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6.4 Neck Anatomy
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into the postauricular hairline. As the surgeon
advances in a subcutaneous plan over the mandibular ramus and body, along the anterior third of
the mandibular body, the surgeon will find the
cylindrical mandibular osteocutaneous ligament
attaching super ficial soft tissue to the mandibular
bony platform. It is this fixed point that causes
jowling when soft-tissue descent droops over this
ligamentous attachment. Release of this ligament
will allow increased mobilization of the face and
neck lift flap. It is imperative to remember that
facial nerve branches are often closely associated
with these retaining ligaments. In addition, when
releasing the zygomatic retaining ligament in a
sub-SMAS plane, one will often find zygomatic
and buccal rami of the facial nerve just caudal to
this ligament. Further sub-SMAS dissection into
the midface and release of the masseteric retaining
ligament will also leave zygomatic, buccal, and
marginal mandibular rami vulnerable. The surgeon
must release these ligaments with patience and
diligence.
11
The mandibular ligament will be
closely associated with marginal mandibular rami
that pass cranially to the ligament. The surgeon
should be aware of this location, although releasing this ligament in the subcutaneous plane should
protect the surgeon from any harm to facial nerve
branches.
12
Regarding facial nerve branch anatomy, Pitanguy’s line remains the most accurate description of
the course of the frontal branch, beginning 0.5 cm
below the tragus and progressing in a straight oblique line over the middle third of the zygomatic
arch to a point 1.5 cm above the lateral brow. This
nerve stays at the level of the arch periosteum until it becomes more superficial roughly 3 cm superior to the arch and innervates the orbicularis oculi
and frontalis muscles on their deep surfaces.
15,16,17
The zygomatic branch passes approximately 1 cm
inferior and deep to the zygomaticus major muscle,
which has been coined the sub-SMAS danger zone.
Due to rich arborization between the zygomatic and
buccal facial nerve rami, accidental injury to one of
these branches will seldom manifest in clinical implications. More relevant to this chapter, the marginal mandibular branches (1–2 rami) will be within
1 to 2 cm of the gonial angle. They are always
located superficial to the facial vessels at the antegonial notch. Proximal to the facial vessels they may be
cranial (80%) or caudal (20%) to the mandibular border. Distal to the facial vessels, however, they are
always cranial to the mandibular border.
5,8,18
As one
progresses even more distally to the mandibular
osteocutaneous ligament described earlier, the marginal mandibular nerve branches pass 1 cm above
this ligament where they continue to run medially
to innervate lip depre ssors.
7
The cervical branches of the facial nerve innervate
the platysma and are likely the least encountered facial nerve branches by the cosmetic plastic surgeon.
However, the platysma muscle is an important lip
commissure depressor. Injury to these branches can
cause marginal mandibular pseudoparalysis but can
be differentiated from true marginal mandibular
nerve injury by a patient’s retained ability to pucker
and evert the lower lip.
19,20
Regarding anatomical
landmarks, within 1.5 cm of the gonial angle, the
cervical branches are deep to the platysma muscle.
The cervical rami split into several branches 1.75 cm
inferior to the gonial angle. The most inferior of
these lies deep to the platysma muscle 4.5 cm caudal to the gonial angle. Cross-connection between
the cervical branches, marginal mandibular ramus,
and transverse cervical nerve have previously been
described.
21,22
6.4 Neck Anatomy
There are six important soft-tissue components in
the neck that one should be aware of when evaluating and operating in this region:
●
Fat compartments.
●
Platysma muscle.
●
Retaining ligaments and filaments.
●
Anterior bellies of the digastric muscles.
●
Submandibular glands.
●
Great auricular nerve.
6.4.1 Fat Compartments
Beginning with the first component, there are
three layers of fat in the neck. The superficial-most
layer lies between the skin and platysma muscle,
known as supraplatysmal fat. The intermediate fat
layer lies within the platysma, or just deep to it
and superficial to the anterior digastric bellies.
