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3.11 Expert Commentary by Dr. Lin
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methods with significant results and a high degree
of patient satisfaction. Other surgical procedures
should be considered when analyzing the aging
neck. Neck contouring procedures can be performed in combination with other surgical procedures such as facelifts, rhinoplasty, and buccal fat
pad removal.
Nonsurgical neck rejuvenation will be discussed
in detail in another chapter. These treatments
aimed at the same three treatable soft-tissue
layers. Energy-based devices treat the skin, promoting collagen production texture and moderate
skin tightening as well as improving skin texture.
Fat reduction can be achieved with deoxycholic
acid or cryolipolysis. The platysma muscle and
bands can be treated with botulinum toxin, which
results in muscle relaxation and a lifting effect
(chemical neck lift, a Nefertiti lift).
6
3.8 Conclusion
Although emerging technologies and minimally
invasive procedures offer some degree of neck rejuvenation, surgical procedures deliver a profound
improvement with long-lasting results. Therefore,
surgery remains the gold standard treatment for
the aging neck.
3.9 Case Examples
3.9.1 Case 1
▶ Fig. 3.1 shows the photographs of a 67-year-old
woman before and 6 weeks after a neck lift and
periocular erbium laser.
3.9.2 Case 2
▶ Fig. 3.2 shows the photographs of an 81-year-old
man before and 10 days after an extended neck lift.
3.9.3 Case 3
Case 3 is a 60-year-old woman. Her photographs
before and 3 weeks after neck lift, filler to lips,
erbium periocular/oral, and 20% trichloroacetic
acid (TCA) peel to face are shown in ▶ Fig. 3.3.
3.9.4 Case 4
▶ Fig. 3.4 shows the photographs of a 62-year-old
woman before and 6 weeks after neck lift.
3.9.5 Case 5
A 60-year-old woman a comprehensive facial and
neck rejuvenation after massive weight loss.
▶ Fig. 3.5 shows her photographs at 6 weeks af ter
the procedure that comprised facelift, neck lift,
brow lift, upper blepharoplasty, 30% TCA peel, and
neck lift.
3.10 Expert Commentary by
Dr. Slavin
This chapter offers an exceptional introduction to
rejuvenation of the neck. We have found that one
of the keys to a happy patient who has undergone
submentalplasty is limiting the scar to less than
3cmsoastopreventitfromridingupontothe
anterior jawline. Moreover, dog-ear corrections
can result in an unfavorable extension of the
scar. We find 3 cm keeps it hidden in the frontal
view. We caution that isolated submentalplast y
in older patie nts with loss of skin elasticit y
should be approached with care as this problem
becomes more conspicuous posttreatment, leading to patient dissatisfaction; in such situations,
it may be necessary to br ing the patient back for
skin tightening. Therefore, preoperative judgment is of utmost importance.
3.11 Expert Commentary by
Dr. Lin
The authors have given an excellent summary of
their approach in the preoperative, intraoperative,
and postoperative course. I cannot agree more that
the goal of any surgery is a satisfied patient, and the
efforts to achieve that end may vary from patient to
patient. The use of TXA has definitely increased and
become routine in many practices. As we have seen
in recent studies, it can be routinely used through
several means of administration.
27
Management of the Aging Neck
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Fig. 3.1 (a– c) Case 1: A 67-year-old woman before and 6 weeks after neck lift and periocular erbium laser.
28
3.11 Expert Commentary by Dr. Lin
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Fig. 3.2 (a– c) Case 2: An 81-year-old man before and 10 days after extended neck lift.
29
Management of the Aging Neck
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Fig. 3.3 (a,b) Case 3: A 60-year-old woman before and 3 weeks after neck lift, filler to lips, erbium periocular/oral, and
20% trichloroacetic acid (TCA) peel to face.
30
3.11 Expert Commentary by Dr. Lin
https://t.me/medicina_free
Fig. 3.4 (a– c) Case 4: A 62-year-old woman before and 6 weeks after neck lift.
31
Management of the Aging Neck
https://t.me/medicina_free
Fig. 3.5 (a– c) Case 5: A 60-year-old woman after massive weight loss. Six weeks after comprehensive facial and neck
rejuvenation: facelift, neck lift, brow lift, upper blepharoplasty, 30% trichloroacetic acid (TCA) peel, and neck lift.
References
[1] Ellenbogen R, Karlin JV. Visual criteria for success in restor-
ing the youthful neck. Plast Reconstr Surg. 1980; 66(6):
826–837
[2] Greer SE, Matarasso A, Wallach SG, Simon G, Longaker MT.
Importance of the nasal-to-cervical relationship to the profile
32
in rhinoplasty surgery. Plast Reconstr Surg. 2001; 108(2):
522–531, discussion 532–535
[3] Matarasso A. Managing the components of the aging neck:
from liposuction to submentalplasty, to neck lift. Clin Plast
Surg. 2014; 41(1):85–98
References
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[4] de Souza Pinto EB. Importance of cervicomental complex treat-
ment in rhytidoplasty. Aesthetic Plast Surg. 1981; 5(1):69–75
[5] American Society for Aesthetic Plastic Surgery. National Cos-
metic Surgery Databank Statistics. Accessed July 25, 2020 at:
http://www.surgery.org/media/statistics
[6] Matarasso A. Managing the buccal fat pad. Aesthet Surg J.
