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7.6 Expert Commentary by Dr. Slavin
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Fig. 7.10 (a–f) Pre- and postoperative views of a 37-year-old female from a weekend lift and lip lift.
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Deep Plane Neck Lift Concepts and Technique
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be achievable. We appreciate their diligence on
offloading tension from the skin closure. Additionally, the suspension sutures of the composite mobile SMAS and skin flap powerfully reverse aging in
the lower and midface.
For surgeons undertaking this technique, extreme
caution is required operating in deep plane danger
zones to reduce risk of the cervical and mental nerve
branches. Our rhetorical question would be: How
many facial nerve injuries (whether temporary or
permanent) are acceptable? Right now, there are
only a small number of surgeons who can claim a
very high degree of safety. Furthermore, we find the
“aberrant excess volume” lateral to the hyoid to be
quite common. Failure to recognize can lead to a
fusiform fullness laterally. Generally, we find this tissue to be c om prised of fat and we carefully excise it.
We strongly agree with the authors’ belief that
vertical vector lift can obviate the need for submandibular gland excision in the large majority of
patients and have found this to be true over the
years. Although the chapter is not focused on the
use of nonsurgical techniques, we agree that RF
devices can be an extremely important element in
the rejuvenation of facial and neck skin. In our
practice, we prefer RF tightening 3 to 6 months
after the surgical necklift.
7.7 Expert Commentary by
Dr. Lin
We greatly appreciate this detailed technical description of their technique and excellent results.
It is interesting and makes sense that a generally
more substantial thickness to support that six
points of fixation for the facial soft-tissue structures
is utilized. As we know from years of experience
with nondeep plane techniques, SMAS plication or
fewer sutures may be used for vector displacement.
References
[1] Robenpour M, F uc hs Orenbach S, Hadash-Bengad R, Robenpour
O, Heller L. The Wide Suture Suspension Platysmaplasty, a
revised technique for neck rejuv ena tion: a retrospective cohort
study. J Cosmet Dermatol. 2021; 20(11):3603–3609
[2] Pérez P, Hohman MH. Neck Rejuvenation. Treasure Island, FL:
StatPearls Publishing; 2021
[3] O’Daniel TG. Optimizing outcomes in neck lift surgery.
Aesthet Surg J. 2021; 41(8):871–892
[4] Jacono A, Bryant LM. Extended deep plane facelift: incorpo-
rating facial retaining ligament release and composite flap
shifts to maximize midface, jawline and neck rejuvenation.
Clin Plast Surg. 2018; 45(4):527–554
[5] Jacono AA, Talei B. Vertical neck lifting. Facial Plast Surg Clin
North Am. 2014; 22(2):285–316
[6] Hodgkinson D. Total neck rejuvenation, harnessing the pla-
tysma in the lower neck and décolletage. Aesthetic Plast Surg.
2022; 46(1):161–172
[7] Feldman JJ. Neck Lift. Boca Raton, FL: CRC Press; 2006
[8] Connell BF, Sundine MJ, eds. Aesthetic Rejuvenation of the
Face and Neck. New York, NY: Thieme; 2016
[9] Jacono AA, Parikh SS, Kennedy WA. Anatomical comparison
of platysmal tightening using superficial musculoaponeurotic
system plication vs deep-plane rhytidectomy techniques.
Arch Facial Plast Surg. 2011; 13(6):395–397
[10] Kamer FM, Frankel AS. Isolated submentoplasty. A limited
approach to the aging neck. Arch Otolaryngol Head Neck
Surg. 1997; 123(1):66–70
[11] Athanasiou A, Rempelos G. Lore’s fascia a strong fixation
point for neck rejuvenation procedures. Clin Plast Surg. 2014;
41(1):43–49
[12] Jacono AA, Malone MH. The effect of midline corset platys-
maplasty on degree of face-lift flap elevation during concom-
itant deep-plane face-lift: a cadaveric study. JAMA Facial Plast
Surg. 2016; 18(3):183–187
88
8 Lateral Skin-Platysma Displacement Technique
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Mario Pelle-Ceravolo and Matteo A. Angelini
Abstract
The most common techniques for neck rejuvenation, despite their aggressiveness, present high platysma bands and skin laxity recurrence rate. The
lateral skin-platysma displacement (LSD) technique
entails only a lateral approach to the neck, avoiding
the submental incision. It is based on one or two
composite platysma-cutaneous flaps, which are repositioned laterally through cable sutures. This technique, besides transecting the platysma completely,
skews the anatomy of the muscle, displacing it in a
more lateral position and thus decreasing the risk of
paramedian band recurrence. The traction, applied
to the midbody of the myocutaneous flaps, achieves
also good results on skin remodeling. The advantage
of the LSD technique compared to other techniques
entailing full neck undermining are limited neck
undermining, absence of submental scar, shorter
operating time, faster patient recovery, satisfactory
resultson platysma bands and skin laxity, and easier
approach to submandibular gland reduction. Other
supplemental technical details are mentioned based
on modification of the LSD technique, on a new cyanoacrylate glue, and on a new technique named
“partial platysmectomy” used in selected cases.
