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Modified Facelift Procedures
Chapter 8 Modified Facelift Procedures Short Scar (Weekend) Facelift Surgical Procedure . . . . . . . . . . . . . . . . 160 Direct Neck Excision Z-Plasty . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Case Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Submentoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Short Scar (Weekend) Facelift Surgical Procedure In the previous chapters I discussed the pluses and minuses of small facelifts (short scar facelifts [SSFLs]). It is obvious that I feel that these types of facelifts are very limited for the average patient of facelift age, however they remain useful for younger patients with minor aging as well as a means of learning facelift surgery for the novice surgeon. It has become very trendy to offer and promote these small facelifts. Many of these procedures omit the critical posterior auricular incision as well the submental incision and platysmaplasty. This type of approach may be acceptable for very small lifts on young patients but this group only makes up 2% of my over 1200 facelifts. I have shied away from this type of approach for the reasons already discussed. I feel it is simply a compromise to result and longevity. If and when I agree to perform a short scar lift, I have the patient sign a consent detailing what the surgery will and will not do. I also have the patient agree to allow me to convert the small lift into a traditional lift if I feel there is too much skin for the small lift to be effective. Although I think these lifts are a great way for novice surgeons to learn facelift surgery, I have time and again started a small lift only to convert it to a traditional lift. Positive aspects of these conservative procedures are that they are simpler to learn and perform, can be done with local anesthesia, do not require bandages, have shorter recoveries, and are easier to market compared with larger procedures.
These procedures also have serious drawbacks. They do not and cannot address moderate and advanced aging to the level of larger lifts. Patients must be told that their result will not be as tight or last as long as conventional lifts. Also of significant importance is the fact that these procedures are designed for younger patients with minimal excess submental and neck skin. Performing an SSFL on the right 38-year-old to 42-year-old patient can be quite effective, whereas performing the same procedure on an older patient or one with advanced aging can be very disappointing for both surgeon and patient. Personally, I feel it is unethical to perform a small lift on a patient who needs a big lift. These conservative lifts involve a preauricular incision with some mastoid extension but generally do not include the posterior auricular incision. For any surgeon who truly understands the pathophysiology and vectors of aging and facelift surgery, the postauricular incision is a requirement to truly tighten the neck with a lasting result. The SSFL, sometimes called weekend facelift (WEFL), is built around omitting the postauricular incision and traditional platysmaplasty and therefore has much less effect on significant jowl and neck aging. These “franchise” lifts go by many names and when performed correctly, they do offer a result, but they are not new miracle procedures, and cannot produce comparable results to more comprehensive facelifts. Frequently, the procedure sounds too good to be true: “local anesthesia, drive home from the office, no bandages, go back to work the next day” can be very inviting to a patient who does not fully understand other available options or the limitations of these lifts.
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the amount of skin present in the neck and submental region. Fortunately, much of this bunching will dissipate with healing, but some will persist and can be noticeable with certain hairstyles. The tradeoff of an improved appearance versus some posterior skin bunching is usually not a problem as long as the patient has been made aware of this preoperatively. I personally had a case where the postauricular bunching took an entire year to dissipate (see Fig. 6.189). In the minimally invasive procedures, I do not routinely perform midline platysmaplasty. If the patient has enough aging to warrant midline platysmaplasty, they need a conventional facelift. I do, however, perform submental liposuction if the patient has excess submental fat and this will usually cause some skin contraction. The short scar or weekend incision for the preauricular region and temporal tuft is identical to a smaller conventional facelift (Fig. 8.1). The short-flap subcutaneous dissection is smaller than conventional facelift and is generally 2 to 4 cm circumferential from the ear (Figs. 8.2–8.5). When addressing the superficial muscular aponeurotic system (SMAS) during SSFL surgery, SMAS plication is the most conservative means of SMAS management and probably produces less swelling and faster recovery (Fig. 8.6). In most cases, I prefer the same SMASectomy procedure as described earlier but on a smaller scale (Fig. 8.7). Although I always advocate using posterior platysma sutures to fashion the sling referred to numerous times in this chapter, it is not as applicable in the short scar lifts because of limited access. In general, there is enough room to place at least one posterior platysma suture below the angle of the mandible to assist in tightening the deeper layers of the neck (Fig. 8.8). After the SMAS is dealt with by the surgeon’s preferred method, the skin must be properly placed on traction. The vector of pull may be somewhat different in the short scar lifts. Although there is no “guaranteed” correct vector and every patient is different, a more vertical vector (as opposed to posterolateral) may be required to tighten the jawline and jowls without bunching the posterior auricular region (Fig. 8.9). This does not always apply and sometimes the posterolateral vector is preferable. All vectors of pull should be tried to see what direction provides the best result with the least amount of posterior skin bunching. When using vertical elevation of the preauricular flap, the surgeon needs to make sure enough skin exists to cover the tragus. Never make skin cutbacks or trim skin until coverage is verified. Once the proper vector is achieved, an anterior skin cutback and key suture are placed in a similar manner as conventional facelift (Figs. 8.10 and 8.11). Once the skin is suspended, the excess skin is trimmed and the lobe delivered in the same fashion as conventional facelift (Figs. 8.12 and 8.13). One of the biggest drawbacks of SSFLs is postauricular skin bunching. This occurs because, unlike conventional facelift, there is no postauricular flap to release and pull the skin. In small lifts this is not problematic and a simple triangle skin flap can remove the dog ear (Fig. 8.14). Larger short scar lifts produce significant bunching and can be more challenging as shown in Fig. 8.2. There
Short scar (weekend) facelift surgical procedure
The main reason I am not a huge proponent of these conservative lifts is simply that the average patient who needs a facelift needs a conventional one. When I do treat patients with WEFL, I ask them to give me permission to add a full posterior auricular incision to obtain a better result if I feel intraoperatively that the small procedure will not address the aging changes. I have done this numerous times when my intraoperative observations show that these patients would ultimately be short changed with the single incision procedure. What continues to amaze me is the amount of excess skin these specific patients exhibit, even with minimal outward signs of aging. In short, although they may not have visible skin excess, most patients in their mid to late fourth decade are candidates for traditional-incision facelift. Fig. 6.188 shows two such patients. Conservative lifts certainly have a place in the armamentarium of the cosmetic surgeon, but my personal requisites are illustrated by the fact that out of over 1000 facelifts, only 2% have been short scar. My personal indications for performing a short scar (limited incision) facelift are: • Young patients with minimal aging • Slightly older patients with minimal to moderate jowl and neck aging • Patients who have medical problems that preclude a larger facelift or anesthesia • Patients with budget or recovery limitations who cannot have a larger lift. As stated very early in this