This layer is known as subplatysmal fat. The deep
layer of fat lies deep to the submandibular glands
and anterior bellies of the digastric muscles.
There is a decreasing amount of adipose tissue
when advancing from the superficial compartment
to the deep compartment. Most neck adipose tissue is supraplatysmal, which is lobular medially
and becomes less dense laterally. Subplatysmal fat
23
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can be significant to a lesser degree and oftentimes
requires excision during surgical neck rejuvenation. The least amount of fat resides in the deep
compartment, and fat excision in this compartment does not play a role in neck rejuvenation.
23,24
6.4.2 Platysma Muscle
The platysma muscle is a filmy, thin muscle that
extends from the clavicle to the menton and cranially connects with the SMAS. It separates the superficial and intermediate layers of neck adipose tissue.
Seventy-five percent of patients have platysma
muscles that decussate for only 1 to 2 cm below the
symphysis menti. Fifteen percent of patients have
muscles that decussate from the symphysis menti
to the thyroid cartilage. Ten percent of patients
have no decussation whatsoever.
24
6.4.3 Retaining Ligaments and
Filaments
The retaining ligaments and filaments of the neck
can be complex for t he novice and even experienced plastic surgeon to understand. Feldman
discusses six identifiable ligaments and three
identifiable filaments in the neck that may need
release to adequately mobilize face and neck lift
flaps. The ligaments are the mandibular, submental,
mastoid-cutaneous, platysma-auricular/ear lobe,
lateral sternomastoid-cutaneous, and platysmamandibular.
platysma-cutaneous, medial sternomastoid, and
skin crease-platysma. There are three ligaments
that also connect the platysma muscle to deeper
soft and bony tissues. These are the hyoid, paramedian platysma, and submandibular ligaments.
However, these three deeper ligaments are rarely
encountered during a neck lift as the platysma is
only undermined and plicated along th e midline.
Regarding the six aforementioned retaining ligaments, the platysma-mandibular ligament connects the platysma-SMAS layer to the mandibular
periosteum.
propriate term for this ligament, some denoting it
as the mandibular septum. However, Feldman has
described the location of this ligament as inferior
and lateral to the mandibular retaining ligament.
On cadaveric study, this ligament was consistently
found to originate from the anterior border of the
masseter at 45.6 mm from the gonial angle along
the mandibular border.
25
The three filaments are the medial
25
There is some debate as to the ap-
7
The plat ysma-auricular
ligament has been described by Furnas as a fibrous
condensation connecting the platysma to the dermis in the inferolateral auricular region. The facelift
surgeon will be very familiar with this condensation when raising the postauricular portion of the
flap just inferior to the lobule. This condensation,
while irritating to transect due to associated perforating vessels, heralds an important warning to the
surgeon that the great auricular nerve is in close
proximity. Cutaneous nerve branches from the
great auricular nerve may be found among these
fibrous septa and furthermore, the tail of the parotid gland may be superficial in the region of this
ligament as well.
10
The submental ligaments form the submental
crease through fasciocutaneous filaments from the
platysma muscle to dermis. Often, the submental
crease is used as a natural landmark for incision
placement just above or below the crease to access
the neck from an anterior approach. How ever, transection of these fibers and surrounding soft tissue is
required for excess submental skin excision and
redraping in order to not accentuate the crease.
6.4.4 Digastric Muscles
The digastric muscles play an important role in
shaping neck contour, specifically the submental
and submandibular triangles. The submental triangle is bordered by the hyoid inferiorly, the anterior
digastric belly superolaterally, and the median raphe
of the mylohyoid medially with the mylohyoid making up the floor and the symphysis menti making
up the apex of the triangle. The submandibular triangle is bordered anteriorly and posteriorly by those
respective bellies of the digastric muscle, superiorly
by the mandibular border, and the floor is once
25
again made up of the mylohyoid muscle.
the submandibular triangle resides the submandibular gland, facial vessels, and lingual and marginal
mandibular nerves. This triangle, of exceptional importance during a neck dissection, can also be useful
in neck contouring during surgical neck rejuvenation as will be described later in this chapter. Additionally, one can partially resect the anterior belly of
the digastric to smoothen the submental triangle
and allow unopposed stylohyoid pull, thus deepening and defining the cervicomental angle.
