Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 336 - файл
.pdf
10.2 Isolated Neck Lift: What Techniques to Use and Why?
https://t.me/medicina_free
with insertion of the needle and start of injection
within previously numbed areas. This subcutaneous
soft-tissue plane offers little resistance to the infusion of the deposited fluid. Since the fluid pressure
and not the sharp spinal needle creates the space
for the local anesthetic, there is negligible pain and
no laceration of vasculature. When submental fat
deep to the platysma is a target, fluid infusion fills
that space as well. Resistance to infusion along the
jawline resistance is also minimal, but the more adherent lateral and midfacial skin is tightly adherent
and thus mildly painful to inject, even with slow infusion. Preliminary syringe liposuction is performed
in adipose-laden necks (▶ Fig. 10.1a).
In nonobese necks, upon completion of the neck
and lower facial infiltration of dilute anesthetic,
FaceTite or an AccuTite handpiece is inserted
through an 18-gauge needle (▶ Fig. 10.1b, c). Over
the past 4 years of frequent experience, the author
now recommends the FaceTite handpiece for the
lower face and neck. For the treatment of this patient, the smaller AccuTite just became available.
Its rapid heating, 7-cm reach, and 2-mm thickness
makes it ideal for this patient’s thinner mid cheek
and periorbital region, but not so much for the
neck. I now recommend the 11-cm reach of the
3-mm-wide FaceTite for the neck.
Regardless of the handpiece, tightening of the
upper neck is through three 18-gauge needle
punctures that subdivide three zones. The central
submental port is the origin to a fan-shaped sweep
of the central zone. Along the midlateral border of
the sternocleidomastoid muscle, a puncture wound
is made for medially directed sweeps under the
mandibular border and over the central platysma.
As a bipolar handpiece is stroked with energy traveling from an active deep electrode to a passive
superficial receiving disk gliding along the skin surface (▶ Video 10.1), the operator must set the temperature upper limits for both the superficial disk
and deep probe. The upper limits of temperature
for the skin surface are from 37 to 40 °C, and the
deep emitting electrode is for ≤ 60°C. The temperature end points are adjusted to the response of the
tissues, with slow elevation to the limit encouraging
a lower setting. Multiple passes are needed to reach
selected temperature end point. A foot pedal controls the release of energy with a readout of the
sensed temperature on the console. The steady
cadence of clangs speeds up as the cutoff temper-
ature is being reached with suspension of emitting energy at triple sounds. A liberal cr isscross of
lateral to central zone is performed. Upon completion of treatment, a partial shrinkage with
Fig. 10.1 Bipolar radiofrequency tightening of the neck with liposuction. (a) A 20-mL syringe with a 1.5-mm threeholed cannula is hand aspirating 15 mL of adipose from the central neck, which undoubtedly includes subplatysmal fat.
(b) AccuTite handpiece with its 4.5-cm probe is held over the suctioned area, and (c) then lies within the defatted neck.
117
Neck Lift after Massive Weight Loss
https://t.me/medicina_free
Video 10.1 AccuTite of the neck, face, and forehead.
tightening of the skin is appreciated with improved neck contours.
Crepe and wrinkled skin are not improved with
FaceTite, and in fact may even be more obvious
because of subcutaneous tissue shrinkage. In those
cases, and when in doubt, proceed with topical bipolar radiofrequency microneedling. The companion to the FaceTite is the Morpheus8 24-pin tip,
which ejects coated needles with from 20 to 50 kJ.
The previous infusion of local anesthetic is adequate
numbing, but if extension to the lips and periorbital
region is desired, then high-concentration topical
anesthetic is applied. For thick neck skin, a 4-mm
depth of penetration is selected with 50% overlap.
A second overlapping pass is customarily done at
2-mm depth, which synergistically injure and contract both immediate subdermal and deep dermal
tissues.
Avoid Bad Results
●
Avoid disappointment in aesthetic improvement.
Realistically estimate the improvement and be
sure the patient not only understands but also
accepts an incomplete result. Be meticulous and
rhythmic in passes with adequate energy and
high enough temperature cutoff with adequate
kilojoule in each zone. Clearly prepare the patient for possible follow-up FaceTite or even a
surgical neck lift after 6 months.
●
Avoid prolonged induration or depression at entry site. Take care not to overexpose the entry
site area to radiofrequency energy.
