level of evidence as outlined by the US
Preventive Task Force.5 Overall, 3 level II-2 studies were identified and
22 level III studies were identified. There were no articles identified
that exhibited level I, II-1, or II-3 evidence. The articles were stratified
according to operative technique categorized by us as either ‘‘open’’ or
‘‘endoscopic.’’ The ‘‘endoscopic’’ category was further subdivided into
‘‘endoscopy assisted’’ and ‘‘completely endoscopic’’ (Table 1). The
open technique approaches include: the lateral transcervical, sub-
mental, retroauricular, and transoral approaches. The endoscopic
assisted approaches include the lateral transcervical, submental, and
transoral endoscopy assisted approaches. The completely endoscopic
approach includes the robot assisted techniques. Advantages and
disadvantages of each technique are summarized in Table 2.
5. Discussion
5.1. Open techniques
5.1.1. Lateral transcervical approach
The lateral transcervical approach is the standard and time-
tested means of surgical access to the SMG. Indications for excision
via this approach include neoplasm of the SMG, chronic
 D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509 505

Fig. 3. A–CCervical incisions (postauricular, lateral transcervical, and submental) for approaches to the submandibular gland (A:Frontal view; B:Lateral view; C:Submental view).

sialadenitis, sialolithiasis, radioactive iodine-induced sialdenitis,6
chronic drooling, Kuttner tumor and Kimura disease.7–9 Some
authors have advocated a partial or total submandibular resection
via a transcervical approach for facial rejuvenation.10
Lateral transcervical submandibular resection is most
commonly performed under general anesthesia. However, some
authors advocate SMG resection under local anesthesia in a select
patient population. Criteria for gland excision under local anes-
thesia include a clinically mobile mass without features of malig-
nancy based on fine needle aspiration biopsy (FNAB) in patients
who prefer local anesthesia or are at high risk with general
anesthesia. In addition, there was no size limitation to the removal
of the mass provided it was deemed to be resectable with a 6 cm
incision. In their study, Chow et al. had no procedures that required
conversion to general anesthesia. They conclude that SMG excision
under local anesthesia is feasible in appropriately selected patients
and ultimately can shorten hospital stay and facilitate day
surgery.11
The standard lateral transcervical approach is described in
Table 37,8 for comparison with other newer approaches that will be
subsequently discussed. Complications of traditional SMG exci-
sion include hematoma (2–10%), wound infection (2–9%), fistula

Table 2
Advantages and Disadvantages of Reviewed Surgical Approaches to the SMG.
506 D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509

Table 3
Traditional approach to the submandibular gland: lateral transcervical approach.

 A 4–6 centimeter incision in placed in lateral neck crease approximately 2 to 3

centimeters below the lower edge of the mandible.
 Subplatysmal skin flap is developed and the marginal mandibular nerve is
identified and protected.
 The facial vein is identified and ligated at the inferior border of the gland and
reflected superiorly with the fascia over the submandibular gland. This
maneuver exposes the submandibular gland and ensures protection of the
marginal mandibular nerve.
 The facial artery is ligated or may be preserved by ligating only the branches
of the facial artery to the gland.
 Blunt dissection then continues towards the superiomedial gland at which
point the mylohyoid muscle must be retracted anteriorly to complete the
dissection.
 Posterior and inferior traction on the gland facilitates identification and
differentiating Wharton’s duct, the lingual nerve with its attachment to the
submandibular ganglion, and the hypoglossal nerve.
 The submandibular duct is then ligated and divided close to its opening in the
floor of the mouth.
 The gland is liberated from the submandibular ganglion and removed
preserving the lingual and hypoglossal nerves.

