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15 Neck Rejuvenation: Complications
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Trina G. Ebersole, Amer H. Nassar, and Sumner A. Slavin
Abstract
Knowledge of complications in rhytidectomy remains an integral part of the surgical procedure
that all aesthetic plastic surgeons should be aware
of. Complications in facial aesthetics are often challenging for the patient–physician dynamic. This
chapter describes common complications as well as
those that appear more infrequently and provides
evidence-based management that all aesthetic surgeons should be familiar with.
Keywords: facelift, neck lift, complications, management, hematoma, seroma, s kin necrosis
Key Points
●
Perioperative normotension should be maintained, with emphasis on avoidance of postoperative hypertension. Avoid intraoperative
hypotension, as this might lead to unrecognized bleeding that will become evident postoperatively in the form of a hematoma.
●
The most commonly injured sensory nerve during a facelift is the great auricular nerve.
●
The most commonly injured motor nerve is the
buccal branch of the facial nerve.
●
Smoking greatly increases the incidence of skin
flap necrosis. Cessation of all nicotine-containing
products is imperative in the perioperative periods.
15.1 Hematoma
Hematoma is the most common complication following facelift. In nonhyptertensive patients, the
incidence of hematoma is approximately 3%;
however, in males or patients with a history of
hypertension, hematoma rates rise to approximately 8%.
medications is prudent as the risk of hematoma increases in patients taking aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDs). There are no
consensus guidelines regarding perioperative discontinuation of anticoagulants and platelet inhibitors. Joint decision-making with the patient and
their primary care physician regarding the safety of
transitioning off certain anticoagulants to proceed
1,2
A proper review of the patient’s home
with an elective surgery may be necessary. Routine
supplements such as ginger, vitamin E, and fish oils
should be discontinued prior to surgery as they
may lead to increased bleeding risk.
3,4
While reviewing that patient’s medications, estrogen management is equally important as it is a known risk
factor for thromboembolism.
5
Combining rhytidectomy with platysmaplasty also increases the risk of
hematoma; strict hemostasis is crucial in preventing this complication.
3
Blood pressure control during the case is key to preventing postoperative
hematoma in facelift surgery. Postoperatively, hypertension can be averted with beta blockade (such
as labetalol) or an alpha agonist (such as cloni-
6
dine).
Adequate analgesia and control of nausea, as
well as strenuous activity restrictions, should be
stressed, as each of these may decrease chances of
developing a postoperative hematoma.
3
Tranexamic acid (TXA) is a synthetic lysine analog that temporarily prevents plasmin from acting
on fibrin clots to dissolve them as well as blocking
platelet activation.
decrease bleeding during rhytidectomy.
7
TXA has been shown to safely
8,9
There
are several ways to empl oy TXA varying from
topical administration to inf i ltration, and even
intravenously during rhytidectomy. Topical TXA
placed on pledgets o n the undersur face of the
skin flap after completion of flap elevation has
been shown to de crease ecchymoses; however,
this was in a low-powered study.
10
Others have
shown that 1.5 mL of TXA mixed into tumescent
solution infiltration subcutane ously into the face
and n eck prior to inci sion significantly reduces
the operative time.
11
Intravenous TXA (1 g preoperatively, with a second 1-g dose 4 hours later)
has also been shown to significantly reduce postoperative ecchym osis.
12
Hematomas are most likely to occur in the first
24 hours after surgery and should be evacuated
immediately. Earlier surgical management will
prevent postoperative skin necrosis and tissue
3
edema.
In a very select few cases of a small fluid
collection, it is possible to aspirate this and observe, but overwhelmingly, most cases require surgical evacuation, as continued pressure on the skin
and soft tissue will ultimately result in a poor cosmetic outcome with tissue retraction and excess
skin laxity.
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15.2 Skin Necrosis
Skin necrosis is more common in subcutaneous
facelifts at a rate of approximate ly 3.6% and further
decreases in the sub-superficial musculoaponeurotic
system (sub-SMAS) techniques to approximately
13
1%.
It is most common in the postauricular sulcus.
Skin necrosis increases with thin flaps or if there is
excess tension on the skin during closure or from a
postoperative hematoma. Skin necrosis is often
managed conservatively with local wound care.
Smoking increases the incidence of skin flap necrosis
by approximate l y 12.5 times.
