24.1 Introduction

The history of neck rejuvenation began with simple skin excision and then progressed to modification of the platysma and the extraction of subcutaneous fat. Bourguet [1] described the first surgical platysmaplasty through a submental incision in 1928. In 1964, Aufricht [2] described a lateral plication of the platysma to the mastoid fascia. Other important concepts came from Connell’s [3] work that demonstrated the need to modify subplatysmal structures such as bulging fat, ptotic submandibular glands, and prominent digastric muscles. In 1988 Feldman [4] described his corset platysmaplasty. This technique is now commonly used to flatten the submental plane and prevent a concave hollow after subplatysmal lipectomy. Of course, Klein’s [5] development of tumescent anesthesia and influence on microcannular liposuction technique gave surgeons another tool to recontour the neck. This set the stage for Courtiss [6] to demonstrate that removal of submental fat with liposuction can, in the correct patient, redrape and recontour the skin of the neck without redundancy.

Over the last decade there has been an exponential increase in the number of new nonsurgical procedures that are designed to rejuvenate the aging

L.A. Cuzalina ( )

Tulsa Surgical Arts, 7316 East 91st Street, Tulsa, OK 74133, USA

e-mail: angelo@tulsasurgicalarts.com

C.E. Bailey

Bailey Cosmetic Surgery and Vein Centre, 1075 Nichols Road, Street 5,

Osage Beach, MO 65065, UK

e-mail: cebailey@baileyveinandskincare.com

neck. Most of them are marketed as being minimally invasive with no down time, yet at the same time providing maximal safety and effectiveness. A popular example includes the use of radiofrequency energy for skin tightening [7]. Applying thermal energy to the dermis is thought to stimulate new collagen formation, which will ultimately result in skin contraction. Laser lipolysis represents another recent innovation that is believed to help with skin tightening through the application of thermal energy, while at the same time enhance the sculpting effect of liposuction. There are also claims that laser-assisted liposuction may provide for more rapid healing and patient recovery [8]. Even Botulinum Toxin Type A has been used to diminish the appearance of unsightly platysmal bands [9]. Another procedure that has received much attention in the realm of neck rejuvenation is mesotherapy. This involves the injection of strategically placed small doses of phosphatidylcholine and deoxycholate (with or without additional homeopathic ingredients) to dissolve fat [10]. While all of these procedures may have some role in neck rejuvenation it is clear that the literature supporting their efficacy and durability is not mature [11, 12]. Just as important is the fact that these procedures do not address the problems of bulging subplatysmal fat, or provide effective long-term solutions for age-related changes of the platysma and submandibular glands. Our goal in writing this chapter is to describe our approach to treating age-related changes of the neck. Even though these patients present with a wide variation of abnormalities, we will provide a simplified approach to stratify the patients to undergo either microcannular liposuction, or some form of submentoplasty, with or without rhytidectomy (Fig. 24.1). The authors have found that an excellent aesthetic outcome that is durable can consistently be provided.

Fig. 24.1 A cosmetic surgeon must have a thorough knowledge of all options in neck surgery to determine what is the best treatment plan for maximum aesthetic results

24.2 Patient Assessment

Prior to any surgical procedure, taking an accurate and focused history along with the performance of an appropriate physical exam is essential. During this time one must develop a clear understanding of the patient’s concerns while simultaneously establishing whether the patient has realistic expectations. As with all cosmetic procedures, reviewing pictures from when the patient felt like they looked their best can be helpful. During the physical exam on cosmetic surgery patients it is very easy to focus on the aesthetic concerns and forget that occasionally a coexistent pathologic abnormality may be present. The physician who evaluates a patient for contour irregularities of the neck or submental fullness must remember that pathologic processes either benign or malignant within the thyroid, salivary glands and or lymph nodes are possible. Suspicious lesions should be dealt with appropriately. Once the physician is certain that there are no pathologic changes he or she should feel comfortable proceeding with the aesthetic evaluation.

The first thing to evaluate is the patient’s skin and its tone. A study by Gryskiewicz [13], stated that the most accurate predictor of poor skin retraction with cervicofacial liposuction is the presence of a crepe paper skin texture, which is characterized by a crisscross pattern of fine creases. This is thought to represent a loss of dermal skin elasticity (Fig. 24.2). The most dramatic skin retraction after closed cervicofacial liposuction is seen in patients younger than 40 (Fig. 24.3). Patients in the age group of 60 and above can however see very pleasing results with this technique if they have adequate skin tone. Another limiting factor in achieving an excellent result with cervicofacial liposuction is the amount of

Fig. 24.2 This patient’s cervicomental skin has clearly lost dermal elasticity and will not respond well to liposuction even if excess adipose tissue was present. She is an ideal candidate for a basic facelift

a

b

Fig. 24.3 (a) Preoperative 27-year-old female. (b) One year postoperative following basic microcannular liposuction superficial to the platysma. This is a good example of a Type I neck that is ideal for liposuction only

