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4.4 How to Avoid Bad Results/Common Pitfalls
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indicated), the lateral neck can be addressed. The
standard intertragal incision for rhytidectomy is
adequate for lateral access. In cases of isolated
neck lift, this incision can be limited to just below the tragus and carried posteriorly into the
hairline. Sharp dissection from posterior to the
midline follows. By dissecting from posterior to
anterior, the subauricular band is released and
skin mobilized. If central neck lift was performed,
this dissection should meet the previously created
space. Careful assessment of the jowl mandibular
septum area is done at this time to ensure they
have been proper l y dissecte d and are not crea ting
abnormal contour at the prejowl sulcus. Failure to
disrupt the mandibular retaining ligament superficially can result in persistent jowling. Care must
be exercised to not penetrate deep in this area,
however, as the marginal mandibular nerve lies
just deep to the platysma/superficial musculoaponeurotic system (SMAS) in this region. Once the
skin has been mobilized and the cutaneous
mandibular ligament released, pulling the lateral
platysma superiorly and posteriorly should demonstrate a sharp jawline. At this point, we are
ready to proceed with lateral platysmal window.
●
The lateral platysmal window is made at a
point on the platysma one fingerbreadth
(1.5cm) below the mandibular angle and one
fingerbreadth anterior to the sternocleidomastoid muscle. This position is selected as it avoids
injury to the adjacent great auricular nerve and
the cervical branch of the facial nerve.
grasping this point with forceps, a 2-cm vertical
5,6
While
platysmal window is created with electrocautery
or scissors. A small flap of platysma is created at
the window with 2-cm anterior dissection. Care
is taken to avoid tearing or macerating this platysmal flap as it will be used for suture purchase
(▶ Fig. 4.1).
●
Fixation to the mastoid fascia. Using 4–0 Mer-
silene sutures, figure-of-eight sutures are placed
into the lateral platysmal window flap and
cabled to the retroauricular mastoid fascia in a
superior- and posterior-oblique vector (just behind and below the ear lobule). Enough tension
is applied to achieve sharp mandibular pull
without cheese wiring the platysmal flap. A second suture is placed in an equivalent fashion
just below or above the initial suture.
●
Optional spanning suture. In selected cases
with thick subcutaneous tissues (e.g., in male
neck lift), a spanning resorbable suture (Vicryl,
PDS) from the submental area to the mastoid
can be placed to further define the mandibular
border (▶ Fig. 4.2).
4.4 How to Avoid Bad Results/
Common Pitfalls
While the lateral platysmal window approach to
neck rejuvenation is relatively simple and safe to
perform—fitting in most standard face and neck lift
approaches—there are some nuanced pitfalls that
should be avoided to optimize neck contour and
avoid recurrence. These are reviewed in ▶ Table 4.1.
Fig. 4.1 Inferomedial platysma is transected,
platysmal midline stitches are placed, and a
lateral window is performed.
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The Use of Platysma Window for Neck Contouring
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Table 4.1 Pitfalls and how to avoid them
Pitfall Complication How to avoid
Fig. 4.2 Spanning suture from the submen-
tal area to the mastoid.