25
6.4.5 Submandibular Glands
The submandibular glands can also play an important role in neck rejuvenation. The submandibular
27,28
29
26
Within
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gland has two lobes: one superficial to the mylohyoid muscle and one deep to it, with both lobes
connected by a bridge of glandular tissue. The
superficial lobe is often the larger of the two, and
when a face and neck lift flap is pulled superolaterally and has been defatted, the superficial lobe
may appear prominent and interfere with a
smooth cervicomental transition. While the deep
lobe of the submandibular gland is deep to the
mylohyoid and is closely associated with the lingual and hypoglossal nerves, the superficial lobe
has a close association with other important facial
structures: the facial vessels and the marginal
mandibular nerve. The facial vessels have an
S-shaped anatomical course. Above the mandibular border at the gonial angle, the vessels are posterolateral to the submandibular gland. As one
courses anterior to the gonion, they bend just
superficial to the glandular fascia and then turn
superiorly to run above the mandibular border as
they course distally at the level of the anterior border of the masseter. Branches from the facial or lingual artery provide the gland with blood supply.
The marginal mandibular nerve passes superficial
to the facial vessels and thus over the glandular
fascia deep to the platysma muscle. When submandibular gland resection is performed, only an
intracapsular partial resection of the superficial
lobe is performed to minimize risk to these important neurovascular structures mentioned earlier.
30
6.4.6 Great Auricular Nerve
While the great auricular nerve is a cutaneous
nerve of the cervical plexus and may seem less important than the aforementioned structures above,
injury to this nerve can have important ramifications on the postoperative neck lift patient. Injury
to the main trunk of the nerve can result in neuromas and hypoesthesia in the cutaneous territory it
supplies. While this lack of sensation will often return, painful neuromas from the initial injury can
persist and be difficult to treat later.
have been several attempts to describe the course
and location of this nerve when dissecting in the
cervical region in order to protect it. McKinney
first described the main trunk’s exit from the sternocleidomastoid fascia 6.5cm inferior to the external acoustic meatus in the middle of the muscle
belly. This is now known as McKinney’s point.
Further attempts have described the territory of
31
Thus, there
Video 6.1 Open anterior approach to the neck in a
65-year-old woman. This b egins with wide under-
mining in the subcutaneous plane, ligamentous
release along the mandibular border, and removal of
excess supraplatysmal fat. Opening of the platysma is
routine, with dissection carried laterally to the
anterior belly of the digastric muscles. Excess sub-
platysmal fat is resected, as well as redundant
digastric muscle and submandibular gland when
necessary. Formal corset platysmaplasty concludes
this portion of the procedure.
the nerve from the sternocleidomastoid muscle
belly to its cutaneous destination. Ozturk et al
described the danger zone that is bordered by an
imaginary line perpendicular to Frankfurt’s horizontal plane that bisects the lobule of the ear.
Another line is drawn from the midlobule at a 30degree angle posterior to the first line. This triangular territory will almost always encompass the
nerve, and dissection should become more superficial when advancing inferiorly toward McKinney’s
point (▶ Video 6.1).
3,7
6.5 Clinical Assessment, Patient
Selection, and Evaluation of the
Neck Lift Patient
It is important to begin the evaluation of any surgical patient with a methodical history a nd physical to assess if they can tolerate the physiological
rigors an d potential complications of surgery. A
thorough listing of their medical comorbidities
and medications should be accounted for. This
allows the surgeon and his ancillary staff to opti-
mize every patient prior to surgery if they are a
candidate. Preoperative hypertension should be
31
documented and controlled with medication if
needed. Patients who are discovered to be labile
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postoperatively should be controlled with antihypertensives, such as clonidine, to avoid hematoma
collection. Additionally, having a patient quit smoking temporarily for 4 weeks prior to surgery has
shown to be beneficial, although permanent cessation is ideal. It is well known that facelift flaps are
10 to 12 times more likely to have wound complications in active smokers, and routine nicotine metabolite testing should be employed if there is suspicion
of noncompliance.
