Fig. 24.14 (a) Thirty-nine-year-old female who has a Type II AC neck, which implies she is a candidate for an isolated submentoplasty [2] and has a weak mandible (A) and low-anterior hyoid

(C). She also has a deep labiomental crease secondary to a deep

bite and mandibular hypoplasia. A chin implant would worsen the LM fold. (b) Therefore, the patient was treated with a mandibular advancement and isolated submentoplasty to correct perioral rhtyids along with the challenging aesthetic neck problem

implant, it is important to ensure that the lateral wings of the implant have not folded over themselves. Also, it is important to ensure that the increased projection from the implant does not accentuate the depth of the labiomandibular sulcus (Fig. 24.14). If this is a problem one can modify the projection of the implant by shaving off some of its height with a number 15 blade. Mandibular deficiency with a deep bite is a common problem that can lead to a poor aesthetic outcome with a chin implant. Usually this problem requires orthognathic surgery for best results. Once the implant is positioned and secured the wound is closed in two layers with a 4–0 Vicryl deep suture and 5–0 plain gut suture for skin. It should be noted that an intraoral

incision can be used for chin implantation but requires cutting the mentalis muscle and an increased risk of morbidity to the mental nerve.

24.10 Submentoplasty

This procedure is designed to treat age-related problems of the neck that cannot be dealt with by liposuction or rhytidectomy alone. It is often combined with rhytidectomy, although it can be very useful as a standalone procedure in the correct patient. The goal of submentoplasty is to treat platysmal banding, sculpt

subplatysmal fat deposits, and finally, address cutis laxis of the neck. Additionally, ptotic submandibular glands can be treated via the submentoplasty incision, and jowling can be improved somewhat.

24.10.1 Submentoplasty Technique

In all patients, we endeavor to perform the procedure in a minimally invasive fashion. We find that there are very few patients who would require a direct excisional submentoplasty with its associated Z or W Plasty incision [29]. The authors would consider using this approach for the rare elderly male patient with extensive cutis laxis of the neck who is not a candidate medically or psychologically for rhytidectomy or general anesthesia.

During the initial evaluation of the patient, the position of the hyoid and length of the mandible are noted. For those patients who have a low hyoid, which results in an obtuse cervicomental angle, the authors will often recommend a chin implant which can create the illusion of a more acute and pleasing cervicomental angle postoperatively.

Type II (Submentoplasty with or without liposuction) (Fig. 24.15): Prior to making our submentoplasty incision, the neck is infiltrated with approximately 150 ml of tumescent fluid. Ideally, a 15 min waiting period is advised prior to beginning the dissection to allow for maximal vasoconstriction. During the infusion, care is taken to stay within the subcutaneous plane. It is not necessary to infiltrate the subplatysmal fat and this may, in fact, be dangerous. It is essential to

a

Fig. 24.15 (a) Preoperative 40-year-old male. (b) One month following an aggressive submentoplasty with subplatysmal fat excision, platysmal resection, and simultaneous chin implant. This is a good example of an obtuse chin neck angle and a diagnosis neck Type II AC

leave an even layer of fat attached to the dermis if one wants to avoid unsightly skin irregularities after redraping.

The usual submentoplasty incision is 3 cm in length and is in the submental crease (unless a chin implant is placed). Once the submentoplasty incision is made, an electrocautery with a Colorado needle tip is used to achieve hemostasis and dissect into the plane between the platysma and the subcutaneous fat. Facelift scissors are then used to create a flap of skin with approximately 5 mm of fat attached to the dermis (Fig. 24.16). Closed liposuction is not preformed prior to submentoplasty because control of the thickness of the skin flap can be more precisely controlled using a combination of scissor dissection to elevate the flap and open liposuction under direct visualization. The dissection is extended to the posterior border of the mandible laterally and down to the inferior border of the thyroid cartilage. Care is taken to ensure that the dermis is not exposed or injured and that the undersurface of the flap is smooth. This type of wide undermining eliminates puckering and bunching of the skin and sets the stage for an aesthetic redraping of the skin once the problems with the underlying tissues have been dealt with. Next, we use a flat 7 mm spatulated cannula to liposuction the fat directly over the platysma under direct vision. Again the goal is to leave a smooth surface.

