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Contents
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5. Triple Suture for Neck Contouring........................................ 43
Enzo R. Citarella, Ramil Sinder, Alexandra Condé-Green, Samir Janne Hasbun, and
Esther Barrios
5.1 Introduction
5.2 Indications .................... 43
................... 43
5.4.1 Case1......................... 49
5.4.2 Case2......................... 51
5.4.3 Case3......................... 51
5.4.4 Case4......................... 52
5.3 Technique ..................... 43
5.5 Expert Commentary by
5.3.1 Position........................ 44
5.3.2 Infiltration ..................... 44
5.3.3 Marking ....................... 44
5.3.4 Liposuction..................... 44
5.3.5 Triple-Suture Technique. . . . . . . . . . 46
5.3.6 Treatment of the Lateral Cervical
Region(V5)..................... 48
5.6 Expert Commentary by
Dr. Slavin
Dr. Lin
...................... 52
......................... 53
References .................... 54
5.4 Case Examples ................. 49
6. Surgical Approach to Neck Rejuvenation ................................ 55
Ritwik Grover, Andrew L. Kochuba, Rafael A. Couto, Jacob N. Grow, and James E. Zins
6.1 Surgical Anatomy of the Lower
Face and Neck
................. 55
6.2 Anatomy ...................... 56
6.3 Retaining Ligaments ........... 56
6.4 Neck Anatomy ................. 57
6.4.1 Fat Compartments. . . . . . . . . . . . . . . 57
6.4.2 PlatysmaMuscle................ 58
6.4.3 Retaining Ligaments and Filaments 58
6.4.4 Digastric Muscles. . . . . . . . . . . . . . . . 58
6.4.5 Submandibular Glands . . . . . . . . . . . 58
6.4.6 Great Auricular Nerve. . . . . . . . . . . . 59
6.5.1 Classification System . . . . . . . . . . . . 61
6.6 Operative Technique ........... 65
6.7 Postoperative Care............. 67
6.8 Complications ................. 67
6.9 Commentary by Dr. Zins........ 68
6.10 Expert Commentary by
Dr. Slavin
...................... 68
6.11 Expert Commentary by
Dr. Lin
......................... 68
6.5 Clinical Assessment, Patient
Selection, and Evaluation of the
Neck Lift Patient
7. Deep Plane Neck Lift Concepts and Technique .......................... 71
Benjamin Talei, Hedyeh Ziai, and Daniel J. Gould
7.1 Patient Considerations,
Indications, and
Contraindications
............... 59
.............. 71
References .................... 69
7.1.1 Patient Considerations . . . . . . . . . . . 71
7.1.2 Indications..................... 72
7.1.3 Contraindications . . . . . . . . . . . . . . . 72
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7.2 What Technique to Use and
......................... 72
Why?
7.3 Technique..................... 73
7.3.1 Deep Plane Face and Neck Lift . . . . 73
7.3.2 Internal Neck Lift . . . . . . . . . . . . . . . 81
7.4 How to Avoid Bad Results/
Common Pitfalls
............... 81
7.5 Case Examples................. 82
7.5.1 Case1......................... 82
7.5.2 Case2......................... 82
7.5.3 Case3......................... 82
7.5.4 Case4......................... 85
7.5.5 Case5......................... 85
7.6 Expert Commentary by
Dr. Slavin
...................... 85
7.7 Expert Commentary by
Dr. Lin
........................ 88
References .................... 88
8. Lateral Skin-Platysma Displacement Technique ........................ 89
Mario Pelle-Ceravolo and Matteo A. Angelini
8.1 Patient Consideration,
Indications, and
Contraindications
.............. 89
8.2 What Technique to Use
and Why?