Fig. 24.4 (Left) Preoperative 37-year-old. (Right) Two months postoperative following aggressive submentoplasty. Significant subplatysmal fat was directly excised under fiber optic illumination. No liposuction was performed until the entire flap was elevated to maintain adequate fat on the skin for redraping

subplatysmal fat that is present. Determining precisely how much subplatysmal fat is present can be difficult. One technique is for the surgeon to pinch the skin gently with his or her fingers, and the observed residual fullness in the neck represents subplatysmal fat. Little has noted that if the submental tissue moves up and down with swallowing then the bulk of the tissue is subplatysmal [14]. Patients with very obtuse cervical-mental angles almost always have significant subplatysmal fat. Also, patients with extremely heavy necks typically have the majority of fat stored in the subplatysmal space (Fig. 24.4). Subplatysmal fat tends to be more firm and fibrous than preplatysmal fat and is more resistant to liposuction. In addition, access to the subplatysmal space with closed liposuction is potentially dangerous making and open approach preferable. Therefore, submentoplasty is necessary to rejuvenate the neck with significant subplatysmal fat (Fig. 24.5). Next, we assess chin projection while viewing the patient laterally. In females the chin should just touch or be no more than 2 mm behind an imaginary line that is perpendicular to Frankfurt’s line. This perpendicular line runs vertically through

Preplatysmal fat

Subplatysmal fat

Platysma

Fig. 24.5 Limited degree of cervicomental angle improvement that would be possible if only preplatysmal fat underwent liposuction and the subplatysmal fat was not addressed in a patient with an obtuse chin–neck angle

the vermillion border of the lip (Fig. 24.6). For men, the chin should touch the vertical line or project up to 2 mm beyond. At this point one should also try to determine the level of the hyoid/thyroid complex. Usually, it resides at the C4 level. A normal, aesthetically pleasing cervicomental angle is 105°–120° [15]. When the hyoid/thyroid complex is low, an obtuse cervicomental angle is created which limits the final aesthetic outcome that can be achieved. Sometimes, one can improve the appearance of an obtuse neck with the placement of a chin implant. The most important reason to recognize a low hyoid/thyroid complex is to counsel the patient regarding this finding, thus ensuring that the patient has realistic expectations regarding the outcome of the procedure.

Another common finding in the aging neck is platysmal banding. With age, the thickness of this muscle diminishes as does its tone. The resultant laxity along with midline atrophy appears as platysmal banding. When seen in the midline, the bands represent the dehiscence of the medial edges of the platysma. Although the bands may have developed some laxity they are still capable of contracting and have some static tone. This is demonstrated by the fact that they become less noticeable when injected with strategically placed botulinum toxin Type A. When evaluating the platysma, it is important to remember that platysmal bands are often not seen with the patient in repose. Asking the patient to animate and contract their platysma with a grimace may give one a better view of platysmal banding. If one does not see platysmal banding at rest and only with animation, removal of subcutaneous fat will leave them exposed. Therefore, these patients are not ideally suited for liposuction

alone. Other contour irregularities that patients find displeasing include jowling, ptotic submandibular glands, and prominent digastric muscles. The ideal treatment for significant jowling is cervicofacial rhytidectomy and patients need to be appraised of this fact. Mild improvement can be achieved via submentoplasty and microcannular liposuction although one needs to stay superficial with suctioning to decrease the chance of marginal mandibular nerve injury. If submandibular gland ptosis is noted within the submental triangle one must decide whether resection is warranted. Prominent digastric muscles also need to be recognized during the initial patient evaluation. While subtotal resection is an option to deal with prominent digastric muscles the authors have been less satisfied with the results and have abandoned the technique because of unacceptable scarring, fibrosis, and contour irregularities. One should focus on not removing too much fat in this area. In addition, it is important to have an appropriate preoperative discussion with the patient regarding realistic expectations when prominent digastrics are present. Finally, one should also evaluate the patient for asymmetry and include these findings in the discussion.

There are several classification schemes that one can use to categorize a patient’s neck for surgical rejuvenation. Dedo’s [16] Type I–VI classification is often quoted and is useful, but we find that most patients can easily fit into several different classes using this approach. The authors’ simplified classification matches physical exam findings with the appropriate operative procedure(s). It also takes into account the need for chin implant, orthognathic surgery, and submandibular gland treatment.

24.3Cuzalina and Bailey Cosmetic Neck Classification

Type I – Liposuction only (patient has good skin tone, minimal subplatysmal fat, no platysmal banding, normal submandibular glands, and minimal to no jowling)

Type II – Submentoplasty with or without liposuction (Patient has fair skin tone, subplatysmal fat bulging, and/or platysmal banding with minimal to no jowling.)

Type III – Rhytidectomy only (Patient has jowling and neck laxity with or without significant preplatysmal fat and the platysma has minimal laxity.)

a

Type IV – Rhytidectomy with submentoplasty with or without liposuction (Patient has significant jowling, facial cutis laxis, and either major platysmal banding or heavy subplatysmal fat for submentoplasty.)

Types I–IV may be followed by the letters A, B, or C.

(A) The patient has microgenia or retrognathia and requires a chin implant or orthognathic surgery, (B) The patient has submandibular gland excessive fullness and may require submandibular gland resection,

(C) The patient has a low hyoid position or obtuse chin neck angle and may have limited improvement capability that requires counseling (Fig. 24.7).

b

Fig. 24.7 Cuzalina and Bailey cosmetic neck classification. The four common neck classifications based on procedures required. (a) Type I requires liposuction only. (b) Type II is best treated with submentoplasty alone. (c) Type III can be treated with a facelift alone. (d) Type IV requires a facelift and submentoplasty combined. Subclassification A, B, and /or C can be added, where A represents chin weakness, B represents submandibular gland fullness, and C represents a low hyoid position