chapter, if a small procedure is performed on a patient who needs a bigger procedure and although the patient may be happy, it is sometimes very obvious that the facelift is not all that it could be and the surgeon could actually get negative publicity as other observers see shortcomings of a small procedure and do not realize it was not a conventional facelift. Short cuts in any procedure can have negative marketing consequences. This type of facelift is a great way for the novice surgeon to learn facelift techniques and some surgeons only perform short-scar procedures. As long as the patient selection is appropriate and the patients are given full disclosure of the pluses and minuses, the procedure is appropriate. When I do perform this procedure on a patient, they are required to sign an additional consent that details the limitations of this type of facelift. Although some surgeons perform these procedures with only local and tumescent anesthesia, I still use general anesthesia. The preauricular work with the SSFL is very similar to a conventional facelift but generally more conservative. The sideburn release incision is generally shorter, and the actual preauricular incision is identical. The main differences are seen when the incision turns the corner of the earlobe. Most of the conservative lifts use a postauricular incision that is made in the postauricular sulcus and extends 2 to 4 cm superiorly. Some surgeons advocate making a horizontal releasing incision across the mastoid region, which is a mistake because it will be very noticeable postoperatively. To pull the jowl and especially the ptotic neck skin and the antiaging vector without a traditional postauricular hairline horizontal releasing incision can result in skin bunching behind the ear. There is no way to prevent this without a longer postauricular hairline incision, and it will be commensurate with
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Fig. 8.1. Both of these patients requested a “weekend” (short scar) facelift. Observing these before picture (A, C) shows that both patients appeared to have only minor skin excess. The intraoperative pictures of both patients show the amount of skin excess that actually existed (B, D). This impressive amount of skin required conversion to a conventional facelift, otherwise the patient would have not had an optimum result and longevity. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.199. Page 122)
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Short scar (weekend) facelift surgical procedure Fig. 8.2. This patient insisted on a short scar facelift and because of the limited postauricular incision, sustained significant skin bunching. The bunching took almost one year to resolve and the bottom images show the patient 12 months later. Surgeons are to be careful about being talked into a deeper procedure than the patient actually need. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.200. Page 123)
Fig. 8.3. This image shows the incision markings and actual incision in a short scar type facelift.
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Fig. 8.4. This image shows the anterior, inferior, and posterior limits of a typical short scar (“weekend”) facelift dissection. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.202. Page 124)
Fig. 8.5. This image shows the dissection completed on a typical short scar facelift. This particular case has a generous posterior auricular dissection because many short scar lifts have a posterior auricular incision, which terminates in the mastoid region as shown in Fig. 8.14. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.203. Page 124)
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Fig. 8.6. This image shows a superficial muscular aponeurotic system plication in a short scar facelift. The plication sutures are diagramed to show their placement, extension, and vectors. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.204. Page 124)
C
Fig. 8.7. Even though the shortscar facelift technique uses smaller dissection than conventional lift, a small superficial muscular aponeurotic system (SMAS)-ectomy is still an option. The left image (A) shows the SMAS strip being excised, the middle image (B)shows the SMAS strip overlying its approximate position, and the right image (C) shows the final SMASectomy sutures. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.205. Page 125)
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Fig. 8.9. Some short scar lifts require a more vertical vector of skin pull and the surgeon should try various vectors to see which produces the best result with the least amount of posterior auricular skin bunching. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.207. Page 125)
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Fig. 8.10. The left image (A) shows typical anterior skin excess on a short scar lift. The center image (B) shows the skin cutback, and the right image (C) shows the key suture placed. Note the blue ink on the skin that was formerly the tragus. This shows how much skin is displaced, even in a small facelift. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.208. Page 126)
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Short scar (weekend) facelift surgical procedure
Fig. 8.8. This image shows a solitary suture securing deep tissues in the area of the posterior platysma to the mastoid fascia. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.206. Page 125)
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Fig. 8.11. The left image (A) shows a skin cutback in a short scar facelift and the right image (B) shows the flap suspended. Note the typical posterior auricular skin bunching seen with these procedures (white arrow). (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.209. Page 126)
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Fig. 8.12. The left image (A) shows the outline of the excess skin to be trimmed, the center image (B) shows the preauricular skin being excised, and the right image (C) shows the temporal skin excision. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.210. Page 126)
Fig. 8.13. The lobe is delivered with a very conservative cut back. In many cases, no cutback is required and the lobe can simply be pulled out. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.211. Page 127)
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B
Fig. 8.14. The left image (A) shows skin bunching on a very conservative short scar facelift. The skin hook retracts the excess and a geometric triangle reduction is performed to remove the pleat (B). It is imperative to keep this extension short and behind the ear to remain hidden. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.212. Page 127)
Fig. 8.15. This image shows a long excision release over the mastoid region to deal with posterior skin bunching on a short scar lift. This level of extension will produce a scar that is not hidden by the ear and is a handicap in terms of aesthetics. A more cephalad posterior auricular would provide better incision and scar management as opposed to the one used in this case as shown in Fig. 8.17. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.213. Page 127)
comes a point when excessive posterior auricular skin signals the need for a conventional lift with postauricular excision. Sometimes less is not more! One common mistake is instead of performing a conventional facelift, surgeons attempt to deal with the excess posterior auricular by large and low excision extension. Although extending the excision over the mastoid region may release the bunching, it also can produce an unsightly scar that is impossible to hide (Fig. 8.15). Again, trying heroic measures to deal with skin excess can easily be avoided by performing a conventional lift, when needed, in the first place. The tragal and earlobe is addressed in the same manner as conventional facelift (Fig. 8.16); the anterior incisions are closed with 5-0 gut suture, and the posterior incision is closed with 4-0 gut suture (Fig. 8.17). Bcause the short flap procedure does not have significant dead space, I do not use postoperative dressings or drains. Hematoma,
Fig. 8.16. This image shows all the skin cutbacks and trimming completed and the sculpted tragus ready for suturing.
tissue necrosis, and other complications are uncommon because of the small nature of the procedure (Figs. 8.18–8.22). Healing is usually much faster and less complicated than bigger procedures. Figs. 8.21–8.23 show before and after images of SSFL (WEFL) patients.
