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1.8 Anterior Digastric and Mylohyoid Muscles
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Bordering on the neck from above, it is formed in
part by the mandibular ligament at its caudal apex.
The labiomandibular fold, comprising skin-wrapped
cheek fat lateral to the crease, commonly requires
consideration when choosing between a cheek lift
(which improves this) or an isolated neck lift (which
does not).
37
Just below the chin, the submental ligaments provide an anchor to the submental skin
crease, likely a result of direct attachment to the
platysma by fasciocutaneous adhesions, while the
platysma has its own independent attachment to
the underlying bone by separate osteofascial fibers.
Laterally, the neck is attached behind the ear to
both the periosteum of the mastoid bone and the
investing deep fascia over the origin of the sternomastoid muscle by a patch of dense connective tissue, the osteofasciocutaneous mastoid-cutaneous
ligament.
39
The only separation between the skin
from the deep fascia in this region is a thin layer of
yellow and white fibrofatty areolar tissue. Within
this thin layer, the terminal mastoid branches of the
great auricular nerve and the lesser occipital nerve
are found.
Meshing with the above-mentioned mastoid-
cutaneous ligaments are the fasciocutaneous
platysma-auricular ligaments, which radiate outward from the skin around the base of the earlobe
and converge with the superficial fascia (platysma–
SMAS layer) below and in front of the ear as well as
the medial sternomastoid-cutaneous filaments
and the upper lateral sternomastoid-cutaneous
ligaments.
40
Typically, at least the most superficial
of these fibers comprising the platysma-auricular
ligament must be cut to free the skin around the
lower ear whenever an earlobe-base incision is
used for a neck lift procedure.
10
In patients presenting with an attached earlobe,
or more severely those who have a congenital pixie earlobe that is pulled caudally toward the angle
of the jaw, there is a thick linear stretch of the
platysma-auricular ligament that forms a distinct
white band tethering the earlobe downward. By
way of a simple electrocautery release of this ligamentous tether, the earlobe can be corrected to
allow for upward retraction and a more pleasant
15
contour.
Lateral (thicker) and medial (thinner)
sternomastoid-cutaneous retaining ligaments in
the neck form the fibrous connection between the
muscle and the skin in the plane of dissection in
neck lift surgery. The relative thickness of these retaining ligaments can often determine the level of
difficulty of neck skin flap elevation, particularly in
the lateral neck. Further medial in the neck are the
medial platysma-cutaneous filaments, the vertical
columns joining the medial edges of the platysma
muscle bellies to the skin.
12
These filaments are
likely responsible for static muscle bands in the medial neck.
10
Finally, the skin crease retaining filaments are
a set of organized retinacula cutis holding the deep
horizontal anterior and lateral neck skin creases as
well as the lateral neck vertical skin creases rela-
38
tively tightly adhered to the underlying fascia.
Typically, severing these retaining filaments while
undermining the neck skin containing the crease
significantly reduces the crease. However, in some
cases the dermis within the crease is thinner and
more compact than it is in the surrounding skin,
making it harder to achieve full eradication of the
crease with skin undermining alone.
10
1.7 Subplatysmal Fat
The subplatysmal fat lies subcutaneously beneath
the superficial fascia of the neck, and as such is attached to the underlying investing deep fascia and
periosteum. As such, this layer of fat tends to be
more fibrous, making it more difficult to remove
than supraplatysmal fat. An equivalent example of
this fatty tissue layer in the face would be the subSMAS fat in the cheek.
42
At the neck midline, the
fat sitting between the medial edges of the platysma muscle bellies is often referred to as interplatysmal fat or midline subplatysmal fat. Strongly
anchoring this interplatysmal fat to the hyoid
bone, perihyoid fascia, digastric muscles, and investing deep fascia of the midline neck is the hyoid
ligament. The quantity of subplatysmal fat can be
quite variable depending on the patient.
1.8 Anterior Digastric and
Mylohyoid Muscles
The submental triangle is comprised of two anterior
bellies of the digastric muscles and the body of the
hyoid bone, with the mylohyoid muscles acting as a
common oral diaphragm between the floor of the
submental triangle and the floor of the mouth.
main actions of the anterior digastric muscles are to
elevate the hyoid bone and provide stabilization
during speech and swallowing, as well as to pull the
jaw downward against resistance. The main action
41
10
2
The
7
Neck Anatomy
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of the mylohyoids is to also elevate the hyoid bone,
in addition to the floor of the mouth and tongue
during speech and swallowing. In the majority of
patients, the mylohyoid muscles are hidden from
view during neck lift surgery, as the anterior digastric muscles are completely covering them.
