Humans ; Practice Guidelines as Topic ; Submandibular Gland ; transplantation ; Transplantation, Autologous

BACKGROUNDAutologous transplantation of the submandibular gland (SMG) into the temporal fossa with microvascular anastomosis has been successfully applied in severe xerophthalmia patients as a permanent tear substitute. However, severe xerophthalmia can be accompanied by salivary gland dysfunction, making such autotransplantation unsuitable. Therefore, SMG allotransplantation might be a solution. The aim of this study was to assess the technical feasibility of submandibular gland allotransplantation.

METHODSTwelve miniature swine were randomized to serve as donors or recipients. One SMG was transplanted between a donor and a recipient. The donor SMG was revascularized by microvascular anastomosis of its vascular pedicle to the recipient lingual artery and external jugular vein. The secretory duct was implanted into the vestibule of the mouth through a subcutaneous tunnel. No immunosuppressive agent was administered. The results were assessed by visual inspection of the secretion, and histopathological examination of the transplanted SMG.

RESULTSTechnically, all surgical procedures were successful. Clear secretion flowed out of the duct as soon as blood supply of the transplanted submandibular gland was reestablished. The secretion of the gland lasted for 5 days. As expected, an acute rejection reaction occurred after surgery because no immunosuppressive agents were used. Secretion from the transplanted SMG ceased within 5 days.

CONCLUSIONSA model of SMG allotransplantation can be established in miniature swine. The technique of submandibular gland allotransplantation is feasible.

Animals ; Microscopy, Electron ; Models, Animal ; Submandibular Gland ; pathology ; transplantation ; ultrastructure ; Swine ; Swine, Miniature ; Transplantation, Homologous

Severe dry eye is a refractory ophthalmologic disease. Our multidisciplinary research group treated severe dry eye by microvascular autologous transplantation of submandibular gland (SMG) during the past 20 years. The SMG, with its blood vessels and Wharton's duct, was harvested from the submandibular triangle and transferred to the temporal area. The blood vessels in the SMG were anastomosed with the temporal blood vessels using a microsurgical technique. Then, the distal end of Wharton's duct was sutured to form an opening in the upper lateral conjunctival fold. The tear was replaced by the secretion of the transplanted SMG to lubricate the ocular surface. In our study, the surgical techniques of blood vessel management were continuously modified to increase the survival rate of the transplanted SMG. A novel surgical modality of partial transplantation of SMG was established to prevent postoperative epiphora. A clinical study with the largest case number in the world was conducted and the effectiveness of transplantation of SMG for severe dry eye was fully confirmed. In order to resolve two main clinical problems including ductal obstruction resulted from low secretion rate during the latent period, and epiphora due to over secretion of the transplanted SMG in the later term of transplantation, the regulation of the secretion mechanism of the normal and transplanted SMG were investigated. New opinions on mechanisms of saliva secretion were provided. Based on the priniciple of translational medicine, the results of related basic research were applied in the clinic. The clinical guidelines for secretion regulation of transplanted SMG were established. A concept of chronic obstructive sialadenitis of transplanted SMG was provided and its diagnostic criteria, diagnostic technique of sialography, and therapeutic regimen were established. As a result, the surgical success rate was obviously elevated, the surgical complications were decreased, and life quality of the patients was greatly improved.
Humans ; Lacrimal Apparatus Diseases/therapy* ; Salivary Ducts ; Submandibular Gland/transplantation* ; Tears ; Transplantation, Autologous

OBJECTIVETo summarize the cooperative measures on circulation restore during the operation of microvascular submandibular gland transfer.

METHODSFifty-six cases of microvascular submandibular gland transfer were performed in Peking University School & Hospital of Stomatology from January 2005 to March 2009. The related data was collected retrospectively and the cooperative measures on circulation restore during the operation were summarized.

RESULTSThe circulation restore of transferred glands were satisfied in all 56 cases when the submandibular gland transfer operation finished. Thrombosis happened in 7 cases within the postoperative 48 hours and the secondary emergency operations were done. At last 6 glands were salvaged and the final successful rate was 98.21%.

CONCLUSIONSuccessful circulation restore was one of the key points on microvascular submandibular gland transfer. The most important mission of the nursing during the operation was the prevention of vascular crisis. The main measures include persistent wet packing using narceine, fomentation using warm saline and special nursing on postoperative complications. Our experience proves that it is beneficial to the success of operation.

Adult ; Female ; Humans ; Postoperative Complications ; Retrospective Studies ; Submandibular Gland ; Tissue Transplantation

OBJECTIVETo summarize the management of blood vessels in the transfer of vascularized autogenous submandibular gland.

METHODSSixty-eight cases of vascularized transfer of autogenous submandibular gland for severe keratoconjunctivitis sicca performed from August 1999 to April 2004 were reviewed. Data collected for each patient included general items, donor and recipient vessels, vessel crisis, salvage of the vessel thrombosis, and survival of transferred glands.

RESULTSAmong the 68 cases, all the donor and recipient arteries were facial artery and superficial temporal artery respectively. For donor veins, 55 were facial veins, 1 was vein near the duct, and 12 were venae comitantes of facial artery. For recipient veins, 62 were superficial temporary veins and five were veins in the upper neck, one was deep temporary vein. Vessel thromboses occurred in 10 cases, 9 were venous and 1 were arterial. The salvage rate was 10.0%, with the overall survival rate of 86.8% of transferred gland.

CONCLUSIONSVariation in venous outflow is common in microvascular transfer of submandibular gland, and anastomosis between venae comitante of facial artery and superficial temporal vein is most dependable. Vessel anastomosis under microscope may reduce the vessel thrombosis rate after operation.

