as surgery. Furthermore, only surgery addresses all components of aging: skin elastosis, platysmal laxity and banding, and adipose accumulation.

59.8 Surgical Treatment

The choice of treatment options, especially surgical options, needs to be tailored to the individual and depend on the patient’s physical findings. There are also progressive degrees of invasiveness, which usually correspond to progressive degrees of pathology, but may also reflect patient wishes with regard to surgical recovery and postoperative outcome. In the primary author’s practice, it is extremely common for patients to preface any discussion of treatment with the phrase: “I want to look natural.” While it may be tempting to try to achieve the best possible postoperative result, it is imperative to respect the desires of the patient. However, one must not sacrifice personal standards solely to please the patient. Ideally, if there is a discrepancy between the patient’s and surgeon’s goals, then a compromise should be reached, or another consultation scheduled for further discussion.

59.8.1 Liposculpting

Liposculpting of the jowl–mandibular and submental regions offers the least invasive means of surgical improvement. An ideal candidate is generally someone younger with mild adipose accumulation in the jowl, submandibular, and submental regions without severe skin elastosis or platysmal laxity or banding.

The jowl–mandibular region can be reached using a 2 mm punch biopsy or stab incision postauricularly at the level of the lobule (Fig. 59.3). The primary author prefers to use microliposuction cannulas for this region in order to avoid skeletonization and also to achieve a gradual transition, or “feathering” into untreated areas. The degree of adipose tissue in the submental region dictates the type of incision and cannula to be used. With minimal subcutaneous fat, a small stab incision in the submental crease allows introduction of a microliposuction cannula. The use of standard 3 mm liposuction cannulas can be used in the submental region to remove subcutaneous fat. While adequate negative pressure may be achieved in many

Fig. 59.3 A patient undergoing jowl–mandibular liposculpture. In this situation a standard number 3 spatula open liposuction cannula is being used. However, a multifenestrated microliposuction cannula is more commonly used for “closed” liposculpturing in this area

cases with standard wall suction, it is frequently necessary to employ a liposuction machine to generate sufficient negative pressure.

In patients with a greater degree of submental adipose tissue, a standard submentoplasty incision, 2.5–3.0 cm in length posterior to the submental crease may be optimal. It is important to detach the membranous raphe beneath the submental crease from the overlying skin to diminish the depth of the submental crease. Improved visualization and access allows for more accurate liposuction as well as visualization of the platysma muscle and decussation.

In some patients with more fibrous adipose tissue, the results of cannula liposuction are limited. Lipectomy, under direct vision, may be performed with care taken to remain above the level of the platysma. However, due to the risk of skeletonization, a conservative approach should be taken and feathering with a microliposuction cannula should be performed lateral to the region of direct lipectomy in order to achieve a gradual transition.

If the patient has obvious subplatysmal fat, it may be addressed in a judicious manner. Small perforations in the platysmal decussation may be made to allow prolapse of the adipose tissue. A standard spatula liposuction cannula will then remove the prolapsed fat and will not violate the platysmal muscle or decussation. This conservative approach will avoid complications involved with subplatysmal dissection under limited

visualization and offers a substantial improvement in the heavy neck.

While liposuction coupled with direct lipectomy when appropriate remain effective and widely used, alternative techniques in liposculpture of the jawline and neck continue to evolve. Becker et al. [31] and Schaeffer [32] have reported on their use of endoscopic liposhaving for liposculpture of the jawline and submental region. The technique involves the creation of approximately 2 cm postauricular incisions with or without a small submental incision. Using traditional sharp dissection skin flaps are raised over the areas requiring contouring. The subcutaneous fat is then shaved using a microdebrider visualized via a 30° endoscope. Adjunctive techniques including platysmal resection and corset platysmaplasty are used as needed.

Liposculpture alone, without addressing the platysma or skin elastosis, will affect a modest improvement in the submental and jowl–mandibular regions. Postoperatively, the primary author has all patients wear a supportive headband so that adhesion of the skin to the underlying soft tissue occurs in a superior fashion.

It bears mentioning that a patient with a large degree of submental adiposity has relatively less skin than a neck with a smaller degree of adipose tissue. This paradoxical finding is demonstrated in Fig. 59.4. It is important to keep this relative skin paucity in mind when reapproximating the submental incision. If excess skin is excised, there may be too much skin tension on the final closure leading to a widened scar or incisional dehiscence.

Fig. 59.4 A patient with abundant submental adipose tissue

59.8.2 Platysmaplasty

If the patient has a Dedo Class IV neck with platysmal banding or laxity, then this must be addressed to optimally improve the cervicomental angle. Pre and intraoperative analysis is essential in selecting the proper surgical technique to correct the patient’s pathology but avoid an unnatural, “operated” appearance. As mentioned in the previous section, platysmal banding is classified as central versus right and left. Central platysmal banding often occurs secondary to subplatysmal fat accumulation with weakening of the platysmal decussation. In one cadaveric study three different forms of platysmal decussation were found [33]. The first type, seen most commonly, involved decussation from the mandibular margin for 1–2 cm below the mentum with separation in the suprahyoid region. The second type, seen less often, involved decussation from the mentum to the thyroid cartilage. The third type, seen least commonly, involved a complete absence of decussation. In general, the degree of decussation correlates with the amount of soft tissue support given to the subplatysmal structures in the midline and will affect the type of platysmal banding found in patients.