14
15.3 Infection
Infections after rhytidectomy are uncommon. Preincisional surgical prophylaxis should be routinely
administered and covers for routine skin flora.
Pseudomonas aeruginosa does colonize the otic
canal and can thus lead to infections, which can be
treated by oral fluoroquinolones, but may need
surgical drainage. In rare instances, Mycobacteria
can colonize the wound. Sterile technique should
be maintained throughout the procedure, like with
any other operation.
resulting in numbness to the region of the earlobe
and the inferior pinna. It is imperative to take precaution while elevating the cervical flap from the
sternocleidomastoid to avoid injury to the great
auricular nerve. If it is identified that the nerve
was inadvertently transected intraoperatively, it
should be repaired using microsurgical techniques.
15.5 Recurrent Platysmal Bands
Most commonly, platysmal bands will recur centrally after several years. This may require reoperation or treatment with chemodenervation.
15.6 Dystonia
There is a fine balance between excess tension and
restoring youth. The tension on the resuspended
tissue should allow for some flexibility for natural
movement in the face and neck for activities of
daily living. If it is too tight, this can cause dystonia, difficulty articulating speech, grimacing, pain
with swallowing, and the sensation of tightness.
This can be treated with valium or botulinum toxin
17
if seen.
15.4 Nerve Injury
Regardless of technique, the incidence of nerve injury is reported in approximately 1% of cases, after
either a subcutaneous or a sub-SMAS facelift.
More than likely, these rates are underreported. A
meta-analysis of complication rates in different
rhytidectomy techniques shows a significant increase in temporary nerve injury in composite rh y tidectomy and hi gh lateral SMAS-ectomy as compared
to SMAS plication.
postoperatively are common and can be due to local
anesthetic.
sient neurapraxia of motor branches is seen in 3
months, and thus initial management is observation
and management of patient expectations. The most
commonly injured motor branch of the facial nerve
is the buccal branch. However, this is often clinically
insignificant as there exists rich arborization between various facial nerve branches in this region.
Patients should be offered chemodenervation of the
unaffected side to improve symme try while awaiting
nerve recov ery .
The great auricular nerve is the most common
sensory nerve injured during rhytidectomy, often
15
Nerve deficits seen immediately
16
Typicall y, spontaneous rec o v ery of tran-
15.7 Scars
Thoughtful surgical scar placement is crucial and
contributes to the final aesthetic result of a facelift.
Excess tension or skin resection can lead to wid-
13
ened scars, alopecia, or hypopigmentation. Unfavorable scarring is often seen postauricularly, due
to skin tension, and submentally, due to inadequate approximation of the tissue. This can also
result in alteration of the hairline or the ear. Incisions placed in the hairline should be beveled so as
to allow hair follicles to grow through and conceal
the scar in the future.
a history of hypertrophic scarring or keloids is
important to discern.
18
Preoperative discussion of
15.8 Case Example
15.8.1 Case 1
3
A 67-year-old woman who had previously undergone facelift and neck lift 12 years prior was interested in rejuvenation of her neck (▶ Fig. 15.1). She
underwent neck lift and did well without issues at
her first postoperative visit. Eight days later, she
called and reported swelling of her left neck
178
15.9 Expert Commentary by Dr. Slavin
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(▶ Fig. 15.2). She was seen in the clinic, and the
area was fluctuant. Approximately 5 mL of serous,
straw-colored fluid was aspirated from the left
neck. We continued a head wrap and light pressure with gauze in this area. Her postoperative
course was otherwise uncomplicated, and she
healed well. Her postoperative photographs at 3
months are shown in ▶ Fig. 15.3 and ▶ Fig. 15.4.
Fig. 15.1 Preoperative photograph showing neck skin
laxity.
15.9 Expert Commentary by
Dr. Slavin
Preoperative discussion with the patient is key to
ensuring good results. Showing the patient their
particular anatomy is vital prior to proceeding
with surgery. The submandibular glands and their
relation to the jowl are one of the key anatomical
Fig. 15.2 Left -sided neck seroma that developed about
8 days postoperatively. This was aspirated and was
about 5 mL of straw-colored fluid.
Fig. 15.3 Postoperative photograph about 3 months
after surgery.
Fig. 15.4 Postoperative photograph showing the left
neck further after aspiration.
