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5.3 Technique
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Fig. 5.10 (a,b) The second isolated MonoNylon 2–0 suture approximates in a deeper plane, the distal edges of the
medial platysmal bands at the level of the thyroid cartilage.
Second Suture
The second suture is a single MN 2–0 suture
placed at the level of the thyroid cartilage, approximating the distal edges of the platysma muscles,
the anterior bellies of the digastric muscles, the
perihyoid fascia, and the superficial cervical fascia,
thereby assisting in the definition of the cervicofacial angle and improvement of the flaccidity in this
region (▶ Fig. 5.10).
Third Suture
The third line of sutures is then pl aced, reinforcing the previous ones described earlier over the
midline with run ning MN 3–0or2–0 sutur es, be-
ginning approximately at the level of the thyroid
cartilage up to the supramental region depending
on each case. This suture does a vertical and superior traction of the infra- and suprahyoid tissues.
This also improves mental ptosis (▶ Fig. 5.11 and
▶ Fig. 5.12).
This line of sutures repositions the supra- and infrahyoid regions and deep tissues in the midline repositioning the submandibular glands. In patients
who still present a herniation of the submandibular
glands, we perform a plication at this level. By
extending above the mentum, these sutures also
Fig. 5.11 Marking with methylene blue of the third
suture starting at the thyroid cartilage up to the mental
or supramental region.
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Triple Suture for Neck Contouring
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Fig. 5.12 The third suture, a line of running MonoNylon
3–0or2–0 sutures, begins at the level of the thyroid
cartilage and proceeds to the supramental region,
tractioning the infra- and suprahyoid regions, finalizing
the treatment of the senile chin deformity and redefinition of the cervico-facial angle.
correct any senile chin deformity, redefining the
cervicofacial angle (▶ Fig. 5.13 and ▶ Fig. 5.14).
5.3.6 Treatment of the Lateral
Cervical Region (V5)
It is impor tant to note that some pat ients only
need the vector 6 corrected. However, in order to
obtain a better result overall, vectors 4 and 5 also
need to be addressed. The dissection is continued onto the face through a classic or reduced
retroauricular incision, which facilitates the sub cutaneous dissecti on of the lateral and posterior
parts of the neck. Underm ining is continued in
the midline through the submental incision
made previously in order to join both dissections, permitting better redistribution of any excess skin.
AMN2–0 suture is used to plicate the lateral
platysma approximately 1.5 cm inferior to the
mandibular line and the corresponding earlobe,
fixating it to the periosteum of the mastoid following a posterior oblique vector. This further defines
the cervicomandibular angle (▶ Fig. 5.15).
The lateral platysma is then plicated parallel to
the anterior border of the sternocleidomastoid
muscle with MN 2–0 sutures, in continuation with
the previous suture placed in the periosteum of
the mastoid. In the majority of our cases, we also
treat the anterolateral middle third of the face (V4)
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Fig. 5.13 Improvement of the cervical
contour after the triple-suture technique.
5.4 Case Examples
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Fig. 5.14 (a,b) A 42-year-old male patient before and after 2 years of
treatment vector 6 only.
with a classic preauricular incision following the
5
hairline
by a stairlike SMAS plication, which allows a better
definition of the mandibular contour and cervicofacial angle, and improves the inferior one-third of
the nasolabial folds.
and differential of improving the contour of the
angle of the neck and the treatment of the deep
structures of the submentum. It is reproducible
and has shown long-term lasting results.
and subcutaneous undermining followed
The technique presented here has the advantage
Fig. 5.15 The posterior oblique traction of the lateral
platysma and its fixation to the periosteum of the
mastoid with MonoNylon 2–0 sutures.
5.4 Case Examples
5.4.1 Case 1
MSC. A 65-year-old man who presented with
severe cervical skin laxity, ptosis of the deep structures of the neck, severe lipodystrophy, and widening of the platysmal bands. Three days after the
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Triple Suture for Neck Contouring
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triple-suture technique and lateral plication, better
definition of the cervicomental angle was achieved
(▶ Fig. 5.16).