..................... 89
8.3 The Rationale of Lateral
Skin-Platysma Displacement
... 90
8.7 Other Options to Avoid
Inadequate Results in Difficult
Necks: Cyanoacrylate Glue and
Platysmectomy
................ 97
8.8 Lateral Skin-Platysma
Displacement Limitations
...... 99
8.9 Discussion .................... 99
8.4 Technique..................... 90
8.5 Vectors of Traction ............ 91
8.10 Conclusions ................... 102
8.11 Expert Commentary by
Dr. Slavin
...................... 102
8.6 Lateral Skin-Platysma
Displacement Variations
8.6.1 Submandibular Gland Resection . . . 96
....... 94
8.12 Expert Commentary by
Dr. Lin
........................ 102
References .................... 103
9. Surgical Techniques for Treatment of the Aging Neck ................. 105
Munique Maia and Marcelo Cunha Araujo
9.1 Introduction
9.2 Facial Analysis and Applied
Anatomy
9.3 Patient Evaluation and Surgical
Goals
9.4 Surgical Techniques............ 107
x
................... 105
...................... 105
......................... 107
9.4.1 Skin........................... 107
9.4.2 FatLayer....................... 107
9.4.3 Platysma Muscle and Subplatysmal
Structures ..................... 107
9.4.4 Submandibular Glands . . . . . . . . . . 112
9.5 Expert Commentary by
Dr. Slavin
...................... 113
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9.6 Expert Commentary by
......................... 113
Dr. Lin
References .................... 114
10. Neck Lift after Massive Weight Loss ..................................... 115
Dennis J. Hurwitz
10.1 Patient Considerations,
Indications, and
Contraindications
10.1.1 Considerations. . . . . . . . . . . . . . . . . . 115
10.1.2 Indications..................... 115
.............. 115
10.2.2 Submental Z-Plasty with
Parallel Oblique Elliptical Excisions
ofSkin......................... 120
10.3 Role of Facelift for Neck Excess... 122
10.4 Expert Commentary by
10.2 Isolated Neck Lift: What
Techniques to Use and Why?
... 116
Dr. Slavin
...................... 124
10.5 Expert Commentary by
10.2.1 FaceTite, AccuTite, and Morpheus8
totheFaceandNeck............. 116
Dr. Lin
......................... 124
References .................... 126
11. The Use of Radiofrequency for Facial Rejuvenation ..................... 127
Erez Dayan and Christopher T. Chia
11.1 Patient Considerations
......... 127
11.5.2 Case2......................... 129
11.2 Technique ..................... 127
11.3 Postoperative Care ............. 128
11.6 Conclusion .................... 129
11.7 Expert Commentary by
Dr. Slavin
...................... 131
11.4 Common Pitfalls ............... 128
11.8 Expert Commentary by
11.5 Case Examples ................. 128
11.5.1 Case1......................... 128
Dr. Lin
......................... 131
References .................... 131
12. Neck Lift and Fat Grafting to the Neck ................................... 133
Aris Sterodimas
12.1 Introduction
12.2 Patients and Methods .......... 134
12.3 Surgical Technique and Fat
Processing and Grafting
12.4 Problem-Based
Examples/Cases
12.4.1 Case1......................... 137
................... 133
........ 134
................ 137
12.4.2 Case2......................... 137
12.4.3 Case3......................... 137
12.4.4 Case4......................... 137
12.5 Discussion ..................... 137
12.6 Conclusion .................... 142
12.7 Expert Commentary by
Dr. Slavin
...................... 142
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12.8 Expert Commentary by
........................ 142
Dr. Lin
References .................... 143
13. Neck Rejuvenation: Noninvasive Techniques ........................... 145
Mathew N. Nicholas, Sara R. Hogan, Michael S. Kaminer, and Jeffrey S. Dover
13.1 Introduction
13.2 The Aging Neck................ 145
13.3 Patient Considerations,
................... 145
13.4.3 Platysmal Banding . . . . . . . . . . . . . . 149
13.4.4 SkinLaxity..................... 149
13.4.5 Submental Fat and Fullness. . . . . . . 154
13.5 Conclusions ................... 161
Indications, and
Contraindications
.............. 146
13.6 Expert Commentary by
Dr. Slavin
...................... 162
13.4 Which Technique to Use and
Why?