10
The
anterior belly of the digastric muscle emerges from
the digastric fossae of the mandible, connecting
with the posterior bellies by way of a round intermediate tendon (splitting the stylohyoid muscle)
held in place by a fascial sling attached to the body
and greater horn of the hyoid bone.
43
The mylohyoid muscles arise from the mylo-
hyoid line at the inner surface of the mandible, extending diagonally across the entire length of the
body of the lower jaw (from below the third molar
to between the mental spine and digastric fossa).
The mylohyoid line creates a separation between
the fossa for the sublingual salivary gland from the
fossa for the submandibular salivary gland, allowing for the fibers of the mylohyoid muscles to run
inferomedially and insert into the body of the
hyoid bone and join its opposite along a median
raphe extending vertically from the hyoid to the
mandible. Posteriorly, the muscle has an oblique
trajectory and is free.
It is not uncommon for gaps between the fibers
of the mylohyoid muscle to lead to herniation of
soft tissues in the floor of the mouth (e.g., the sublingual glands), which can produce a mass bulging
from the submandibular triangle.
10
Neurovascular supply to the mylohyoid and anterior digastric muscles comes from the mylohyoid
nerve and the submental artery and vein (in addition to a small mylohyoid artery). This neurovascular bundle runs together just under the lower border of the mandible atop the mylohyoid muscle
within the capsule of the submandibular salivary
gland to the lateral edge of the anterior digastric.
1.9 The Facial Nerve and Lower
Lip
Likely of greatest clinical significance to surgeons
performing neck rejuvenation procedures is the
anatomical layout of the facial nerve branches providing lower lip depressor innervation, as the
iatrogenic injury to these branches can commonly
cause deformities characterized by the absence of
downward motion on the affected side during
smile and/or speech, as well as a slight rise of the
affected hemilip margin.
44
These deformities can
be temporary or permanent, as discussed earlier in
this chapter, with the vast majority of cases demonstrating signs of injury being mild and transient.
Complete recovery from the neuropraxia (local
conduction blocks) of these nerve branches by
segmental remyelination tends to occur within 6
weeks postoperatively.
45
Should the nerve be injured to the point of axonotmesis, the nerve regenerates at a rate of 1 to 3 mm per day following surgery, with full recovery typically occurring within
4 months postoperatively.
10
1.9.1 Mandibular and Cervical
Nerve Branches
The main trunk of the facial nerve typically bifur-
2
cates within the parotid gland, just posterior to
the ramus of the mandible approximately onethird of the way from the angle of the mandible to
the mandibular condyle. This bifurcation typically
provides two main divisions: the temporofacial division (cephalic) and the cervicofacial (caudal).
There are rare cases of main trunk division into
more than two subsidiaries. While considerable
variation exists in the exact pattern of subdivision
of these nerve branches within the parotid gland
(even from one side to the other in the same patient), the iconic branches are termed frontal (temporal), zygomatic, buccal, marginal mandibular,
and cervical, making their way toward the muscles
of facial expression.
Of particular relevance and anatomical importance to neck rejuvenation procedures are the
marginal mandibular branch and the cervical
branch of the facial nerve. The first (marginal mandibular) innervates the depressor anguli oris (discussed previously), depressor labii inferioris, and/
or the mentalis muscles, while the latter (cervical)
innervates the platysma—exclusively.
The marginal mandibular nerve (or nerves) exits
the anteroinferior edge of the parotid gland approximately 0.5 to 1.5 cm anterior to the posterior
border of the mandible, and from 1.5 cm above the
angle of the mandible to 1 cm below the angle.
emerges in variable numbers: as a single nerve
(40%), two branches (50%), or three to four branches
(10%), with each branch traversing forward above,
along, or below the jawline within a horizontal
bandwidth extending from 2 cm above the inferior
border of the mandible to 3 cm below.
branches that remain above the jawline are typically
encapsulated by the parotideomasseteric fascia,
46
2
48
47
Those
2
It
8
References
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running forward over the masseter into the buccal
fat pad, which is also protected by the same deep
fascial membrane.
