189 All things considered, treatment failure and recurrence after 2-DL is presumably multifactorial and presumably includes alternative salivary pathways. 2-DL in comparison with alternative treatment for anterior drooling In our institute, there is limited experience with 4-DL, so we cannot make an institutional comparison of 2- and 4-DL. A meta-analysis that compared the surgical procedures to treat drooling reported 64% subjective treatment effect after 4-DL against an average subjective success of 82% for all surgical procedures combined. However, the authors concluded that the studies were of methodologically low quality and were heterogeneous and therefore difficult to compare.62 Although xerostomia was not reported in any of the 4-DL studies, it was reported after SMDR, and bilateral parotid duct ligation and SMGE.54, 59, 63-65 We, therefore, advocate 2-DL over 3- or 4-DL as initial surgical treatment for anterior drooling because there is a smaller risk of over-treatment and xerostomia. In our study, 64% of 2-DL patients recommend surgery to peers after a median follow-up of 5.2 years. The main reason for patients not to recommend 2-DL to peers was recurrence. This compares to 84% of patients satisfied with SMDR in a recent cross-sectional(n = 62, median follow-up 13 months).64 Reasons not to undergo similar surgery again in the latter study were trauma, pain, changes in saliva consistency, recurrence, and lack of effectiveness. Although there were no cases of profuse drooling after a median of 13 years follow-up, there was no formal baseline assessment.64 Due to the heterogeneity in international literature, we intend to further reflect on the results of 2-DL compared to SMGE and SMDR in our institute. The medium-term objective and subjective results after 2-DL seem inferior to other surgical techniques such as SMDR and SMGE.48, 51 Both 2-DL and SMDR seemed to relieve the impact of drooling on daily life and care, social interaction and both treatments appeared to improve caregivers impression of patient self-esteem, but, again, the effect seemed larger after SMDR. It is however possible that this is, to some extent, explained
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