4 Gland Duct Ligation

Four Gland Duct Ligation with Botulinum Injections 


This video visualizes the four-duct ligation surgery for chronic sialorrhea. Sialorrhea is characterized by the improper spilling of saliva, most commonly due to poor muscle coordination1. Controlling oral secretions with the perioral muscles and the act of swallowing takes precise contraction from voluntary and reflex contractions. Sialorrhea is common in newborns and children up to 5 since they have not learned to coordinate these contractions yet1. The most common etiology of persistent, or new, sialorrhea is cerebral palsy, amyotrophic lateral sclerosis, seizures, cerebrovascular accidents, facial paralysis, and dental problems1.While many neurological conditions can predispose a child to sialorrhea, cerebral palsy is most common, comprising up to 10% of cases3.The side effects of untreated sialorrhea include increased risk of infections, dental caries, and interference with speech. Aspiration pneumonia is a serious consequence from pooling of saliva in the posterior pharynx3. Patients can also become malnourished due to trouble chewing, loss of fluids/electrolytes, and loss of protein2. Non-evasive measures such as oral motor therapy, behavior modification therapy via biofeedback, and drug therapy should be considered before proceeding to surgical treatment2. Surgical treatment is preferred when the patient is at risk for aspiration pneumonia3. One of the most common surgical procedures for sialorrhea is the four-gland duct ligation. While the four-gland duct ligation is low risk for complications, facial swelling, aspiration pneumonia, oxygen desaturation, and vomiting are potential complications. Out of these, facial swelling was the most common adverse event3. 


An appropriate surgical candidate was identified in the clinic and advised about the risks and benefits of the procedure. The patient was appropriately prepped and inducted under general anesthesia. An oral side bitter was placed to visualize the oral cavity. Stensen’s duct was identified on the left with army navy retraction. A lacrimal probe was used to maintain the duct opening and an alice retractor was used to hold the duct in place. The dissection was performed bluntly and with cautery. Care was taken to prevent injury to the duct and to provide clear exposure. The probe was removed, and the proximal portion of the duct was ligated with two oppositely placed 3.0 silk sutures. The mucosa was then closed with 4.0 chromic suture in a simple interrupted stitch. The same procedure was performed on the contralateral side. The focus was then turned to whartons duct. The oral side bitter was removed, and the tongue was retracted using an army navy. The right papilla was identified and retracted with a Geralds with teeth to maintain proper visualization of the duct. Blunt and cautery dissection was performed around the duct for proper exposure. Once down to the base of the duct, tonsil clamps were used to clamp just proximal to the gland to aid with suture ligation. Two oppositely placed 3.0 silk sutures were used to ligate the duct. The mucosa was closed with a 4.0 chromic stitch. The exact same procedure was performed on the left whartons duct. Once complete the oral cavity was irrigated and cleaned. Ultrasound was then brought into the field. Under direct visual guidance 1mg/kg of botulinum toxin was injected into the parotid and submandibular glands using the hockey shaped ultrasound probe. Having tolerated the procedure well, the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.  


There were no complications encountered before, during, or after the procedure. The patient was followed in clinic for 1 year and the patient’s care giver reported satisfactory reduction in sialorrhea.  


This video shows the steps of performing a 4-gland duct ligation with botulinum toxin injections. It is a commonly indicated procedure in children under 5 years of age for chronic sialorrhea refractory to other treatment options. While not first line therapy, this procedure should be heavily considered for due to post-operative success and care giver satisfaction.  








Jean-Paul Meningaud, Poramate Pitak-Arnnop, Luc Chikhani, Jacques-Charles Bertrand, Drooling of saliva: A review of the etiology and management options, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Volume 101, Issue 1,2006, Pages 48-57, ISSN 1079-2104 
Little, S.A., Kubba, H. and Hussain, S.S.M. (2009), An evidence-based approach to the child who drools saliva. Clinical Otolaryngology, 34: 236-239. https://doi-org.libproxy.uams.edu/10.1111/j.1749-4486.2009.01917.x 
Khan WU, Islam A, Fu A, et al. Four-Duct Ligation for the Treatment of Sialorrhea in Children. JAMA Otolaryngol Head Neck Surg. 2016;142(3):278–283. doi:10.1001/jamaoto.2015.3592

Excision of Facial Venous Malformation


Facial venous malformations are challenging vascular anomalies that can significantly impact a patient’s quality of life. These malformations, characterized by abnormal clusters of dilated veins in the facial region, can cause significant cosmetic deformities, bleeding, and functional impairments. Surgical excision of facial venous malformations is a treatment option, aiming to address both the concerns and functional limitations associated with these vascular anomalies.

Case presentation:

The affected area on the lateral aspect of the upper eyelid margin was treated with a YAG laser set at 20 watts and one-second exposure time. This was followed by excision of a 1 x 2 cm segment of the affected skin above the eyelid margin. Using electrocautery, the skin, subcutaneous tissue, and venous malformation were dissected, avoiding branches of the facial nerve to the orbicularis oculi muscle. The incision was carried around the obvious margins of the malformation down to the temporalis muscle fascia. The dissection was performed underneath the lesion until it was completely resected. After excision of a portion of the eyebrow involved in the malformation, the deeper parts of the upper eyelid and orbicularis muscle affected by the venous malformation were removed. The deep portion of the dissection was not very vascular and was controlled with the bipolar and monopolar cautery. To achieve primary closure, we carefully undermined the forehead and facial skin. The lower facial skin flap was elevated and advanced, and primary closure was achieved with Vicryl sutures. Closure of the eyelid skin to the lateral forehead skin followed with chromic and Vicryl sutures to alleviate tension. Although the larger vascular lesion was excised from the skin and subcutaneous tissue, residual malformation remained around the upper eyelid and lateral orbital rim. This was dissected under the skin to remove the vessels and preserve the eyelid skin. Post-procedure, Mastisol and Steri-Strips were applied to the suture line to relieve tension and help wound healing.  The estimated blood loss was less than 30 mL. The patient had no complications and did well.