50
Those branches that exit the
parotid gland below the jawline tend to remain beneath the investing deep fascia before perforating
the deep fascia just below the anterior tip of the parotid to enter the subplatysmal plane, then continuing forward just superficial to the capsule of the
submandibular salivary gland. Interestingly, most if
not all marginal mandibular nerve branches that
run below the jawline end up taking turns in their
trajectory to end up above the jawline before entering their target muscles of innervation in the lower
2
lip.
As the marginal mandibular branch of the facial nerve traverses the path of the facial vein
and facial ar tery along th e jawline, the nerve
branch is found superficial to the facial vein over
the lower masseter muscle edge in 95% of cases,
while the nerve branch traverses superf icial to
the more anteriorly situated facial artery in (theoretically) 100% of cases—although there may be
some occasional rami that do pass deep to the
facial artery.
10
The main branch of the cervical nerve typically
descends within the parotid gland posterior to the
ramus of the mandible, then splitting off from the
marginal mandibular branch prio r to emerging at
the caudal tip of the gland accompanied by the
retromandibular vein (eventually becoming the
external jugular vein, discussed previously). The
main cervical branch gives off either a single or
multiple superior cervical branches, which pierce
the investing deep fascia at or just inferior to the
jawline. These branches then turn forward and
travel parallel to the jawline on the deep surface
of the platysma before splitting into several
smaller branches entering the platys ma 2 to 3 cm
medial to the medial edge of the sternomastoid
muscle to in nervate the superior two-thirds of
the platysma muscle.
51
The somewhat more predictable inferior cervical branch runs downward for 3 to 4 cm beneath
the investing deep fascia along or just below the
anterior edge of the sternomastoid muscle, then
penetrating the investing deep fascia before continuing forward parallel to the mandible just beneath the platysma. The rami also emerge at this
point to innervate the remaining inferior one-third
of the platysma muscle, commonly anastomosing
with the sensory transverse cutaneous nerves of
the neck.
1.10 Conclusion
The importance of precision in one’s knowledge of
facial and neck anatomy cannot be overstated. The
techniques forthcoming in this textbook, both surgical and nonsurgical, to rejuvenate the neck are
bound by the limits of the aforementioned anatomical structures. We hope this can serve as an
accurate and clinically relevant reference to the
important anatomy as these techniques are discussed herein.
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2 Neck Rejuvenation: Evaluation and Management
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Jose Foppiani and Samuel J. Lin
Abstract
This chapter thoroughly discusses surgical and
nonsurgical modalities of treatment of neck rejuvenation. It highlights the aesthetics of the neck as
well as its evaluation and how that evaluation can
guide the choice of therapy for the patient. There
is a vast array of old and new treatment options in
this growing realm of cosmetic surgery, and an
attempt to present them holistically is provided in
this chapter. These include various minimally invasive procedures such as the use of injectables and
lasers, as well as surgical procedures such as suction
lipectomy and neck lifts. Granularities exist between
and within procedures, and this chapter explores
these in detail to highlight the indications, techniques, complications, and excepted results of each
technique. Ultimately, patients with minimal excess
skin but an excess of preplatysmal submental fat are
indicated to undergo nonsurgical procedures. In
contrast, patients with excess skin or significant
platysmal banding should undergo a surgical approach tailored to their characteristics. As neck rejuvenation grows in popularity, aesthetic surgeons
have the chance to personalize treatment for their
patients to ensure exceptional results with minor
complications.
Keywords: aesthetics of the neck, neck rejuvenation, surgical and nonsurgical intervention, complications, postoperative care
●
The choice of technique and the approach
should be guided by the specific characteristics
of each patient.
●
Poor outcomes tend to be the result of inappropriate patient evaluation leading to suboptimal
choice of surgical procedures.
●
Well-planned postoperative care improves the
outcomes and significantly decreases the rate of
complications.
2.1 Introduction
2.1.1 Demographic of Neck Lift/
Rejuvenation Procedures
Neck rejuvenation is one of the most commonly
performed aesthetic surgical procedures in the
1
world.
It represented over 260,000 of all aesthetic
procedures in 2016.