179
Neck Rejuvenation: Complications
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areas I discuss with my patients preoperatively. It
is also important to take note of the patient’s earlobe preoperatively and discuss this with them in
terms of whether it is hanging or attached. Additionally, a neck with wrinkling around the thyroid
area is a warning sign, as they often get recurrent
puckering in this region, despite adequate treatment during the procedure.
15.10 Expert Commentary by
Dr. Lin
I commend my coeditors on this important chapter.
Personally, I counsel patients on the differences
between medical/surgical complications and “aesthetic” complications. Clearly, the medical/surgical
complication risk relates to conditions that may require additional procedures for scarring or wound
healing or others related to life-threatening conditions such as an expanding neck hematoma. Also,
“aesthetic” complications may also translate to
additional procedures, and these may relate to recurrent jowling, neckbands, and skin contour asymmetries. It is imperative that the patient is informed
of these risks preoperatively on all aspects of neck
lifting. As one progresses in practice, it is key that
one constantly critically evaluates one’s results to
continue improving. Earlier in practice, maintaining
vigilance for prevention of medical/surgical complications then includes developing experience optimizing what one can offer the individual patient in
order to maximize a lasting aesthetic result over
many procedures.
References
[1] Rohrich RJ, Sinno S, Vaca EE. Getting better results in facelift-
ing. Plast Reconstr Surg Glob Open. 2019; 7(6):e2270
[2] Baker DC, Stefani WA, Chiu ES. Reducing the incidence of
hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr
Surg. 2005; 116(7):1973–1985, discussion 1986–1987
[3] Stuzin JM. MOC-PSSM CME article: face lifting. Plast Reconstr
Surg. 2008; 121(1) Suppl:1–19
[4] Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks
of herbal, homeopathic, and dietary supplements: a hidden
nightmare for plastic surgeons? Aesthet Surg J. 2012; 32(3):
332–346
[5] Chattha A, Brown E, Slavin S, Lin S. Oral Contraceptive ma-
nagement in aesthetic surgery: a survey of current practice
trends. Aesthet Surg J. 2018; 38(3):NP56–NP60
[6] Barton FE, Jr. Aesthetic surgery of the face and neck. Aesthet
Surg J. 2009; 29(6):449–463, quiz 464–466
[7] Rohrich RJ, Cho MJ. The role of tranexamic acid in plastic sur-
gery: review and technical considerations. Plast Reconstr
Surg. 2018; 141(2):507–515
[8] Kochuba AL, Coombs DM, Kwiecien GJ, Sinclair NR, Zins JE.
Prospective study assessing the effect of local inf iltration of
tranexamic acid on facelift bleeding. Aesthet Surg J. 2021; 41
(4):391–397
[9] Laikhter E, Comer CD, Shiah E, Manstein SM, Bain PA, Lin SJ. A
systematic review and meta-analysis evaluating the impact
of tranexamic acid administration in aesthetic plastic surgery. Aesthet Surg J. 2022; 42(5):548–558
[10] Butz DR, Geldner PD. The use of tranexamic acid in rhytidec-
tomy patients. Plast Reconstr Surg Glob Open. 2016; 4(5):
e716
[11] Couto RA, Charafeddine A, Sinclair NR, Nayak LM, Zins JE.
Local infiltration of tranexamic acid with local anesthetic reduces intraoperative facelift bleeding: a preliminary report.
Aesthet Surg J. 2020; 40(6):587–593
[12] Cohen JC, Glasgold RA, Alloju LM, Glasgold MJ. Effects of
intravenous tranexamic acid during rhytidectomy: a randomized, controlled, double-blind pilot study. Aesthet Surg J. 2021;
41(2):155–160
[13] Barton FE Jr. The Aging Face: Rhytidectomy and Adjunctive
Procedures. Selected Readings in Plastic Surgery. Vol. 6.
Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2001
[14] Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking
on skin-flap survival in the face lift patient. Plast Reconstr
Surg. 1984; 73(6):911–915
[15] Jacono AA, Alemi A S, Russell JL. A meta-analysis of complica-
tion rates among different SMAS facelift techniques. Aesthet
Surg J. 2019; 39(9):927–942
[16] Warren RJ, Aston SJ, Mendelson BC. Face lift. Plast Reconstr
Surg. 2011; 128(6):747e–764e
[17] Hoefflin SM. The youthful face: tight is not right, reposition-
ing is right. Plast Reconstr Surg. 1998; 101(5):1417
[18] Barton FE Jr. Facial Rejuvenation. Boca Raton, FL: Quality
Medical Publishing/CRC Press; 2008
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Index
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Note: Page numbers set bold or italic indicate headings or figures, respectively.