In this case, the surgical intervention effectively removed most of the facial venous malformation. Despite some residual malformation, the procedure yielded satisfactory outcomes with no postoperative complications. The residual malformation in the upper eyelid can be controlled with a YAG laser and/or sclerotherapy.

Excision of a Dermoid Cyst

This video demonstrates the excision of a supraorbital dermoid cyst in a pediatric patient. This lesion was located just superior to the right lateral orbit.

Plastibell Circumcision with a Frenulum-Sparing Technique

Plastibell circumcision with frenulum-sparing technique

Ismael Zamilpa MD and Madison Haraway

Introduction: The penile frenulum connects the prepuce to the glans on the underside of the penis. Although the frenulum plays a role in sexual arousal, it can cause painful erections when its length is too short. Conventional neonatal circumcision techniques involve removing the entire foreskin covering the glans, often with division of the frenulum (1). Recently, tissue-sparing approaches have become a matter of interest to reduce the risk of complications, such as bleeding, altered glans sensitivity, and meatal stenosis.

Methods: We describe a frenulum-sparing technique in combination with the Plastibell method. Lysis of preputial adhesions near the frenulum is performed carefully. Selection of an appropriately sized bell is paramount as oversize or undersize can cause bell migration and tissue necrosis (2). The bell should fit snugly over two-thirds of the glans of the penis and fall off spontaneously within 3-7 days.

Results: The patient is a 2-month-old male who presented to Arkansas Children’s Urology with phimosis, which is preputial tightness that prevents foreskin retraction over the glans. He was born at 37 weeks gestation and was not circumcised at birth due to concern for heart murmur. After obtaining cardiac clearance and parental consent, Plastibell circumcision was performed with good preservation of the frenulum, and the patient tolerated the procedure well.

Discussion/conclusions: There is current controversy over the ideal extent of preputial preservation during circumcision. Several publications have highlighted the frenulum’s function in penile erection, owing to its innervation by fine-touch sensory receptors, such as Meissner’s corpuscles (1).

By leaving the frenulum intact, we aim to reduce the risk of complications, particularly meatal stenosis, which is the narrowing of the urethra in circumcised children (3). These children commonly present with symptoms of high-velocity stream (usually upwards), dysuria, and urinary frequency after toilet training.

In conclusion, this tissue-sparing approach potentially reduces complications, improves cosmesis, and retains sensitivity.


Shenoy SP, Marla PK, Sharma P, Bhat N, Rao, AR. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. Journal of clinical and diagnostic research. 2015; (9)12: PC01-3. doi:10.7860/JCDR/2015/14972.6860.

Nagdeve NG, Naik H, Bhingare PD,Morey SM. Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: A randomized controlled trial. Journal of Pediatric Urology. 2013; 9(5): 675-682. doi:10.1016/j.jpurol.2012.08.001.

Abid AF, Hussein NS. Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urology annals. 2021; 13(1): 62-66. doi:10.4103/UA.UA_30_20.

Epicardial Lead Extraction after Sudden Cardiac Arrest

Institution: University of Arkansas for Medical Sciences


Monroe McKay mpmckay@uams.edu

Ashley Wilson

Christian Eisenring

Brian Reemtsen

Lawrence Greiten

Jump Graft Repair of Coarctation of the Aorta

This is a video showcasing a jump-graft repair for Coarctation of the aorta.

Coarctation of the aorta is one of the most well-known and documented congenital heart defects. Innovations in the field have led to a several options for surgical repair. However, patients with coarctation of the aorta remain at high risk for a number of morbidities including recoarctation aortic aneurysms and dilations, and sudden death. Our video showcases a jump graft repair, which is an underutilized approach for coarctation repair. Our goal is to educate others in the field on the proper technique and utility of this operation.

Aortic Valve Replacement via the Ross Procedure

A brief patient history is provided, followed by preoperative imaging, intraoperative repair, and postoperative imaging.

Inferior Oblique Myectomy

Inferior oblique myectomy is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by transecting it. The patient is a four old with a history of inferior oblique overaction and vertical strabismus, which can be corrected by resection of the inferior oblique muscle.

The ointment was applied to the cornea. Forced ductions were performed and identified restriction of the inferior oblique. A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the Inferior Oblique. The inferior oblique muscle is isolated using a Stevens tenotomy hook followed by Jameson muscle hooks. The inferior rectus was identified on a steven’s hook medially to the inferior oblique. The lateral rectus was then identified on a steven’s hook laterally to the inferior oblique. This was done to ensure that neither muscle was incorporated with the portions of the inferior oblique muscle to be cut. Wescott scissors were used to cut both ends of the muscle. Bipolar cautery forceps were used to cauterize the resected proximal and distal ends of the inferior oblique muscle. The two ends were released and the remaining muscle ends were allowed to retract into the orbit. The conjunctiva was closed using a plain gut suture.

No complications arose during the procedure. Postoperatively, the patient had a subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the one follow-up, the redness and pain had resolved.

Inferior oblique myectomy effectively treats inferior oblique overaction and vertical strabismus associated with this condition.

Repair of a Non-coronary Sinus of Valsalva Aneurysm Rupture

A brief patient history is given, followed by preoperative imaging, intraoperative repair, and postoperative imaging.

Minimal incision Partial Sternotomy ASD Repair

This video showcases a minimal incision, partial sternotomy exposure for complete ASD patch repair performed at Arkansas Children’s Hospital.

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