Keywords: neck rejuvenation, platysma flaps, platysma ba nds, platysma transecti on, platysmectomy, anter ior neck flaccidit y, submandibular
gland reduction
Key Points
●
The most effective techniques commonly used
for neck rejuvenation, besides complications and
long postoperative course, present high platysma
bands and anterior laxity recurrence rates.
●
The LSD technique is based on full platysma
transection and on composite skin-platysma
flaps, which are pulled through different vectors and anchored to solid structures.
●
The advantages of the LSD technique are limited
neck undermining, absence of submental scar,
short operating time, fast patient recovery, satisfactory result on platysma bands and skin laxity, and easy approach to submandibular gland
reduction.
●
Different types of LSD techniques exist based on
diverse vectors (LSD V and LSD P) and number
of flaps (LSD 1 and LSD 2). Each variation applies to specific anatomical features.
●
A new cyanoacrylate glue offers an exciting tool
that enhances the result of the skin traction and
allows the removal of cutaneous laxity with no
tension on the suture lines.
8.1 Patient Consideration,
Indications, and Contraindications
Skin laxity and platysma bands are the most common features of aging in the anterior neck area.
The excess skin is usually confined to the lateral
neck areas in younger people (< 40 years). In most
older patients (> 60 years), overabundant skin accumulates particularly in the anterior neck region.
Skin laxity of the neck is commonly treated
through skin–muscle undermining, traction applying specific vectors, and removal of overabundant
tissue.
Platysma bands may be any of the following:
●
Hypertonic: The underlying muscle is thick and
appears like a violin string, also when relaxed.
●
Hypotonic: The platysma is flaccid and thin.
●
Pseudobands: The bands consist only of a skinfold without muscle inside.
The hypertonic bands are the most difficult to
eradicate and present a high recurrence rate in
spite of aggressive treatments.
8.2 What Technique to Use and
Why?
For more than 25 years (1983–2009) we have used
a technique based on complete neck undermining
and full-width platysma transection to treat platysma bands and anterior neck skin laxity.
In a study published in 2016, we evaluated the
recurrence rate of anterior skin laxity and platysma
bands. At 1 year postoperatively, 48% of patients
showed recurrent anterior skin excess and 45% had
recurrence of bands.
Due to the disappointing results of this technique, along with all the disadvantages of a complex
3
1,2
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operation, we studied and experienced another approach to treat platysma bands and anterior skin
laxity and developed a new technique named lateral
skin-platysma displacement (LSD) technique.
4
8.3 The Rationale of Lateral
Skin-Platysma Displacement
This technique entails only a lateral approach
without any submental incision and anterior neck
undermining. The platysma is undermined, up to
its medial border starting on its midbody and not
on its posterior border, with the aim of rendering
it mobile. This is followed by horizontal muscle
transection, strong skin–muscle flap traction in a
lateral direction, and then suturing to the flap to
the mastoid fascia or to the platysma-auricular ligament using cable stitches.
This maneuver results in a shift of the muscle
from the anterior to the lateral neck area, leaving
little muscular tissue in the anterior neck. This maneuver also completely skews the anatomy of the
platysma by relocating the muscle in a more lateral and horizontal position, thus definitely decreasing the risk of formation of new bands.
Physics teaches us that the pulling effect of traction on elastic tissue decreases as the distance
between the place where the trac tion is applied
and the target area increases.
Most classical techniques pull the skin or skin/
muscle cervical flap from its lat eral border to redrape
the skin of the anterior neck.
This action has only a modest effect on remodeling
the anterior neck skin, as the site where traction is
applied is 12 to 14 cm away from the target area
where the effect of the traction is desired (i.e., the
anterior neck).
In contrast, exerting traction on the midbody of
the platysma-skin flap, that is, closer to the anterior neck, is more effective in treating anterior skin
laxity.