Direct Neck Excision Z-Plasty Introduction The previous section detailed comprehensive treatment of lower facial aging with facelift surgery and this chapter discusses alternative lifting techniques. Comprehensive face and neck lift remains the gold standard for treatment of jowls and excess neck skin. Not all patients are candidates for comprehensive facelift for medical reasons, inability to take time off, finances, or simply wanting a more conservative procedure. It is imperative for the surgeon and the patient to realize that any procedure that is more conservative will yield less of a treatment result. In cases of excess neck skin and submental aging without significant jowling, the direct excision Z-plasty neck left may be appropriate. The positives include 167
Direct neck excision Z-plasty
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Fig. 8.17. The anterior incisions are closed with 5-0 gut suture (A) and the posterior incision is closed with 4-0 gut suture (B). (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.214. Page 127)
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Fig. 8.18. This right image shows a patient 24 hours after short scar (“weekend”) facelift and the right image shows the same patient at one week. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.215. Page 128)
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Fig. 8.19. This patient is shown before (A) and after (B) after short scar facelift. This is the same patient shown in Fig. 8.18. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.216. Page 128)
a small surgical procedure with minimal recovery and a dramatic change in submental aesthetics. Negatives include a visible scar and the fact that only the anterior neck is improved. A sharp cervicomental angle is central to an overall appearance of youth and strength. Defined by the intersection of the facial plane with a line from the cervical point to the menton, 168
the cervicomental angle is acute in youth and becomes obtuse with age or even effaced. Restoration of the obtuse cervicomental angle is a key aim of surgery of the lower third of the aging face. Widening of the cervicomental angle with age is caused by the combined effects of loss of skin elasticity, increase in submental fat, and soft tissue ptosis, including the platysma muscle and
Surgical Technique Fig. 8.20. This patient is shown one week after short scar facelift and light periorbital laser resurfacing.
The patient is marked sitting in the upright position, with head held in the Frankfort horizontal plane. A midline vertical, Fig. 8.21. This 42-year-old female is shown before and after short scar facelift and chin implant. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.217. Page 129)
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facial units or may present with persistent skin laxity after facelift surgery. Other patients seek isolated correction of the lax neck or wish to avoid the stigmata of traditional periauricular facelift incisions. These groups of patients can benefit from more targeted neck rejuvenation. Traditional approaches to direct treatment of the aging neck include liposuction, open submentoplasty, and suture suspension techniques. Although these procedures address the fat and sometimes the platysma, they can be inadequate for patients with inelastic or excessive cervical skin and will often lead to unsatisfactory rejuvenation and early recidivism. Direct excision and simple primary closure of the redundant skin in either a transverse or vertical fashion creates an unfavorable scar prone to contracture and webbing. To address this problem, direct excision of neck skin with Z-plasty closure (as described by Biggs [1983]) is a viable alternative for isolated treatment of the male neck. This chapter presents experience with direct excision of redundant neck skin with submentoplasty and Z-plasty closure in both male and female patients. In previous articles, the application of direct neck excision has been limited mainly to male patients, especially those who are balding or have heavy beards. This has been expanded to include any patient who is uncomfortable with undergoing a traditional facelift and is willing to accept isolated rejuvenation of the neck in exchange for a fine Z-plasty incision line. Certain male patients, in particular, fear the social stigma of periauricular incisions, no matter how well executed, and are more comfortable with the more “functional-appearing” Z-plasty incision. This technique has also been adapted as a planned second stage revision for after facelift or concomitantly with a facelift, for patients with either thick, excessive, heavy skin or fine, crepey, inelastic skin.
Direct neck excision Z-plasty
submandibular glands. Abnormally low and anterior hyoid bone position and/or microgenia can accentuate these features. Traditionally, the cervicomental angle has been addressed together with a tightening of the jawline and jowls via cervicofacial rhytidectomy and submentoplasty. Correcting these interrelated areas simultaneously contributes to a natural appearing rejuvenation of the lower third of the face. For selected patients, however, direct rejuvenation of the aging neck is an appropriate option. These patients may evidence primary aging changes of the neck out of proportion to adjacent
Fig. 8.22. This 54-year-old female is shown before and after short scar facelift and full face CO2 laser skin resurfacing. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.218. Page 129)
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Fig. 8.23. This 44-year-old female is shown before and after short scar facelift and chin implant. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.219. Page 130)
elliptiform incision is marked on the anterior neck, with its apex in the submental triangle and its inferior extent as low as necessary to encompass the redundant neck excess. In most individuals, the inferior extent of the incision is at the level of the thyroid notch; however, with extreme cases, it may be carried down as low as the suprasternal notch. The width of the ellipse is marked conservatively to avoid excessive tension in the final closure. The intended level of the new cervical point/neck crease is also marked (Fig. 8.24). In many cases the actual incision is directly on the midline, especially in patients with a symmetric “turkey gobbler” skin excess. In patients with solitary isolated lateral excess, the incision can be made off center to better address the precise excess. A single dose of intravenous antibiotic is given for skin flora coverage. Once an adequate plane of intravenous sedation and 170
analgesia is achieved, the anterior neck is infiltrated with the surgeons preferred tumescent anesthetic solution and sufficient time is allowed for the epinephrine to exert maximum hemostatic effect. During this time, markings are reconfirmed and the patient is sterilely prepped and draped. The procedure begins with full-thickness skin incision with a No. 10 Bard-Parker blade. Dissection is then carried down through the subcutaneous fat with needle-tipped electrocautery hemostasis (Fig. 8.25). The excessive skin and midline submental/preplatysmal fat are removed en bloc (see Fig. 8.25 and Fig. 8.26). The medial platysmal borders are identified and treated in a similar manner to conventional facelift/submentoplasty. Bilateral neck flaps are then created by elevating thin subcutaneous flaps off the preplatysmal flaps on each side of the neck to the anterior borders of the sternocleidomastoid muscles. Most of the