A
Ablative fractional CO2 laser
148
Absorbable polydioxanone,
facial and neck rejuvenation
with 19
AccuTite 115, 116
Adipose tissue graft 136
Adipose-derived stem cells
(ADSCs) 135, 137
Adiposity 13, 116
ADSCs, see Adipose-derived
stem cells (ADSCs)
Aging neck
– criteria for 12
– management of
–– ancillary procedures and
nonsurgical treatments 26
–– case examples 27
–– complications 26
–– operative procedure 24
–– patient analysis 23
–– patient selection and
preoperative planning 24
–– postoperative care 25
–– surgical technique 24
– management of 23
– tr eating soft-tissue
components in 23
Aging neck, subplatysmal
techniques for treatment of
– facial analysis and applied
anatomy 105
– patient evaluation and
surgical goals 107
– surgical techniques
–– fat layer 107
–– platysma muscle and
subplatysmal structures
107
–– skin 107
–– submandibular glands 112
– surgical techniques 107
Aging neck, subplatysmal
techniques for treatment of
105
Allis clamp 18
American Society for Aesthetic
Plastic Surgery 23
Anatomical structures in neck
and lower face 5
Anatomy of neck
– anterior digastric and
mylohyoid muscles 7
– cervical triangles 1
– critical structures
surrounding neck muscles
–– external jugular vein 4
––
superficial veins 4
– critical structures
surrounding neck muscles 4
– digastric muscles 58
– facial nerve and lower lip,
mandibular and cervical
nerve branches 8
– facial nerve and lower lip 8
– fasciae of the neck
–– carotid sheath 2
–– deep 2
–– infrahyoid muscle fascia 2
–– prevertebral fascia 2
–– superf icial 1
–– visceral fascia 2
– fasciae of the neck 1
– fat compartments 57
– great auricular ner ve 59
– platysma and lower lip 3
– platysma muscle 58
– retaining ligaments and
filaments 58
– retaining ligaments of the
face and neck 6
– sensory distribution in the
neck
–– great auricular nerve 4
–– lesser occipital nerve 5
–– spinal accessory nerve 6
– sensory distribution in the
neck 4
– submandibular glands 58
– subplatysmal fat 7
Anatomy of neck 1, 57
Anderson Bear Claw retractor
76
Anterior digastric and
mylohyoid muscles 7
Anterior jugular veins 4
Antibiotic ointment 25
Apyx Medical 134
Arrhenius relationship 128
Aspirin 177
ATX-101 155
B
Bipolar radiofrequency
subcutaneous lipolysis 116
Bipolar radiofrequency
tightening 115
Bipolar RF 128
Blood pressure (BP) 26
Botulinum toxin 14
Botulinum toxin A 147
BP, see Blood pressure (BP)
C
Cable sutures 89, 91, 94
Calcium hydroxylapatite 147
Caprini score 59
Carotid sheath 2
Cervical skin flap 91
Cervical triangles 1
Chemical peels 146, 154
Chin 13
Clinician-Reported Submental
Fat Rating Scale (CRSMFRS) 155
CM angle, see Cervicomental
(CM) angle
2-cm rule 172
Cobra neck deformity 174
Complications, in neck
rejuvenation
– case example 178
– dystonia 178
– hematoma 177
– infection 178
– nerve injury 178
– recurrent platysmal bands
178
– scars 178
– skin necrosis 178
Complications, in neck
rejuvenation 177
CONTOUR study 155
Corset platysmaplasty 19, 74
Cosmeceuticals 146
CR-SMFRS, see Clinician-
Reported Submental Fat
Rating Scale (CR-SMFRS)
Crevasse technique 79
Critical structures surrounding
neck muscles
– external jugular vein 4
– superf icial veins 4
Critical structures surrounding
neck muscles 4
Cryolipolysis 15, 158, 161
D
Deep fasciae 2
Deep plane face and neck lift
73
Deep plane neck lift concepts
and technique
– bad results/common pitfalls,
avoiding 81
– case examples 82
– contraindications 72
– indications 72
– patient considerations 71
– technique
–– deep plane face and neck
lift 73
–– internal neck lift 81
– technique 73
– technique to be used 72
Deep plane neck lift concepts
