Submandibular gland reduction

What it is

The submandibular gland is a salivary gland that sits under each side of the jaw. With age it drops rather than grows: on scans the total gland size stays the same while more of it sits below the jawline (PMID 35639754, PMID 23884853). Its size follows body weight, and most growth happens before 40 (PMID 33079222). As the jawbone thins with age, the gland and the floor of the mouth are pushed lower (PMID 11598819).

A low or large gland often shows only after a neck lift. Once the fat over it is removed and the skin and muscle are tightened, the gland stands out as a lump under the jaw (PMID 1924563). Liposuction and skin and muscle tightening do not correct it, so the gland, the deep fat and the digastric muscle each need to be looked for before surgery (PMID 36563673).

Where it came from

• In 1991 de Pina described removing the superficial part of the gland for patients whose glands spoiled the result of a facelift (PMID 1924563).
• In 2003 Singer and Sullivan at Brown University mapped the nerves, duct and vessels around the gland in cadavers to make partial removal safer (PMID 12973234). Sullivan then described lifting the gland to the jawbone without removing tissue (PMID 19338933), and Guyuron in 2008 wrapped the gland in a sling of fascia anchored to the inside of the jaw (PMID 18766063).
• In 2015 Mendelson, in Melbourne, reported more than a decade of gland reductions with facelifts and found a complication rate close to that of a neck lift with platysma tightening alone, plus three specific risks: deep bleeding, nerve weakness in repeat neck lifts and saliva collections (PMID 25989302).
• More recently, vessel-sealing and ultrasonic instruments have been used to divide the gland with less bleeding (PMID 38546581, PMID 40236889).
• In 2026 O'Daniel and Duff in Louisville published the Carina technique, a seven-step method built from more than two decades of one surgeon's practice (PMID 42759497).

Who it suits

• Fullness under the jaw that is gland, not fat. Examination and photographs, including an upward view with the neck bent, show whether the gland, the deep fat or the digastric muscle is responsible (PMID 30268240).
• Larger glands. Men and people who are overweight have larger glands (PMID 35639754).
• East Asian patients, whose lower face has less bony support and thinner soft-tissue cover, so a prominent gland shows more (PMID 42695798).
• Repeat neck lifts. Gland reduction is done more often in secondary facelifts, and temporary nerve weakness is more frequent in secondary neck lifts (PMID 25989302).
• People who prefer to keep the gland. A sling suspension (PMID 18766063) or an extended SMAS facelift, which nearly removed the visible gland without cutting it (PMID 41418069), are alternatives.

How it is done

• Partial removal. Through an incision under the chin and beneath the platysma muscle, the surgeon removes the superficial part of the gland and leaves the deeper part working (PMID 1924563, PMID 12973234).
• Staying clear of the nerve. The branch of the facial nerve that moves the lower lip runs outside the gland's capsule (PMID 12973234) and stays within about 2 cm of the jaw border; working well in front of the jaw angle and lower in the neck avoids it (PMID 27025245).
• Controlling bleeding. The gland's blood comes mainly from the facial artery and the submental artery (PMID 36967478). Surgeons divide it with a vessel-sealing device (PMID 38546581, PMID 42022460), an ultrasonic dissector (PMID 40236889) or bipolar cautery lobule by lobule, then seal the remaining gland with fibrin glue and inject botulinum toxin to quiet saliva (PMID 42695798).
• The Carina technique. Incision placement, wide elevation of the platysma, a clear line of sight, a working space, freeing the gland, a controlled reduction and closure of the gland's capsule, each step set up for the next (PMID 42759497). The authors state that the method does not replace anatomic knowledge and judgment (PMID 42759497).
• Part of a deep neck lift. In deep neck surgery the gland is often reduced along with the fat beneath the platysma and the digastric muscles (PMID 33543747).
• Lifting the gland instead. A fascia sling fixed to the inner jaw with bone anchors (PMID 18766063), stitches to the lining of the jawbone (PMID 19338933) or to the gland's fascia (PMID 11598819), a cradle made by stitching the platysma to the hyoid bone, so far tested only in cadavers (PMID 27462572), or a deep SMAS-platysma flap released from its ligaments, which holds the gland up like a sling (PMID 41418069, PMID 35446382).
• Injections. Botulinum toxin injected into the gland under ultrasound shrinks it without surgery (PMID 32337352), and ultrasound mapping has been used to choose injection points (PMID 38712848).

Results and how long they last

• Every study in a review of partial gland removal reported a better neck shape against standard measures of an attractive neck (PMID 31970454).
• Lifting the gland with a fascia sling removed the fullness in most patients and left a little in some; one large gland had to be removed later (PMID 18766063).
• An extended SMAS facelift without gland removal nearly eliminated the visible gland and sharpened the neck angle at about 8 months (PMID 41418069). A platysma "hammock" flap kept gland visibility low at 18 to 21 months (PMID 35446382).
• Lobule-by-lobule removal in East Asian patients gave a consistently sharper jawline on standardized photographs (PMID 42695798).
• How long the result lasts has not been studied well: most reports are single-surgeon series with surgeon-rated photographs, and reviews ask for prospective studies with patient-reported outcomes (PMID 31970454, PMID 41092483, PMID 39652837).