Moreover, pulling the platysma flap without
undermining it, as we do during the full transection technique, means that the traction is exerted
on a muscle that is adherent to the deep tissue,
which means after it has been pulled laterally and
sutured under tension, it will have the tendency to
resume its previous position. A more efficient remodeling of the anterior skin is obtained if traction
is exerted on the platysma, after having undermined it from the deep investing fascia. This is followed by tacking the muscle at a shorter distance
5,6,7,8,9,10,11,12,13,14,15
from the midline, pulling it laterally together with
the skin and suturing the myocutaneous flap to the
mastoid fascia or the platysma-auricular ligament.
The traction exerted on the midbody of the
musculocutaneous f lap allows for the removal of a
larger quantity of excess skin at the retroauricular
area without exerting excessive tension.
Guerrero-Santos et al,
Gonzalez
similar rationale but with different technical details.
blemishes over the anterior neck (digastric muscle
hypertrophy, presence of perihyoid fascia, etc.), the
LSD technique is not the appropriate technique, as
an anterior approach would be indicated to treat
each specific issue.
13,18
have published a technique based on a
When other factors are responsible for different
16
Guerrerosantos,17and
8.4 Technique
The patient is marked in the upright position. The
anterior vertical platysma bands are marked, and a
5- to 6-cm vertical line indicating the incision into
the midbody of the platysma is drawn parallel and
6 to 7 cm lateral to the midline, keeping its upper
end at 4 cm from the lower mandibular border. A
horizontal line is marked between the lowest point
of the vertical platysma incision and a point at 2 cm
below the lower border of the hyoid bone to indicate the line of the platysma transection (▶ Fig. 8.1).
After having prepared and infiltrated the area to
be undermined with 250 mL of saline containing
20 mL of mepivacaine 2% and 2 mg of epinephrine,
we carry out cutaneous undermining, which, in
the neck area, extends to approximately 1.5cm beneath the marked vertical incision on the platysma. Thus, approximately 5 to 6cm of anterior neck
skin on each side is not undermined and remains
attached to the platysma (▶ Fig. 8.2; ▶ Video 8.1).
After carrying out good hemostasis, we make a
5- to 6-cm vertical eyelet using Metzenbaum scissors on the platysma parallel to its fibers, following
the preoperative marking, that is, 1 cm lateral to
the limit of the cutaneous undermining. The highest point of this incision is never closer than 4 cm
to the mandibular border to avoid any injury to
the mandibular branch (▶ Fig. 8.3).
A horizontal tunnel under the muscle is carried
out by spreading the scissors in the subplatysmal
plane to reach a point beyond the medial border of
the anterior platysma band (▶ Fig. 8.4).
We undermine the platysma from lateral to
medial bluntly, taking care not to injure the facial
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8.5 Vectors of Traction
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Fig. 8.1 First we mark the hyoid bone
(single green spot), then the paramedian platysma band (vertical red line),
then the 5- to 6-cm-long vertical
incision on the platysma (lateral vertical
blue line) at 6 to 7 cm from the midline,
and then the platysma transection line
from the bottom of the vertical
incision on the platysma to a point
that is 1.5 to 2 cm lower than the
hyoid bone.
Fig. 8.2 The cervical skin flap is undermined up to 5 to
6 cm from the midline. The undermining overcomes
about 1.5 cm of the vertical incision on the platysma.
vein, which is frequently visible underneath the
muscle at the level of the posterior border of the
submandibular gland (SMG). This maneuver is essential to obtain an adequate mobilization of the
platysma. Then we insert a slim retractor under
the muscle to check that no muscular tissue is left
behind and to avoid injury to any structure deep
to the muscle. We divide the platysma in its full
thickness horizontally to its medial border, ensuring that all medial platysma fibers were sectioned
(▶ Fig. 8.5 and ▶ Fig. 8.6).
Once the platysma has been mobilized, we carry
out the traction of the myocutaneous flap.
8.5 Vectors of Traction
The vector of tract ion may vary, resulting either in
a posterior (“LSD P”; ▶ Fig. 8.7) or in a vertical vector (“LSD V”; ▶ Fig. 8.8).
Video 8.1 The lateral skin-platysma displacement
(“LSD”) technique: a new and proven technique for
neck rejuvenation.
When we opt for LSD P, we pass a 3–0 PDS suture into the mastoid aponeurosis. The needle then
takes a solid bite into the lower portion of the
upper platysma flap and then is passed again into
the mastoid aponeurosis (at ~5 cm behind and 10–
12 cm below the tragus) in an area posterior to the
course of the greater auricular nerve. The suture is
not tied at this time (▶ Fig. 8.9).