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Direct neck excision Z-plasty Fig. 8.24. This series of markings shows the typical incision outline. Because this patient had increased skin/muscle excess on the left medial platysmal band, the incision in this case is made lateral to the midline. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.330. Page 178)
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Fig. 8.25. The left image (A) shows the skin incision, the right image (B) shows the en bloc resection at the preplatysmal level. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.331. Page 178)
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Fig. 8.26. The left image (A) shows the surgical defect after resection and the right image (B) shows the temporary sutures used to determine the cervicomental angle which is shown by the black line. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.332. Page 179)
dissection is accomplished with sequential spreads of a medium or large facelift scissor. Bridging vessels are identified and cauterized with bipolar cautery as needed. While elevating the flaps, several millimeters of subcutaneous fat are preserved to prevent dermal adhesion to the underlying muscle as well as to protect the dermal plexus. A headlight or lighted facelift retractor can be helpful with the lateral most extents of this dissection. Liposculpting is performed in a similar manner to conventional facelift and to address any focal areas of fat. Subplatysmal lipodystrophy and/or submandibular gland ptosis may also be addressed, if needed, by elevating the platysma off the deep cervical fascia from medial to lateral. Care is taken during debulking of ptotic submandibular glands to preserve the marginal mandibular nerve and avoid the facial vessels. If indicated, maneuvers such as debulking and plication of the anterior bellies of the digastric muscles or placement of a chin implant may also be accomplished at this time. After the fat contours have been addressed, a median platysmaplasty is performed. A 3-0 polydioxanone suture (PDS) suture is used to approximate the medial edges of the platysma. The initial suture is placed at the level of the desired cervical point marked preoperatively, and a running simple stitch is used to approximate the medial edges of the platysma up to the mandibular symphysis. Care is taken not to recruit excessive amounts of platysma and fat into this suture, to avoid excessive bulk in the central neck. Upon reaching the mandibular symphysis, the suture is run back down to the cervical point for an additional layer of strength and is then tied. Next, a 1-cm notch is cut from the medial edges of the platysma bilaterally, inferior to the cervical point. This prevents postoperative banding of the free edges of the inferior aspect of the platysma. This process is the same as conventional midline platysmaplasty described earlier in this chapter. With the shaping of the preplatysmal fat, platysma, and, if necessary, subplatysmal fat complete, attention is turned to the Z-plasty closure of the neck incision. The wound is temporarily closed in a simple vertical line with simple interrupted sutures (Fig. 8.27). The mark at the cervical point is once again verified and 172
used as the central limb for Z-plasty. An incision is made diagonally, at 30 degrees to the cervical point line, on each neck flap, creating the triangular flaps to be transposed (Fig. 8.28). The temporary sutures are then removed, and the wound is closed in layers, with 4-0 and 5-0 Monocryl in the deep layer and tension-free 6-0 running, locking Prolene in the skin (Fig. 8.29). Care and time should be given to the ends of the incision. Despite the primary Z-plasty, some degree of standing cone deformity may occur at the superior and inferior extents of the incision, requiring additional careful tailoring of the skin of these areas, with possible Burrows’ triangle excisions. With meticulous attention to hemostasis throughout the procedure and before closing, no drain is necessary. The wound is dressed with bacitracin and a nonadherent dressing and a facelift-type fluffy pressure dressing is applied, concluding the procedure. The patient is examined in office on postoperative day one, the dressing is discontinued, and sutures are removed on postoperative day seven. The patient is allowed to shower and pat the wound dry beginning on postoperative day one.
Case Presentations Figs. 8.30 to 8.34 show before and after cases of direct neck excision Z-plasty.
Complications Complications for this procedure are similar to facelift incisions and it is not uncommon for patients to undergo steroid injection for scar improvement, laser or light therapy for incision erythema, and scar revision for cone deformities at the incision edges. Major complications are rare.
Conclusion Direct excision of the neck is a targeted procedure that specifically addresses the multifactorial issues, which together created
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Fig. 8.27. The left image (A) shows the Z-plasty markings 30 degrees to the cervical line, one each flap and the right image (B) shows the Z-plasty incisions after release of the temporary sutures. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.333. Page 179)
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Fig. 8.28. The left image (A) shows the Z-plasty incisions in position and the right image (B)shows them transposed. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.334. Page 180)
cervical ptosis and laxity. It is not a substitute for a conventional facelift but rather an alternative. The curved and concave surface of the neck is notorious for poor scarring and banding with total vertical or horizontal incisions, but when the wound tension is shifted via Z-plasty, extremely aesthetic incisions can be crafted in the cervicomental region. All the patients treated were happy with their outcomes and valued the procedure and result over conventional facelift. In summary, direct neck excision is an effective technique that yields high rates of patient satisfaction when performed on patients with specific aging changes and desires. Although not as
comprehensive as conventional facelift, the surgery, anesthesia, recovery and cost are markedly less than that of a facelift. This procedure can be a viable alternative to conventional facelift for: • Patients with cervicomental aging and minimal jowling • Patients who only desire improvement of their neck • Patients without the finances, recovery window, or medical clearance for conventional facelift • Patients wanting to avoid the stigma of facelift incisions or hairline changes associated with facelift surgery. Like any surgical procedure, this technique is not applicable to all patients but rather a more select group. If the patient has the 173
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Fig. 8.29. The left image (A) shows closure of the subcutaneous layer and the right image (B) shows final suture closure. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.335. Page 180)
Fig. 8.30. This male patient is shown 60 days after direct excision Z-plasty. The patient also had open sculpting of the jowls and a chin placed through the main incision. Photo courtesy of Dr. Mike Nayak. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.336. Page 181)
aging changes compatible with this procedure and a thorough understanding of the benefits and drawbacks, this surgery has merit for both the patient and surgeon.