formation (1–3%), and neurological complications. Neurological

complications include damage to marginal mandibular (7.7–36%),
hypoglossal (0–7%) and lingual (0–22.5%) nerves.6–9,12,13
Fig. 4. Submental approach.
5.1.2. Submental approach
The submental approach provides access to the submandibular
triangle via a midline horizontal incision just superior to the sub-
incision is carried downward through the subcutaneous tissues and
mental-cervical crease at the level of the hyoid bone, (4.5  1.9 cm).
onto the sternocleidomastoid muscle at which point the flap is
The location is patient dependent determined by pre-existing neck
elevated anterior to the SMG. Special attention must be paid to
creases, amount of submental fat and skin texture. The site of the
avoid damage to the hair follicles and great auricular nerve and its
incision is marked pre-operatively along the least prominent line of
branches during flap elevation in order to prevent postoperative
the submental area in the frontal and lateral views of the face and the
complications. Once the gland is exposed, extirpation proceeds as
neck. The submental approach allows quick access to the gland. The
in any open approach.15 Due to the depth of the operative field
SMG is bluntly dissected free of surrounding fascia in a subplatysmal
(Fig. 3), endoscopy can enhance the view of the operative field
plane. The dissection differs from the traditional approach in that the
(Fig. 5).
anterior free edge of the gland is first encountered (Fig. 4A and B).
In his study, comparing this approach to the standard trans-
Following this, the facial vein and artery are ligated and the gland is
cervical approach, Roh found no significant differences in operative
separated from the edge of the mylohyoid muscle. The submandib-
time, scar hypertrophy and length of hospital stay between the two
ular ganglion is identified and separated from the gland. Finally the
procedures. In his series, there were no iatrogenic palsies of the
submandibular duct is ligated and the gland is delivered through the
marginal mandibular nerve with the retroauricular approach, while
incision. A drain is placed within the incision and is removed on the
second or third postoperative day.14
Roh compared the submental approach to the traditional lateral
transcervical approach in a prospective randomized fashion. There
were a total of 20 patients, with 10 patients in each arm of the study.
There were no statistically significant differences in the two
approaches with respect to incision length, operative time, nerve
injuries, and number of days of hospitalization. However, the
average visual analog scales measurements showed a higher patient
satisfaction due to cosmetic concerns in the submental approach
group (p ¼ 0.01; 8.8  1.9 vs. 5.4  3.2).14