States alone encompassed over 181,000 procedures
in 2019 and over 160,000 procedures in 2020.
popularity thus requires the aesthetic surgeon to
possess an in-depth knowledge of surgical and nonsurgical neck rejuvenation procedures. This knowledge must include a solid comprehension of the
aesthetic principles of the neck area, the anatomy
of the neck, surgical techniques, and potential complications. This knowledge then enables the aesthetic surgeon to discuss with their patients the
most appropriate procedures to achieve their goals.
2
Furthermore, the United
1
This
Key Points
●
The Ellenbogen Brooks criteria provide a comprehensive guideline for an aesthetically pleasing
neck.
●
The evaluation of the neck’s anatomical fea-
tures guides the choice of procedures and significantly influences the outcomes of given
procedures.
●
Patients with minimal skin excess and mostly
preplatysmal fat should undergo minimally
invasive procedures such as lasers, injectables,
and other techniques described in this chapter.
●
Patients with excess skin, subplatysmal fat, and
other deeper neck defect should undergo surgical
procedures.
2.1.2 Criterion for a Youthful
Aesthetically Pleasing Neck
The concept of beauty has been explored from the
very inception of mankind. As far back as antiquity, artists and philosophers pondered on the characteristics of beauty. Most notably, Plato explored it
in great depth in his time.
nomic changes arose in history, what and how to
determine if a feature is aesthetically pleasing has
proven a challenge.
view exi st on the matter. Yet, commonality may
be found within them. Some culture favor lean
body and faces, while others prefer curves. Moreover, symmetry is usually the unifying ground.
Mathematicians have long tried to establish a
3,4
However , as socioeco-
3,4
Many theories and points of
5,6
11
Neck Rejuvenation: Evaluation and Management
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Fig. 2.1 Characteristic of the youthful neck in (a) male and (b) female patients. NLCP, nose–lip–chin plane; SCM,
sternocleidomastoid muscle. (These images are provided courtesy of MUDr. Roman Kufa and MUDr. Lukáš Frajer.)
clear definition of beauty, but despite the existing
controversy , the golden ratio and Fibonacci sequence
have proven crucially insightful. They stress again
the importance of symmetry and proportions.
7,8,9,10
As of today, the Ellenbogen Brooks crit eri a ha v e provided a fairly universal set of guidelines in defining a
youthfully aesthetic neck and thus what surgeons
should strive toward (▶ Fi g. 2.1).
11,12
These criteria
include the follo wing:
●
A distinct inferior mandibular border.
●
A visible subhyoid depression.
●
A visible thyroid cartilage bulge.
●
A visible anterior border of the sternocleidomastoid muscle.
●
A cervicomental angle of 105 to 120 degrees.
11
2.1.3 Criteria for an Aging Neck
Similarly to the face, the neck is subject to the aging
process. This aging process induces transformations
that are usually classified as either chronological or
photo induced.
sis of the shape, texture, and color of the neck
region.
of the quality and quantity of soft tissues. A lifetime
of facial expression, elastosis, gravitational forces,
and tissue atrophy have a significant impact on the
appearance of the neck. This appearance is uniq ue to
each patient, but trends may be found within populations.
exposure to the sun), specific populations and ethnic
13,14
This results in the metamorpho-
13,14
This change is caused by the degradation
13,14,15
Based on their lifestyle (especially skin
groupsmayhaveverydifferent neck morphology
requiring distinctive interventions. Individuals with
a Fitzpatrick phototype of V or VI, for example, have
a higher amount of melanin protecting them from
the effects of photoaging more so than individuals
with Fitzpatrick phototype I or II.
15
This relativ e lower loss of collagen and elastin usually translate into a
younger appearance.
15
This may imply that for individuals of the same age, an aesthetic surgeon may
prefer to choose an invasive versus a noninvasive
method because of the patient’s characteristics. Ad-
ditionally, the characteristic histological differences
and wound healing of individuals of different ethnic
origin may warrant different approaches. Fibroplasia
in these groups may be more significant than in
others, and thus careful consideration of tensions on
incision sites is necessary.
15,16
Despite the inherent
differences between ethnic groups, the following
criteria represent a unified definition of an aging
neck region:
●
An obtuse cervicomental angle, caused by loose/
excess skin with an excess of subplatysmal fat and
a low position of the hyoid bone.