32
Supplements and nonsteroidal
anti-inflammatory drugs (NSAIDs) that can cause
bleeding diatheses should also be discontinued 2
weeks prior to surgery. Finally, women on oral contraceptives will have an increased likelihood of
deep vein thrombosis (DVT) during a prolonged
surgery, especially when combined with smoking,
so a discussion should be had with patients regarding temporary cessation for 2 weeks prior to surgery. The surgeon should be capable of calculating
the Caprini score on all patients to fully and objectively evaluate DVT/pulmonary embolism (PE) risk
prior to prolonged surgery. It is important to remember the importance of thorough evaluation of
the face and neck lift patient as they often present
at an advanced age with natural progression of
comorbid illnesses.
Rarely does rejuvenation of the face and neck
exist in isolation of one another. While the focus of
this chapter will be on the neck and the lower face,
when planning operative intervention, a thorough
and methodical evaluation of every patient’s face
and cervical region together is imperative to
achieving excellent results. For nearly a century,
facelifts relied purely on posterolateral preauricular skin excision with primary closure to re-elevate
ptotic facial soft tissue. However, just as the mastopexy evolved into reshaping and anchoring the
structure of the breast as opposed to simply redraping skin, so has the face and neck lift evolved
to encompass longer-lasting structural maneuvers
as opposed to skin-only procedures.
When evaluating the neck lift patient, in addition
to a full-face examination as mentioned, soft-tissue
quality should primarily be assessed from the sternal notch to the lower lip. It is important for the
cosmetic surgeon to assess every soft-tissue layer of
the face and neck, beginning preoperatively with
the most superficial layers, and then intraoperatively under direct vision of the SMAS/platysma
and subplatysmal fat. During initial clinical assessment, the patient’s skin quality should be noted.
It is important to educate the patient that skin
quality will naturally decline with age: a result
of apoptosis in the epider mal layer, reduction in
the number of melanocytes, as well as atrophy of
dermal collagen and appendages.
33,34
Outside of
these intrinsic factors, the patient should also be
educated on the external forces that alter skin quality such as smoking, weight fluctuation, sun exposure, medical comorbidities, and collagen vascular
diseases. All of these forces can cause skin elastosis,
or an inability for the skin to recoil as it once did.
This is important to note, and also to discuss with
the patient because neck rejuvenation relies heavily on skin recoil in order to achieve excellent
35
results.
When skin quality is a significant problem,
ancillary techniques such as filler, chemical peels,
and injectable lipolysis can be helpful and will be
touched upon in other chapters of this book.
When evaluating the face, it is important to do
so in a standardized fashion that allows consistent
analysis of problem regions. We prefer to divide
the face in vertical thirds and horizontal fifths to
allow side-to-side comparison and plan for surgical or minimally invasive maneuvers that can help
achieve the patient’s goals. Evaluation should be
done with the patient seated so that the surgeon
can assess the full effects of gravity on the soft tissues. The patient should also be assessed in both
repose and with dynamic animation, not only to
evaluate facial nerve function but also to understand the power of that patient’s muscles of facial
expression and their effect on skin wrinkling. As
the surgeon’s assessment moves toward the lower
face and neck, it is important to notice the natural
differences in soft-tissue characteristics between
these two regions. Neck skin tends to be thinner
than facial skin and has less elasticity. The neck
soft tissue exists in layers just as in the face: skin
followed by superficial subcutaneous fat overlying
the SMAS/platysma unit, followed by a deeper
subcutaneous layer, and finally the deep fascia
overlying critical cervical structures. Knowledge of
these contiguous layers in the face and neck allows
the surgeon to navigate the cervicofacial region
freely, blending these regions seamlessly. Patients
should also be thoroughly educated on the impact
of a neck lift. It will have its most powerful influence on the neck profile, helping turn an obtuse
cervicomental angle into a narrower one. It will
have little effect above the lower mandibular
border,sopatientswithconcernsoflowerface
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6.5 Clinical Assessment, Patient Selection, and Evaluation
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ptosis and jowling should be educated that these
concerns may not be completely corre cted by
neck rejuvenation alone. In fact, an improved
neck contour can further highlight contour def iciencies of the lower face.