Submentoplasty Submentoplasty describes a procedure where the soft tissues of the submental region are treated to improve neck and chin aesthetics. Like many of these truncated procedures, submentoplasty represents a compromise only applicable to very select patient populations. This procedure generally works best on younger patients with significant submental excess (usually fat coupled with 174
recessive chin) but without significant skin excess (see before and pictures in this chapter). As discussed earlier in the diagnostic section this procedure is also more dramatic on patients who have an acute cervicomental angle and is less effective on patients with an obtuse cervicomental angle (Fig. 8.35). In addition, this procedure is less effective on patients who have significant jowling. To recap the aforementioned, any patient with significant submental fullness, skin excess, and jowling, is a candidate for facelift surgery and not submentoplasty. As I have said numerous times in this textbook, if a surgeon attempts to perform a smaller procedure on a patient who needs a bigger procedure, both parties will be
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Fig. 8.31. The same patient shown in the left lateral view. Photo courtesy of Dr. Mike Nayak. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.337. Page 181)
Fig. 8.32. The same patient is shown in the left three-quarter view. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.338. Page 182)
disappointed. An estimation of result can be made by retracting the submental soft tissues posteriorly (Fig. 8.36). Some patients (and surgeons) do not understand how a concavity can be made from a convexity. Basically, when considering surface area and contour, it takes the same amount of tissue for a concavity or convexity in the submental region (Fig. 8.37).
Surgical Technique The submentoplasty procedure is basically the same as the submental treatment described in the submental part of the facelift chapter. It concerns: • Submental incision • Submental liposuction • Possible deep platysmal lipectomy
• Platysmal plication (or platysectomy) • Possible periincisional skin excision. The goal of the procedure is to debulk the region and redrape the skin, thus creating a more youthful neck and cervicomental angle. The first step is to inject tumescent anesthesia and for all of the area to blanch. A routine submental incision is made at or below the submental crease. The incision should be small enough to be aesthetic and large enough to allow access without traumatizing the skin margins. Aggressive submental liposuction is performed in this area commensurate with the amount of preplatysmal fat present. At this point the platysma is generally visualized and I prefer to excise several centimeters of muscle on each side the platysmal midline. This exposes the subplatysmal fat which lies between the mandibular border and the anterior bellies of the 175
Fig. 8.33. This female patient is shown 6 months after direct neck excision Z-plasty and open jowl sculpting. Photo courtesy of Dr. Mike Nayak. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.339. Page 182)
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Fig. 8.34. The same patient shown in Fig. 8.33 is shown here. The aesthetic scar is a trade-off for avoiding traditional facelift. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.340. Page 183)
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Fig. 8.35. This image illustrates how the angulation of the neck anatomy and submental region will affect a final result. Patients with acute cervicomental angles will have better results than patients with obtuse cervicomental angles (A-F). (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.18. Page 44)
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Fig. 8.36. Retracting the soft tissues in the submental region can be useful to estimate a result by exposing the submental anatomic outlines (A, B).
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Fig. 8.37. The left image (A) shows a dotted outline of a patient with submental ptotic tissues. The right image (B) shows a line of the same length on a patient with a corrected submental region. Although the tissue outline has changed, the length of the outline remains the same or similar.
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Fig. 8.38. After tumescent anesthesia and submental incision, a subcutaneous dissection is performed in the same manner as platysmaplasty (A, B).
Fig. 8.39. Submental liposuction is performed in all aspects of the anterior and lateral neck and inferior mandibular border. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.73. Page 70)
Fig. 8.40. Many submentoplasty patients have excess deep subplatysmal fat which can be recontoured if necessary. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.74. Page 70)
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Fig. 8.41. The left image (A) shows the medial borders of the platysmal muscle. The center image (B) shows a 2-0 Vicryl suture securing the medial borders of each platysma muscle and the right image (C) shows the shoestring type platysmaplasty bringing the medial borders of the platysma together moving the neck superiorly and posteriorly.
Fig. 8.42. A silicone chin implant can be a dramatic addition in conjunction with submentoplasty. The left image (A) shows a silicone implant and a measurement of the patient’s midline. The right image (B) shows the silicone implant placed on the anterior mandible and secured with a single titanium screw. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.76. Page 71)
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Fig. 8.43. Liposuction and/or buccal fat reduction can also make significant contributions to the final result in conjunction with a submentoplasty (A, B).
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Fig. 8.44. This patient is shown before (A) and 24 hours after (B) submentoplasty. This is an out-of-town patient and no final follow-up photos were available.
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Fig. 8.45. This patient is shown before (A) and 24 hours after (B) submentoplasty, jowl liposuction, chin implant, and buccal fat reduction.
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Fig. 8.46. The same patient as shown in Fig. 8.45 is shown in the lateral view before (A) and 90 days after (B) her surgery.
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Fig. 8.47. This patient is shown in the lateral view before (A) and 90 days after (B) submentoplasty, jowl liposuction, chin implant, and buccal fat reduction.
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B Fig. 8.48. The same patient as shown in Fig. 8.47 is shown in the three-quarter view (A, B).
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B Fig. 8.49. This patient is shown in the frontal view before (A) and 90 days after (B) submentoplasty.
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B Fig. 8.50. This patient is shown in the lateral view before (A) and 90 days after (B) submentoplasty.
digastric muscle. If this is excessive, it is reduced with scissors and/ or shrunk back with radiowave or cautery. Some patients may need significant reduction of the subplatysmal fat whereas others do not require any treatment. Care is always used so as not to create an over correction (Cobra deformity [see Fig. 8.34]). Concomitant jowl liposuction can be performed either through this
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incision or through stab incisions in inferior lobe region. Many of these patients have full faces and may also benefit from simultaneous and buccal fat reduction. Figs. 8.38 to 8.43 show key intraoperative steps in submentoplasty. Figs. 8.44 to 8.50 show before and after submentoplasty cases.
