Safe Submandibular Gland Reduction in 7 Steps: The Carina Technique

Patient awareness and demand for SMG reduction are advancing at a significant rate, yet most plastic surgeons receive no formal training in SMG management. Surgeons are increasingly performing this procedure with less anatomic preparation and operative experience.

To present a seven-step operative algorithm for safe SMG reduction, developed from over 24 years of single-surgeon experience, and to report associated outcomes and complications.

Records from 2018 to 2022 of patients undergoing a deep cervicoplasty that included SMG reduction were reviewed.

Of 1,100 patients, 922 underwent SMG reduction (1,844 glands). Complications included bilateral temporary lower lip dysfunction in all anterior neck lift patients (asymmetric recovery, 7.1%), transient xerostomia (2 patients), and recurrent sialadenitis (1 patient). No sialoceles, uncontrolled intraoperative hemorrhage, or postoperative hematomas occurred. A seven-step operative algorithm is described: (1) incision placement, (2) wide platysmal elevation, (3) visual axis optimization, (4) optical cavity creation, (5) gland mobilization, (6) controlled reduction (Carina technique), and (7) capsular reconstruction.

Standardized, sequential operative protocols have been shown across surgical disciplines to reduce complications and improve reproducibility, and the seven-step algorithm presented here applies this principle to SMG reduction by structuring access, exposure, and reduction so that each step establishes the conditions necessary for the next. The favorable outcomes in this series reflect that the algorithm provides a reproducible framework for safely structuring this procedure and does not substitute for the anatomic command and judgment required to perform it.