Incorrect location of
platysmal window
Inadequate skin
dissection
Failure to divide bands Persistent or recurrent
Cheese wiring of the
lateral platysma
Inadequate platysmal
flap excursion
Failure to debulk
preplatysmal fat along the
inferior mandibular border
Injury to the great
auricular nerve/cervical
branch of the facial nerve
Contour abnormalities or
bunching; persistent
jowling
bands
Inability to adequately
tension platysma; poor
neck contour and
persistent bands
Inability to adequately
tension platysma; poor
neck contour and
persistent bands
Poor neck contour and
blunted jawline
Careful placement of 2 cm vertically oriented window one
fingerbreadth below the angle of the mandible and one
fingerbreadth anterior to the sternocleidomastoid muscle
Wide undermining of skin anteriorly, inferiorly, and
posteriorly. Focused superficial release of mandibular
cutaneous ligament at prejowl sulcus. Redrape skin, assess,
and perform additional skin undermining anywhere bunching
or tethering is appreciated
Mark bands preoperatively, identify these following skin
mobilization, and sharply divide the platysma from above at
the location corresponding to each band
Careful dissection of both the skin and platysmal window to
preserve thickness/integrity of the platysmal flap
Tension distribution with figure-of-eight or mattress-type
suture
Ensure tension is set adequately with the head in the neutral
position; use posterior and superior oblique vectors
Deliberate sharp debulking of preplatysmal fat along the
new mandibular border after securing the platysmal
window
38
4.5 Case Example
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A 79-year-old male patient presented to the clinic
with concerns of a poorly defined jaw and neck,
with a “tired appearance.” From the facial analysis,
we can observe the following: transverse forehead rhytids, upper eyelid dermatochalasis, severe tear trough deformities bilaterally, central fat
compartment atrophy and descent, prominent
nasolabial fold, lower third of face skin excess and
jowls, central platysmal bands (< 2 cm from mid-
line), su bmandibular gland prominence, blunt ing
of the mandibular border, and an overall ovalshaped face.
4.7 Expert Commentary by Dr. Lin
●
Meticulous excision of residual fat on the anterior surface of the platysma along and inferior to
the mandibular border.
●
Sharp incision of the platysmal bands under
direct vision.
●
Tension spanning suture from the menton to
the mastoid fascia for adjunct mandibular border enhancement.
The patient is shown before the procedure and at
2.5 years postoperatively in ▶ Fig. 4.3.
See narrated video for a step-by-step sequence
to the lateral platysmal window (▶ Video 4.1).
4.5.1 Goals
●
To restore central fat compartments and blend
the eyelid–cheek junction: (combination of lift
and fill facelift with lower lid blepharoplasty).
●
To e liminat e platysmal banding and skin ex c es s of
the neck and restore a sharp, masculine mandibular border.
4.5.2 Approach
●
Upper and lower lid blepharoplasty with lateral canthopexy and release of the orbitomalar ligament.
●
Fat transfer to the deep cent ral face, upper and
lower lids, lid–cheek junction, nasolabial folds.
●
Submental incision, central platysma imbrication, and inferior wedge myomectomy.
●
Intertragal preaur icular incision and skin elevation of the face and neck.
●
Deliberate release of cutaneous attachments of
the mandibular septum to address jowls.
●
Supero-oblique SMAS manipulation/plication to
resuspend descended tissues of the lower face
and mandibular border.
●
Lateral platysmal window for posterior-oblique
platysmal tensioning for neck and jawline contour.
4.6 Expert Commentary by
Dr. Slavin
In patients with platysmal banding medially and
laterally, we find that the platysma needs to be addressed from both submental and lateral access.
One of the biggest challenges with platysmal
bands is recurrence of the band. In order to prevent recurrence, surgeons will need to employ aggressive plication techniques, as presented in this
chapter. Standard plication techniques or access
from only a submental incision is subject to a risk
of recurrence with the patient returning a year later requiring skin tightening and potential anterior
submentalplasty. While 2 cm works as a rule of
thumb in experienced hands, we caution the
young surgeon going forward with an isolated anterior access.
4.7 Expert Commentary by Dr. Lin
This is an excellent approach in the setting where a
submental incision is not preferred or in the cases
where central banding is not present. The platysma
layer/SMAS, as mentioned, on revision cases may be
attenuated, so care is required for meticulous tissue
handling in order to allow dissection to occur without macerating this platysmal la y er.
39
The Use of Platysma Window for Neck Contouring
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Fig. 4.3 (a– c) This is a 79-year-old
male patient who presented to the
clinic with concerns of a poorly defined
jaw and neck, with a “tired appearance.” From the facial analysis, we can
observe transverse forehead rhytids,
upper eyelid dermatochalasis, severe
tear trough deformities bilaterally,
central fat compartment atrophy and
descent, prominent nasolabial fold,
lower third face skin excess and jowls,
central platysmal bands (< 2cm from
midline), submandibular gland prom-
inence, blunting of the mandibular
border, and an overall oval-shaped
face.
40
Video 4.1 Step-by-step sequence to the lateral platys-
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mal window.