Short Scar (Weekend) Facelift Surgical Procedure In the previous chapters I discussed the pluses and minuses of small facelifts (short scar facelifts [SSFLs]). It is obvious that I feel that these types of facelifts are very limited for the average patient of facelift age, however they remain useful for younger patients with minor aging as well as a means of learning facelift surgery for the novice surgeon. It has become very trendy to offer and promote these small facelifts. Many of these procedures omit the critical posterior auricular incision as well the submental incision and platysmaplasty. This type of approach may be acceptable for very small lifts on young patients but this group only makes up 2% of my over 1200 facelifts. I have shied away from this type of approach for the reasons already discussed. I feel it is simply a compromise to result and longevity. If and when I agree to perform a short scar lift, I have the patient sign a consent detailing what the surgery will and will not do. I also have the patient agree to allow me to convert the small lift into a traditional lift if I feel there is too much skin for the small lift to be effective. Although I think these lifts are a great way for novice surgeons to learn facelift surgery, I have time and again started a small lift only to convert it to a traditional lift. Positive aspects of these conservative procedures are that they are simpler to learn and perform, can be done with local anesthesia, do not require bandages, have shorter recoveries, and are easier to market compared with larger procedures.
These procedures also have serious drawbacks. They do not and cannot address moderate and advanced aging to the level of larger lifts. Patients must be told that their result will not be as tight or last as long as conventional lifts. Also of significant importance is the fact that these procedures are designed for younger patients with minimal excess submental and neck skin. Performing an SSFL on the right 38-year-old to 42-year-old patient can be quite effective, whereas performing the same procedure on an older patient or one with advanced aging can be very disappointing for both surgeon and patient. Personally, I feel it is unethical to perform a small lift on a patient who needs a big lift. These conservative lifts involve a preauricular incision with some mastoid extension but generally do not include the posterior auricular incision. For any surgeon who truly understands the pathophysiology and vectors of aging and facelift surgery, the postauricular incision is a requirement to truly tighten the neck with a lasting result. The SSFL, sometimes called weekend facelift (WEFL), is built around omitting the postauricular incision and traditional platysmaplasty and therefore has much less effect on significant jowl and neck aging. These “franchise” lifts go by many names and when performed correctly, they do offer a result, but they are not new miracle procedures, and cannot produce comparable results to more comprehensive facelifts. Frequently, the procedure sounds too good to be true: “local anesthesia, drive home from the office, no bandages, go back to work the next day” can be very inviting to a patient who does not fully understand other available options or the limitations of these lifts.
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the amount of skin present in the neck and submental region. Fortunately, much of this bunching will dissipate with healing, but some will persist and can be noticeable with certain hairstyles. The tradeoff of an improved appearance versus some posterior skin bunching is usually not a problem as long as the patient has been made aware of this preoperatively. I personally had a case where the postauricular bunching took an entire year to dissipate (see Fig. 6.189). In the minimally invasive procedures, I do not routinely perform midline platysmaplasty. If the patient has enough aging to warrant midline platysmaplasty, they need a conventional facelift. I do, however, perform submental liposuction if the patient has excess submental fat and this will usually cause some skin contraction. The short scar or weekend incision for the preauricular region and temporal tuft is identical to a smaller conventional facelift (Fig. 8.1). The short-flap subcutaneous dissection is smaller than conventional facelift and is generally 2 to 4 cm circumferential from the ear (Figs. 8.2–8.5). When addressing the superficial muscular aponeurotic system (SMAS) during SSFL surgery, SMAS plication is the most conservative means of SMAS management and probably produces less swelling and faster recovery (Fig. 8.6). In most cases, I prefer the same SMASectomy procedure as described earlier but on a smaller scale (Fig. 8.7). Although I always advocate using posterior platysma sutures to fashion the sling referred to numerous times in this chapter, it is not as applicable in the short scar lifts because of limited access. In general, there is enough room to place at least one posterior platysma suture below the angle of the mandible to assist in tightening the deeper layers of the neck (Fig. 8.8). After the SMAS is dealt with by the surgeon’s preferred method, the skin must be properly placed on traction. The vector of pull may be somewhat different in the short scar lifts. Although there is no “guaranteed” correct vector and every patient is different, a more vertical vector (as opposed to posterolateral) may be required to tighten the jawline and jowls without bunching the posterior auricular region (Fig. 8.9). This does not always apply and sometimes the posterolateral vector is preferable. All vectors of pull should be tried to see what direction provides the best result with the least amount of posterior skin bunching. When using vertical elevation of the preauricular flap, the surgeon needs to make sure enough skin exists to cover the tragus. Never make skin cutbacks or trim skin until coverage is verified. Once the proper vector is achieved, an anterior skin cutback and key suture are placed in a similar manner as conventional facelift (Figs. 8.10 and 8.11). Once the skin is suspended, the excess skin is trimmed and the lobe delivered in the same fashion as conventional facelift (Figs. 8.12 and 8.13). One of the biggest drawbacks of SSFLs is postauricular skin bunching. This occurs because, unlike conventional facelift, there is no postauricular flap to release and pull the skin. In small lifts this is not problematic and a simple triangle skin flap can remove the dog ear (Fig. 8.14). Larger short scar lifts produce significant bunching and can be more challenging as shown in Fig. 8.2. There
Short scar (weekend) facelift surgical procedure
The main reason I am not a huge proponent of these conservative lifts is simply that the average patient who needs a facelift needs a conventional one. When I do treat patients with WEFL, I ask them to give me permission to add a full posterior auricular incision to obtain a better result if I feel intraoperatively that the small procedure will not address the aging changes. I have done this numerous times when my intraoperative observations show that these patients would ultimately be short changed with the single incision procedure. What continues to amaze me is the amount of excess skin these specific patients exhibit, even with minimal outward signs of aging. In short, although they may not have visible skin excess, most patients in their mid to late fourth decade are candidates for traditional-incision facelift. Fig. 6.188 shows two such patients. Conservative lifts certainly have a place in the armamentarium of the cosmetic surgeon, but my personal requisites are illustrated by the fact that out of over 1000 facelifts, only 2% have been short scar. My personal indications for performing a short scar (limited incision) facelift are: • Young patients with minimal aging • Slightly older patients with minimal to moderate jowl and neck aging • Patients who have medical problems that preclude a larger facelift or anesthesia • Patients with budget or recovery limitations who cannot have a larger lift. As stated very early in this chapter, if a small procedure is performed on a patient who needs a bigger procedure and although the patient may be happy, it is sometimes very obvious that the facelift is not all