2006; 26(3):330–336
[7] Matarasso A, Sinno S. Isolated neck lift. In: Chung K, Thor ne
C, Sinno S, eds. Operative Techniques in Facial Aesthetic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2019:238–241
[8] Matarasso A. Managing the components of the aging neck:
from liposuction to submentalplasty, to neck lift. Clin Plast
Surg. 2014; 41(1):85–98
[9] de Pina DP, Quinta WC. Aesthetic resection of the submandibu-
lar salivary gland. Plast Reconstr Surg. 1991; 88:779–787
[10] Mendelson BC, Tutino R. Submandibular gland reduction in
aesthetic surgery of the neck: review of 112 consecutive
cases. Plast Reconstr Surg. 2015; 136(3):463–471
[11] O’Daniel TG. Understanding deep neck anatomy and its clini-
cal relevance. Clin Plast Surg. 2018; 45(4):447–454
[12] Auersvald A, Auersvald LA. Management of the submandibular
gland in neck lifts: indications, techniques, pearls, and pitfalls.
Clin Plast Surg. 2018; 45(4):507–525
[13] Ellenbogen R. Pseudo-paralysis of the mandibular branch of
the facial ner ve after platysmal face-lift operation. Plast
Reconstr Surg. 1979; 63(3):364–368
[14] Yousif J, Matloub H, Sanger J. Hyoid suspension of the platys-
ma: a novel technique for the aging neck. Plast Reconstr Surg.
2014; 133(4 Suppl):976
[15] Baker DC, Chiu ES. Bedside treatment of early acute rhyti-
dectomy hematomas. Plast Reconstr Surg. 2005; 115(7):
2119–2122, discussion 2123
[16] Young VL, Boswell CB, Centeno RF, Watson ME. DMSO: appli-
cations in plastic surgery. Aesthet Surg J. 2005; 25(2):201–
209
[17] McKinney P, Katrana DJ. Prevention of injury to the great
auricular nerve during rhytidectomy. Plast Reconstr Surg.
1980; 66(5):675–679
[18] Durnig P, Jungwirth W. Low-molecular-weight heparin and
postoperative bleeding in rhytidectomy. Plast Reconstr Surg.
2006; 118(2):502–507, discussion 508–509
[19] Reinisch JF, Bresnick SD, Walker JW, Rosso RF. Deep venous
thrombosis and pulmonary embolus after face lift: a study of
incidence and prophylaxis. Plast Reconstr Surg. 2001; 107
(6):1570–1575, discussion 1576–1577
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4 The Use of Platysma Window for Neck Contouring
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Rod J. Rohrich, Justin Bellamy, and Nelson A. Rodriguez-Unda
Abstract
Neck aesthetics are a key component of a youthful
appearance. Mastering a safe, e
reproducible technique for neck contouring remains
essential for success in facial rejuvenation. Here we
describe our approach to neck and jawline contouring using the lateral platysmal window, with or
without a central nec k lift component. This approach
to neck rejuvenation can be performed alone; however, it becomes even more effective when combined with rhytidectomy. An understanding of the
underlying anatomy contributing to neck deformity
guides the surgical approach. By using an anatomydriven, systema tic approach as we describe here, this
technique can impart robust tightening of the lower
face and neck while simultaneously minimizing risk
of injury to nearby structures.
Keywords: neck lift, facelift, lateral platysmal window, neckcontouring, neck rejuvenation
ffective, robust, and
Key Points
●
A sharp jawline and neck are essential to a harmonious, youthful appearance.
●
Lateral platysmal window is a safe, reproducible
approach to lateral neck rejuvenation that works
well alone or combined with rhytidectomy.
●
It can be performed with or without central/
deep neck rejuvenation.
○
Dynamic bands greater than 2 cm off-midline
AND no deep neck deformity → lateral neck
only.
○
Dynamic bands less than 2 cm off-midline OR
deep neck deformity → add central neck component.
●
A 2-cm vertical incision in the platysma placed
1.5 cm below the mandibular angle and 1.5 cm
anterior to the sternocleidomastoid (SCM) muscle.
4.1 Patient Considerations,
Indications, and Contraindications
While neck aesthetics remain an essential component of facial harmony, there are variable anatomical
contributions to poor neck contour. Careful consideration to specific patient characteristics guides best
surgical interventions. In 1980, Ellenbogen and
1
Karlin
highlighted the most important features of
the youthful neck, including a distinct mandibular
border, anterior border of sternocleidomastoid
muscle, subhyoid depression, thyroid bulge, and a
cervicomental angle of 105 to 120 degrees. For such
aesthetics to be realized, both the central and lateral neck must be addressed. The treatment approach
must address skin excess, muscle laxity, fatty excess
in the deep and superficial planes, as well as skin
resurfacing. The lateral platysmal window provides
an effective, safe, and reproducible approach to
neck contouring.
central neck component in severe cases, and naturally fits into the flow of traditional rhytidectomy
and facial rejuvenation procedures.