●
Aging chin and lower face with the effacement
of sharp mandibular border.
12,17
12,17
2.2 Neck Evaluation
An evaluation of the neck depicting the anatomical
relationship between the platysma and preplatysmal
fat is shown in ▶ Fi g. 2.2.
12
Fig. 2.2 Anatomical relationship between platysma and
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preplatysmal fat.
2.3 Neck Rejuvenation Procedures
2.2.3 Platysma
The key in platysma evaluation is to define the
degree, direction, and location of banding both
passively and dynamically.
21,22
2.2.4 Digastric Muscle
The preeminence of the digastric muscle is imperative to evaluate. It can form a subtle but nevertheless visible distortion of the contour of the inferior
border of the mandible.
erance may be created by the digastric muscle following submental fat removal. This leads to poor
aesthetic results for the patient. While preoperative assessment is possible in an emaciated neck, a
surgeon should evaluate/reevaluate the digastric
muscle intraoperatively.
12,21
Additionally, a protub-
12,21,22
2.2.1 Skin
The evaluation of the patient’s skin is paramount
to present to the plastic surgeon initial information he or she needs to devise the optimal treatment strategies. The quality of the skin, notably
its elasticity, as well as the quantity of the skin,
notably any absolute/ relative excess, should be
investigated.
12,18,19
Additionally, rhytids forming
both passively and actively should all be thoroughly evaluated.
12,18,19
Skin in relative excess
will typically solely require redra ping followed by
recontouring. On the other hand, skin with poor
elasticity will require skin excision as well.
12,18,19
One should note that worse skin quality will necessitate a potentially longer skin incision.
12,18,19
A recent framework proposed suggests evaluating
the quality of the skin in three categories: vis ible,
mechanical, and topographical.
20
This would uniformly codify the approach to skin evaluation
among aesthetic surgeons.
2.2.2 Adiposity
The next step is the evaluation of the adipose tissue distribution, which is key in defining the approach that the aesthetic surgeons should follow.
The adipose tissue accumulates in either the preplatysmal or subplatysmal plane.
mental pinching maneuver is used in order to
identify the total amount of fat.
while still pinching the same location, the patient
is instructed to contract their platysma. The remaining fat felt during this contraction reflects the
fat present in the preplatysmal layer (▶ Fig. 2.3).
21
A midline sub-
12,21
Afterward,
21
2.2.5 Submandibular Gland
As part of the intraoperative evaluation, the extent
of the submandibular protrusion/bulging should
also be assessed.
12,21,22
The surgeon will need to address the submandibular gland that is ptotic, either
surgically or with the patient preoperatively.
2.2.6 Chin
The chin plays a crucial role in relation to facial
proportion and should thus be ev aluat ed accordingly
including its angle classification. Any abnormalities
of the chin can result in suboptimal contouring of
the neck.
12,21,22
2.3 Neck Rejuvenation
Procedures
The treatment algorithm for patient’s neck rejuvenation procedures is complex. The most consistent
approach following the aforementioned evaluation
of the patient is to take a targeted layer approach
to the patients
●
Superficial:
○
Skin.
○
Subcutaneous fat.
●
Intermediate:
○
Platysma (muscle banding target).
●
Deep:
○
Digastric muscle.
○
Submandibular gland.
○
Suprahyoid fascia.
○
Subplatysmal fat pad.
12,21,22
:
12,21,22
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Neck Rejuvenation: Evaluation and Management
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Fig. 2.3 Evaluation of submental fat in a (a) male and (b) a female patient. (These images are provided courtesy of
MUDr. Roman Kufa and MUDr. Lukáš Frajer.)
2.3.1 Nonsurgical Procedures
Botulinum Toxin
Botulinum toxin has long been used in the field of
aesthetic surgery.
14
23,24,25,26,27,28
It has an especially
important role in the head and neck region. Young
patients with minimal/moderate active banding,
minimal rhytids/jowls, and with minimal skin laxity
requiring minor cervicomental angle contouring are
2.3 Neck Rejuvenation Procedures
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all good candida t es for botulinum toxin use.25On the
other hand, patients with excess skin or passive
platysma banding would not be indicated for sole
botulinum toxin therapy. As a rule of thumb, the
preliminary dosage in patients is 5 to 20 injections
per platysmal band.
