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8.7 Other Options to Avoid Inadequate Results in Difficult Necks
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Fig. 8.17 The horizontal muscle splitting exposes the
right submandibular gland. The periglandular capsule is
opened, and the gland is freed from its adhesions and
mobilized.
The submandibular space is in continuity with the
anterior neck due to the horizontal platysma split.
In the case of hemorrhage, the blood collection
will not remain in a closed space, creating compression on the airways, but will spread into the
anterior neck and can be treated like a neck hematoma, avoiding life-threatening situations.
23
8.7 Other Options to Avoid
Inadequate Results in Difficult
Necks: Cyanoacr ylate Glue and
Platysmectomy
Despite the LSD technique and its good efficacy in
treating skin laxity, in patients with considerable
excess skin, we still have had some disappointments
due to recurrent excess anterior skin excess. During
last 2 years, we have been using a different technique based on the use of a powerful cyanoacrylate
glue that can create instant adhesion between the
skin flaps and the deep tissues, allowing us to ameliorate the result of our traction maneuvers on the
skin.
Nowadays, in some patients with overabundant
and flaccid excess skin on the anterior neck, a
modified variation of the LSD technique is carried
out. The neck is widely undermined in the subcutaneous plane up to 2 to 3 cm from the midline.
The platysma muscle, which, in this case, has no
more adherence to the skin, is transected and sutured, as in the above-described LSD technique.
Fig. 8.18 The protruding portion of the gland is
resected “step by step.”
Fig. 8.19 A large piece of the submandibular gland has
been resected.
Eventually this consists of a two-plane facelift
but with lateral platysma displacement.
When we are ready for f lap tract ion, we apply
a layer of glue on the surfaces of the flaps and
deep t issues, thr ough its specif ic sprayer device
(▶ Fig. 8.20a, b). We then strongly pull the flap
following the selected vectors (▶ Fig. 8.20c) and
apply pressure for 90 seconds to let the glue polymerize (▶ Fig. 8.20d). This creates immediate
adhesion between the skin flap and the deep tissue (▶ Fig. 8.20e). A second pull applied more
laterally on the flap followed by an additional
glue applicat ion enables us to remove a greater
amount of skin with no tension on the suture line
(▶ Fig. 8.20f, ▶ Fig. 8.21, and ▶ Fig. 8.22). Cyanoacrylate glue is much m ore powerful than any
fibrin glue as, besides having analogous benefit
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Lateral Skin-Platysma Displacement Technique
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Fig. 8.20 (a) The cyanoacr ylate glue with its CO2reservoir and applicator device. (b) Spraying the glue on the neck.
(c) The f lap is strongly pulled following the appropriate vector. (d) Uniform pressure is applied on the f lap for 90
seconds. (e) Complete adhesion of the skin flap has been achieved by the glue. (f) The excess skin can be removed
without applying any tension on the suture line.
Fig. 8.21 (a,c,e) Preoperative image of a 65-year-old female patient (status post rhytidectomy 10 years before) with
moderate amount of anterior excess skin and fat, platysma bands, and ill-defined neck contour. (b,d,f) At 18 months
postoperatively after atypical LSD 1 with full neck undermining and glue application. The cervicomandibular angle is
nicely contoured, with absence of redundant skin.
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8.9 Discussion
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Fig. 8.22 (a) Preoperatively under
forced platysma contraction. Paramedian and lateral bands are evident.
(b) Postoperatively under forced platysma contraction. There is absence
of visible bands.
Fig. 8.23 The marking outlines the areas of the
platysma muscle to be removed.
in terms of sealing and hemostasis, the former
has also a great capacity in f ixating the f l aps and
holding the traction.
In some patients with real thick hypertonic platysma, we carry out a localized platysmectomy instead of using the LSD technique (▶ Fig. 8.23).
This technique entails the following:
●
A wide subtotal subcutaneous (▶ Fig. 8.24a) and
subplatysmal undermining (▶ Fig. 8.24b).