A second similar suture is placed to reinforce the
first between the lower flap and a site 1 to 1.5 cm
cranial than the first one on the mastoid fascia.
One or two additional sutures are placed between the upper platysma flap and the mastoid
fascia 1 to 1.5 cm cranially to the previous ones. At
the end of suturing, we pull on the sutures to evaluate the adequateness of the traction.
Since the platysma does not reach the mastoid
aponeurosis, we use “cable” sutures to hold the
muscle in position (▶ Fig. 8.10).
Once the four sutures are in place, they are tied,
starting with the lower ones, securely but not
tightly to avoid cheesewiring the muscle.
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Fig. 8.3 (a,b) The scissors carry out the vertical incision on the platysma at 4 cm lower than the mandibular border to
avoid the risk of injuring the mandibular nerve.
Fig. 8.4 (a,b) The subplatysmal undermining is carried out beyond the medial border of the muscle. Medially to the
vertical line, the whole platysma is still attached to the skin.
Fig. 8.5 (a,b) The platysma is completely transected from its lateral incision to its medial border.
The lower platysma flap is t reated only when
excess skin is obvious in the lower neck area. In
these patients, similar cable suturing is carried out
between the lower platysma flap and the lower
mastoid area.
When we opt for “LSD V,” the anchor point is no
more on the mastoid area but the platysmaauricular ligament, about 2 cm caudad to the
tragus. When two platysma flaps are used, the
upper flap is anchored to the platysma-auricular
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8.5 Vectors of Traction
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Fig. 8.6 Inspecting the transection
line, checking out that no muscular
fibers has been left behind. Used with
permission from Pelle-Ceravolo M,
Angelini M. Lateral Skin-Platysma
Displacement: A New Approach to
Neck Rejuvenation Through a Lateral
Approach. Clin Plast Surg. 2019
Oct;46(4):587–602.
Fig. 8.7 (a,b) The skin-platysma flap may be pulled through a horizontal vector and attached to the mastoid fascia (“LSD P”).
Fig. 8.8 (a,b) The skin-platysma flap may be pulled through a vertical vector and attached to the platysma-auricular
fascia (“LSD V”).
ligament and the lower flap is anchored to the
mastoid fascia.
Each suture is passed back and forth (catching
first the mastoid fascia or the platysma-auricular
ligament, then the platysma, and again the mastoid
fascia or the platysma-auricular ligament), leaving approximately 1 cm of space between the two
threads to decrease the amount of fat bulging
through the sutures. Sometimes fat protruding
between the sutures is treated by cauterization.
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Fig. 8.9 Passing a suture between the myocutaneous
flap and the mastoid aponeurosis.
Fig. 8.10 Cable sutures are used (due to the long
distance between the myocutaneous flap and the
mastoid aponeurosis) to avoid excessive tension and
“cheesewiring.”
Fig. 8.11 (a) Preoperative image of a
57-year-old female patient showing fat
neck treated trough LSD V-1 associated with supra- and subplatysmal
liposuction. (b) At 6 months postoperatively. Improvement of the cervicomandibular angle with satisfactory
skin remodeling.
The choice between the two vectors is based on
the anatomy of the cervicomandibular area.
LSD V has more power in defining the cervicomandibular angle but creates a certain fullness
below the mandibular angle (▶ Fig. 8.11), whereas
LSD P has less power on the cervicomental angle
but achieves a better outlining of the mandible line
and avoids any excess volume over the submandibular area (▶ Fig. 8.12).
Furthermore, in patients in whom the SMG is already visible and no reduction is planned, LSD P is,
usually, the selected option. When in doubt, we
try both vectors and then choose the one that
shows the best result.
8.6 Lateral Skin-Platysma
Displacement Variations
The level of plat ysma transection may vary according to the patient’s features and mainly the presence of lower cervical skin flaccidity. In a patient
without low cervical skin flaccidity, the transection line starts at about 9 cm from the mandible
ending at 2 cm below the hyoid bone, and only one
myocutaneous flap is used for traction (“LSD 1”;
▶ Fig. 8.13).
This is the most frequently used technique at
the present time.
When lower neck cutaneous laxity is present,
the transection line is higher, starting at about
7 cm from the mandible and ending at 2 cm below the hyoid bone, and two myocutaneous flaps
are confectioned and (“ LSD 2”; ▶ Fig. 8.14 and
▶ Fig. 8.15).
The strong traction on the mobilized plat ysma
skews the alignment of the muscular fibers and
moves the muscle away from the anterior neck,
displacing it laterally. Little platysma is left over
the anterior neck, which explains why this technique entails a low risk of band recurrence
(▶ Fig. 8.16).