24
A grand total of 40 to 100
units are thus used in most patients per treatment.
Overall, good results are achieved in young people
where minimal/moderate active banding is present.
Botulinum toxin can successfully be used to tighten
neck jowls, reduce horizontal neck rhytids, and improve skin laxity.
23
It is important to note that botulinum toxin also has good results in correcting minor
defects as an adjunct in other procedures.
26
Its use
delays the need for surgical procedures, but one
should note that another procedure will most often
be needed down the line. Common complications include muscle paralysis, dysphagia, erythema, edema,
ecchymosis, and hyperpigmentation.
24
Due to its
versatile nature, botulinum toxin injections remain
one of the leading nonsurgical aesthetic procedures
worldwide, with an excellent rate of efficacy and patient satisfaction. The accumulation of clinical evidence with botulinum toxin has led to refinements
in treatment planning and implementation over the
years. Internationally, the Global Aesthetics Consensus Group has repeatedly advocated an ontologydriven, patient-tailored approach to enable optimal
efficacy and safety in patient populations that are
rapidly diversifying with respect to ethnicity , gender,
28
and age.
Microfocused Ultrasound System
The Ulthera microfocused ultrasound system has
received an increasing level of attention over the
last decade.
the years including a 103-patient study in 2014 in
the United States.
microcoagulative zones and collagen neosynthesis
effect, the Ulthera system achieved promising results in skin tightening. Indeed, up to 60% decrease
in skin laxity was reported using this system.
Since then, another study in 2019 was conducted,
which included 50 adult patients.
were treated with the Ulthera 3.0-mm probes to
target the deep dermis and the 4.5-mm Ulthera
probe to target the superficial muscular aponeurotic system.
skin laxity in this patient population.
Ulthera system may be a tool for the aesthetic surgeon for targeting skin laxity in neck rejuvenation.
This system may be advantageous in populations
29,30
It underwent multiple studies over
29
This study showed that via its
30
The subjects
30
It showed up to 93% improvement in
30
Overall, the
with darker Fitzpatrick skin types where unlike
laser devices or ultrasound therapy, it does not
target melanin.
lasers for these populations.
30
This makes it a safer choice over
30
Patients with a body
mass index (BMI) over 30 tend to have a high degree
of subplatysmal fat, making the Ulthera system sub-
24
optimal to use in that population.
29
Some complications to keep in mind with this system include
immediate posttreatment pain, erythema, edema,
and bruising.
30
Lasers/Radiofrequency Devices
Lasers and other radiofrequency devices are another emerging toolbox for the aesthetic surgeon
when targeting skin laxity and fat debulking.
Similarly to the Ulthera system, treatments with
these devices cause adipocytes to coagulate as well
as stimulating dermal neocollagenesis. Multiple
devices currently exist within this category:
●
The PrecisionTx introduced in 2012 is a bidirectional dual-wavelength laser at 1,320 and
1440 nm that leads to fat cavitation. This laser
fires forward in the direction of the cannula at a
90-degree angle, enabling the clinician to rotate
his or her wrist and thus treat both deep and
superficial dermis.
●
The ThermiTight system introduced in 2013 is a
30
percutaneous monopolar electrode causing the
dermis to reach 50 to 70 °C while keeping the
epidermis at a temperature of 45 °C. The whole
preplatysmal fat area may be targeted in this
way, one of the most advantageous features of
this system.
●
The NeckTite system introduced in 2016 is a
30
percutaneous bipolar electrode that may be
used with radiofrequency lipolysis devices to
improve neck contouring.
30
Other topics will be covered in detail in later chapters of this book. As a group, the percutaneous
thermal devices have multiple advantages. These
29
include single-treatment modality, the capability to
contour and adjust the location of adipose tissue removal, and its effectiveness in achieving excellent
skin tightening.
30,31
Common complications include
swelling, bruises, pain, and a risk of skin burn.
Cryolipolysis
Cryolipolysis is a technique implemented using
Zeltiq’s Cool Sculpting and its CoolMini applicator
handpiece available since 2015 following the
30
15
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approval of the device by the Food and Drug
Administration (FDA).