5.4.2 Case 2
SC. A 53-year-old man where vectors 4, 5, and 6
were treated, showing the long-term results of the
technique at 18 years postop (▶ Fig. 5.17).
Fig. 5.16 Case 1: MSC, a 65-year-old
man who presented with severe cervical skin laxity, ptosis of the deep
structures of the neck, severe lipodystrophy, and widening of the platysmal
bands. Three days after the triplesuture technique and lateral plication,
better definition of the cervicomental
angle was achieved. Note the drains
used. Vectors 3, 4, 5, and 6 treated.
Fig. 5.17 (a,b) A 53-year-old man
showing the long-term results of the
technique at 18 years postop. Vectors
4, 5, and 6 were treated.
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5.4 Case Examples
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5.4.3 Case 3
LMC. A 66-year-old woman. Preoperative and 2year postoperative pictures showing improved
jowl and chin contouring (▶ Fig. 5.18).
5.4.4 Case 4
JCK. A 55-year-old patient. Preoperative and 2-year
postoperative pictures showing improved chin contouring (▶ Fig. 5.19).
Fig. 5.18 Case 3. LMC, A 66-year-old
woman. Preoperative and 2-year postoperative pictures showing improved
jowl and chin contouring. Bilateral
upper blepharoplasty was performed.
Vectors 2, 4, 5, and 6 were treated.
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Triple Suture for Neck Contouring
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Fig. 5.19 Case 4. JCK. A 55-year-old
patient. Preoperative and 2-year postoperative pictures showing improved chin
contouring. Vectors 1, 2, 3, 4, 5, and
6 were treated.
5.4.5 Case 5
NFH. A 59-year-old patient. Preoperative and 3-year
postoperative pictures showing improved contour
and angle of the ja w (▶ Fig. 5.20).
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5.5 Expert Commentary by
Dr. Slavin
This is a novel attempt to correct the s enil e chin
deformity as most treatments do not address
5.6 Expert Commentary by Dr. Lin
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Fig. 5.20 Case 5. NFH. A 59-year-old
patient. Preoperative and 3-year postoperative pictures showing improved
contour and angle of the jaw. Bilateral
upper blepharoplasty was performed
and Vectors 1, 2, 3, 4, 5 and 6 were
treated.
Video 5.1 Triple suture for neck contouring.
this condition. While the second suture is a
powerful maneuver in experienced hands, it is
not clear how the third row of suture s improves
submandibular gland prominence and associated
ptosis. Usually, we find that problem needs to be
corrected lateral to midline. The authors’ results
are noteworthy for establishing a well-defined
anterior neck and hyoid contour. The illust rations of patients with neck flexion are i mpressive with the degree of improvement seen
▶ Vi deo 5.1.
5.6 Expert Commentary by
Dr. Lin
The authors present an excellent approach to the
use of differential suture plication vectors for
maximizing neck contouring. The combination of
sutures including the second set is nicely shown
defining the cer vi comental angle, which specifically fixates deeper structures.
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Triple Suture for Neck Contouring
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References
[1] Miller CC. Subcutaneous section of the facial muscles to erad-
icate expression lines. Am J Surg. 1907; 21:235
[2] Kolle FS. Plastic and cosmetic surgery. Ann Surg. 1911; 54:717
[3] Citarella ER, Pitanguy I. Videoendoscopia no rejuvenescimen-
to facial. In: Pitanguy I, ed. Cirurgia plástica: uma visão de
sua amplitude. São Paulo: Atheneu; 2016:165–180
[4] Citarella ER, Condé-Green A, Sinder R. Triple suture for neck
contouring: 14 years of experience. Aesthet Surg J. 2010; 30
(3):311–319
[5] Pitanguy I. Aesthetic Plastic Surgery of the Head and Body.