●
The removal of a 3- to 4-cm-wide strip of platysma from its lateral to its medial border
(▶ Fig. 8.24c–e and ▶ Fig. 8.25).
●
Suturing the upper platysma flap to the mastoid
area with a posterior and slightly oblique vector
(▶ Fig. 8.26).
●
Using the glue to create a strong traction on the
anterior skin flap.
This technique has been rendered effective by the
use of the glue that fulfills the physical principles
on which the LSD technique is based, that is, “The
closer to the target area is the point of traction, the
more effective is the traction
4
” (▶ Fig. 8.27 and
▶ Fig. 8.28).
8.8 Lateral Skin-Platysma
Displacement Limitations
There are some patients in whom the LSD technique cannot achieve optimal results:
●
Patients who present considerable amount of
subcutaneous fat in the anterior neck. In these
individuals, an aggressive liposuction over the
anterior neck necessary to obtain a good cervicomandibular angle would destroy most of the
attachments between the platysma and the
skin, rendering the traction on the myocutaneous flap less effective.
●
Patients with abundant subplatysmal fat.
Although suction carried out through the lateral
subplatysmal incision can remove much of this
fat, a more precise sculpturing can be obtained
through a submental incision.
●
When digastric hypertrophy is present and submental approach is necessary to shave or to
remove the digastric muscles.
●
In very difficult necks, that is, necks with anteriorized hyoid bones, “frozen necks,” or secondary
situation with irregularities of the contour.
8.9 Discussion
All techniques based on complete neck undermin-
1,2,5,6,7,9,19,20,21,22,24,25,26,27,28,29,30,31,32,33
ing
tain risks, such as blood flow impairment, perioral
muscular disturbances, visible irregularities, and
certainly a long recovery, due to the extensive
undermined area in some cases (“leather neck”).
Another drawback of full neck undermining is that
a certain number of patients cannot be treated
entail cer-
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Lateral Skin-Platysma Displacement Technique
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Fig. 8.24 On a specimen. (a) Marking the area of platysma to be removed. (b) Undermining the platysma. (c,d) Upper
and lower incision of the muscle. (e) The muscle strip is ready to be removed.
whom there is a clear indication for a full neck
undermining, and we still carry out this approach in
a certain number of our patients. On the other hand,
we think that the LSD technique represents a valid
alternative for neck rejuvenation that can provide a
good outcome but with fewer drawbacks.
Fig. 8.25 On a patient: The strip of removed platysma is
placed on the platysmectomy area.
with this technique due to other factors, such as
smoking, different therapies, and skin conditions
that increase the risk of long flaps.
The length of the postoperative recovery period
is one of the most important factors influencing
the patient’s decision in our practice. The patients’
happiness is frequently related to the time necessary to return to a normal working or social life.
The full neck undermining technique is becoming
anachronistic and not applicable in many patients,
as it constitutes an extended withdrawal from normal life, a condition that is unacceptable for many
patients. However, there are some patients in
The main advantages of the LSD technique are
the following
●
Partial neck undermining means less time and
less risk.
●
No submental scar.
●
Good results in treating platysma bands and anterior skin laxity in many patients.
●
It has been shown that the LSD technique produces a notable decrease in the length of the postoperative recovery period of the LSD procedure
when compared to other techniques with similar
results.
●
A 9-year experience with this technique confirmed a very high patient satisfaction rate and
an extremely low complication rate.
●
An evaluation of our patients showed that at 1
year the recurrence rate of platysma bands and,
to a lesser extent, anterior neck skin laxity is
lower in patients treated with the LSD technique compared to those treated with the full
neck undermining technique.
●
The horizontal platysma transect ion allows an
easier reduction of the SMG through the retroauricular approach than through the submental
approach.
3,4
:
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8.9 Discussion
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Fig. 8.26 Tractioning the platysma flap. (a) The dotted line indicates the platysma flap after the platysmectomy. (b) A3–
0 polydioxanone suture catches the mastoid fascia. (c) The suture catches the platysma flap. (d) The suture is passed
back to the mastoid fascia. (e) The two sutures are tied.