and technique 71
Deep plane technique 73
Deep vein thrombosis (DVT)
26, 59
Demographic of neck lift/
rejuvenation procedures
11
Deoxycholic acid 16, 155,
155, 156, 158, 161
Depressor anguli oris 3–4
Depressor labii inferioris 3
Dermal fillers 150
Dermal microneedling 116
Dermarolling 154
Digastric muscle excision
18
Digastric muscles, anterior
bellies of 7
Digastric muscles 13, 58, 109
Dimethyl sulfoxide (DMSO)
26
Dissection 36
DMSO, see Dimethyl sulfoxide
(DMSO)
Dug out deformity 174
DVT , see Deep vein
thrombosis (DVT)
Dynamic Platysmal Band
Photonumeric Assessment
Scale 149
Dyschromia
– chemical peels 146
– cosmeceuticals 146
– lasers and energy-based
devices 147
Dyschromia 146
Dystonia 178
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Index
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E
Ear deformity 174
Epinephrine 24, 116
Evaluation of neck
– adiposity 13
– chin 13
– digastric muscle 13
– platysma 13
– skin 13
– submandibular gland 13
Evaluation of neck 12
External jugular vein 4
F
Facelift 122, 168–169, 170
Facelift flaps 56
FaceTite 115–116, 116, 118,
128
Facial analysis and applied
anatomy 105
Facial nerve and lower lip,
mandibular and cervical
nerve branches 8
Facial nerve and lower lip 8
Facial rejuvenation,
radiofrequency for
– case examples 128
– common pitfalls 128
– patient considerations 127
– postoperative care 128
– technique 127
Facial rejuvenation,
radiofrequency for 127
Facial shrug 4
Facial/neck analysis 36
Fasciae of neck
– carotid sheath 2
– deep 2
– infrahyoid muscle fascia 2
– prevertebral fascia 2
– superf icial 1
– visceral fascia 2
Fasciae of neck 1
Fasil Face and Neck Laxity
Grading Scale 149, 151
Fat compartments 57
Fat grafting
– patients and methods 134
– problem-based examples/
cases 137
– surgical technique and fat
processing and grafting
134
Fat grafting 133
Fat layer 107
FDA, see Food and Drug
Administration (FDA)
Fibroplasia 12
Fillers 147
Fitzpatrick skin types 12, 15
Five-point Allergan Transverse
Neck Lines Scale 147
Food and Drug Administration
(FDA) 151
Fractional RF 128
Fraxel Re:Store DUAL 147
Five-point Dynamic Platysmal
Band Photonumeric
Assessment Scale 149
G
Great auricular nerve 4, 59,
178
H
Helium plasma 134
Hematomas 177, 177
History of neck rejuvenation
– aging neck, criteria for 12
– demographic of neck lift/
rejuvenation procedures 11
– evaluation of neck
–– adiposity 13
–– chin 13
–– digastric muscle 13
–– platysma 13
–– skin 13
–– submandibular gland 13
– evaluation of neck 12
– nonsurgical procedures
–– botulinum toxin 14
–– cryolipolysis 15
–– deoxycholic acid 16
–– lasers/radiofrequency
devices 15
–– microfocused ultrasound
system 15
–– stromal vascular gel 16
– nonsurgical procedures 14
– surgical procedures
–– liposuction 16
–– submental anterior neck
lift 17
– surgical procedures 16,17
– youthful aesthetically
pleasing neck, criterion for
11
Horizontal/transverse
necklines
– fillers 147
– lasers and energy-based
devices 148
– neuromodulators 147
Horizontal/transverse
necklines 147
Hyo neck lift 19
Hyoid bone 90, 91
Hyoid ligament 7
Hypertension 177
Hypertonic bands 107, 112
Hypotonic bands 107
I
Incision 36
Incisivus labii inferioris 3
Infection 178
Inferomedial platysma 37
Infrahyoid muscle fascia 2
Intense pulsed light (IPL) 147
Internal neck lift 81
IPL, see Intense pulsed light
(IPL)
Isotonic saline 135
K
Knize’s classification system
62
KTP, see Potassium titanyl
phosphate (KTP)
L
LAL, see Laser-assisted
liposuction (LAL)
Laser and energy-based
devices 158
Laser-assisted liposuction
(LAL) 16
Lasers and energy-based
devices 147–148, 151
Lasers/radiofrequency
devices 15
