The objective is to evaluate the technique of microvascular autologous submandibular gland transfer for the treatment of severe keratoconjunctivitis sicca. From August 1999 to April 2002, 38 patients with severe keratoconjunctivitis sicca were treated by autologous submandibular gland transfer to the temporal region of the skull. The related vessels were anastomosed to the superficial temporal artery and vein. When the vein was too small, venous bridging was applied. Prior to cutting off the gland, the facial artery was preserved and infused with heparin in normal saline after the gland had been freed to allow inspection of the blood oozing from the three veins. This would be helpful in the selection of a relevant vein for anastomosis. Wharton's duct was transplanted to the upper lateral conjunctiva fornix, and the gland was left denervated. Postoperative scintigraphy with Tc99m pertechnetate, follow-up studies, and management of complications were performed. The transplantations were successful in 33 cases, their symptoms of xerophthalmia disappeared. The discomfort resulting from bright light and wind was also relieved. These patients could stop applying artificial tears. In five patients the transplanted glands did not survive. Epiphora occurred in eight cases. They were successfully treated by reducing the size of the graft. Obliteration of Wharton's duct took place in two cases and was treated by the reconstruction of the duct or duct orifice. Microvascular autologous submandibular gland transfer is a lasting and effective solution for severe cases of keratoconjunctivitis sicca.