Visualization can be enhanced with a lighted tongue “sweetheart” retractor. The medial edges of the platysma are then identified and grasped with a hemostat or Kelly clamp. The surgeon has the option to resect lax platysma or perform a midline plication. If suture plication is used; the platysma must be healthy and thick or the patient will be at risk for relapse of

b

The dotted line represents the area of undermining for a classic submentoplasty

Fig. 24.16 Initial sharp scissor dissection for a submentoplasty from a submental crease incision “prior to” any liposuction in order to leave a uniform thickness (5–7 mm) of fat attached to the undersurface of the skin. A smooth fatty layer protecting the dermis is critical for avoiding fibrous and surface irregularities during liposuction, submentoplasty, or facelifting. The dotted line represents the area of undermining for a classic submentoplasty

because of dehiscence of the plication. The electrocautery with a Colorado tip is then used to resect the midline platysma and subplatysmal fat (Fig. 24.17). We make sure not to over-resect fat in this area as this may also lead to a displeasing midline contour postoperatively. It is in this region that the anterior jugular veins

Platysma

Subplatysmal fat

Mylohyoid

can cause problematic bleeding. Therefore, excellent visualization and precise resection of subplatysmal fat is essential. If bleeding is encountered, precise application of cautery or suture ligation will allow the operation to proceed. Once the midline fat has been resected, a decision is made as to how much tension will be present if a simple midline platysmal plication is performed. If tension is deemed excessive, we identify the hyoid and begin to back-cut the platysma at this level with the Colorado tip electrocautery. The incision extends approximately 5–7 cm in length and parallels the inferior border of the mandible. Extreme care is taken to avoid injury to nerves or vessels. Next, the platysma is undermined superiorly along the length of the back-cut. If submandibular gland ptosis is a concern, resection of the superficial lobe of the gland is performed at this time. Once the platysma has been dissected free bilaterally, a corset platysmaplasty can be performed. Beginning inferiorly, the medial platysmaplasty can be performed. The medial platysmal edges are sutured to the hyoid fascia with a 2–0 Monocryl suture (Fig. 24.18). A running suture is then used to further plicate the medial edges of the platysma in a cephalad direction. At the completion of the plication the surface of the platysma must be very smooth

(Fig. 24.19). If a chin implant is to be used to help with deficient chin projection or a low hyoid position, the implant is placed at this time.

When patients present with an obese neck, with or without platysmal banding, we perform a more aggressive submentoplasty. The submentoplasty incision and scissor dissection proceeds in the same manner as described earlier. Again, extreme care is taken to leave a uniform layer of fat attached to the dermis that is approximately 5 mm in thickness. Open liposuction is performed under direct vision and submental fat excised in the midline. Next, lateral division of the platysma is performed at the level of the hyoid, and parallel to the inferior border of the mandible. At this point, instead of performing a corset platysmaplasty a larger amount of platysma is resected superior to this back-cut incision (Fig. 24.20). Patients with heavy difficult necks often have very thin platysma muscle that increases the likelihood of recurrence with only a midline corset plication. A more aggressive resection of the platysma allows properly debulking these heavy necks of suband preplatysmal fat that result in a much more refined aesthetic improvement. The deep tissues must be left with a smooth surface. Once the resection is complete, we can “fine tune” or sculpt the surface contour with judicious use of the electrocautery. With this kind of aggressive platysmal resection, it is also helpful to leave a slightly thicker layer of fat on the skin flap (5–7 mm). The technique is challenging but we find it to be a more aesthetically pleasing and durable result in those patients with a thick difficult neck (Fig. 24.21). Using this approach, we no longer worry about the late reappearance of midline paramedian platysmal bands resulting from the breakdown of a plicated

Fig. 24.20 A more aggressive platysmal resection. This technique is useful for heavier necks with extensive platysmal laxity

atretic platysma. Obviously, this type of aggressive resection of the platysma is not appropriate in the patient with a thin neck.

Type III (Rhytidectomy with or without liposuction): In patients with jowling and cutis laxis of the face with a thin neck, we proceed with rhytidectomy and rely on the posterior direction of pull to eliminate laxity in the neck and jowls (Fig. 24.22). When we have decided that cervicofacial liposuction is necessary with the facelift, the liposuction procedure is performed first. This can help to facilitate later flap dissection.

Type IV (Rhytidectomy and submentoplasty with or without liposuction): In neck rejuvenation, patients who present with jowling and significantly lax tissue below the mandible, a rhytidectomy will be needed along with a submentoplasty (Fig. 24.23). Some surgeons believe that a submentoplasty is rarely necessary when performing a facelift because moving the SMAS and platysma posteriorly is adequate to improve anterior neck contour. We feel that this leads to early recurrence of neck laxity and platysmal banding. In addition, some surgeons feel that the anterior plication of the platysma may inhibit posterior elevation of the jowl thereby diminishing the

efficacy of the facelift (Fig. 24.24). We believe that submentoplasty is virtually always a necessary adjunct to a facelift. Maintaining harmony between the aging face and neck is always an important goal, and we feel that it is the rare patient that will not benefit from directly rejuvenating the neck at the same time that the facelift is being performed. This is especially true if there is heavy subplatysmal fat or major platysmal laxity.

In all postoperative neck rejuvenation patients, care is taken to ensure that the skin is smooth and that folding or wrinkling does not occur when the tailored piece of Reston Foam® is placed. The area is then dressed.