Ann R Coll Surg Engl 1994; 76: 108-109

SURGICAL TECHNIQUE

surgical approach salivary gland

Colin Yates
Consultant
MB ChB FDSRCS

to

the sublingual

Department of Oral and Maxillofacial Surgery, Wexham Park Hospital, Slough

Key words: Sublingual salivary gland; Surgical approach

A new surgical approach to the sublingual salivary gland is described, the key feature of which is the use of a flap rather than the usual incision. The flap includes the submandibular duct and, because of the relationship of the duct and lingual nerve, aliows early identification of the latter before dissection of the gland. Improved access also simplifies dissection of the gland, particularly on its deep aspects where troublesome bleeding may be encountered.

The sublingual salivary gland is conventionally approached through a simple incision in the floor of the mouth directly over the gland (1) (Fig. 1). Using this route, access for dissection is limited and important related structures not easy to identify. The use of a flap greatly improves access and facilitates identification of the submandibular duct and lingual nerve.

Surgical anatomy
The sublingual salivary gland is a superficial structure covered only by mucosa and produces the sublingual fold in the floor of the mouth. It reaches the midline anteriorly and may overlap the submandibular salivary gland posteriorly. The structures at risk during dissection of the gland are the submandibular duct and the lingual nerve. The duct lies superficially in the floor of the mouth medial to the sublingual fold, and is crossed inferiorly by the nerve which then enters the tongue (Fig. 2). The sublingual
Correspondence to: Mr C Yates MB ChB FDSRCS, Department of Oral and Maxillofacial Surgery, Wexham Park Hospital, Slough SL2 4HL
Figure 1. Conventional approach.
artery and vein also lie on the medial aspect of the gland close to the submandibular duct and lingual nerve.

Technique
The outline of the flap is illustrated in Fig. 3. It is cut squarely at the corners to simplify orientation for repair and in the midline extends between the submandibular duct orifices. A very thin flap is raised to include the submandibular duct. No attempt should be made to produce a more substantial flap as this will cause the

Surgical approach to the sublingual salivary gland

109

DUCT

SUBMANDIBULAR

\~~ ~ ~I;
s
S

LINGUAL NERVE
SUBLINGUAL GLAND
SUBLINGUAL

0 0

Figure 2. Lingual nerve passing inferior to sublingual duct.

Figure 3. Outline of the flap.

SUBMANDIBULAR DUCT
SUBLINGUAL PAPILLA

LINGUAL

DUCT

SUBLINGUAL GLAND

(a)
Figure 4. Sublingual duct elevated by tip of scissors.

(b)

operator to enter the gland itself and lose the plane of dissection. Separation of the flap will be most difficult just beneath the sublingual fold where the multiple minor sublingual ducts tether the gland to the mucosa. The submandibular duct is thus raised with the flap, and bearing in mind the anatomical relationship between the duct and the lingual nerve, leads directly to the latter (Fig. 4a,b). In this way, the two key structures at risk in the procedure have been identified at a very early stage in the dissection. With this exposure, dissection of the gland from its bed is relatively straightforward and identification of the

sublingual vessels medial and inferior to the submandibular duct and lingual nerve simplified. The flap is repositioned with resorbable sutures. No drainage is necessary.

Reference
I Yoel J. Pathology and Surgery of the Salivary Glands. Springfield: Charles C Thomas, 1975: 1179.

Received 8 June 1993