......................... 146
13.4.1 Dyschromia.................... 146
13.4.2 Horizontal or Transverse
Necklines...................... 147
13.7 Expert Commentary by
Dr. Lin
........................ 162
References .................... 162
14. Revisional and Secondary Neck Lifts ..................................... 167
Ashley N. Boustany, Vickram J. Tandon, and Sumner A. Slavin
14.1 Revisional versus Secondary
Rhytidectomy
14.1.1 Revisional Neck Lifts. . . . . . . . . . . . . 167
14.1.2 Secondary Neck Lifts . . . . . . . . . . . . 168
................. 167
14.2 Patient Considerations ......... 169
14.2.1 Identification of Deformity . . . . . . . 170
14.2.2 Factors Influencing Longevity and
Outcomes...................... 170
14.3.1 Poor Scar Placement. . . . . . . . . . . . . 171
14.3.2 Scarred Tissue Planes. . . . . . . . . . . . 173
14.3.3 Platysmal Bands . . . . . . . . . . . . . . . . 173
14.3.4 Midline Ridge Deformity . . . . . . . . . 173
14.3.5 Submental Hollowing . . . . . . . . . . . 174
14.3.6 Vertical Band Deformity . . . . . . . . . 174
14.3.7 Subauricular Band Deformity . . . . . 174
14.3.8 EarDeformity.................. 174
14.4 Expert Commentary by
Dr. Lin
........................ 174
14.3 Problem-Based Technical
Considerations
................ 171
15. Neck Rejuvenation: Complications....................................... 177
Trina G. Ebersole, Amer H. Nassar, and Sumner A. Slavin
15.1 Hematoma
.................... 177
15.2 Skin Necrosis .................. 178
15.3 Infection ...................... 178
xii
References .................... 175
15.4 Nerve Injury ................... 178
15.5 Recurrent Platysmal Bands ..... 178
15.6 Dystonia ...................... 178
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15.7 Scars .......................... 178
15.8 Case Example .................. 178
15.8.1 Case1......................... 178
15.9 Expert Commentary by
Dr. Slavin
15.10 Expert Commentary by
Dr. Lin
References .................... 180
...................... 179
......................... 180
Index................................................................................. 181
xiii
Videos
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Video 3.1: Neck Lift
Video by Munique Maia, Alan Matarasso
Video 4.1: Step-by-Step Sequence to the Lateral Platysmal Window
Video by Rod J. Rohrich
Video 5.1: Triple Suture for Neck Contouring
Video by Enzo R. Citarella, Ramil Sinder, Alexandra Condé-Green, Esther Barrios, Samir Janne Ha sbun
Video 6.1: Anterior Approach to the Neck
Video by James E. Zins, Andrew L. Kochuba
Video 7.1: Deep Plane Neck Lift
Video by BenjaminTalei, Daniel J. Gould
Video 8.1: Lateral Skin –Platysma Displacement (LSD): A New and Proven Technique for Neck Rejuvenation
Video by Mario Pelle-Ceravolo, Matteo A. Angelini
Video 9.1: The Aging Neck: Subplatysmal Techniques
Video by Marcelo Cunha Araujo
Video 10.1: AccuTite of the Neck, Face, and Forehead
Video by Dennis J. Hurwitz
Video 11.1: Marking for Bipolar Radiofrequency of Lower Face and Neck
Video by Erez Dayan
Video 11.2: Fractional Radiofrequency Using Morpheus8 (InMode; Lake Forest, CA)
Video by Erez Dayan
Video 12.1: Performing Neck Liposuction Using the Syringe Method
Video by Aris Sterodimas
Video 12.2: The Adipose Tissue Aspirated by Liposuction Is Processed
Video by Aris Sterodimas
Video 12.3: Lipografting of the Malar Area Assisted by Stromal Enriched Lipograft
Video by Aris Sterodimas
xiv
Foreword
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“As to methods, there may be a million and then some,
but principles are few. The surgeon who grasps principles can successfully select his own methods.”
Harington Emerson
Throughout history and across cultures, a long and
graceful neck has been synonymous withbeauty. The
mind recognizes this lovely feature of human beauty
within seconds of visually taking it in. So, it naturally follows that beautiful rejuvenation of the neck
remains at the top of every plastic surgeon’s desired
outcome for every patient who seeks help in this
regard—and when it is not accomplished, a sense of
failure ensues. From early attempts at skin excision
to modern techniques aimed at restoring tissue
quality and tone, achieving per fect neck rejuvenation continues to be the “Holy Grail” of facial rejuvenation. Neck Rejuvenation: Surgical and Nonsurgical
Techniques by Samuel J. Lin, MD, and Sumner A.