Fig. 8.27 (a,c,e) Preoperative images of a 55-year-old female patient with noticeable paramedian platysma bands at
rest and anterior excess skin. (b,d,f) At 1 year postoperatively after platysmectomy was carried out with the application
of cyanoacrylate glue. 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.
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Lateral Skin-Platysma Displacement Technique
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Fig. 8.28 (a) Preoperative image of
the same patient in ▶ Fig. 8.27 under
forced platysma contraction. The
muscular contraction shows impressive paramedian and lateral platysma
bands. (b) At 1 year postoperatively.
Under forced platysma contraction,
there is absence of both paramedian
and lateral platysma bands and excess
skin.
8.10 Conclusions
Currently, patient demands include not only the
surgical outcome but also the length of postoperative recovery period. The duration of the period in
which patients must abandon their normal life
constitutes a critical issue in making treatment decisions. This is one of the important reasons why
many patients opt for simpler and easier solutions,
which are often inappropriate for treating important deformities, especially in the neck.
Neck rejuvenation is a very challenging issue.
Several authors have lately emphasized the importance of maneuvers directed to achieve good cervical contouring through aggressive lipectomy and
reduction of the SMG and digastric muscles in the
large majority of patients. This approach can produce precise neck sculpturing, but, in our opinion,
should not be applied indiscriminately to all patients, as it represents an aggressive solution that
entails long postoperative recovery time and a certain risk of complications.
The LSD technique represents, in our opinion, a
technique that can achieve satisfactory results
with low complication and recurrence rates and
can be carried out successfully in about 70% of the
patient candidates for neck rejuvenation.
Until 2011, we opened the neck in approximate l y
65% of our patients during a cervicofacial facelift.
After the year 2012, the percentage of neck
openings dropped to approximately 15 to 20% due
to the advantages provided by the LSD technique,
which has now become our technique of choice in
neck rejuvenation.
8.11 Expert Commentary by
Dr. Slavin
Dr. Pelle-Ceravolo and Dr. Angelini present an innovative technique that achieves a high degree of
lateral platysmal tightening that mobilizes the
entire unit of a myocutaneous flap to tighten the
neckline. Moreover, it obviates the need for a
submental incision. Although the technique has
been proven to be safe in authors’ hands, it could
increase the risk of a marginal mandibular nerve
injury as it approaches an area anteriorly where
there are multiple variations in the anatomy of
the nerve.
Two of the more frustrating problems that occur
in the context of neck rejuvenation—recurrent platysmal bands and skin la xity—are addressed by
this technique. The authors perform a platysmal
transection up to the most anterior band. Their
technique differs from the common practice of
anterior corset platysmaplasty, a fundamental maneuver for plastic surgeons, but also one that may
not completely eliminate all platysmal bands from
reappearing postoperatively. Certainly, this novel
approach produces excellent results with limited
neck dissection. It is also a very f lexible technique,
as described in the section on lateral skin displacement variations, allowing adjustments for different
patient features. Finally, the addition of cyanoacrylate glue provides another reassurance that the
mobilized myocutaneous flap will be adherent to
the deep tissues and remain affixed.
8.12 Expert Commentary by
Dr. Lin
The authors present an excellent representation of
the evolution of their technique over time with
modifications to the correction of platysmal banding and other challenging anatomical features of
the neck. The creation of platysmal flap(s) to reorient the anatomy of the neck in order to prevent
the recurrence of vertical neck banding is creative
and has been studied by the authors, with a recent
series of patients.
102
References
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(2):308–321
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fat neck. Ann Plast Surg. 1983; 10(5):371–385
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9 Surgical Techniques for Treatment of the Aging Neck
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Munique Maia and Marcelo Cunha Araujo
Abstract
Early signs of aging can be seen on the neck before
they appear on the face. A number of noninvasive
procedures are available to reverse the signs of
aging in these areas. Although these procedures
can delay the need for a facelift, they are less effective on the neck. A neck lift is a highly benef icial
and effective procedure to address the major components of aging (skin, muscle, and adipose tissue).