●
Avoid facial animation weakness. Avoid injury to
the mandibular branch of the facial nerve by not
crossing the distal mandible from the lateral
neck or lower face. A direct lateral sweep from a
puncture wound near the mental foramen best
avoids mandibular branch injury during lower
facial treatment.
●
The finer and more controllable AccuTite allows
for reliable subdermal movement to avoid injury to the buccal, zygomatic, and frontal
branches of the facial nerve. Also, reduce energ y
to under 30kJ in those areas.
●
Avoid blistering skin injury. Do not push the pedal
until you know where the subdermal probe is. Do
no torque the probe against the dermis. Immediately apply cold saline or ice for skin blisters.
●
Avoid prolong swelling and induration. When
high cutoff limits are chosen, avoid overtreatment. Apply reliable, comfortable, and prolonged elastic skin support. Early posttreatment
lymphatic massage, preferably with HiVamat
and external ultrasound, works and is reassuring. Percutaneous bipolar radiofrequency early
scar modulation with InMode’s Forma has softened many indurated areas of healing.
Two recent cases are presented. The first is a near
ideal case of a mild sagging of the lower face and
neck with excess submental adiposity. The second
case is an elderly MWL patient who desires correction of her skin laxity through excision of large
stretches of skin throughout her body but not her
face.
Case Examples
Case 1
A 57-year-old w oman preferred a minimally invasi v e
approach to recontouring her face and neck to a
facelift. Her focus was the fullness of her neck, which
while loose would predictably be very loose with
hanging skin after liposuction (▶ Fig. 10.2a and
▶ Fig. 10.3a). Sixteen milliliters of fatty emulsion was
removed from the super wet neck (▶ Fi g. 10.1a).
Then AccuTite was applied for 2 kJ each to the neck,
lower face, and periorbital region (▶ Fig. 10.1b, c;
▶ Video 10.1). The correction of neck and facial skin
rolls and laxity is seen 1 year later (▶ Fig. 10.2c and
▶ Fig. 10.3b).
Case 2
A 66-year-old woman desired noninvasive reduction
of her sagging neck (▶ Fig. 10.4a and ▶ Fig. 10.5a).
After infusion of saline with xylocaine and epinephrine, FaceTite bipolar radiofrequency was applied
with external limit of 38 °C and internal limit of
118
10.2 Isolated Neck Lift: What Techniques to Use and Why?
https://t.me/medicina_free
Fig. 10.2 Right lateral marked face (a) before and (b) 4 months after AccuTite treatment was applied to the submentum
and lateral neck (2 kJ), midface (1kJ), and orbital regions (1kJ) as planned in purple.Thegreen prejowl sulcus receives 3 mL
of injected fat. In total, 16mL of fat was aspirated, and skin laxity of the submentum was corrected. (c) The jawline was
clearly defined, and the jowls flattened. The periorbital regions are smoother.
68 °C for a total of 12 kJ for the entire neck. Twenty
milliliters of fatty fluid was syringe aspirated. Eight
milliliters of aspirated fat was Telfa rolled and injected to her prejowl sulcus. Swelling lasted several
Fig. 10.3 Frontal views of the patient
in ▶ Fig. 10.2 (a) before and (b) 4
months after AccuTite treatment was
applied to the face and neck.
months but dissipated through the use of HIVAMAT
electrophysiological lymphatic massage. Six months
later, she is pleased with her new neck and jawline
contours (▶ Fig. 10.4b and ▶ Fig. 10.5b).
119
Neck Lift after Massive Weight Loss
https://t.me/medicina_free
Fig. 10.4 (a) Frontal pre-FaceTite and
20-mL syringe liposuc tion of the neck
and lipoaugmentation of the jawline in
a 65-year-old woman. (b) One year
later, a tighter and better suspended
neck can be seen. Her underlying
platysma bands are more obvious, but
are of no concern to her.
Fig. 10.5 Left lateral facial view of the
same patient as in ▶ Fig. 10.4 with
(a) before and (b) 1 year after FaceTite
and 20-mL syringe liposuction of the
neck.
10.2.2 Submental Z-Plasty with
Parallel Oblique Elliptical Excisions
of Skin
When moderate to severe deformity is predominantly submental, and especially when there are
prominent medial platysma bands, Z-plasty is favored. The patient needs to see pictures of the Zshaped scar, which zigzags from the menton to
near the thyroid cartilages. The scars tend to heal
favorably but on rare occasion may hypertrophy.