Slavin, MD is a timely contribution that emphasizes
the importance of principles and consolidates expert
approaches to neck lifting and neck rejuvenation in
one outstanding volume. This comprehensive book
brings us a step closer to unraveling the mysteries
surrounding the pursuit of the Holy Grail of neck
rejuvenation. I have learned so much from Dr. Slavin
over the decades since we were young colleagues
together, and he and Dr. Lin are the perfect editors
for this important and latest contribution to our aesthetic surgery library.
The book’s well-organized content makes it an
excellent resource for seasoned plastic surgeons
seeking ideas and technical assist ance. It is equally
valuable for early career surgeons aiming to broaden their knowledge of neck rejuvenation in general.
Unsurprisingly, the foundation of every surgical or
nonsurgical approach lies in understanding neck
anatomy. Our comprehension of thi s anatomy continues to evolve, bearing implications for patient
safety and the avoidance of complicat ions. Operating in the subplatysmal plane car ries the risk of
injuring facial ne rve branches, while inadequate
knowledge of feeding vessel locations can lead to
problematic bleeding. Fear and lack of knowledge
regarding the anatomy often keep plastic surgeons
within their comfort zones, reluctant to explore the
depths of the neck. This book will improve the level
of comfort.
The editors take us on a journey through history,
covering essential general principles followed by a
range of individualized approaches, all written by
renowned experts. These approaches can be tailored
to suit the specific aging patterns of individual
patients. Like every facet of plastic surgery, accurate
diagnosis is key, and these well-written chapters
help shorten the learning curve for both novice surgeons entering the field of facial rejuvenation and
experienced surgeons seeking to improve their results. This resource will spare them the disappointment of subpar outcomes when employing a new
technique for the first time. Whether rejuvenating
the neck solely through lateral or submental approaches or combining multiple techniques, accurate
diagnosis is crucial. Surgeons must know when to
employ a specific method or opt for a more aggressive intervention to prevent recurrence of aging
changes and the need for secondary surgery. The
book also covers the challenges posed by the population of individuals who have undergone significant
weight loss, as well as the treatment of complications
and secondary neck surgery.
Throughout my four decades of grappling with
neck surgery challenges, I have frequently experienced less-than-satisfactory results often arising
from the misconception that a thin platysma muscle
can provide long-term support for heavy neck structures. Consequently, I have had to revise many of
those patients, achieving uniformly more successful
outcomes by addressing the heavy structures in the
subplatysmal plane more aggressively. By studying
the approaches described in these chapters, surgeons can identify patients who resemble those they
encounter and determine the most predictably
effective strategies. Failure to address the neck adequately can lead to disappointment with the entire
facelift procedure!
Recent advancements in nonsurgical approaches
have brought these alternatives into the mainstream, particularly for younger patients or those
who reject the idea of surgery. We are presented
with an array of options, including fat grafting, radiofrequency, and ultrasound energy tightening of
the neck. Undoubtedly, these technologies will continue to improve over time. Even now, they represent reasonable alternatives for refining minor skin
irregularities or addressing loose submental skin
xv
Foreword
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while also providing an option for maintaining good
surgical facelift results over time.
This book is not merely a decorative addition to an
office bookshelf; it is a practical resource that will be
picked up, perused, and studied repeatedly. It stands
as the most up-to-date reference on neck rejuvenation
available. Its comprehensive nature ensures that it covers all aspects of the topic without overwhelming the
reader. So, dive into its pages and relish the wealth of
knowledge it offers, just as I have.
James C. Grotting, MD, FACS
Past Chair, The American Board of Plastic Surgery
Former President, The American Society for
Aesthetic Plastic Surgery
Former Chairman, Board of Trustees,
American Society of Plastic Surgeons
Grotting Plastic Surgery
xvi
Preface
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It is our sincere pleasure to introduce you to this
book, ent itled Neck Rejuvenation: Surgical and
Nonsurgical Techniques, which has been the product of many colleagues’ efforts and many decades’
worth of patient care experience. Our friend and
colleague Dr. Joel Feldman taught us many innovative techniques in his preeminent work, Necklift,
which inspired us to put together a version that
included additional techniques along with nonsurgical techniques that have flourished recently.
