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\begin{document}

\title{Submandibular gland degloving: a modified sialoadenectomy technique for
benign disease}



\author[1]{Pierangela Tramaloni}%
\author[2]{Davide Rizzo}%
\author[3]{Roberto Gallus}%
\author[1]{Luca Mureddu}%
\author[1]{Paolo Tropiano}%
\author[1]{Claudia Crescio}%
\author[1]{Emilia Degni}%
\author[3]{Alberto Artuso}%
\author[2]{Francesco Bussu}%
\affil[1]{Azienda Ospedaliero-Universitaria di Sassari}%
\affil[2]{Universita degli Studi di Sassari Dipartimento di Scienze Mediche Chirurgiche e Sperimentali}%
\affil[3]{Mater Olbia Hospital}%


\vspace{-1em}



  
  \date{May 19, 2024}


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\textbf{Key points}

\begin{itemize}
\tightlist
\item
  We describe 35 cases of submandibular degloving, a recently encoded
  technique for submandibular sialoadenectomy in benign pathology
\item
  Malignancy has been reliably excluded through clinical assessment and
  fine needle aspiration cytology
\item
  It is based on blunt subfascial supracapsular dissection in order to
  spare fascia along with facial vessels and \emph{marginalis
  mandibulae} nerve (MMN) within
\item
  No recurrences have been recorded
\item
  The rate of injury to the nerves at risk (MMN, lingual, hypoglossal)
  is lower than what reported in the literature for the ``classical''
  transcervical and transoral techniques
\end{itemize}

\textbf{Introduction:}

The submandibular gland (SMG) lies deep to the platysma, encapsulated by
the investing layer of the deep cervical fascia. It is lined by a
capsule of connective tissue which harbours \emph{septi} , subdividing
the gland in lobes, through which the vascular and nervous components
branch (figure 1).

Several benign disorders requiring a surgical excision (sialoadenectomy)
can affect the SMG, such as chronic sialadenitis, often deriving from
sialolithiasis, and benign tumours.

Different approaches to perform a submandibular sialoadenectomy have
been described, for all of them the most frequent and feared
complications are nerve injuries with obvious relevant functional and
cosmetic sequelae. In fact, three important nerves lie in proximity to
the gland: the marginal branch of the facial nerve (\emph{marginalis
mandibulae} nerve, MMN), the hypoglossal nerve, and the lingual nerve.

In the standard transcervical technique, the gland is removed with a
layer of fascia over it and MMN is usually shielded by ligating the
facial vessels lying immediately deep to it and pulling up their distal
stumps (Hayes-Martin maneuver).

We recently described and demonstrated the submandibular degloving, an
alternative transcervical submandibular sialoadenectomy technique for
benign diseases, based on a supracapsular subfascial dissection (figure
2)\textsuperscript{1}. The fascia is incised over the inferior aspect of
the gland, and carefully dissected from the \emph{capsula} . In this way
the fascia is fully preserved along with facial vessels and MMN lying
within it, without any need for a traumatic dissection of the branch. At
the same time the degloving leaves a further fascial layer also on the
hypoglossal nerve (whose direct exposure is not mandatory) and on the
lingual nerve which is anyway easily visualised and preserved.

In the present work, we evaluate surgical endpoints, postoperative
complications and clinical outcomes of the technique, and compare them
with other experiences in the literature.

\textbf{Methods:}

We retrospectively analysed the case records of all patients submitted
to submandibular gland degloving (as previously
described\textsuperscript{1}), by the same surgeon as first operator
(FB) in a single academic center from September 2017 to December 2021.
Data have been collected and reported following STROBE guidelines for
observational studies. The observational retrospective nature of the
study allowed the exemption from IRB approval.

Preoperative work-up included: collection of clinical history, physical
examination, ultrasound and, in case of clearly identifiable lesions,
ultrasound-guided FNAB (Fine Needle Aspiration Biopsy) with Rapid On
Site Evaluation (ROSE) as previously described\textsuperscript{2}. We
consider the submandibular degloving contraindicated, and we never
performed it, in case of suspicion of solid malignancy.

We recorded demographic, clinical and surgical data in order to assess
the safety of the technique.

Surgical time has been computed from infiltration of the skin to the
last stitch.

Surgical drains were removed when the amount of collected fluid became
less than 20 ml in 24 hours.