References
[1] Ellenbogen R, Karlin JV. Visual criteria for success in restoring
the youthful neck. Plast Reconstr Surg. 1980; 66(6):826–837
[2] Pezeshk RA, Sieber DA, Rohrich RJ. Neck rejuvenation
through the lateral platysma window: a key component of
face-lift surgery. Plast Reconstr Surg. 2017; 139(4):865–866
References
[3] Narasimhan K, Stuzin JM, Rohrich RJ. Five-step neck lift: inte-
grating anatomy with clinical practice to optimize results.
Plast Reconstr Surg. 2013; 132(2):339–350
[4] Cruz RS, O’Reilly EB, Rohrich RJ. The platysma window: an
anatomically safe, efficient, and easily reproducible approach
to neck contour in the face lift. Plast Reconstr Surg. 2012; 129
(5):1169–1172
[5] McKinney P, Katrana DJ. Prevention of injury to the great
auricular nerve during rhytidectomy. Plast Reconstr Surg.
1980; 66(5):675–679
[6] Rohrich RJ, Taylor NS, Ahmad J, Lu A, Pessa JE. Great auricular
nerve injury, the “subauricular band” phenomenon, and the
periauricular adipose compartments. Plast Reconstr Surg.
2011; 127(2):835–843
41
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5 Triple Suture for Neck Contouring
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Enzo R. Citarella, Ramil Sinder, Alexandra Condé-Green, Samir Janne Hasbun, and Esther Barrios
Abstract
Neck treatment is important for better contouring
and repositioning of structures that su
ptosis over time. Global facial aging can be treated
by 6 vectors (V1–V6). The neck region corresponds to vectors 4 to 6, which can be treated together or individually. This technique consists in
the placement of thre e typ es of sutures: a first
line of sutures t ra c tioning the platysma and the
anterior belly of the digastric muscle, a second
single suture at the level of the thyroid cartilage,
and a third running suture starting at the level of
the thyroid cartilage up to the supramental region. With the triple-suture technique, the longterm results are maintained in the experience of
the senior author.
Keywords: triple suture, lateral plication, liposuction, neck contouring, neck lift, facelift
ffer from
Key Points
●
Indications: skin excess, skin laxity, excess fat in
the submental region, and treatment of the
bands of the platysma muscles.
●
Technique: triple-suture technique.
●
Surgical technique: liposuction of the cervical
region. Treatment of the submental region and
platysmal bands: plication of the medial borders of the platysma muscle. Triple suture: first
line of sutures, second single suture, and third
suture line of running sutures.
●
Treatment of the cervical region and the lower
face.
configuration due to the three dimensionality, with
the overlap of structures of different thickness and
consistencies, ranging from soft tissues and elastic
tissues to bone.
Since the first reports of surgical facial rejuvenation by Miller
the changes that occur in facial soft tissues and
that lead to an aged appearance allowed the development of new techniques to address the specific
anatomy of facial aging.
Once the diagnosis is made, the ideal treatment is
individualized to each patient. There are different
dissection planes for each region of the face and
through these dissections, we identify six vectors of
traction. Vectors 1, 2, and 3 can be performed using
videoendoscopy. Vectors 4 and 5 are treated with a
stairlike superficial musculoaponeurotic system
(SMAS) plication with lateral traction of the platysma. Vector 6 is tractioned after undermining of the
tissues of the face in a subcutaneous plane and a
subplatysmal plane, then the triple-suture technique
is performed.
In the experience of the senior author, treating
the different regions of the face and neck through
different vectors of traction facilitates the surgical
planning indicated for each patient (▶ Fig. 5.1).
1
and Kolle,2better understanding of
3
4
5.2 Indications
The cervical region is a part of the surgical treatment of the face. The neck lift and facelift treating
the lower third of the face are indicated when aging
is diagnosed in the superficial and deep structures
of the cervical region and also in varying degrees of
lipodystrophy.
5.1 Introduction
Rhytidectomy was originally created as a simple
method for correction of the aging face, with resection of excess skin followed by suture of the skin
under tension. The procedure evolved to encompass
a wide range of techniques that reposition the tissues of the face, in an attempt to rejuvenate the face.