that it could be and the surgeon could actually get negative publicity as other observers see shortcomings of a small procedure and do not realize it was not a conventional facelift. Short cuts in any procedure can have negative marketing consequences. This type of facelift is a great way for the novice surgeon to learn facelift techniques and some surgeons only perform short-scar procedures. As long as the patient selection is appropriate and the patients are given full disclosure of the pluses and minuses, the procedure is appropriate. When I do perform this procedure on a patient, they are required to sign an additional consent that details the limitations of this type of facelift. Although some surgeons perform these procedures with only local and tumescent anesthesia, I still use general anesthesia. The preauricular work with the SSFL is very similar to a conventional facelift but generally more conservative. The sideburn release incision is generally shorter, and the actual preauricular incision is identical. The main differences are seen when the incision turns the corner of the earlobe. Most of the conservative lifts use a postauricular incision that is made in the postauricular sulcus and extends 2 to 4 cm superiorly. Some surgeons advocate making a horizontal releasing incision across the mastoid region, which is a mistake because it will be very noticeable postoperatively. To pull the jowl and especially the ptotic neck skin and the antiaging vector without a traditional postauricular hairline horizontal releasing incision can result in skin bunching behind the ear. There is no way to prevent this without a longer postauricular hairline incision, and it will be commensurate with
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A
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Fig. 8.1. Both of these patients requested a “weekend” (short scar) facelift. Observing these before picture (A, C) shows that both patients appeared to have only minor skin excess. The intraoperative pictures of both patients show the amount of skin excess that actually existed (B, D). This impressive amount of skin required conversion to a conventional facelift, otherwise the patient would have not had an optimum result and longevity. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.199. Page 122)
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Short scar (weekend) facelift surgical procedure Fig. 8.2. This patient insisted on a short scar facelift and because of the limited postauricular incision, sustained significant skin bunching. The bunching took almost one year to resolve and the bottom images show the patient 12 months later. Surgeons are to be careful about being talked into a deeper procedure than the patient actually need. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.200. Page 123)
Fig. 8.3. This image shows the incision markings and actual incision in a short scar type facelift.
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Fig. 8.4. This image shows the anterior, inferior, and posterior limits of a typical short scar (“weekend”) facelift dissection. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.202. Page 124)
Fig. 8.5. This image shows the dissection completed on a typical short scar facelift. This particular case has a generous posterior auricular dissection because many short scar lifts have a posterior auricular incision, which terminates in the mastoid region as shown in Fig. 8.14. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.203. Page 124)
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Fig. 8.6. This image shows a superficial muscular aponeurotic system plication in a short scar facelift. The plication sutures are diagramed to show their placement, extension, and vectors. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.204. Page 124)
C
Fig. 8.7. Even though the shortscar facelift technique uses smaller dissection than conventional lift, a small superficial muscular aponeurotic system (SMAS)-ectomy is still an option. The left image (A) shows the SMAS strip being excised, the middle image (B)shows the SMAS strip overlying its approximate position, and the right image (C) shows the final SMASectomy sutures. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.205. Page 125)
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Fig. 8.9. Some short scar lifts require a more vertical vector of skin pull and the surgeon should try various vectors to see which produces the best result with the least amount of posterior auricular skin bunching. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.207. Page 125)
C
Fig. 8.10. The left image (A) shows typical anterior skin excess on a short scar lift. The center image (B) shows the skin cutback, and the right image (C) shows the key suture placed. Note the blue ink on the skin that was formerly the tragus. This shows how much skin is displaced, even in a small facelift. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.208. Page 126)
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Fig. 8.8. This image shows a solitary suture securing deep tissues in the area of the posterior platysma to the mastoid fascia. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.206. Page 125)
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Fig. 8.11. The left image (A) shows a skin cutback in a short scar facelift and the right image (B) shows the flap suspended. Note the typical posterior auricular skin bunching seen with these procedures (white arrow). (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.209. Page 126)
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Fig. 8.12. The left image (A) shows the outline of the excess skin to be trimmed, the center image (B) shows the preauricular skin being excised, and the right image (C) shows the temporal skin excision. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.210. Page 126)
Fig. 8.13. The lobe is delivered with a very conservative cut back. In many cases, no cutback is required and the lobe can simply be pulled out. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.211. Page 127)
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B
Fig. 8.14. The left image (A) shows skin bunching on a very conservative short scar facelift. The skin hook retracts the excess and a geometric triangle reduction is performed to remove the pleat (B). It is imperative to keep this extension short and behind the ear to remain hidden. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.212. Page 127)
Fig. 8.15. This image shows a long excision release over the mastoid region to deal with posterior skin bunching on a short scar lift. This level of extension will produce a scar that is not hidden by the ear and is a handicap in terms of aesthetics. A more cephalad posterior auricular would provide better incision and scar management as opposed to the one used in this case as shown in Fig. 8.17. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.213. Page 127)
comes a point when excessive posterior auricular skin signals the need for a conventional lift with postauricular excision. Sometimes less is not more! One common mistake is instead of performing a conventional facelift, surgeons attempt to deal with the excess posterior auricular by large and low excision extension. Although extending the excision over the mastoid region may release the bunching, it also can produce an unsightly scar that is impossible to hide (Fig. 8.15). Again, trying heroic measures to deal with skin excess can easily be avoided by performing a conventional lift, when needed, in the first place. The tragal and earlobe is addressed in the same manner as conventional facelift (Fig. 8.16); the anterior incisions are closed with 5-0 gut suture, and the posterior incision is closed with 4-0 gut suture (Fig. 8.17). Bcause the short flap procedure does not have significant dead space, I do not use postoperative dressings or drains. Hematoma,
Fig. 8.16. This image shows all the skin cutbacks and trimming completed and the sculpted tragus ready for suturing.
tissue necrosis, and other complications are uncommon because of the small nature of the procedure (Figs. 8.18–8.22). Healing is usually much faster and less complicated than bigger procedures. Figs. 8.21–8.23 show before and after images of SSFL (WEFL) patients.
