Authors of section

Authors

Nicolas Homsi, Paulo Rodrigues, Gregorio Sánchez Aniceto, Beat Hammer, Scott Bartlett

Executive Editors

Edward Ellis III, Eduardo Rodriguez

General Editor

Daniel Buchbinder

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Submandibular approach

1. Principles

This approach is selected for fractures of the mandibular body and angle regions unsuitable for intraoral treatment.
This applies to more difficult fracture patterns such as comminuted, atrophic, and defect fractures in order to allow optimal manipulation of the fragments, good control of the lingual cortex and inferior border, and the application of the selected hardware.

Variations
The incision can either be parallel to the inferior border of the mandible (A) or be placed in an existing skin crease (B) for maximum cosmetic benefit.

The incision can either be parallel to the inferior border of the mandible (A) or be placed in an existing skin crease (B)

If using skin creases for the incision, the orientation of the scalpel blade is parallel to the relaxed skin tension lines (RSTL).

The orientation of the scalpel blade is parallel to the RSTLs

Neurovascular structures
The main neural structure is the marginal mandibular branch of the facial nerve (CN VII). The facial artery and vein are also encountered during this dissection.

The main neural structure is the marginal mandibular branch of the facial nerve

Exposure offered by extraoral approaches
Submandibular approach

Submandibular approach

Retromandibular approches

  • Transparotid
  • Retroparotid
Retromandibular

Preauricular approach

Preauricular approach

Facelift incision (rhytidectomy)

Facelift incision (rhytidectomy)

2. Skin incision

General consideration
Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. The two options currently available are the use of local anesthetic or a physiologic solution with vasoconstrictor alone.

Use of a local anesthetic containing a vasoconstrictor may impair the function of the marginal mandibular nerve and prevent the use of a nerve stimulator during the surgical procedure. Therefore, consideration should be given to using a physiological solution with vasoconstrictor alone or injecting the local anesthetic with vasoconstrictor in a very superficial manner.

The length of the incision depends on fracture extend and the planned internal fixation technique. Diagram shows a skin incision 2-3 cm below the inferior border of the mandible.

Skin incision below the inferior border of the mandible

Incision of skin and subcutaneous tissues exposes the underlying platysma muscle.

Incision of skin and subcutaneous tissues

3. Dissection

In order to protect the marginal mandibular branch of the nerve, the platysma is undermined bluntly with scissors prior to dividing it with a scalpel.

The platysma muscle is divided sharply, preferably 2-3 cm below the mandibular border, not necessarily at the same level of the skin incision.

The platysma muscle is divided sharply

Superior subplatysmal dissection would expose the underlying marginal mandibular branch of the facial nerve (CN VII). This is not usually necessary.

By ligating and dividing the facial artery and vein and then retracting the vessels superiorly, the marginal mandibular branch of the facial nerve remains included in the superior flap and is thus protected.

Ligating and dividing the facial artery and vein and then retracting the vessels superiorly

4. Exposure

Divide the pterygomasseteric sling and incise the periosteum at the inferior border to expose the fracture site.

Divide the pterygomasseteric sling and incise the periosteum

Expose the body and angle region.

Expose the body and angle region.

5. Wound closure

For wound closure, the pterygomasseteric sling is closed.

For wound closure, the pterygomasseteric sling is closed

The wound is closed in layers to realign the anatomic structures and eliminate dead space. The platysma muscle is closed. A variety of skin closure techniques are available based on surgical preference. A drain may be used if necessary.

The wound is closed in layers to realign the anatomic structures