New York, NY: Springer Verlag; 1981
54
6 Surgical Approach to Neck Rejuvenation
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Ritwik Grover, Andrew L. Kochuba, Rafael A. Couto, Jacob N. Grow, and James E. Zins
Abstract
This chapter will highlight several important factors the surgeon must keep in mind when performing a neck lift. While a brief history of the
evolution of face and neck lifting will be discussed,
the chapter primarily focuses on the anatomical
layers of the neck, with emphasis on the course of
the facial nerve, and how these layers can be approached safely and individually in order to optimally improve neck aesthetics. The chapter further
expands upon the preferred techniques utilized by
these authors and also touches upon the important
pitfalls and complications that can lead the surgeon wayward during a surgical neck lift. We have
also added a video demonstration that highlights
our technique of establishing the most common
location of the great auricular nerve’s emergence
from the deep fascia of the neck where it is likely
to be injured. Included are figures showing the
various degrees of soft-tissue laxity of the neck
and the techniques employed to confront each of
them. Finally, given that the senior author of this
chapter is a world-renowned aesthetic surgeon of
the face and neck, we found it fitting to conclude
the chapter with expert commentary on how the
surgical approach to the neck has evolved over
time. In writing this book chapter, we t ruly hoped
to impart some wisdom for both novice and expert
surgeons for this alluring and delicate surgery, and
in the process, learned much about our own techniques and results.
Keywords: neck lift, McKinney
rejuvenation, great auricular, re taining ligaments
’s point, surgical neck
Key Points
●
Thorough knowledge of the lower face, neck
anatomy, and retaining ligaments is critical to a
fundamental understanding of how to reshape
the neck with a surgical approach.
●
Surgical rejuvenation of the neck can be tremendously successful in reshaping not only the
aesthetic contour of the neck but also the cervicomental region as a whole.
●
Success depends on thorough and methodical
evaluation that allows optimal patient selection
and the best chance of a pleasing aesthetic result: this includes comorbid medical conditions
that often accompany this age group.
●
Surgical neck rejuvenation must be done from
an oblique and anterior approach to optimize
the vectors of soft-tissue tightening.
●
Common mistakes with surgical neck rejuvenation begin with a poor assessment of the etiology of poor neck appearance: skin and subcutis
excess versus platysmal banding versus subplatysmal fat excess or some combination of the
aforementioned. Failing to adequately treat
gland hypertrophy and erroneous vector of pull
on the soft tissue that may compromise the final
aesthetic appearance of the neck and cervicomental angle are also common pitfalls for the
novice facial aesthetic surgeon.
●
Case-based examples with media supplements
and expert commentary complete this chapter.
6.1 Surgical Anatomy of the
Lower Face and Neck
Face and neck lift has changed tremendously in
the last century. Nearly 100 years ago, facial laxity
was treated with simple posterolateral skin excision
and suture closure—with only short-term success.
The modern-day face and neck lift has become an
amalgamation of decades of surgical advancement,
trial and error, and the addition of minimally invasive techniques such as lipofilling. Today, most patients with concerns of soft-tissue laxity and aged
appearance of the face will arrive at their appointment with excellent background knowledge of the
available surgical and nonsurgical techniques to
treat this concern. However, few of these patients
understand the dynamic interplay between the face
and neck. To achieve maximum aesthetic success,
both the face and neck must be treated as one contiguous unit. This principle must be communicated
to the patient during initial evaluation and surgical
planning. The reverse is also true: Patients with
principle aesthetic complaints regarding the neck
should also be evaluated for possible rejuvenation
of the face that will allow an elegantly blended
transition from the neck to the lower face and
beyond.
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Surgical Approach to Neck Rejuvenation
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6.2 Anatomy
Prior to surgical intervention, it is imperative that
the plastic surgeon thoroughly understand the
anatomy of the superficial and deep planes of the
face and cervical region. One will quickly realize
that throughout the face and neck there is a fibrous
network of collagen that connects underlying fat
and soft tissue to overlying skin and dermis. This
reticular cutis creates a unique network of stringy
tetherings connecting deep tissue to superficial tissue. However, there are certain regions of the midface, lower face, and neck where these fibrous
strings coalesce into ribbonlike structures that may
run in transverse, oblique, or longitudinal fashions.