As such, patients must accept that risk. If the
lengthy Z-pattern scars are unacceptable, then a
more limited U-plasty or FaceTite is offered.
The Z is designed starting with the central incision extending vertically from the chin menton to
120
near the thyroid cartilages (▶ Fig. 10.6). Each limb
is angled 60 degrees from the central line. An elliptical excision of skin is drawn with two-thirds the
width toward the center and one-third lateral to
each limb. The inner small Z can be incised, and
the triangular flaps elevated full thickness over the
underlying platysma. Once these flaps are transposed, the accuracy of the drawn elliptical excisions down to the platysma muscle is verified and
adjusted accordingly. Subplatysmal dissection can
remove excess adipose and even hypertrophied
digastric muscle and submandibular glands. The
medial platysma bands can be imbricated, sutured
down to the hyoid fascia (preferably) and transected as desired. After defatting the Z-plasty flaps,
the left side triangular flap is suture advanced
10.2 Isolated Neck Lift: What Techniques to Use and Why?
https://t.me/medicina_free
Fig. 10.6 (a) A submental Z-plasty
with ellipses aligned over the short
limbs, having one-third of the width
lying to the outside of the limbs. The
tip of the right flap is labeled “A” and
the left flap is labeled “B.” (b) Four
years later, the transposed limbs are
on a flat submentum with faint, thin
scars. The tips labeled “A” and “B” are
seen in their interposed positions.
along the right jaw line. Then the right flap is sutured toward the thyroid cartilages. As the deep
sutures are placed between the flaps, the submentum is flattened and the tension at the base of
these flaps beautifully depresses the skin inferior
to the mandibular border. If not, then more skin
and/or adipose has to be recovered. The interpolated transposition flaps lengthen the distance
from the menton to the thyroid cartilages, which
is needed to span the increase surface of the now
deeper upper neck midline.
Submental Z-Plasty
●
Easily executed within 90 minutes, including
administering local infiltration of anesthesia.
●
Excision of both horizontal and vertical excess
skin of the midneck.
●
Adjustable extent of skin resection.
●
Access to modify the platysma and deeper
structures.
●
Scar hidden under the chin.
●
Can be combined with liposuction of the lateral
neck.
Avoid Bad Results
●
Avoid residual submental laxity or excessively
tight closure. An adequately sized Z-plasty is de-
signed, which extends from the menton to the
thyroid cartilage. The width of the short limb elliptical resections needs to be just right. Too
narrow and there will be residual laxity. Too
wide and the tight closure may dehisce or leave
wide scars. Be conservative in the initial cutout, but be prepared to excise more skin if preliminary alignment reveals laxity.
●
Avoid recurrent platysma medial bands. Not only
should medial platysma bands be securely sutured together, but the complex should also be
sutured to the suprahyoid fascia.
●
Avoid standing cones. The standing cones of the
Z-plasty corners will be prominent unless defatted or T-plasty excised.
●
Avoid e xcess submental adiposity. After the two
triangular f laps of the Z-plasty are elevated off
the platysma muscle, evenly trim the deep fat
from the flaps. Also, conservatively excise excess
midline subplatysmal fat overlying the digastric
and mylohyoid muscles.
●
Avoid triangular flap tip necrosis due to excessive
tension. The transpose triangular flaps are sewn
into position with subdermal interrupted absorbable suture from the base to the tip to progressively advance the skin under even tension.
Then they are sutured together, creating the
central transverse closure.
●
Avoid uneven closure. Using operative magnification, a running 6–0 monofilament suture precisely aligns the skin edges with a transdermal
bite in setting the corners.
●
Avoid a gap in the beard along the closure using
operative magnification and proper angulation
of the skin incision to preserve hair follicles and
align the skin closure to minimize trauma to the
follicles along the edge.
121
Neck Lift after Massive Weight Loss
https://t.me/medicina_free
Clinical Case Examples for
Submental Z-Plasty
Case 1
Submental laxity without jowls. A 52-year-old
woman lost 50 lb, leaving her with sagging and fullness of the central neck without jowls (▶ Fig. 10.7a).