Lateral and medial
sternomastoid-cutaneous
retaining ligaments 7
Lateral cervical region,
treatment of 48
Lateral neck 36
Lateral platysmal window 37
Lateral skin-platysma
displacement (LSD)
technique
– avoidance of inadequate
results in difficult necks 97
– contraindications 89
– indications 89
– limitations 99
– patient consideration 89
– rationale of 90
– submandibular gland (SMG)
resection 96
– technique 90
– technique to be used 89
– vectors of traction 91
Lateral skin-platysma
displacement (LSD)
technique 89
LBO laser, see Lithium
triborate (LBO) laser
Le Louarn, Claude 19
Lesser occipital nerve 5
Lidocaine 24
Lipectomy 64
Lipodystrophy 64
Liposuction, incision 44
Liposuction 16, 44, 44, 45,
65–66, 115, 129, 134
Lithium triborate (LBO) laser
147
Loose neck skin 115
Lower face and neck, surgical
anatomy of 55
LSD technique, see Lateral
skin-platysma displacement
(LSD) technique
Luer-Lok syringe 134
M
Mandibular and cervical nerve
branches 8
Mandibular ligaments 6
Massive weight loss (MWL)
115
Mastoid fascia, fixation to 37
Mastoid-cutaneous ligaments
7
McKinney’s point 59
Medial platysma-cutaneous
filaments 7
Medial sternomastoid-
cutaneous filaments 7
Mentalis 3
Mercedes cannula 24
Methicillin-resistant
Staphylococcus aureus
(MRSA) 26
MFU-V, see Microfocused
ultrasound with
visualization (MFU-V)
Microbotox technique 149
Microfocused ultrasound 148,
152
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Index
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Microfocused ultrasound
system 15
Microfocused ultrasound with
visualization (MFU-V) 154
Microfocused ultrasound with
visualization (MFU-V) 148,
152–153
Microneedling 154
Middle fascia 2
Midline ridge deformity 173
MonoNylon (MN) 2–0 sutures
47–49
MonoNylon (MN) 3–0 sutures
46, 46–48
Monopolar capacitive-coupled
radiofrequency (MRF) 154
Monopolar capacitive-coupled
radiofrequency (MRF) 148,
151, 153
Monopolar radiofrequency
151, 161
Morpheus8 116
MRF, see Monopolar
capacitive-coupled
radiofrequency (MRF)
MRSA, see Methicillin-
resistant Staphylococcus
aureus (MRSA)
MWL, see Massive weight loss
(MWL)
Mycobacteria 178
Mylohyoid muscles 8
N
Neck lift
– patients and methods 134
– problem-based examples/
cases 137
– surgical technique and fat
processing and grafting
134
Neck lift 24, 26, 116, 133
Neck lift after massive weight
loss
– considerations 115
– indications 115
– isolated neck lift
–– AccuTite 116
–– FaceTite 116
–– Morpheus8 116
–– Submental Z-plasty 120,
121, 121, 123–124
– isolated neck lift 116
– role of facelift for neck
excess 122
Neck lift after massive weight
loss 115
Neck liposuction 24, 61
Neck Rejuvenation: Evaluation
and Management 11
Neck skin laxity 63, 63
NeckTite system 15
Nefertiti lift 149
Nerve injury 178
Neuromodulators 147, 149
Nitroglycerin 26
Nonablative fractional
photothermolysis 147
Noninvasive neck rejuvenation
techniques
– aging neck 145
– contraindications 146
– dyschromia
–– chemical peels 146
–– cosmeceuticals 146
–– lasers and energy-based
devices 147
– dyschromia 146
– horizontal/transverse
necklines
–– fillers 147
–– lasers and energy-based
devices 148
–– neuromodulators
– horizontal/transverse
necklines 147
– indications 146
– patient considerations 146
– platysmal banding,
neuromodulators 149
– platysmal banding 149
– skin laxity
–– chemical peels 154
–– dermal fillers 150
–– dermarolling 154
–– lasers and energy-based
devices 151
–– microneedling 154
–– platelet-rich plasma 154
– skin laxity 149
– submental fat and fullness
–– cryolipolysis 158, 161
–– deoxycholic acid 155, 156,
161
–– laser and energy-based
devices 158
– submental fat and fullness
