The commissure–mandibular area is next assessed. This area is commonly referred to as “Marionette lines,” but proper clarification of the proper nomenclature is warranted. The commissure–mandibular fold (CMF) refers to the extent of tissue lateral to the actual Marionette line. It is a measure of soft tissue excess and descent. The commissure–mandibular crease refers to the actual depth of etched rhytid formation within the Marionette “Groove.” In general, the crease tends to increase in severity with advancing age. The commissure–mandibular groove (CMG) refers to the concavity between the CMF and the lower lip. The distinction in terms is important when discussing the use of fillers and the location of injection. One would never inject the fold as that would accentuate the depth of the groove. However, it is quite appropriate to fill the depth of the crease or to inject the CMG to create a smooth contour and to decrease or eliminate the CMG.

The corner of the mouth, or oral commissure, is next evaluated. With advancing age and loss of soft tissue support, the commissure commonly becomes downturned, creating an “unhappy” appearance. Not only should the degree of the depression be noted, but each side should be compared to document pretreatment asymmetry and to help guide treatment.

a

b

Fig. 59.2 (a) Neck with lateral platysmal banding. (b) Neck with central platysmal banding

59.6 Submental/Neck Evaluation

The evaluation of the submental area has several components. Skin elastosis is evaluated in a similar manner to that of the jowl–mandibular region using both visual inspection and manual palpation. Medial–lateral as well as superior–inferior movement should be assessed. The amount of adipose tissue, both subcutaneous and subplatysmal, should be estimated by visualization as well as palpation. Accumulation of fat is not universal with age, and skeletonization of subcutaneous muscles should be avoided to preserve a natural appearance. Platysmal banding should be assessed with the patient in repose as well as with animation. A distinction must be made between lateral banding and central banding (Fig. 59.2) as this may dictate treatment. By asking the patient to curl the lower lip or grimace, the anterior edge of the platysma may be brought into relief. Central vertical skin pleating may commonly be found between lateral platysmal banding and represents a medial–lateral skin excess.

Inferiorly in the neck, any lower fullness or adipose tissue should be evaluated. Implications of these findings are further discussed in the surgical technique selection section. The depth of horizontal rhytids should also be assessed.

All of the above findings should be clearly documented on the assessment form. Special description of any unusual pathology should be made. All findings should be demonstrated and explained to the patient, so that surgical recommendations may be better understood and realistic postoperative expectations better achieved.

59.7 Surgical Technique Selection

59.7.1 Nonsurgical Intervention

Prior to discussion of surgical treatment, it is prudent to discuss the concept of noninvasive treatments. In the primary author’s practice, this generally includes four

different treatment modalities: the use of Botulinum Toxin A, light-based skin tightening procedures, the use of fillers, and resurfacing techniques.

Dedo Class II pathology. Again, it must be emphasized that these procedures will not be able to achieve the same degree of improvement in skin laxity as surgery.

Botulinum Toxin A is now a widely used for the nonsurgical treatment of platysmal bands [28, 29]. Originally available only as Botox®, distinct formulations of botulinum toxin A are currently available or will soon be available in the United States. Although possessing similar efficacies, different types of neurotoxins have distinct dosing parameters. For the purpose of this discussion all doses mentioned are appropriate for Botox®.

It appears that the best indication for botulinum toxin A treatment of the aging neck may be for strong, hypertrophic bands that are exaggerated with animation. In the primary author’s practice, the technique involves grasping the anterior edge of the platysmal band and injecting 40 units or more along the anterior edges of the right and left platysmal bands. These bands may extend as far inferior as the clavicle. Botulinum toxin A may also be injected intradermally along horizontal rhytids to achieve some degree of effacement, but the results may be inconsistent.

59.7.3 Skin Tightening Procedures

Skin tightening procedures include the use of devices, such as the Affirm Multiplex™, Thermage® or Titan®, to achieve a degree of dermal heating. Thermage® involves the use of radiofrequency energy in order to heat the tissue, while Titan® and the Affirm Multiplex™ use infrared light. These technologies are most appropriately used in patients with skin elastosis, since adipose tissue or muscle banding will not be addressed by superficial dermal heating. Mild to moderate improvement may be seen after two treatments, spaced 1 month apart. These procedures may also have some prophylactic benefit by increasing dermal collagen, while degenerative changes may be delayed or slowed. However, it is extremely important to properly counsel the patient on posttreatment expectations. The best candidates for these treatments may be young adults with

Injectable fillers, such as nonanimal hyaluronic acid (Juvederm™, Restylane®, and Perlane®), or hydroxylapatite (Radiesse®), may be used to fill horizontal neck creases. In the primary author’s practice, filling of such creases and grooves is generally limited to nonpermanent fillers, although permanent fillers are available. In terms of mandibular rejuvenation, hyaluronic or hydroxylapatite fillers are ideal for correction of the commissure–mandibular groove and depressed oral commissure when injected intradermally. Temporary correction of the Pre-Jowl groove and microgenia may be achieved with supraperiosteal/ submuscular injection of larger volume fillers, such as Perlane® or Radiesse®.

59.7.5 Laser Resurfacing

Resurfacing techniques can be an important adjuvant in many patients seeking facial rejuvenation. Whereas ablative laser resurfacing using traditional carbon dioxide resurfacing had limited utility in the neck, newer fractionated technologies are proving useful [30]. Multiple technologies exist including numerous fractionated carbon dioxide laser systems along with proprietary laser systems such as the Cutera Pearl™ and Affirm Multiplex™. All of these may improve dyschromias, horizontal furrows, and offer some degree of skin tightening. The primary author has recently begun to use a fractionated carbon dioxide laser system coupled with a low powered erbium-YAG laser (Whisper–Erbium YAG Extend Ablation Laser™) for the majority of patients seeking ablative skin resurfacing of the neck.

While noninvasive treatments have merit unto themselves, they may be most appropriate in patients unwilling or unable to undergo surgery. They can also serve as valuable adjuncts to surgical correction. However, there is not currently any noninvasive treatment that can offer the same degree of skin tightening