Her Z-plasty is shown in ▶ Fig. 10.6. The 2-month
lateral neck image result shows complete correction
of her central laxity (▶ Fig. 10.7b), which remained
unchanged 4 years later (▶ Fig. 10.7c). Her frontal
before (▶ Fig. 10.8a) and after (4 year) views
(▶ Fig. 10.8b) also show the maintained correction
with no jow ls and minimally visible scar.
Case 2
Recurrent submental skin laxity. A 62-year-old
woman lost 110 lb after gastric bypass. Most concerned about her pelicanlike neck, she requested a
complete vertical facelift (▶ Fig. 10.9a). As lateral
facial images show 2 months later, her entire sagging neck was much improved (▶ Fig. 10.9b). As
typical for MWL-damaged skin, a year later, she
had partial recurrence of the hanging skin, so a
submental Z-plasty was planned (▶ Fig. 10.9c). The
submental improvement remains 6 years later
(▶ Fig. 10.9d). A submental Z-plasty with a central
vertical limb and obliquely oriented elliptical excisions were cut as drawn (▶ Fig. 10.10a). The medial
edges of the platysma muscle were sutured to the
hyoid fascia. The faintly, thinned scarred Z lies
on the still-flattened submentum 6 years later
(▶ Fig. 10.10b).
10.3 Role of Facelift for Neck
Excess
Candidates for neck lifts after MWL have considerable excess skin and tissue la xity of both the
face and neck. Due to the generalized severity of
the skin laxity, an isolated neck lift is rarely indicated. Having a practice with emphasis on body
contouring, from time to time, I perform a facelift on MWL, using a modified version of the
MACS lift.
a facelift that includes distinctly superior vertical
11
The most impactful neck lift is an extension of
Fig. 10.7 Left lateral facial views of the patient in ▶ Fig. 10.6. (a) Immediately pre-op with minimal jowls and obtuse and
full mentocervical angle. (b) Four months after the Z-plasty, deep and flat submentum with defined distal jawline can be
seen. (c) Four years later, the early postoperative contours are maintained.
122
10.3 Role of Facelift for Neck Excess
https://t.me/medicina_free
Fig. 10.8 The frontal facial views of
the patient in ▶ Fig. 10.6 (a) before
and (b) after the Z-plasty. The submental fullness is gone and a faint end
of the Z-plasty scar overlies her thyroid
cartilages.
Fig. 10.9 Right lateral facial views of a 63-year-old massive-weight-loss (MWL) patient with Z-plasty for partial
recurrence of neck laxity after vertical facelift. (a) Before vertical facelift with obtuse neck and poorly defined jawline
and jowls. (b) Two months after vertical facelift showing tight and flat submentum and well-defined jawline without
jowls. (c) Two years after her facelift, she shows 50% recurrence of submental skin laxity and less definition of her jawline
with a Z-plasty drawn. (d) Six years later, the submentum remains deep and flat, although the jawline is not well defined.
123
Neck Lift after Massive Weight Loss
https://t.me/medicina_free
suture advancement of the SMAS platysma complex
(▶ Fig. 10.11, ▶ Fig. 10.12, ▶ Fig. 10.13, ▶ F i g. 10.14).
For the past 15 years, I realized that both the most
effective and natural-appearing facelift has both a
vertical plication lifts of the SMAS platysma complex and the overlying skin. Following a vertical lift
with a no. 1 PDO barbed suture deep imbrication of
the SMAS/platysma complex (▶ Fig. 10.12), a vertical skin excision with lipoaugmentation of the midface was done. Compare the preoperative pictures
(▶ Fig. 10.13) with the postoperative 18-month
result (▶ Fig. 10.14).
10.4 Expert Commentary by
Dr. Slavin
This is an outstanding chapter by one of the experts in the field of reconstruction and aesthetic
improvement in the MWL patient. He tackles a difficult problem, recognizes the intrinsic changes to
the skin in this population, and comes up with a
thoughtful, multimodal approach, appreciating
that an isolated skin pull will have variable results.
10.5 Expert Commentary by
Dr. Lin
The treatment of the neck following significant
weight loss is a challenge. As noted by the author,
oftentimes external scars (i.e., Z-plasty) will be required to achieve the optimal result for neck contouring. Counseling of the patient that trading off
contour for visible scars with understanding of this
concept is emphasized in the chapter. Finally, as
mentioned, revisions may be required with continued laxity of the skin with time.