Aging of the neck can be due to a multitude of
factors in any of the aforementioned layers of the
neck from superficial to deep: excess skin of poor
quality, excess preplatysmal fat, platysmal laxity
and banding, digastric hypertrophy, submandibular gland ptosis, and hyoid anomalies.
36
True and
moderate excess skin of the neck requires at least
a postauricular facelift incision in order to excise
skin and pull the soft tissues in the appropriate
posterolateral vector. Mild to moderate skin excess
may be treated with a minimal-access facelift incision and submental incision with neck skin redraping. Many cosmetic surgeons feel that minimal skin
excision is necessary in the patient with mild to
moderate skin excess.
37,38,39,40,41,42,43,44
This is because centrally, platysmal plication and concomitant facelifting with posterolateral traction on neck
skin will create a more submandibular surface area
that will need skin coverage. These maneuvers convert an obtuse cervicomental angle into an acute
one, requiring the excess skin for redraping this
increase in surface area and definition.
45
Assessment of the face and neck can be done
rapidly in the clinical setting as well as with photographs taken at the time of the consultation.
When assessing the face in vertical thirds, the lowest third is the most relevant to neck rejuvenation
due to proximity. Lower face deficiency, whether it
be in the sagit tal, axial, or coronal plane, can significantly impact facial aging.
46
The lower face extends from the oral commissure to the menton. It
is imperative to remember that all layers of the
face age with time, including the bony platform,
and all layers need to be assessed and corrected individually. In the lower face, this includes atrophy
of the bony mandible and menton. A deficient
menton in the vertical or horizontal plane fails to
put appropriate stretch on the neck soft-tissue
envelope and can thus contribute to skin and platysmal banding as well as an obtuse cervicomental
angle. Performing a vertical or horizontal genioplasty (or implant) at the time of neck lift may be
required to expand the neck soft-tissue envelope
and achieve the appropriate cervicomental angle.
Further, the gonial angle in the lower face should
be thoroughly assessed as a part of neck rejuvenation. Defining the inferior mandibular border is
essential to a youthful appearance. The gonial
angle can at times be masked by excess subcutaneous tissue directly overlying it, or just posterior
and inferior to it.
47
This can leave the lower face
looking widened and aged, and can contribute to
the appearance of jowling. Fat resection over the
gonial angle, posterior and inferior to it, can define
the mandibular border and narrow the lower face.
Rotational SMAS flap tightening in the postauricular
region followed by central platysmal tightening will
help polish these landmarks. Platysmal banding
should also be assessed. Treating muscle laxity and
dehiscence with skin redraping only will inevitably
result in recurrence. Pre- and postplatysmal fat
should also be assessed in the clinical setting. Preplatysmal fat excess can be evaluated by asking the patient to grimace to note laxity in the muscle versus
the subcutaneous lay er covering the muscle. Postplatysmal fat is exceedingly difficult to assess in the
clinical setting. Any doubt should warrant platysmal
division and fa t assessment intraoperativel y.
48
6.5.1 Classification System
Our preferred method of isolated surgical neck rejuvenation is the anterior approach that has been
well described by numerous authors. While minor
variations exist within the anterior approach
method, they all rely on the same principles of division of neck retaining ligaments and cutaneous
septa, relying on the neck skin’s unique ability to
contract and scar down to the platysma in a redraped fashion. This ability was discovered almost
on accident by early proponents of neck liposuc-
29,49
tion.
preplatysmal fat and skin excess with its promotion of scarring, the anterior open approach allows
for more finesse maneuvers to be added to neck
rejuvenation. Three main advantages of the open
approach are as follows: removal of fat in all layers
relative to the platysma, the ability to open the
platysma to treat digastric hypertrophy or submandibular gland ptosis, and the ability to plicate
the platysma and treat banding in order to restore
a youthful cervicomental angle.
neuvers accomplished with a traditional facelift
can be accomplished with the anterior open approach as well, except for the rotational SMAS flap
that tightens the platysma around the gonial angle
of the face.
on the obliqueness of the cervical mental angle.