154
Noninvasive neck rejuvenation
techniques 145, 145, 162
Nonsteroidal anti-
inflammatory drugs
(NSAIDs) 59, 177
Nonsurgical procedures
– botulinum toxin 14
147
– cryolipolysis 15
– deoxycholic acid 16
– lasers/radiofrequency
devices 15
– microfocused ultrasound
system 15
– str omal vascular gel 16
Nonsurgical procedures 14
NSAIDs, see Nonsteroidal anti-
inflammatory drugs
(NSAIDs)
O
Occipital hairline step-off
deformities 172
Orbicularis oris 3
Osteofasciocutaneous
mastoid-cutaneous
ligament 7
P
PAH, see Paroxysmal adipose
hypertrophy (PAH)
Paroxysmal adipose
hypertrophy (PAH) 15
Pars labialis platysma 3
Pars mandibularis platysma 3
Pars marginalis 3
Pars modiolaris platysma 3
Pars peripheralis 3
Patient-Reported Submental
Fat Rating Scale (PR-
SMFRS) 155
PE, see Pulmonary embolism
(PE)
Pixie ears 170, 174
Platelet-rich plasma 154
Platysma 13, 90, 92
Platysma and preplatysmal fat,
anatomical relationship
between 13
Platysma bands 107
Platysma f lap 99, 101
Platysma f lap cervical
rhytidoplasty 19
Platysma muscles 3, 45–46,
47, 57, 58, 107
Platysma window for neck
contouring
– candidate 35
– case example
–– approach 39
–– goals 39
– case example 39
– central neck 35
– common pitfalls, avoiding
37,38
– contraindications 36
– platysmal bands 35
– technique 36
– technique to be used 36
Platysma window for neck
contouring 35
Platysma-auricular ligament
7, 58
Platysmal banding,
neuromodulators 149
Platysmal banding 149, 173
Platysmal muscle sling 19
Platysmal plication 36
Platysmal surface, palpation
of 36
Platysmaplasty 64
Poly-L-lactic acid 150
Potassium titanyl phosphate
(KTP) 147
PR-SMFRS, see Patient-
Reported Submental Fat
Rating Scale (PR-SMFRS)
PrecisionTx 15
Prejowl notch 6
Prevertebral fascia 2
Prominent submandibular
glands 110, 115
Pseudomonas aeruginosa 178
Pulmonary embolism (PE) 26
R
Radiofrequency for facial
rejuvenation
– case examples 128
– common pitfalls 128
– patient considerations 127
– postoperative care 128
– technique 127
Radiofrequency for facial
rejuvenation 127
Radiofrequency microneedling
(RFMN) devices 153
Radiofrequency-assisted
liposuction (RFAL) 17, 129–
130
Recurrent platysmal bands
178
REFINE clinical trials 155
REFINE-1 and REFINE-2 trials
155, 158
Renuvion device 139
Renuvion system 134
Reoperative neck lift,
technical considerations in
171
183
Index
https://t.me/medicina_free
Reoperative neck lift 169
Retaining ligaments
– and filaments 58
– of face and neck 6
Retaining ligaments 56
Revisional and secondary neck
lifts
– expert commentary 174
– patient considerations
–– factors influencing
longevity and outcomes
170
–– identif ication ofdeformity
170
– patient considerations 170
– problem-based technical
considerations
–– ear deformity 174
–– midline ridge deformity
173
–– platysmal bands 173
–– scar placement 171
–– scarred tissue planes 173
–– subauricular band
deformity 174
–– submental hollowing 174
–– vertical band deformity
174
– problem-based technical
considerations 171
Revisional and secondary neck
lifts 167
Revisional neck lifts 167
RFAL, see Radiofrequency-
assisted liposuction (RFAL)
RFMN devices, see
Radiofrequency
microneedling (RFMN)
devices
Rhytidectomy 43, 172
Rhytidectomy technique 170
Right and left anterior jugular
veins 4
Risorius 3
S
SAL, see Suction-assisted
liposuction (SAL)
Scarred tissue planes 173
Scars 178
SCM muscle, see
Sternocleidomastoid (SCM)
muscle
Secondary neck lifts 168
SEL, see Stromal enriched
lipograft (SEL)
Sensory distribution in the
neck
– great auricular ner ve 4
– lesser occipital nerve 5
– spinal accessory nerve 6
Sensory distribution in the
neck 4
Seromas 26