The human face is composed of numerous anatomical structures arranged in different depths and
proportions. It presents a high complexity in its
5.3 Technique
The triple-suture techni q ue for the submental region
combines the treatment of the vertical vector of the
submentum—V6 —individually or in conjunction
with vectors 5 (lateral oblique) and 4 (SMAS stairstep plication).
In this chapter, we describe step by step the
technique used by the senior author for treating
the superficial and deep structures of the neck.
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Triple Suture for Neck Contouring
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Fig. 5.1 Regions and vectors: 1-V1. Vector 1 is divided
into three parts according t o the areas to be treated: 1A—
head of the eyebrow; 1B—body of the eyebrow; 1C—tail of
the eyebrow. Vector 2: temporal region. Vector 3:
anteromedial middle third of the face. Vector 4: anterolateral middle third of the face. V5: retroauricular and
lateral cervical region. Vector 6: midline cervical region.
5.3.1 Position
This technique is performed with the patient in a
supine position, under intravenous sedation, with
the neck placed in hyperextension.
5.3.2 Infiltration
The cervical region is infiltrated with a vasoconstrictive solution made of lidocaine 0.5%, bupivacaine 0.125%, and epinephrine 1:240,000.
5.3.3 Marking
Liposuction area marking and area to be treated in
the submental region is performed as shown in
▶ Fig. 5.2.
5.3.4 Liposuction
Liposuction is performed in the anterior middle
cervical region through a 0.5-cm incision in the
Fig. 5.2 Liposu ction area marking and area to be
treated.
midline, 2 mm below the submental crease. In
patients with lateral lipodystrophy of the neck,
additional stab incisions are made under each
earlobe for lateral liposuct ion and improved access to the supramandibular fat (jowl; ▶ Fig. 5.3).
Incision
The submental incision is then extended to 2.5 to
3cm (▶ Fig. 5.4), and generous undermining is per-
formed in a subcutaneous plane in the mental and
supramental regions, as well as the central and
lateral cervical regions, releasing the mandibular
ligaments (▶ Fig. 5.5).
After undermining, we identify the medial fibers
of the platysma and its anatomical variation, as
well as its flaccidity and thickness (▶ Fig. 5.6).
Undermining is performed in a subplatysmal plane
in order to assess the medial borders of the platysma and to remove any muscle excess in the midline
(▶ Fig. 5.7). The cephalic border of the platysma is
tractioned in order to remove any excess and fixate
it to the mental periosteum with repositioning of
the supra- and infrahyoid tissues.
44
Fig. 5.3 Liposuction with a blunt-tip 3-mm-diameter
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cannula with three holes.
5.3 Technique
Fig. 5.4 Submental incision of 2.5 and 3 cm length.
Fig. 5.5 Subcutaneous undermining of the supramental
region when necessary and release of the mandibular
ligaments.
Fig. 5.6 Visualization of the medial fibers of the
platysma before subplatysmal dissection.
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Triple Suture for Neck Contouring
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Fig. 5.7 (a– c) Resection of the cephalic border of the platysma then fixation to the periosteum of the mento with
MonoNylon (MN) 3–0.
Fig. 5.8 Beginning of the first line of sutures with
MonoNylon 3–0.
5.3.5 Triple-Suture Technique
First Suture
Once the fixation of the platysma to periosteum of
the mento is done, the first line of sutures approximates the medial edges of the platysma in the
46
Fig. 5.9 The first line of inverted, separated MonoNylon
3–0 sutures is placed, approximating the edges of the
medial platysmal bands and the anterior belly of the
digastric muscles.
midline and the anterior bellies of the digastric
with an inverted interrupted MonoNylon (MN) 3–
0 sutures beginning in the submental region and
running down to the level of the thyroid cartilage
(▶ Fig. 5.8 and ▶ Fig. 5.9). We may observe in some
patients a herniation of the subplatysmal fat. However, since we do remove that fat, we do cauterize
it creating a lipolysis facilitating the complete plication of the midline reducing the content of the
subplatysmal fat.
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