However, while liposuction addresses the
50,51
All neck ma-
52
We used the Knize classification system based
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Grade I patients have no neck skin laxity, grade II
patients have mild neck skin laxity, grade III
patients have moderate neck laxity, and grade IV
patients have severe neck skin laxity (▶ Fig. 6.1).
A four-tier grading system allows the surgeon to
classify patients appropriately during their clinic
assessment and mentally prepare for the optimal
treatment approach to be executed in the operative
setting. Typically, grade I patients can be treated
with liposuction alone, as this maneuver treats preplatysmal fat excess and allows the overlying skin
to adhere tightly to the underlying platysma layer.
However, if a grade I patient is suspected of having
mostly intraplatysmal or subplatysmal fat, then
the anterior incision must be made to allow the
surgeon to treat these problem regions directly.
However, in the clinical setting, it is difficult to
determine how much excess neck subcutaneous
tissue is preplatysmal versus subplatysmal. The
grimace maneuver can be useful here. If the skin
flattens over the platysma with this maneuver,
more subcutaneous tissue can be expected to be
intra- and subplatysmal rather than overlying the
platysma muscle (▶ Fig. 6.2).
Grade II patients who also have an obtuse cervi-
comental angle are good candidates for the anterior
approach. Both preplatysmal and subplatysmal fat
can be resected. Skin can be widely undermined
laterally to the gonial angle and sternocleidomastoid, and inferiorly to the level of the thyroid carti-
53
lage. This allows for clear visualization of the entire
platysma for plication, treatment of banding, as
well as redraping of skin to f it the new, narrower
cervicomental angle. Again, because an obtuse angle is turned into a narrow one, more skin, not less,
is needed to cover this increased distance. Thus,
after the aforementioned maneuvers, neck skin is
never resected anteriorly. In fact, neck skin should
be preserved to adequately redrape over the increased submandibular surface area (▶ Fig. 6.3).
Grade III patients can become challenging with
moderate skin laxity. Again, adequate undermining to the borders of the platysma is necessary in
order to break up cutaneous ligaments in order for
skin redraping and scarring over the platysma. It is
important to note that with greater undermining
and preplatysmal fat resection comes greater responsibility of creating uniform neck lift flaps. The
increased surface area on which the neck skin will
scar down to the platysma creates more opportunity for contour deformities to expose themselves.
Thus, the more maneuvers exercised in an open
approach neck lift, the more care must be taken.
When a full face and neck lift is being performed,
45
Fig. 6.1 (a–h) Knize’s classification system. Reproduced with permission from Kochuba AL, Surek CC, Ordenana C,
Vargo J, Scomacao I, Duraes E, Zins JE. Anterior Approach to the Neck: Long-Term Follow-Up. Aesthet Surg J. 2021
Jul 14;41(8):861–870.
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Fig. 6.2 A 52-year-old woman presenting with an obtuse cervicomental angle and neck laxity (top). She underwent isolated
submental lipectomy and platysmaplasty. Postoperative photographs were obtained at the 12-month follow-up (bottom).
this presents less of a challenge as postauricular
flaps allow for excellent visualization of the neck
from several angles. However, when doing an anterior approach only, maintaining uniformity of
the flaps while excising pre- and postplatysmal
fat takes undivided attention and careful progress. While skin laxity may dictate the treatment
algorithm the majority of the time, certain patient
characteristics may require different maneuvers.
