193 literature. Lastly, yet importantly, clinical success was defined as a ≥50% reduction in DQ or VAS. The definition of success is arbitrary on the one hand. On the other hand, the definitions include both the objective and the subjective effect, and there seemed a relation between treatment success and the impact of drooling on daily life, social interaction, and self-esteem.67 Conclusion This thesis demonstrates that 2-DL is more effective compared to BoNT-A, but it is more invasive and carries greater morbidity in the short term. 2-DL has a substantial recurrence, but it should be noted that the effect of BoNT-A is always temporary. Although this thesis provides clues that there is some loss of effect after repeated BoNT-A injections, BoNT-A remains effective in a vast degree of patients after multiple injections. Therefore it remains the first-line medical treatment for drooling refractory to conservative measures for patients after 4 years. It appears that there is a tradeoff tobemadebetween invasiveness andeffectiveness when it comes to the treatment of anterior drooling. The data and findings collected in this thesis make it possible to carefully inform patients and their caretakers of this trade-off thus help to tailor the desired treatment and outcomes in each case. Thus, with the caveats outlined above, we believe 2-DL can be considered as a surgical treatment for refractory drooling for the following patients: • Patients or caregivers who have a desire for a longer-lasting effect than can be achieved with botulinum toxin • Patients or caregivers who have a well-founded resistance to SMDR or SMGE. Well-founded resistance to SMDR could include risk for adverse events, multiple days admission, or intensive care unit admission. For SMGE, well-founded resistance could include risk for adverse events, external scarring, or admission. • Patients with anterior drooling with absolute or relative contraindications for SMDR, such as:
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