These ligamentous attachments connect superficial
layers of the face and neck to deep bony platforms
or fascial planes in the cervicofacial region. Accompanying these ligaments are nerves and vertical
perforating vessels that can make division of these
ligaments tedious and, at times, sanguineous. The
goal of the introductory portion of this chapter will
be to review the comprehensive ligamentous network in the neck and lower face to help the surgeon
become familiar with this complex anatomy. Intimate knowledge of these fibrous networks will
assist the surgeon in evaluating the present-day face
and neck lift patient and carry out the appropriate
surgical maneuvers to optimally correct soft-tissue
ptosis of the neck.
It is well known that the human body has concentric layers from superficial to deep that, despite
our contour irregularities, persist in all directions.
This is no different for the cervicofacial region. There
is a delicate layering from superficial to deep in the
face and neck that starts with skin. This is followed
by subcutaneous tissue, then the superficial musculoaponeurosis incorporating the muscles of facial expression and platysma inferiorly. Then, a deep fascial
system and its associated deep muscle group lies
over the final laye r, the bony platform. To review, the
superficial musculoaponeurotic system (SMAS) is a
defined aponeurotic layer laterally. It blends seamlessly with the t emporoparietal fascia superolaterally
over the temporalis muscle and is in continuity with
the frontalis muscle superomedially. The SMAS becomes quite thin when advancing from lateral to
medial where it covers the orbicularis oculi. In the
lower face, the SMAS is more muscular and is in continuity with the platysmal extensions emanating
from the neck.
branches of the facial nerve laterally, accidental or
1
Where the parotid covers the
purposeful invasion of the SMAS is allowed as the
parotideomasseteric fascia provides a protective
barrier between the surgeon and these important
neural structures. However, medial to parotid extensions, it is imperative that the surgeon respect the
anatomy from superficial to deep in order to avoid
denervation of critical facial nerve branches.
Remaining in a subcutaneous plane is always safe
with respect to facial nerve branches. SMAS plication or SMAS resection is also safe when performed
distal to the anterior border of the parotid gland
where fixed SMAS can be approximated to loose
distal SMAS. Here, muscles of facial expression are
under a well-defined SMAS layer and are also innervated on their deep surface. The frontal branch is
just above the periosteum of the zygomatic arch
deep to the parotid masseteric fascia. Thus, it is safe
to delicately lift a SMAS-only layer or plicate it.
Medial to the temporal extension of the zygomatic
arch, the surgeon begins to drift into extremely
superficial muscles of facial expression such as the
orbicularis oculi where accidental SMAS injury,
muscle injury, and thus facial nerve zygomatic
branch injury are more plausible with potential
2,3,4,5,6,7,8,9
2,3,4
6.3 Retaining Ligaments
It is imperative to clarify the retaining ligament
anatomy throughout the lower face and neck in
order to obtain excellent surgical neck lift results.
As stated earlier, there are predictable patterns of
fibrous attachments between deep and superficial
tissues in the face and neck. These are “zones of
fixation” where gravity and soft-tissue atrophy are
unable to have an impact. Instead, these factors
will affect the soft tissue surrounding these zones
and will cause skin and subcutaneous tissue to
droop over these fixed points, creating hollows
and mounds as opposed to a smooth contiguous
surface characteristic of the youthful face. Not only
knowledge of these fibrous ribbons heralds important landmarks for facial nerve branches but also
their adequate release is necessary to allow mobilization of the soft tissue in the face and neck distal
to the ligamentous attachments in the appropriate
2,10,11,12,13,14
vector.
We will begin by describing the retaining ligaments of the lower face. Facelift flaps have been
elevated in the standard fashion beginning in the
pretemporal hairline, advancing inferiorly in the
preauricular crease, around the lobule, and finally
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