Patients with heavy necks, regardless of skin laxity and fat excess, may require some skin excision
to allow the smoothest cervicomental contou r
possible.
glands can also become exposed when preplatysmal fat is thinned and platysmal banding is plicated. These glands can then become a bulging
nuisance in the submandibular triangle and the
superficial lobe may need to be excised to restore
smooth neck contour. Others, such as our group,
suspend the submandibular gland rather than excise it, which reduces, but does not completely
resolve, the ptosis (▶ Fig. 6.4).
which will not have a good result from an open
45,54
Similarly, ptotic submandibular
Grade IV patients have severe neck skin laxity,
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Fig. 6.3 A 57-year-old woman who presented with an obtuse cervicomental angle with submental and submandibular
lipodystrophy and prior thyroidectomy scar retraction (top). She underwent anterior lipectomy and platysmaplasty in
addition to transconjunctival lower lid blepharoplasty. Postoperative photographs were obtained at the 14-month
follow-up (bottom).
neck lift alone. These patients need a standard facelift in combination with a neck lift to resect excess
skin and pull the neck skin in the appropriate vector.
A final option for these patients is direct excision
with opposing Z-plasty closure to allow for as much
neck mobility as possible (▶ Fig. 6.5).
We as a group do not believe in spanning sutures.
Again, the success of neck lifting depends on the
elasticity of the skin and its ability to scar down
64
54,55,56
to the underlying muscle platform once cutaneous
septa are divided. The undermined region of neck
skin should progress as far as skin laxity extends. For
instance, in patients with lateral skin laxity, undermining can be done as far as over the entire sternocleidomastoid muscle. In our hands, we find that
contouring the neck with this approach, along with
fat resection and primary muscle plication, gives a
long-term, natural-appearing neck as opposed to the
6.6 Operative Technique
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Fig. 6.4 A 50-year-old woman who presented with an obese neck, neck laxity, and lipodystrophy of the neck (top). She
underwent anterior lipectomy and platysmaplasty in addition to bilateral upper eyelid blepharoplasty. Postoperative
photographs were obtained at the 18-month follow-up (bottom).
tight, bandlike appearance in the submandibular triangle that sometimes acc ompan y spanning sutures.
6.6 Operative Technique
It is imperative that the patient be marked in the
seated or standing position to understand the full
nature of neck skin, fat, and platysma laxity. Markings can incorporate a variety of planning steps.
The incision can be marked over or below the submental crease. Additionally, the lateral extent of
skin undermining can be marked as well. Platysmal banding can be marked and further delineated
with the grimace test, as well as differences in regions of pre- versus subplatysmal fat. After induction, the patient’s neck is infiltrated with 50 mL of
0.5% lidocaine with epinephrine 1:200,000. This is
infused in the preplatysmal plane, with extra care
laterally where the external jugular vein is superficial and can be accidentally cannulated. The surgeon should have already decided at this point
whether or not liposuction of the neck will be the
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Surgical Approach to Neck Rejuvenation
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Fig. 6.5 A 57-year-old woman who presented with facial aging including jowling and an obtuse cervicomental angle with
skin laxity in the neck (top). She underwent rhytidectomy with an extended superficial musculoaponeurotic system
(SMAS) and anterior lipectomy with platysmaplasty. Postoperative photographs were obtained at the 12-month follow-up
(bottom).
primary mode of intervention. If this is the case,
well-disguised stab incisions in the submental
crease and postauricular region should be made.
Liposuction should be performed with utmost
care as uneven preplatysmal liposuction or overly
aggressive maneuvers can result in an uneven
contour of the neck with poor scarring to the platysma. It should be done in a crosshatch fashion
to ensure an even plane of subcutaneous tissue
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remains over the platysma muscle for optimal
contour and scarring.
If direct surgical rejuvenation is the modality of
choice, liposuction should be avoided at the start
of the case as blunt cannula trauma to the platysma
and preplatysmal fat will bruise and distort the
plane necessary for supraplatysmal dissection. Once
the submental incision is made, usually 3.5 cm in
length, the supraplatysmal fat is undermined in an
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