187 structured checklist to identify complications. Serious adverse events (AEs) related to the intervention occurred in 3 patients (5.9%) and included admission for postoperative nausea, and bilateral ranulae, and recurrent submandibular infection, which both required surgical intervention. The number of AEs is nonetheless in line with what has been reported for 4-DL.54, 55 Furthermore, this thesis shows a substantial improvement in the impact of drooling on daily life, daily care, and material damage after BoNT-A and 2-DL. Nonetheless, there was a significantly greater improvement of the impact of drooling on everyday life and care, material damage, and social interaction after 2-DL compared to BoNT-A. These findings are in line with literature that reported a significant increase in the quality of life and significant relief in daily care after 2- and 4-DL.56 Although varying outcome measures make direct comparison difficult, our results generally resemble findings in previous literature.52-56 We conclude that the degree of serious AEs after 2-DL is limited, and most patients respond well to 2-DL in both short (8 weeks) and medium-term follow-up (32 weeks) relieving patients of the impact of drooling on daily life and care, material damage, and social interaction. Nonetheless, there is some degree of treatment failure, and 26% of patients recurred between 8 and 32 weeks after 2-DL. Recurrence and surgical failure This work revealed a currently unexplained recurrence after 2-DL, for which additional treatment is indicated in one-third of patients. Alternative salivary pathways were proposed as the leading reason for recurrence and treatment failure of 2-DL. Namely, nuclear imaging revealed uptake and washout of radionucleotides of the submandibular salivary glands after 2-DL with ligatures, Furthermore, upon re-exploration in two patients in another institute, alternative duct openings were present distal to the sublingual caruncle.52, 57 It is believed that the use of ligatures, rather than clips, increases the risk for alternative salivary pathways by potential ligature slipping, increased tissue reaction, and eventually fistulation. This theory may be substantiated by our finding that three out of four patients in whom
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