224 SUMMARY of 2-DL is offset by a larger treatment success proportion than BoNT‐A. Future research should confirm this and focus both on the long‐term costs and the effect of both treatments over multiple cycles. Chapter 7 Previous studies revealed that submandibular duct ligation (2-DL) is significantly more effective than submandibular BoNT-A. However, 26% of patients recurred in the period between week 8 and 32 weeks after 2-DL. In the available literature, recurrence varies from 0% to 58%, but studies that focus on the long-term effect of 2-DL are scarce and of limited methodological quality. Chapter 7 aims to evaluate the medium to long-term (1 to 12 years) effectiveness of 2-DL. The cohort consisted of 42 patients with a mean age of 13 years. Main outcomes included a Visual Analog Scale (VAS) collected at baseline, 32 weeks postintervention, and 1 – 12 years postintervention in a cross-sectional setup. This chapter shows a significant subjective 2-DL effect on drooling severity in the medium to long-term as reported by patients and caregivers. Still, there is also a certain degree of recurrence in this period, and 33% of the patients required subsequent treatment. However, the majority of patients and/or caregivers would recommend 2-DL to peers. Chapter 8 Chapter 8 aims to evaluate the effect of revision surgery for drooling refractory to submandibular duct surgery. Furthermore, it is yet unrevealed if treatment failure is primarily explained by surgical failure, i.e. alternative submandibular salivary pathways, (compensatory hyper-)salivation of the parotid glands, or whether other clinical variables explain treatment failure. The second aim of this study is to find an explanation for unsuccessful submandibular duct surgery. The cohort was historically identified wherein patients with severe drooling who underwent unsuccessful submandibular duct surgery requiring a reintervention, were fit for inclusion. A reference cohort was used to control for clinical variables. Ten patients were included, of whom six were males. Eight patients underwent duct ligation, and 2 patients underwent submandibular duct relocation. Subsequent reintervention included submandibular gland extirpation (SMGE) in 7 patients and parotid duct
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