5.1.3. Retroauricular approach

Roh also described a retroauricular approach to the SMG.15 Since
the initial report in 2005, Roh and other authors have continued to
report on the utility of this approach.16 The main advantage is the
improved cosmesis of the resultant scar. The incision is designed in
the lower portion of the postauricular sulcus arching toward the
middle to upper 1/3rd of the sulcus before transitioning across and
downward into the hairline; the portion of the incision in the
hairline is set ½ to 1 cm into the hair bearing area (Fig. 3B). The
main disadvantage of the retroauricular approach is the extent of
the skin flap that must be raised to access the Wharton’s duct Fig. 5. Retroauricular approach. View of skin flap elevated prior to full exposure of the
proximally which can be 10 cm from the postauricular incision. The submandibular triangle.
 D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509
there were two such reported complications with the standard
approach. The study concluded that the retroauricular approach is
safe and comparable to the standard approach. As would be
expected, the overall patient satisfaction with the resultant scar on
a visual analog scale was significantly higher with patients from the
retroauricular cohort (p < 0.001; 8.9 þ/ 0.9 points vs. 4.2 þ/ 2.9
points).16
5.1.4. Transoral approach
While first described in modern medical literature in 1960,17 the
transoral approach to the SMG had not gained popularity until
recently described by Hong et al18,19 (see Table 4). Advantages of the
transoral approach include: less risk of iatrogenic injury to the
marginal mandibular nerve, avoidance of an external scar, minimal
risk of postoperative mucocele formation, or inflammation of
Wharton’s duct.18,19 In his series, Hong reported on 31 patients who
underwent a transoral resection of the SMG and later followed this
with a retrospective chart review of 77 patients undergoing the
same surgery showing similar results. Abnormal tongue sensation
was noted in 74% of patients and temporary limitation of tongue
movement was noted in 70% of patients.20 Restriction of tongue
movement due to scar contraction was noted in 10% of patients in
the first paper but this was lowered to 2% in the most recent article
with these patients being asymptomatic.18,20 Hong later followed
the initial report with a review of 12 patients with pleomorphic
adenoma of the SMG excised with this approach. They noted 50%
of patients had anesthesia of the tongue and 40% had limitation of
tongue movement, all of which resolved within two weeks of
surgery.21 Weber et al. have published their experience with seven
patients reporting 43% abnormal tongue sensation, no change in
tongue movement or restriction due to scar contracture. They
attributed their lower complication rates to several critical
maneuvers such as planning to leave a cuff of gingival mucosa to
allow a tension free closure and prevent tongue tethering. The
authors limited the amount of lingual nerve dissection conse-
quently limiting stretch injury to the nerve which is responsible for
abnormal tongue sensation. The authors pointed out that the only
patient in their experience where a transoral approach was inad-
equate to allow excision of the gland had previous surgery and
a small oral cavity. These can be considered as relative contrain-
dications to this approach.19 Kauffman recently reported a case
series of nine patients with only 25% of patients having temporary
change in tongue sensation and no patients having lasting
complications. This series further validates the safety of transoral
excision in selected patients.22
5.2. Endoscopic approaches
As technology advances and the boundaries of the endoscope
are ever challenged, it logically follows that this technology be
Table 4
Transoralapproach to the submandibular gland.
 An incision is made in the floor of mouth from the submandibular papilla to
the retromolar trigone.
 A cuff of mucosa on the gingival side is preserved to allow for tension free
closure and to prevent limitation of tongue mobility due to scar contracture.
 The lingual nerve is identified and dissected free of its attachments to the
submandibular duct and gland.
 The submandibular gland is bluntly dissected and delivered into the surgical
wound by applying external pressure on the neck.
 The hypoglossal nerve is identified and preserved.
 Branches of the facial artery and vein are ligated with care not to disrupt the
marginal mandibular branch of the facial nerve.
 The gland is removed and the wound bed irrigated and closed in a tension
free manor.
507
applied to the excision of the SMG. Endoscopic approaches to the
SMG can be further classified as ’’endoscopy assisted’’ and
‘‘completely endoscopic’’ approaches.
5.2.1. Endoscopic-assisted transoral approach
Endoscopically-assisted transoral excision of the SMG again is
similar to its open counterpart. The main advantage of the endo-
scopic assistance in addition to those that are natural to the
transoral approach i.e. lack of a cervical scar and lower incidence of
facial nerve palsy again, are good visualization, magnification and
illumination of the anatomical landmarks, and consequently
a wider surgical field as compared to the conventional intraoral
approach (Figs 6 and 7). Guerrissi and Taborda describe two cases
with this technique which were successfully performed for siala-
denitis secondary to sialolithiasis.3 However, Weber et al did not
perceive any difficulties with exposure via the conventional
transoral incision. In their series, a single patient required conver-
sion to a transcervical approach which in their opinion would not