Skin 13, 107
Skin crease retaining
filaments 7
Skin laxity
– chemical peels 154
– dermal fillers 150
– dermarolling 154
– lasers and energy-based
devices 151
– microneedling 154
– platelet-rich plasma 154
Skin laxity 149
Skin necrosis 178
Skin-platysma flap 93
SMAS, see Superf icial
musculoaponeurotic system
(SMAS)
SMFRS, see Submental Fat
Rating Scales (SMFRS)
SMG, see Submandibular
gland (SMG)
Sodium bicarbonate 116
Soft-tissue contraction 128,
134
Spinal accessory ner ve 6
Sternocleidomastoid (SCM)
muscle 23, 76, 116
Steven’s Kaye scissors 76–77
Stromal enriched lipograft
(SEL) 133, 135, 137
Stromal vascular fraction
(SVF) 16, 133, 135
Sub-superficial
musculoaponeurotic system
(sub-SMAS) techniques
178
Subauricular band deformity
174
Subcutaneous fat 170
Submandibular gland (SMG)
13
, 58 , 96, 112, 155
Submental access 74,81
Submental anterior neck lift
17
Submental cr yolipolysis 158–
159
Submental fat 13, 14,15
Submental fat and fullness
– cryolipolysis 158, 161
– deoxycholic acid 155, 156,
161
– laser and energy-based
devices 158
Submental fat and fullness
154
Submental Fat Rating Scales
(SMFRS) 158
Submental hollowing 174
Submental Z-Plasty 115, 120,
121, 121, 123–124
Submentalplasty 24
Subplatysmal fat 7, 18, 99,
108–109
Subplatysmal techniques for
treatment of aging neck
– facial analysis and applied
anatomy 105
– patient evaluation and
surgical goals 107
– surgical techniques
–– fat layer 107
–– platysma muscle and
subplatysmal structures
107
–– skin 107
–– submandibular glands
112
– surgical techniques 107
Subplatysmal techniques for
treatment of aging neck
105
Suction-assisted liposuction
(SAL) 16
Superficial fascia 1
Superficial musculoaponeuro tic
system (SMAS) 1, 18, 25, 36,
43, 56, 81, 110, 125, 133, 168,
170
Superficial veins 4
Surgical approach to neck
rejuvenation
– anatomy 56
– anatomy of neck
––
digastric muscles 58
–– fat compartments
–– great auricular nerve 59
–– platysma muscle 58
–– retaining ligaments and
filaments 58
–– submandibular glands 58
– anatomy of neck 57
– classification system 61
– clinical assessment 61
– complications 67
– evaluation of neck lift
patient 59
57
– lower face and neck,
surgical anatomy of 55
– operative technique 65
– patient selection 61
– postoperative care 67
– retaining ligaments 56
Surgical approach to neck
rejuvenation 55
Surgical procedures
– liposuction 16
– submental anterior neck
lift 17
Surgical procedures 16,17
Surginet 25
Suspension sutures 19
SVF, see Stromal vascular
fraction (SVF)
T
ThermiTight system 15
Tranexamic acid (TXA) 177
Transverse Neck Lines Scale
scores 148
Triple suture for neck
contouring
– case examples 49
– indications 43
– technique
–– infiltration 44
–– lateral cervical region,
treatment of 48
–– liposuction 44, 44, 45
–– marking 44
–– position 44
–– triple-suture technique 46
– technique 43
Triple suture for neck
contouring 43
TXA, see Tranexamic acid
(TXA)
U
UAL, see Ultrasonic-assisted
liposuction (UAL)
Ulthera microfocused
ultrasound system 15
Ultra-violet radiation (UVR)
exposure 145
Ultrasonic-assisted liposuction
(UAL) 16
Upper lateral sternomastoid-
cutaneous ligaments 7
UVR exposure, see Ultra-violet
radiation (UVR) exposure
184
Index
https://t.me/medicina_free
V
Vascular endothelial growth
factor (VEGF) 127
Vector planning 20
VEGF, see Vascular endothelial
growth factor (VEGF)
Vertical band deformity 174
Vicryl 4–0 113
Visceral fascia 2
VitaCyte LLC 135
W
Weekend lift 81, 82
X
Xylocaine 116
Y
Youthful aesthetically pleasing
neck, criterion for 11
Youthful neck, characteristic
of 12
Z
Z-plasty 115
185
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