The challenge is to produce a result that changes a
patient’s life for the better in a single day. This is no
small feat, but when that goal has been reached, the
gratitude of the cosmetic surgery patient must be experienced to be believed. They can reach the height,
without exaggeration, of ineffable daily happiness.
Their joy is expressed in many ways but most often
in the currency of smiles and hugs. Many of our most
gratifying moments in medicine have come from
these patients; they vindicate all our efforts as doctors, in general, and plastic surgeons, in particular.
But there is, of course, a flipside to the coin of
patient appreciation—those who are dissatisfied because of unmet expectations. There is little, if any,
forgiveness in aesthetic plastic surgery. It is therefore incumbent on us to work assiduously for a goal
of the best final result, commensurate with our surgical skills. More recently, however, the advances
emanating from nonsurgical techniques are leaping
in front of us; they should be used as enhancers and
not viewed as competitors, and sometimes even
embraced as saviors. We are fortunate that the
nonsurgical advances offer our patients and us the
opportunity of improved s urgical results without
repeat operation.
The modern aesthetic plastic surgeon must be
versed in both the surgical and nonsurgical techniques for achieving an optimal cosmetic result when
a patient enters the office and states “I hate my
neck.”
If teaching aesthetic surgery to trainees is one of
the more difficult challenges for those of us in the
mentoring side of the profession, it surely compensates with tremendous satisfaction. We are grateful
to every fellow, resident, and student who has
joined us in this endeavor. What we do in our work
is “right out there,” visible to all. That is the very
special quality of aesthetic surgery—none of us can
escape Judgment Day in the office. Those who practice aesthetic surgery must, by the nature of this
work, strive to understand each patient’s uniqueness, and always remember the investment of the
patient, both emotional and financial: They trust us
with their faces!
The ability to deliver a safe and durable neck rejuvenation procedure to a patient is always fulfilling
to the practicing plastic surgeon, and this feeling of
fulfillment to the patient never gets old. The results
before and after improved jowling and neck bands
remain an important marker of a happy patient,
although durability without complications is a delicate balance. Additionally, it may be enlightening to
the readership to know that even the great humanitarian, plastic surgeon, and editor-in-chief emeritus
of the journal Plastic and Reconstructive Surgery,Dr.
Robert Goldwyn, well into his retirement, at one
point quipped, “Thank goodness I don’t have to
worry about any more recurrent platysmal bands!”
Thank you for spending your precious time reading this book.
Samuel J. Lin, MD, MBA, FACS
Sumner A. Slavin, MD
xvii
Acknowledgments
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Sumner Slavin helped to recruit and give me an
amazing opportunity to begin my career in Boston. I
am forever appreciative of his constant mentorship,
support, guidance, and insights about career and life.
I give a huge thank you to all the authors who made
this book possible. Thank you to Munique Maia and
Vickram Tandon for the journey and helping to carry
the project to the finish line! Judith Tomat and Karen
Edmonson were amazing partners at Thieme who
were truly wonderful to work with to get this book
completed—Thank you all!
Samuel J. Lin, MD, MBA, FACS
The first acknowledgment must be given to Dr. Sam
Lin—an indefatigable colleague full of good judgment, knowledge, patience, and humor; surely hiring him for over a decade as Chief of the Division of
Plastic Surgery at Beth Israel Deaconess Medical
Center will always stand out as one of the best decisions I ever made.
I also wish to acknowledge Dr. Monique Maia, an
outstanding fellow in our Harvard Plastic and Reconstructive Fellowship Training Program who served as
our Managing Editor; thanks to Dr. Vickram Tandon,
our most recent Fellowship graduate, who assisted in
the preparation of multiple chapters by bringing his
excellent perspectives on what is important for the
young plastic surgeon entering practice; and, of
course, thanks to the superb colleagues listed on
each chapter who contributed their latest ideas and
innovations.
Judith Tomat’s guidance and persistence was indispensable in helping this book emerge from concept
to reality.
In my office, I wish to thank Karen Hamilton,
always in contact with everyone involved in this production, coordinating and communicating with all the
parties involved. Nothing happens without Karen’s
energetic input.
xviii
Sumner A. Slavin, MD
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