2
It can be easily combined with a
3
4.1.1 Who Is a Candidate?
Virtually all patients undergoing primary rhytidectomy are candidates for lateral platysmal window
given the shared preauricular incision. Young patients with isolated central neck concerns who explicitly desire to avoid a preauricular incision may
be better treated with a deep central neck lift alone;
however, this is a relatively uncommon scenario. In
the revision neck lift patient, the platysmal window
remains highly effective, but the surgeon should
anticipate a potentially thin and friable platysma
requiring additional care to avoid cheese wiring of
the tissues with large movements.
4.1.2 Platysmal Bands
Particular attention should be paid toward the location and nature of any neck bands, as this helps
determine whether a lateral-only approach is adequate. Centrally located and dynamic bands (≤ 2cm
from midline) may be difficult to adequately treat
from a lateral-only access. On the c ontrary, platysmal
bands greater than 2 cm from midline can be sharply
incised from above via the lateral access and redistributed with the lateral platysmal window without
the need for central access.
4.1.3 The Central Neck
Preoperative assessment should evaluate for significant subplatysmal fat, presence of dynamic central
35
The Use of Platysma Window for Neck Contouring
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bands, and the presence of ptotic submandibular
glands. The presence of any or all these fea tures ma y
favor includin g a central neck component.
4.1.4 Contraindications
There are no absolute preoperative contraindications to lateral platysmal window. In the revisionary
case, an attenuated platysma may be encountered
with difficulty accomplishing lateral tension. Should
the lateral platysma become completely incompetent intraoperatively, a central plication approach
may be preferred to avoid further cheese wiring of
the platysma.
4.2 What Technique to Use and
Why?
Patients can be stratified into three groups based
on anatomical needs and patient desires.
●
Lateral neck-only. Patients with platysmal bands
greater than 2 cm off-midline and primarily submental fat can be managed with lateral platysmal
window only through face and neck lift incision.
●
Lateral and central neck. These patients may
also benefit from central neck incision to manage the deep neck or central bands if deformity
is present. We find, however, that in the absence
of significant subplatysmal fat, any bands located greater than 2cm off-midline can be managed from the lateral access with myotomy/myomectomy.
●
Central neck only. Young patients with isolated
submental adiposity without skin excess. These
patients do not require lateral platysmal window.
Their management depends upon the etiology of
their submental fullness. Central fullness attributable entirely to subcuteanous adiposity may be
managed with either liposuction alone (with or
without adjunct s kin tightening modalities), while
sub-platysmal fullness requires debulking of the
sub-platysmal structures and platysmaplasty. The
details of isolated deep central neck management
are beyond the scope of this chapter .
4.3 Technique: A Stepwise
Summary
●
Facial/neck analysis. Paramount to safe and successful neck rejuvenation is preoperative analysis
and planning. This involves classification of the
location of the platysmal band (central platysmal
bands < 2cm off-midline, lateral bands >2 cm off-
midline), evaluation for the presence of excess
subcutaneous fat versus deep subplatysmal fat,
submandibular gland ptosis, and any other neck
scars (e.g., prior neck lift, tracheostomy scar) that
could compromise s kin perfusion.
●
Incision. If deep central neck pathology must be
addressed, then the central neck component
must be performed first. A 2- to 2.5-cm incision
is made behind the submental crease. Incision
directly in the submental crease is avoided because it may exacerbate the indent at the crease.
By choosing a more posterior incision 5 to 8 mm
posterior to the submental crease, a smooth and
pleasing transition from the menton to the neck
may be accomplished. This dissection is carried
deep until the platysma is identified.
●
Dissection. With an assistant applying countertension on the anterior neck, dissection proceeds sharply with anterograde electrocautery
hemostasis as required. A 3-mm-thick subcutaneous flap is created down to the level of the
4
thyroid cartilage and as far laterally as ergonomically achievable (this dissection will later
be communicated with the lateral neck dissection). Following skin flap elevation, residual of
the subcutaneous fat left on the platysmal surface is excised under direct visualization. Prior
to proceeding, hemostasis is again confirmed
with care to avoid injury to the adjacent anterior jugular veins.
●
Platysmal plication. The medial platysmal bands
are identified under direct vision on both sides
and correlated to preoperativ e markings and photographs. Using a 4–0 braided/nonabsorbable suture (Mersilene), the platysma is reapproximated
in the midline from the level of the caudal aspect
of the thyroid cartilage to the most cephalad margin of the platysma. We often perform this in a
two-layered, running fashion. Subsequently, using
an extended Bovie tip, a 2-cm platysmal wedge
myomectomy is performed at 1.5 cm below the
caudal platysmal plication. This avoids recurrent
or cicatricial banding.
●
Palpation of the platysmal surface. Assess for a
smooth anterior neck surface. Any imperfections are addressed with additional undermining or excision of subcutaneous fat under direct
visualization, as needed.
●
The lateral neck: incision and skin dissection.
With the central neck pathology corrected (as
36
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