Fig. 10.10 Submental views of the
patient in ▶ Fig. 10.9. (a) Preoperative
with drawn Z-plasty and obliquely
oriented ellipses. The tips are labeled
“a” and “b.” Six years postoperatively
with transposed flaps lying flat with
the tips labeled “a” and “b.” (b) The
scars are faint and thin.
Fig. 10.11 Vertical facelift with midface fat grafting. Right lateral face on operating room table (a) before with markings
and (b) immediately after the procedure.
124
10.5 Expert Commentary by Dr. Lin
https://t.me/medicina_free
Fig. 10.12 Right lateral face of the patient in ▶ Fig. 10.11 with facelift skin flap elevated. The pattern of the planned
vertically oriented superficial musculoaponeurotic system (SMAS)/platysma imbrication with a single double-armed no.
1 PDO Quill is drawn. There are 10 essential imbrications. The first four throws securely elevate the SMAS and upper
platysma several centimeters. 1 bite is the initial oblique pass of the double-armed barbed suture deeply through the
temporalis muscle (cranial suspension). 2 and 3 are each two slightly divergent descending bites through SMAS, which
are then cinched pulling the SMAS/platysma about 1 cm cephalad. 4 is the continuation of the posterior limb through
the parotid fascia to below the angle of the mandible, which is then cinched for further vertical pull on the platysma. 5 is
the horizontally oriented series of bites through platysma taking a hairpin turn and then continuing through 6 and 7
before being cinched up to the anchoring first bites. The platysma is now lifted and pulled posterior and since the
submental skin is still attached (no open neck), it has been tightly pulled. Suture tracts 8 and 9 obliquely efface the
jowls. 10 and subsequent tidying bites flatten and secure the mushrooming imbricated tissues.
Fig. 10.13 Preoperative marked photos of the patient in ▶ Fig. 10.11 and ▶ Fig. 10.12 showing severely hanging skin in
(a) frontal, (b) right oblique, and (c) right lateral views.
125
Neck Lift after Massive Weight Loss
https://t.me/medicina_free
Fig. 10.14 (a–c) Postoperative views of the patient in ▶ Fig. 10.11, ▶ Fig. 10.12, ▶ Fig. 10.13 at 18 months showing
absence of loose and hanging skin and appropriate fullness of the midface.
References
[1] Dayan E, Chia C, Burns AJ, Theodorou S. Adjustable depth
fractional radiofrequency combined with bipolar radiofrequency: a minimally invasive combination treatment for skin
laxity. Aesthet Surg J. 2019; 39 Suppl_3:S112–S119
[2] Cronin TD, Biggs TM. The T-Z-plasty for the male “turkey
gobbler” neck. Plast Reconstr Surg. 1971; 47(6):534–538
[3] Gradinger GP. Anterior cervicoplasty in the male patient.
Plast Reconstr Surg. 2000; 106(5):1146–1154, discussion
1155
[4] Miller TA. Excision of redundant neck tissue in men with pla-
tysma plication and Z-plasty closure. Plast Reconstr Surg.
2005; 115(1):304–313
[5] Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;
85(3):333–343
[6] Hamilton JM. Submental lipectomy with skin excision. Plast
Reconstr Surg. 1993; 92(3):443–447, discussion 448
[7] Weisman PA. Simplified technique in submental lipectomy.
Plast Reconstr Surg. 1971; 48(5):443–446
[8] Yousif NJ, Matloub HS, Sanger JR. Hyoid suspension neck lift.
Plast Reconstr Surg. 2016; 138(6):1181–1190
[9] Hurwitz DJ. Comprehensive Body Contouring Surgery, Face-
lift in the MWL Patient. Geneva: Springer Verlag; 2016
[10] Labbé D, Franco RG, Nicolas J. Platysma suspension and pla-
tysmaplasty during neck lift: anatomical study and analysis
of 30 cases. Plast Reconstr Surg. 2006; 117(6):2001–2007,
discussion 2008–2010
[11] Dayan E, Burns AJ, Rohrich RJ, Theodorou S. The use of radio-
frequency in aesthetic surgery. Plast Reconstr Surg Glob
Open. 2020; 8(8):e2861–e2867
126
Соседние файлы в папке @xirurgi_2025