31
This system utilizes the
cold sensitivity of adipocytes to sele ctively induce
their apoptosis. Indeed, the target pre platysmal
fat is kept at a temperature of –10 °C for 45 minutes.
Patients usually have to undergo one to two treatments in order to see noticeable changes.
31
Overall,
this technique has been shown to decrease superficial fat thickness by 2mm and up to 77% of patients
report improvements in submental appearance.
However, it is important to note that similarly to
other devices covered in this chapter, the final
reduction in the cervicomental angles occurs over
the course of 3 or 4 months posttherapy. The
advantages of this modality include the ability to
debulk large areas of submental fat and a low risk
of complications in addition to the noninvasive nature of the procedure. Like all other devices, some
disadvantages do exist. These include the inability
to treat skin laxity and platysmal band, the need for
multiple costly sessions, and lack of precise targeting of fat debulking. There is a rare risk of paroxysmal adipose hypertrophy (PAH), which results in
the hypertrophy of adipose cells following treatment. However, it is important to note that the persistence or “growth” of fat may also be due to
weight gain and not PAH. It is also important to
note that a “butter stick” appearance of the submental may occur for a few minutes posttherapy.
31
Deoxycholic Acid
Deoxycholic acid is a chemical substance that can be
used to target excessive submental adiposity.
It usually requires four to six treatment sessions
with 4 to 6 mL of the chemical per treatment.
30-gauge needle is used, and 20 to 30 injections of
0.2 mL are given in a 1-cm grid pattern over the
submental area.
12,31
Overall, the treatment may
decrease the submental fullness/adip ose content
as exhibited by two phase 3, randomized, doubl eblind, placebo-contr olled clinical studies conducted in 57 centers in Germany, France, Spain,
Italy, Belgium, and the United Kingdom.
cholic acid is a treatment with good co ntrol over
area and amount of adipose fat reduc ti on and
moderate skin tightening effect. Complications
include pain with administration, lack of clinical
improvement, or hematoma formation in up to
72% of the patient; swelling; and the possibility of
exposing the platysmal bands if the adipose layer
is skeletonized. Patients with bleeding disorders
are usually contraindicated for this treatment.
32
12,31,32
12,31
Deoxy-
Stromal Vascular Gel
Stromal vascular fraction (SVF) gel is another injectable indicated for use in neck rejuvenation specifically to target horizontal neck wrinkles.
preparation of lipoaspirate necessitates multiple
steps. It requires two centrifugations with collection of the middle layer following the first centrifugation and re-centrif ugation of that collected
layer. Various protocols to produce SVF gel exist.
31
Once produced, the SVF gel is injected via a subcision
underneath neck wrinkles. A beveled hypodermic
needle is used to loosen up the tissue to which the
wrinkles are bound. Injections should be performed
at points 0.5cm apart along the horizontal neckline s,
depositing 0.05 to 0.1 mL of SVF gel at each injection
33
point.
Overall, improvement in horizontal wrinkles
is evident. However, it is important to note that complication rates tend to be higher with SVF gel. Complications include erythema, edema, ecchymosis,
and hyperpigmentation.
2.3.2 Surgical Procedures
An overview of surgical treatment options based
on patient anatomical characteristics is presented
in ▶ Table 2.1.
Liposuction
Liposuction
gery procedure is one of the most commonly performed treatment modality worldwide.
Multiple subtypes of liposuction devices exist:
●
Suction-assisted liposuction (SAL).
●
Ultrasonic-assisted liposuction (UAL).
A
●
Laser-assisted liposuction (LAL).
●
Radiofrequency-assisted liposuction (RFAL).
Liposuction has developed significantly since its
first use in the field of aesthetic surgery. Articles
dating back to 1996 described the comparative
benefits of suction lipectomy. It was then described that the marriage of SAL and UAL enhanced results and minimized complications.
of 2018, authors thoroughly explored the benefits
of UAL and LAL over SAL.
the following:
●
UAL over SAL in the treatment of gynecomastia.
●
LAL and UAL over SAL with decreased hemoglobin/hematocrit in high-volume lipoaspirate.
●
LAL over SAL with skin tightening in select areas
notably the submental area.
29,31,34,35,36,37
as a general aesthetic sur-
36
These notably include
33
The
33
1
35
As
16
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