Adolescent ; Adult ; Blood Vessels ; transplantation ; Child ; Female ; Humans ; Keratoconjunctivitis Sicca ; surgery ; Male ; Retrospective Studies ; Submandibular Gland ; blood supply ; transplantation ; Transplantation, Autologous ; Vascular Surgical Procedures ; Young Adult

OBJECTIVETo summarize operation key points, prevention and management of complications in vascularized autotransplantation of submandibular gland for treatment of severe keratoconjunctivitis sicca.

METHODS23 patients with severe keratoconjunctivitis sicca were treated by this procedure. Postoperative (99m)Tc images, follow-up studies, and management of complications were performed.

RESULTSThe transplantations were successful in 19 cases, whose symptoms of xerophthalmia disappeared. The patients could stop applying artificial tears. In 4 patients the transplanted glands did not survive. Epiphora occurred in 5 cases. They were successfully treated by reducing the size of the graft. Obstruction of the Wharton's duct took place in one case and was treated by reconstructing the duct. When the superficial temporal vein was too small, venous bridging was applied. To select a relevant vein for anastomosis, blood oozing from the three veins was carefully inspected prior cutting off the gland when the external maxillary artery was preserved and was infused with heparin after the gland had been freed.

CONCLUSIONSIf every point has been properly managed, the successful rate of operation could be warranted.

Adolescent ; Adult ; Child ; Female ; Humans ; Keratoconjunctivitis Sicca ; surgery ; Male ; Middle Aged ; Postoperative Complications ; prevention & control ; Submandibular Gland ; blood supply ; transplantation ; Transplantation, Autologous ; Treatment Outcome

OBJECTIVETo observe the effect of capsaicin on the secretion of the transferred gland in "latent period".

METHODSForty-two patients (45 sides of eye), who received the microvascular autologous submandibular gland transfer in our hospital, were treated with two different types of capsaicin stimulations. The secretion function of the transferred glands was evaluated by Schirmer's test. The effect of capsaicin and its time-variation regularity were observed. In the meantime, the results of capsaicin were compared with some other stimulation methods, such as acid, chewing and physiotherapy with infrared rays.

RESULTSThe capsaicin gargle, capsaicin cream and physiotherapy could all promote the secretion of the transferred gland, while the effects of the capsaicin stimulation were more obvious. The other two stimulations (acid and chewing) had no effect on the secretion of the transferred gland.

CONCLUSIONSThe capsaicin stimulation can be taken as one of the effective means to promote the secretion of the transferred glands in "latent period" and to prevent the obstruction of the ducts. Because of its convenience and blandness, the capsaicin cream is the first choice of the clinical application options for the transferred submandibular gland in "latent period".

Adolescent ; Adult ; Capsaicin ; pharmacology ; Child ; Female ; Humans ; Keratoconjunctivitis Sicca ; surgery ; Male ; Middle Aged ; Saliva ; secretion ; Submandibular Gland ; secretion ; transplantation ; Transplantation, Autologous ; Young Adult

Autologous submandibular gland (SMG) transplantation has been proved to ameliorate the discomforts in patients with severe keratoconjunctivitis sicca. The transplanted glands underwent a hypofunctional period and then restored secretion spontaneously. This study aims to investigate whether autonomic nerves reinnervate the grafts and contribute to the functional recovery, and further determine the origin of these nerves. Parts of the transplanted SMGs were collected from the epiphora patients, and a rabbit SMG transplantation model was established to fulfill the serial observation on the transplanted glands with time. The results showed that autonomic nerves distributed in the transplanted SMGs and parasympathetic ganglionic cells were observed in the stroma of the glands. Low-dense and unevenly distributed cholinergic axons, severe acinar atrophy and fibrosis were visible in the patients' glands 4-6 months post-transplantation, whereas the cholinergic axon density and acinar area were increased with time. The acinar area or the secretory flow rate of the transplanted glands was statistically correlated with the cholinergic axon density in the rabbit model, respectively. Meanwhile, large cholinergic nerve trunks were found to locate in the temporal fascia lower to the gland, and sympathetic plexus concomitant with the arteries was observed both in the adjacent fascia and in the stroma of the glands. In summary, the transplanted SMGs are reinnervated by autonomic nerves and the cholinergic nerves play a role in the morphological and functional restoration of the glands. Moreover, these autonomic nerves might originate from the auriculotemporal nerve and the sympathetic plexus around the supplying arteries.
Animals ; Autonomic Pathways ; growth & development ; Fascia ; innervation ; Female ; Humans ; Keratoconjunctivitis Sicca ; surgery ; Male ; Models, Animal ; Rabbits ; Recovery of Function ; Secretory Rate ; Submandibular Gland ; innervation ; transplantation ; Transplantation, Autologous

Adult ; Dentist-Patient Relations ; Dentistry ; Dentists ; legislation & jurisprudence ; Dissent and Disputes ; legislation & jurisprudence ; Female ; Humans ; Keratoconjunctivitis Sicca ; surgery ; Liability, Legal ; Malpractice ; legislation & jurisprudence ; Submandibular Gland ; transplantation

Animals ; Botulinum Toxins, Type A ; pharmacology ; Capsaicin ; pharmacology ; Carbachol ; pharmacology ; Humans ; Keratoconjunctivitis ; surgery ; Phenylephrine ; pharmacology ; Saliva ; drug effects ; Submandibular Gland ; drug effects ; transplantation ; Translational Medical Research