have been preventable even with endoscopic guidance.19
It must be recognized that the endoscopy assisted transoral
approach has several disadvantages which are common to all endo-
scopic procedures and include: the cost of the endoscopic equipment,
the learning curve associated with the surgeon becoming familiar
with the technique, and increased operative and setup time.23
5.2.2. Endoscopic-assisted submental approach
Chen et al., describe a minimally invasive endoscopic invasive
resection of the SMG. The incision placement for this approach is in
a submental area similar to the submental approach described by
Roh et al.24 This procedure differs from the conventional submental
approach in that a smaller incision (20–25 mm) is placed over the
skin crease in the hyoid midline. Dissection is performed in a sub-
platysmal plane. The first assistant maintains an operative view
using an endoscope and the second assistant maintains the working
space with two retractors which lift up away from the skin. Vessels
are ligated using Endoclips (Ethicon Endosurgery) and excision is
performed standard fashion using an ultrasound-activated scalpel
(Harmonic Scalpel, Ethicon Endosurgery). A drain is placed for
drainage.25
Fig. 6. Transoral approach. Endoscopic view of transoral approach showing subman-
dibular duct (D), lingual nerve (L), and sublingual gland (SLG).
508 D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509
Fig. 7. Transoral approach. Endoscopic view of the operative field.
The advantages of this approach include a smaller incision as
compared to the standard submental approach and the previously
discussed advantage of endoscopic visualization. In addition, the
use of an ultrasound-activated scalpel which does not transmit an
electric current reduces the risk of thermal injury to the marginal
mandibular nerve as compared to monopolar and bipolar electro-
cautery.26 However, the disadvantages include those that are
common to all endoscopic procedures as well as a significant
increase in operative time as compared to the conventional sub-
mental approach [70 min, (50–120 min) vs. 41 min, (32–56 min)].25
The application of endoscopic approaches in soft tissue surgery
has been thwarted by the challenges fundamental to endoscopic
neck surgery including the lack of a well-defined sac and the risk of
emphysematous dissection.23 The risk of CO2 insufflation to create
a working space in the neck includes massive subcutaneous
emphysema, hypercarbia, gas embolization, and some types of
arrhythmias.25 Terris et al, developed hybridized techniques to
enable an endoscopic approach for the resection of the SMG in
a porcine model.27 However, the era for endoscopic neck surgery
began with the first description of a parathyroidectomy using CO2
insufflation.28,29 Since then there have been number of reports that
have used CO2 insufflation for the purpose of endoscopic neck
surgery. These developments will certainly define the approaches to
the SMG in the future.
5.2.3. Endoscopic transcervical approach
Guyot et al (2005) described an endoscopic approach for the
SMG that does not rely on CO2 insufflation to create an operative
pocket. In a cadaveric study carried out on 6 non-embalmed
cadavers, 12 endoscopic submandibular resections were per-
formed. Access to the subplatysmal plane of dissection was ach-
ieved via two 15 mm incisions (one anterior and the other
posterior), 10 mm below the submandibular area. A 4 mm diam-
eter, 30-degree endoscope provided the surgical view when placed
in the posterior incision. The operative pocket was created and
maintained using trans-cutaneous sutures. The dissection was
otherwise conducted in a usual fashion. Extirpation of the gland
was done through one of the incisions. In all cases gland excision
was successful. The operative time decreased with experience from
120 min for the first case to 35 min for the last case. The limitations
for an endoscopic approach were defined as presence of
inflammatory adherences to surrounding structures that resulted
in a bloody surgical field.30
5.2.4. Endoscopic submandibular gland excision using CO2
insufflation
Monfared et al (2002) described an endoscopic approach to the
SMG in a porcine model using balloon dissection to create an oper-
ative pocket which was constantly maintained with low pressure (no
more than 4 mm Hg) CO2 insufflation. Three incisions were made.
The central 14 mm incision accepts the 12 mm trocar which houses
the endoscope while the two lateral incisions (6–7 mm) were used to
place the 5 mm operative trocars. Twelve SMGs were successfully
excised endoscopically in seven pigs with no conversion to open
surgery. The median operative time was 59 min (range, 42–
165 min).27 Terris recently expanded this approach with the addition
of the daVinci robotic system to resect the SMG with a mean oper-
ative time of 48 min and with no conversions to open surgery.27,31
The main advantage of the robotic-enhanced endoscopic surgery
includes a virtual three dimensional vision projection system with an
endoscopic arm and two operative arms that can be controlled by the
surgeon from a remote console. In addition, the robotic arm permits
use of a full range of articulated instruments which can reproduce
surgical maneuvers in difficult to access locations. The disadvantages
of robotic surgery such as high cost and lengthy setup time are great,
and further customization of surgical instrumentation for otolaryn-
gology practice remain to be challenges for the future.23,32
6. Conclusions
Newer approaches to the SMG have distinct advantages in terms
of cosmesis over the traditional lateral transcervical approach.
Although most approaches are feasible and have been successfully