Central banding may be found primarily in patients with a Type II decussation. With a complete decussation of muscle fibers, there will be no anterior edge of the platysma muscle to form lateral banding. With a Type I decussation, central banding may be seen in the suprahyoid neck in the region of the intact decussation. Conversely, lateral banding may be observed primarily in patients with a Type III, or absent, decussation. Due to the lack of platysmal fiber interdigitation, there is no central support for the subplatysmal soft tissue and lateral banding may be found at the anterior edge of the platysma on either side. Lateral banding may also be seen in Type I decussation in the region of the neck below the intact decussation, especially in the infrahyoid region. Lateral banding may extend as far inferiorly as the clavicle, in which case, it is very difficult to improve.

If central banding is due to subcutaneous adipose tissue, then liposuction or lipectomy may be adequate. However, if there is significant platysmal decussation laxity, two therapeutic options exist. If direct lipectomy has been performed, then often some degree of central platysmal resection may concurrently occur. If that is the case, the cut edges of the platysma may be imbricated together with a 3–0 Prolene suture in an

interrupted or continuous fashion. This will afford some central tightening and reinforcement of cervicomental fascial support. An alternate option is not to disrupt the weakened decussation, but to tighten the platysmal sling posteriorly with plication or imbrication as part of a rhytidoplasty, or face–neck lift.

The treatment of lateral banding depends on the severity, extent, and location of the bands. Rohrich [27] categorizes lateral platysmal banding into wide (greater than 2 cm) and narrow (less than 2 cm). While the primary author does not use the exact interband distance to determine treatment options, the interband distance relative to the size of the entire neck helps dictate treatment. For those bands that are sufficiently close together, a vertical resection of muscle along both bands is performed to the level of the hyoid. Prolene sutures (3–0), in an interrupted or continuous fashion, are then used to approximate the edges of the muscle in a corset fashion. If the bands are pronounced below the hyoid, then a horizontal wedge is resected on either side at the cervicomental angle. This horizontal section allows the inferior portion of the band to fall posteriorly and inferiorly when platysmal plication/imbrication is performed subsequently during rhytidoplasty. For extreme inferior banding (Fig. 59.5) to the level of the sternum/clavicle, a vertical neck lift may be helpful, which is subsequently described in greater detail.

Fig. 59.5 A patient with extreme inferior platysmal banding. This degree of inferior banding is difficult to correct with a classic face/neck lift and submentoplasty. A vertical neck lift will help correct this pathology

If the interband distance is sufficiently wide so that reapproximation of the bands would result in excess tension, the bands are not reapproximated and the incision is left open until after the rhytidoplasty. With posterior platysmal plication or imbrication, the bands may be pulled even further apart. If they have been previously reapproximated, then the posterior pull will be limited and this may limit the improvement in lateral neck laxity. After the rhytidoplasty has been completed, the submental region may be reevaluated and, if able to be done without excess tension, the platysmal bands may be reapproximated at this time.

A number of techniques have been described as adjuncts or alternatives to platysmal section, imbrication, and plication. Although the primary author does not typically use them of particular note is Giampapa’s interlocking mattress suture technique [7]. Coupled with liposculpture of the jawline and submental region interlocking sutures are placed subcutaneously running from the right platysma to the left mastoid and left platysma to right mastoid. The sutures are placed so they run obliquely from just off midline inferiorly toward the mastoid superiorly. The desired effect is to pull the platysma muscles together in the midline and pull the anterior neck upward defining the jawline and cervicomental angle. Variations on this technique using endoscopy can also be employed [34].

After the adipose tissue and platysma has been addressed, the skin may be evaluated. In the large majority of patients in the primary author’s practice, no submental skin excision is performed during primary submentoplasty. In cases of severe skin excess, or in select revision cases, a vertical ellipse of skin may be excised, creating a “T”-shaped scar. Meticulous closure of the vertical portion of the “T” with intradermal sutures and long-term use of Steri-Strips™ helps to avoid postoperative scar widening. Alternative techniques in the treatment of skin redundancy include vertical elliptical skin excision coupled with Z-plasty, W-plasty, and double advancement flap closure [35]. If there is significant inferior skin redundancy, then a horizontal neck lift may be required for optimal correction. This procedure is discussed later in the chapter.

Isolated submentoplasty may be performed for patients with excess submental adipose tissue and minimal skin elastosis. With younger patients having good skin elasticity, one can expect a significant degree of postoperative skin retraction and redraping. Another indication is for patients with mild platysmal banding

and adipose tissue. These patients tend to be in the fourth and fifth decades of life without significant skin excess. As mentioned previously, it is important to have the patient wear a support sling postoperatively to ensure optimal skin envelope adherence. Figure 59.6 demonstrates an ideal candidate for isolated submentoplasty, jowl–mandibular liposculpturing, and alloplastic mandibular augmentation.

a

c

Fig. 59.6 (a, b) Preoperative patient with microgenia, significant submental and jowl–mandibular adipose tissue. (c, d) Postoperative after submentoplasty, and placement of an alloplastic chin–jowl implant

59.8.3 Rhytidoplasty

The preceding paragraphs all addressed surgical correction of the submental area. However, unless there is minimal skin laxity, improvement of the cervicomental angle cannot be adequately improved without some form of rhytidoplasty. In the primary author’s practice, the term “face/neck lift” is used in patient discussion

b

d