Post-operative follow up was performed through physical examination and
concomitant neck ultrasonography, 6 months after the surgery and then
every year (just for neoplastic lesions).

\textbf{Results:}

In the study period, 35 patients underwent submandibular degloving at
our division and have been included in the present study.

Descriptive statistics, including definitive histopathological reports
and complications, is summarized in table I.

No recurrences of the primary disease have been recorded in the follow
up (median follow up 30 months, range 9-60 months).

\textbf{Discussion:}

In recent years, sialendoscopy has demonstrated effectiveness in
avoiding sialoadenectomy, and therefore external approaches, in selected
cases of obstructive and non neoplastic pathology\textsuperscript{3}. In
many of these cases, and in case of bulky intraductal palpable stones in
the floor of mouth, the same results are obtained by transoral incision
and removal.

However, in many cases of neoplastic pathology and chronic sialadenitis,
sialoadenectomy remains indicated. With the advent of minimally invasive
techniques, there has been a renewed interest in developing approaches
that avoid visible scars, including robotic-assisted
trans-hairline/retroauricular approaches (DOI:
10.1016/j.ijom.2012.04.008) and transoral robotic surgery
(TORS)\textsuperscript{4}. Yet, the ``classical'' transcervical approach
remains the most validated and popular among head and neck surgeons, and
the less demanding in terms of time and technology required. The
submandibular degloving, always performed in the present
series\textsuperscript{1}, is a variant of the classical transcervical
approach.

In table II results and complication rate among different
sialoadenectomy techniques in different series are compared.

In the present series, the most relevant complication was the
postoperative bleeding in a patient with a large (4.5 cm) benign tumor
(pleomorphic adenoma); such large dimensions may be a contraindication
to the described technique.

Another complication has been a surgical bed hematoma after the removal
of the suction drain, associated with uncontrolled hypertension on the
6th postoperative day; it required the placement of a new suction drain
and the adjustment of antihypertensive therapy, and confirmed our
attitude, differently from some recent reports\textsuperscript{5}, to
always use suction drains to reduce the risk of postoperative
haemorrhage and infection.

Benign tumours do not disrupt the capsular layer of the gland so that if
the technique is carried out correctly the risk of spillage is supposed
to be minimal. This assumption is confirmed by the fact that in the
present series we recorded no recurrences among the benign tumors
resected.

However, in the literature, the most relevant risk in submandibular
gland surgery is the damage to the nerves lying in the area. The
Hayes-Martin maneuver is the most adopted trick to spare the MMN. On the
other hand, the main arguments of the advocates of the intraoral
approach are that it avoids the cervical incision and, most of all, the
dissection in close proximity to MMN itself. However, such approaches
are associated with a higher risk of lingual and hypoglossal nerves
injury and limitation in tongue movements\textsuperscript{6--89}(see
table II). In addition, intraoral dissection is difficult in chronically
inflamed glands with severe adhesions to surrounding tissue, and
conversion to the transcervical approach may be
necessary\textsuperscript{8}.

Because of such a markedly higher overall rate of nerve injury in
transoral approaches, the transcervical approach remains the standard
for submandibular sialoadenectomy. The present work is the first series
of submandibular deglovings in the literature showing a neural
complication rate (only two cases of transient nerve dysfunction in the
present series) lower than the classical submandibular sialoadenectomy
operation\textsuperscript{7,10--17}. Such preliminary results, if
confirmed on larger series, would support submandibular degloving, based
on blunt subfascial and supracapsular dissection, sparing of the fascial
layer and of vessels and nerves within it\textsuperscript{1}, as a new
standard for submandibular sialoadenectomy.

\textbf{References:}

1. Piras, A., Rizzo, D., Gallus, R., Artuso, A. \& Bussu, F.
Submandibular gland degloving: A minimally invasive function-preserving
surgical approach for benign diseases. \emph{Head Neck} (2021)
doi:10.1002/hed.26728.

2. Petrone, G. \emph{et al.}Utility of ultrasound-guided fine needle
aspiration cytology in assessing malignancy in head and neck pathology.
\emph{Cytopathology}(2021) doi:10.1111/cyt.12955.

3. Chandra, S. R. Sialoendoscopy: Review and nuances of technique.
\emph{J. Maxillofac. Oral Surg.} \textbf{18},1--10 (2019).

4. Floros, P., Sorrentino, M. \& Magnuson, J. S. Transoral robotic
parapharyngeal approach to the submandibular space. \emph{Head Neck}
\textbf{42}, 3776--3778 (2020).