performed in humans, they are not widely practiced or accepted as
standard of care in most academic institutions and also in
community settings. In cases where SMG resection is deemed
necessary, we recommend careful selection of the approach based
on individual patient characteristics and needs, skill and experience
of the surgeon, familiarity with endoscopic technique, and avail-
ability of necessary instrumentation.
Conflicts of interest
None
Funding
None
Ethical approval
Not applicable
Acknowledgement
The authors would like to thank Dr. Richard Whitworth and Dr.
William Swartz, Mr. Antony Wells and Mr. Reginauld Delmore,
Department of Anatomy; Jeffrey LaCour MD, Department of
Otolaryngology Head and Neck Surgery, Louisiana State University
School Health Sciences Center, New Orleans, LA; Eugene New, New
Orleans, LA (for illustrations), and Trey Joseph, Stryker, New
Orleans, LA for their contributions.
References
1. Cummings C. Otolaryngology & head neck surgery. In: Cummings C, editor.
Salivary gland. New York: Mosby; 1998. p. 1201–9.
2. Lalwani A. Current Diagnosis and Treatment in Otolaryngology–Head and Neck
Surgery: Second Edition. New York: McGraw-Hill Medical, 200:5.
3. Guerrissi JO, Taborda G. Endoscopic excision of the submandibular gland by an
intraoral approach. J Craniofac Surg 2001;12:299–303.
4. Moore KL, Dalley AF. Clinically Oriented Anatomy, Fourth Edition. Philadelphia,
PA: Lippincott Williams & Wilkins; 1999. 1012–1015.
 D.D. Beahm et al. / International Journal of Surgery 7 (2009) 503–509
5. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, et al. Current methods of
the US preventive services task force: a review of the process. Am J Prev Med
2001;20:21–35.
6. Smith AD, Elahi MM, Kawamoto Jr HK, Lorenz HP, Hedrick MH. Excision of the
submandibular gland by an intraoral approach. Plast Reconstr Surg
2000;105:2092–5.
7. Preuss SF, Klussmann JP, Wittekindt C, Drebber U, Beutner D, Guntinas-
Lichius O. Submandibular gland excision: 15 years of experience. J Oral Max-
illofac Surg 2007;65:953–7.
8. Torroni AA, Mustazza MC, Bartoli DD, Iannetti GG. Transcervical submandibular
sialoadenectomy. J Craniofac Surg 2007;18:613–21.
9. Milton CM, Thomas BM, Bickerton RC. Morbidity study of submandibular gland
excision. Ann R Coll Surg Engl 1986;68:148–50.
10. Singer DP, Sullivan PK. Submandibular gland I: an anatomic evaluation and
surgical approach to submandibular gland resection for facial rejuvenation.
Plast Reconstr Surg 2003;112:1150–4. discussion 1155–1156.
11. Chow TL, Chan TT, Choi CY, Lam SH. Submandibular sialoadenectomy with local
anesthesia in the era of minimally invasive surgery. Otolaryngol Head Neck Surg
2008;138:752–5.
12. Berini-Aytes L, Gay-Escoda C. Morbidity associated with removal of the
submandibular gland. J Craniomaxillofac Surg 1992;20:216–9.
13. Smith WP, Peters WJ, Markus AF. Submandibular gland surgery: an audit of clinical
findings, pathology and postoperative morbidity. Ann R Coll Surg Engl 1993;75:164–7.
14. Roh JL. Removal of the submandibular gland by a submental approach:
a prospective, randomized, controlled study. Oral Oncol 2008;44:295–300.
15. Roh JL. Retroauricular hairline incision for removal of upper neck masses.
Laryngoscope 2005;115:2161–6.
16. Roh JL. Removal of the submandibular gland by a retroauricular approach. Arch
Otolaryngol Head Neck Surg 2006;132:783–7.
17. Downton D, Qvist G. Intra-oral excision of the submandibular gland. Proc R Soc
Med 1960;53:543–4.
18. Hong KH, Kim YK. Intraoral removal of the submandibular gland: a new
surgical approach. Otolaryngol Head Neck Surg 2000;122:798–802.
509
19. Weber SM, Wax MK, Kim JH. Transoral excision of the submandibular gland.
Otolaryngol Head Neck Surg 2007;137:343–5.
20. Hong KH, Yang YS. Surgical results of the intraoral removal of the subman-
dibular gland. Otolaryngol Head Neck Surg 2008;139:530–4.
21. Hong KH, Yang YS. Intraoral approach for the treatment of submandibular
salivary gland mixed tumors. Oral Oncol 2008;44:491–5.
22. Kauffman RM, Netterville JL, Burkey BB. Transoral excision of the subman-
dibular gland: techniques and results of nine cases. Laryngoscope 2009;119:
502–7.
23. Terris DJ, Amin SH. Robotic and endoscopic surgery in the neck. Operative
Techniques in Otolaryngol; 2008::36–41.
24. Roh JL, Yoon YH, Park CI. Removal of nonthyroidal neck masses with improved
cosmetic outcomes in skin-lifting surgery. Otolaryngol Head Neck Surg 2006;135:
463–8.
25. Chen MK, Su CC, Tsai YL, Chang CC. Minimally invasive endoscopic resection of
the submandibular gland: a new approach. Head Neck 2006;28:1014–7.
26. Jackson LL, Gourin CG, Thomas DS, Porubsky ES, Klippert FN, Terris DJ. Use of
the harmonic scalpel in superficial and total parotidectomy for benign and
malignant disease. Laryngoscope 2005;115:1070–3.
27. Monfared A, Saenz Y, Terris DJ. Endoscopic resection of the submandibular
gland in a porcine model. Laryngoscope 2002;112:1089–93.
28. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary
hyperparathyroidism. Br J Surg 1996;83:875.
29. Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT. Endoscopic endocrine surgery
in the neck. An initial report of endoscopic subtotal parathyroidectomy. Surg
Endosc 1998;12:202–5. discussion 206.
30. Guyot L, Duroure F, Richard O, Lebeau J, Passagia JG, Raphael B. Submandibular
gland endoscopic resection: a cadaveric study. Int J Oral Maxillofac Surg
2005;34:407–10.
31. Terris DJ, Haus BM, Gourin CG, Lilagan PE. Endo-robotic resection of the
submandibular gland in a cadaver model. Head Neck 2005;27:946–51.
32. Haus BM, Kambham N, Le D, Moll FM, Gourin C, Terris DJ. Surgical robotic
applications in otolaryngology. Laryngoscope 2003;113:1139–44.