As the platysma maintains its attachments to
the skin of the anterior neck, traction on the platysma creates a powerful pull on the anterior neck
skin, which is displaced laterally. Moving the excess skin closer to the mastoid area facilitates the
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8.6 Lateral Skin-Platysma Displacement Variations
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Fig. 8.12 (a,c) Preoperative image of a
63-year-old female patient with moderate skin laxity and obvious submandibular gland protrusion. (b,d) At 18
months postoperatively after LSD P-1
with submandibular gland reduction
and secondary mentoplasty. Good
cervicomandibular angle was achieved.
The gland treatment is mandatory in
such a case to obtain adequate neck
contour. (a,b,c) Used with permission
from Pelle-Ceravolo M, Angelini M.
Lateral Skin-Platysma Displacement:
A New Approach to Neck Rejuvenation
Through a Lateral Approach. Clin Plast
Surg. 2019 Oct;46(4):587–602.
(d) Reproduced from Araujo M, Boggio
R, Maino M, Uebel C, Viterbo F.
Cirurgia Plástica da Face e Cosmiatria.
Thieme; Brazil, 2024.
Fig. 8.13 (a,b) An L-shaped incision
creates one single myocutaneous flap.
Nothing is done on the lower f lap in
the absence of lower neck flaccidity
(“LSD1”).
removal of a larger amount of skin on the retroauricular area without tension.
The lateral portion of the platysma is mostly
left undisturbed unless some lateral platysma
bands required treatment. In this case, we remove
a horizontal strip of the lateral platysma starting
from its lateral border at 5 to 6 cm from the lower
mandibular border to avoid injury to the mandibular nerve, which runs more cranially to this point.
Fig. 8.14 (a,b) In the presence of lower
cervical flaccidity, two myocutaneous
flaps are created and pulled laterally
through cable sutures (“LSD 2”).
In patients with excess fat over the anterior
neck, liposuction is performed at the beginning of
the procedure, that is, before the skin under mining phase. Superficial liposuction is car ried out
through a small incision in the submental fold.
Subplatysmal liposuction is done after the tunnel
under the muscle has been created through the
same t unnel or through a minimal submental
incision.
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Fig. 8.15 (a,c) Preoperative image of a
60-year-old female patient with the
presence of platysma bands and skin
laxity also in the lower neck. (b,d) At
2 years postoperatively after LSD P-2,
there is absence of the platysma
bands. The lower cervical skin laxity
has noticeably improved. Used with
permission from Pelle-Ceravolo M,
Angelini M. Lateral Skin-Platysma
Displacement: A New Approach to
Neck Rejuvenation Through a Lateral
Approach. Clin Plast Surg. 2019
Oct;46(4):587–602.
Fig. 8.16 On a specimen. (a) LSD 1: Pulling the platysma flap displaces the muscle laterally and the skin that is attached
to it. (b) The procedure has been carried out only on the right side. Very little platysma is left on the anterior neck. On
the opposite untreated site, the whole platysma is on the anterior neck. Used with permission from Pelle-Ceravolo M,
Angelini M. Lateral Skin-Platysma Displacement: A New Approach to Neck Rejuvenation Through a Lateral Approach.
Clin Plast Surg. 2019 Oc t;46(4):587–602.
8.6.1 Submandibular Gland
Resection
SMG reduction is disliked by many surgeons who
consider it too aggressive to be combined with a
facelift. In our opinion, which is shared by many
other authoritative colleagues,
ment is indicated in a considerable number of patients (about 30–35% of our patients), and in many
of them, it represents a “conditio sine qua non” if
satisfactory results are to be obtained. Even slightly
visible glands preoperatively may become obvious
after neck contouring maneuvers.
The horizontal incision on the platysma carried
out via the LSD technique exposes the SMG and
4,5,11,19,20,21
this treat-
constitutes an easy approach for gland reduction
(▶ Fig. 8.17, ▶ Fig. 8.18, ▶ Fig. 8.19).
For many years we have carried out gland re-
duction through a submental approach.
Indeed, from the year 2010 onward, in all patients with obvious SMG and submitted to LSD, we
began to use the retroauricular transplatysmal approach routinely to reduce the gland, as we found
that it offers numerous advantages compared to
the submental approach:
●
Wider exposure.
●
Easier hemostasis.
●
Faster execution.
●
Absence of submental scar.
●
No risk of compressing hematoma.
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6,7,9,18,22,23
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