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Plunging Ranula

Transcervical approach after two failed transoral approaches

1.Right submandibular region. Annotated are the lower border of the mandible, the protrusion of the ranula in the neck, the anterior border of the sternomastoid muscle, and the incision.

2. Incision of the skin and the platysma.

3. The facial artery is divided and sutureligated along the lower border of the submandibular salivary gland.

4. Elevation of the fascia from the anterior surface of the submandibular gland together with the artery preserving the marginal branch of the facial nerve.

5. Starting the dissection of the submandibular salivary gland along its lower border.

6. Dissection and elevation of the submandibular salivary gland. After retraction of the digastric muscle the hypoglossal nerve comes into view.

7. Closer view. The retraction of the digastric muscle reveals the mylohyoid muscle and the hypoglossal nerve.

8. Dissection and ligation of the facial artery along the upper border of the submandibular gland.

9. Mobilization and retraction of the submandibular salivary gland permits the identification of the ranula.

10. The lingual nerve forming a curve is noted, as well as its relation with the ranula.

11. Dissection along the ranulas surface, facilitating the transection of the submandibular ganglion.

12. Dissection to transect the submandibular ganglion.

13. View after the transection of the ganglion. The ganglion is grasped by the forceps for reasons of demonstration.

14. Closer view. At the tip of the forceps lies the submandibular ganglion, and beneath the forceps lies the ranula.

15. Retraction of the specimen after freeing the lingual nerve. The submandibular gland is grasped by the forceps. Above the gland lies the ranula and following, the sublingual gland.

16. Dissecting along the Whartons duct.

17. Transection and ligation of the Whartons duct. Completion of the operation.

18. The surgical specimen. En bloc resection of the submandibular gland, the ranula, and the sublingual gland.