5. Park, H. S., Lee, S. M., Lee, K. H., Chun, M. S. \& Kim, H. S. Safety
of drainless excision of the submandibular gland. \emph{Braz. J.
Otorhinolaryngol.} \textbf{86}, 626--631 (2020).

6. Hong, K. H. \& Yang, Y. S. Surgical results of the intraoral removal
of the submandibular gland.\emph{Otolaryngol. Head Neck Surg.}
\textbf{139}, 530--534 (2008).

7. G\selectlanguage{ngerman}ülsen, S. \& Ulutas, S. Submandibular Gland Surgery; Transoral
Versus Conventional Transcervical Approach. \emph{J. Craniofac. Surg.}
\textbf{31}, e224 (2020).

8. Singh, P. P. \& Goyal, M. Our Experience with Intraoral Submandibular
Gland Excision. \emph{Indian J. Otolaryngol. Head Neck Surg.}
\textbf{72}, 297--301 (2020).

9. Weber, S. M., Wax, M. K. \& Kim, J. H. Transoral excision of the
submandibular gland.\emph{Otolaryngol. Head Neck Surg.} \textbf{137},
343--345 (2007).

10. Papaspyrou, G., Werner, J. A. \& Sesterhenn, A. M. Transcervical
extirpation of the submandibular gland: the University of Marburg
experience. \emph{Eur. Arch. Otorhinolaryngol.} \textbf{271}, 2009--2012
(2014).

11. Preuss, S. F. \emph{et al.} Submandibular gland excision: 15 years
of experience. \emph{J. Oral Maxillofac. Surg.} \textbf{65}, 953--957
(2007).

12. Torroni, A. A., Mustazza, M. C., Bartoli, D. D. \& Iannetti, G. G.
Transcervical submandibular sialoadenectomy. \emph{J. Craniofac. Surg.}
\textbf{18}, 613--621 (2007).

13. Springborg, L. K. \& Møller, M. N. Submandibular gland excision:
long-term clinical outcome in 139 patients operated in a single
institution. \emph{Eur. Arch. Otorhinolaryngol.} \textbf{270},
1441--1446 (2013).

14. Kukuckova, B. \& Svec, M. Surgical management of submandibulary
gland diseases: ten years of experience. \emph{Bratisl. Lek. Listy}
\textbf{112}, 264--268 (2011).

15. Hernando, M. \emph{et al.} Complicaciones quirúrgicas de la cirugía
submaxilar. \emph{Acta Otorrinolaringol. Esp.} \textbf{63}, 42--46
(2012).

16. Chiesa Estomba, C.\emph{et al.} Neurological complications and
quality of life after submandibular gland resection. A Prospective,
non-randomized, single-centre study. \emph{Otolaryngol. Pol.}
\textbf{73}, 32--37 (2019).

17. Erbek, S. S., Köycü, A., Topal, Ö., Erbek, H. S. \& Özlüo\selectlanguage{polish}ğ\selectlanguage{english}lu, L. N.
Submandibular Gland Surgery: Our Clinical Experience. \emph{Turk Arch
Otorhinolaryngol} \textbf{54}, 16--20 (2016).

\textbf{Tables.}

\textbf{Table I} . Clinical features and surgical outcomes.

\textbf{Table II.} Comparison of complication rates in different series.

\textbf{Figure legends.}

\textbf{Figure 1.} A section of a resected submandibular gland (A) with
residual fascia (f) on it, lying upon the capsula (c ), which is a
stromal component in continuity with the septi within the gland itself.
The same anatomy is simplified in a drawing (B): the dissection in
submandibular degloving occurs between the fascial (f, in green) and the
capsular (c, in pink) planes.

\textbf{Figure 2.} Facial artery and vein are preserved at the end of
the procedure\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/figure-1/figure-1}

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\includegraphics[width=0.70\columnwidth]{figures/figure-2/figure-2}

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\textbf{Hosted file}

\verb`Table I.docx`  available at \url{https://authorea.com/users/591519/articles/627439-submandibular-gland-degloving-a-modified-sialoadenectomy-technique-for-benign-disease}

\textbf{Hosted file}

\verb`Table II.docx`  available at \url{https://authorea.com/users/591519/articles/627439-submandibular-gland-degloving-a-modified-sialoadenectomy-technique-for-benign-disease}

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