Risks and how surgeons lower them

• Lower-lip weakness. Temporary weakness of the muscle that pulls the lower lip down is the most common complication. Pooled rates range from about 1 in 25 (PMID 40421667) to about 1 in 10 across all approaches (PMID 41092483); a review of partial removals found about 1 in 20, always temporary, with no permanent nerve injury (PMID 31970454). In Mendelson's series it followed about 1 in 22 operations and resolved fully by 3 months (PMID 25989302). In O'Daniel's series, every patient whose neck was opened from the front had temporary weakness of the lower lip on both sides, and in about 1 in 14 the two sides recovered unevenly (PMID 42759497). Approaches from behind the ear had the highest nerve injury rates (PMID 41092483), and repeat neck lifts carry more risk (PMID 25989302).
• Deep bleeding. A hematoma deep in the neck can press on the airway. Early reoperation for bleeding was needed in about 1 in 55 patients in Mendelson's series, one of them potentially fatal (PMID 25989302); pooled data put hematoma at about 1 in 90 (PMID 40421667). Bleeding from the gland itself was rare in a review of partial removals (PMID 31970454), and series using vessel sealing or the Carina technique reported no hematoma (PMID 38546581, PMID 42759497).
• Saliva collection (sialocele). About 1 in 75 in pooled data (PMID 40421667), about 1 in 22 in Mendelson's series, all resolved by 3 months (PMID 25989302), and none in the Carina series (PMID 42759497). Botulinum toxin is now the main way to prevent and treat it (PMID 39224090).
• Dry mouth. Rare after partial removal, and no permanent dry mouth was reported in the reviews (PMID 31970454, PMID 40421667). Removing the whole gland, as in cancer surgery, lowers resting saliva flow (PMID 20227906); aesthetic surgery leaves the deep part in place (PMID 1924563).
• Firmness under the skin of the neck, about 1 in 5 where it was reported, usually settling over months (PMID 40421667).
• Experience. Outcomes improve with the surgeon's experience (PMID 40421667), and most plastic surgeons receive no formal training in gland surgery (PMID 42759497).
• Toxin injections. One patient had severe trouble swallowing, with food entering the airway, after high-dose injections given without ultrasound; it resolved by 5 months (PMID 41595371).

Recovery

• Most complications resolve within a few months (PMID 40421667); in Mendelson's series every saliva collection and nerve weakness had resolved by 3 months (PMID 25989302).
• Lower-lip weakness recovered within 8 weeks in one series (PMID 42022460) and within 6 months in another (PMID 38546581).
• A saliva collection is drained with a needle and treated with botulinum toxin (PMID 42695798).
• Endoscopic and inside-the-mouth approaches were linked to faster recovery (PMID 41092483).

With a facelift

• Mendelson reduced the gland in about 1 in 8 first facelifts and 1 in 4 repeat facelifts (PMID 25989302).
• Deep-plane surgeons who release and lift the SMAS-platysma flap report less visible glands without removing them (PMID 41418069, PMID 35446382).
• In East Asian deep neck lifts, gland reduction is combined with a facelift or neck lift when the skin is loose (PMID 42695798), and the tail of the parotid gland in front of the ear can be shaved at the same time (PMID 42137253).

Questions to ask a surgeon

• Is the fullness under my jaw gland, deep fat or muscle? (PMID 30268240)
• Will you remove part of the gland, suspend it, or lift it with the SMAS and platysma? (PMID 41418069)
• How often do your patients have lower-lip weakness, and how long does it last? (PMID 31970454)
• How do you control bleeding deep in the neck, and what is the plan if my neck swells the first night? (PMID 25989302)
• How do you prevent and treat a saliva collection? (PMID 39224090)
• How many gland reductions have you done? (PMID 42759497)

Open questions

• Nerve risk: pooled reviews report rates from about 1 in 25 to 1 in 10 (PMID 40421667, PMID 41092483), while single-center series report temporary weakness only (PMID 42759497, PMID 42137253).
• Descent or growth: imaging shows the gland drops with age (PMID 23884853, PMID 35639754) and its size follows body weight (PMID 33079222), which favors lifting over cutting in some patients (PMID 18766063, PMID 41418069).
• Instruments: vessel-sealing series report no hematoma (PMID 38546581), but the one comparison of ultrasonic dissection with cautery found no significant difference (PMID 40236889).
• Botulinum toxin given during surgery to reduce saliva leaks is used (PMID 42695798, PMID 39224090) but makes instrument comparisons harder to read (PMID 40236889).
• Reviews call for standard protocols, prospective studies and patient-reported outcomes (PMID 41092483, PMID 31970454).

Terms

• Submandibular gland: salivary gland under each side of the jaw; removing a whole gland lowers resting saliva flow (PMID 20227906).
• Gland ptosis: descent of the gland below the jawline with age (PMID 23884853).
• Partial resection (reduction): removing the superficial part of the gland and leaving the rest in place (PMID 1924563).
• Capsule: the fibrous covering of the gland; the Carina technique closes it after reduction (PMID 42759497).
• Digastric triangle: the space under the jaw, bounded by the digastric muscle, that holds the gland (PMID 12973234).
• Sialocele (sialoma): collection of saliva under the skin after gland surgery (PMID 25989302).
• Xerostomia: dry mouth (PMID 20227906).
• Marginal mandibular branch: facial nerve branch that lowers the lower lip; it runs near the lower jaw border (PMID 27025245).
• Vessel sealing (LigaSure): bipolar device that seals vessels and tissue as it divides them (PMID 38546581).
• Basket suspension: wrapping the gland in fascia and anchoring it to the jaw (PMID 18766063).
• Carina technique: O'Daniel's seven-step gland reduction method (PMID 42759497).

Papers