We present a systematic approach to analyze and
treat the aging neck based on anatomy and individual features. Different techniques are discussed
for each particular concern.
Keywords: aging n eck, surgical neck lift, facial
analysis, neck rejuvenation
Key Points
●
The systematic approach guides surgical planning and delivers consistent outcomes with low
morbidity.
●
Skin excision is the least important step in neck
rejuvenation surgery.
●
Submandibular resection should be reserved
only for severe cases. It should not be a routine
procedure.
●
We can frame the face and neck, modify angles
and shadows, and ultimately create beauty.
9.1 Introduction
When looking at a beautiful face and neck, our eyes
are directed to a well-defined mandibular border
and the elegant contour of the cervical region.
When considering neck rejuvenation, nonsurgical procedures are less effective and surgical options are the gold standard in this region. Surgical
treatments for the aging face and neck result in
better and long-lasting outcomes. The traditional
idea of lifting the neck to reverse the signs of aging
is shortcoming. We believe that modern techniques and refinements allow the surgeon to not
only lift the lax tissue but also remodel, sculpt, and
even modify and enhance features of patients
who are young and attractive. As plastic surgery is
constantly evolving, we need to amplify our goals,
accept new concepts, and develop a surgical plan
at the tridimensional level. We can frame the face
and neck, modify angles and shadows, and ultimately create beauty!
The goal of this chapter is to demonstrate the
techniques utilized by the senior author in a systematic way. The systematic approach guides surgical planning and delivers consistent outcomes
with low morbidity.
9.2 Facial Analysis and Applied
Anatomy
The transitional zone between the lower face and
neck has unique features. The cervical region has
been studied by many authors. As described by
Feldman, the cervical region has eight subunits.
The operative planning is guided by preoperative assessment of the anatomical structures and
takes into consideration each of the following
subunits:
●
Skin, which covers all subunits. Evaluation of
the skin will determine the optimal incision and
the direction of the skin pull.
●
Subcutaneous fat. Careful analysis should be done
to determine fat removal, preservation, or fat
grafting. Tw o approaches are considered: closed
approach with liposuction or open approach with
direct ex c ision .
●
Chin. Assessment of microgenia, prognathism,
and ptosis (▶ Fig. 9.1).
●
Mandibular border and jowls. Careful analysis of
the mandibular contour, jowls, and prejowl sulcus should be done (▶ Fig. 9.2).
●
Submental region. This is an important area and
needs a detailed analysis and accurate diagnosis.
Ellenbogen described the visual criteria of the
youthful neck
●
A distinct inferior mandibular border from the
mentum to the angle of the mandible with no
jowl overhang.
●
Subhyoid depression.
●
Visible thyroid cartilage.
●
Visible anterior border of the sternocleidomastoid muscle, distinct in its entire course from
the mastoid to the sternum.
46
:
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Surgical Techniques for Treatment of the Aging Neck
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Fig. 9.1 (a– c) The preoperative pictures show a 30-year-old woman with excess subcutaneous fat. The postoperative
pictures were taken 4 months after neck liposuction under local anesthesia.
Fig. 9.2 The left picture shows a thin
patient with a well-defined mandibular
border. The right picture shows a heavy
neck with an obtuse cervicomental
angle.
●
A cervicomental (CM) angle between 105 and
120 degrees (90-degree sternocleidomastoid to
the submental line).
We utilize the layered approach for diagnosis and
treatment. From superficial to deep, all struct ures
are analyzed. Skin, subcutaneous tissue, platysmal
bands, subplatysmal and interplatysmal fat, anterior digastric muscles, and perihyoid fascia and
hyoid bone.
●
Infrahyoid region. Evaluate the platysmal bands.
●
Lateral aesthetic triangle: anterior to the sternocleidomastoid muscle. Evaluate the tissue and the
submandibular glands.
106
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