Direct Neck Excision Z-Plasty Introduction The previous section detailed comprehensive treatment of lower facial aging with facelift surgery and this chapter discusses alternative lifting techniques. Comprehensive face and neck lift remains the gold standard for treatment of jowls and excess neck skin. Not all patients are candidates for comprehensive facelift for medical reasons, inability to take time off, finances, or simply wanting a more conservative procedure. It is imperative for the surgeon and the patient to realize that any procedure that is more conservative will yield less of a treatment result. In cases of excess neck skin and submental aging without significant jowling, the direct excision Z-plasty neck left may be appropriate. The positives include 167
Direct neck excision Z-plasty
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Fig. 8.17. The anterior incisions are closed with 5-0 gut suture (A) and the posterior incision is closed with 4-0 gut suture (B). (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.214. Page 127)
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A
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Fig. 8.18. This right image shows a patient 24 hours after short scar (“weekend”) facelift and the right image shows the same patient at one week. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.215. Page 128)
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Fig. 8.19. This patient is shown before (A) and after (B) after short scar facelift. This is the same patient shown in Fig. 8.18. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.216. Page 128)
a small surgical procedure with minimal recovery and a dramatic change in submental aesthetics. Negatives include a visible scar and the fact that only the anterior neck is improved. A sharp cervicomental angle is central to an overall appearance of youth and strength. Defined by the intersection of the facial plane with a line from the cervical point to the menton, 168
the cervicomental angle is acute in youth and becomes obtuse with age or even effaced. Restoration of the obtuse cervicomental angle is a key aim of surgery of the lower third of the aging face. Widening of the cervicomental angle with age is caused by the combined effects of loss of skin elasticity, increase in submental fat, and soft tissue ptosis, including the platysma muscle and
Surgical Technique Fig. 8.20. This patient is shown one week after short scar facelift and light periorbital laser resurfacing.
The patient is marked sitting in the upright position, with head held in the Frankfort horizontal plane. A midline vertical, Fig. 8.21. This 42-year-old female is shown before and after short scar facelift and chin implant. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.217. Page 129)
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facial units or may present with persistent skin laxity after facelift surgery. Other patients seek isolated correction of the lax neck or wish to avoid the stigmata of traditional periauricular facelift incisions. These groups of patients can benefit from more targeted neck rejuvenation. Traditional approaches to direct treatment of the aging neck include liposuction, open submentoplasty, and suture suspension techniques. Although these procedures address the fat and sometimes the platysma, they can be inadequate for patients with inelastic or excessive cervical skin and will often lead to unsatisfactory rejuvenation and early recidivism. Direct excision and simple primary closure of the redundant skin in either a transverse or vertical fashion creates an unfavorable scar prone to contracture and webbing. To address this problem, direct excision of neck skin with Z-plasty closure (as described by Biggs [1983]) is a viable alternative for isolated treatment of the male neck. This chapter presents experience with direct excision of redundant neck skin with submentoplasty and Z-plasty closure in both male and female patients. In previous articles, the application of direct neck excision has been limited mainly to male patients, especially those who are balding or have heavy beards. This has been expanded to include any patient who is uncomfortable with undergoing a traditional facelift and is willing to accept isolated rejuvenation of the neck in exchange for a fine Z-plasty incision line. Certain male patients, in particular, fear the social stigma of periauricular incisions, no matter how well executed, and are more comfortable with the more “functional-appearing” Z-plasty incision. This technique has also been adapted as a planned second stage revision for after facelift or concomitantly with a facelift, for patients with either thick, excessive, heavy skin or fine, crepey, inelastic skin.
Direct neck excision Z-plasty
submandibular glands. Abnormally low and anterior hyoid bone position and/or microgenia can accentuate these features. Traditionally, the cervicomental angle has been addressed together with a tightening of the jawline and jowls via cervicofacial rhytidectomy and submentoplasty. Correcting these interrelated areas simultaneously contributes to a natural appearing rejuvenation of the lower third of the face. For selected patients, however, direct rejuvenation of the aging neck is an appropriate option. These patients may evidence primary aging changes of the neck out of proportion to adjacent
Fig. 8.22. This 54-year-old female is shown before and after short scar facelift and full face CO2 laser skin resurfacing. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.218. Page 129)
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Fig. 8.23. This 44-year-old female is shown before and after short scar facelift and chin implant. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.219. Page 130)
elliptiform incision is marked on the anterior neck, with its apex in the submental triangle and its inferior extent as low as necessary to encompass the redundant neck excess. In most individuals, the inferior extent of the incision is at the level of the thyroid notch; however, with extreme cases, it may be carried down as low as the suprasternal notch. The width of the ellipse is marked conservatively to avoid excessive tension in the final closure. The intended level of the new cervical point/neck crease is also marked (Fig. 8.24). In many cases the actual incision is directly on the midline, especially in patients with a symmetric “turkey gobbler” skin excess. In patients with solitary isolated lateral excess, the incision can be made off center to better address the precise excess. A single dose of intravenous antibiotic is given for skin flora coverage. Once an adequate plane of intravenous sedation and 170
analgesia is achieved, the anterior neck is infiltrated with the surgeons preferred tumescent anesthetic solution and sufficient time is allowed for the epinephrine to exert maximum hemostatic effect. During this time, markings are reconfirmed and the patient is sterilely prepped and draped. The procedure begins with full-thickness skin incision with a No. 10 Bard-Parker blade. Dissection is then carried down through the subcutaneous fat with needle-tipped electrocautery hemostasis (Fig. 8.25). The excessive skin and midline submental/preplatysmal fat are removed en bloc (see Fig. 8.25 and Fig. 8.26). The medial platysmal borders are identified and treated in a similar manner to conventional facelift/submentoplasty. Bilateral neck flaps are then created by elevating thin subcutaneous flaps off the preplatysmal flaps on each side of the neck to the anterior borders of the sternocleidomastoid muscles. Most of the
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Direct neck excision Z-plasty Fig. 8.24. This series of markings shows the typical incision outline. Because this patient had increased skin/muscle excess on the left medial platysmal band, the incision in this case is made lateral to the midline. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.330. Page 178)
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Fig. 8.25. The left image (A) shows the skin incision, the right image (B) shows the en bloc resection at the preplatysmal level. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.331. Page 178)
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Fig. 8.26. The left image (A) shows the surgical defect after resection and the right image (B) shows the temporary sutures used to determine the cervicomental angle which is shown by the black line. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.332. Page 179)
dissection is accomplished with sequential spreads of a medium or large facelift scissor. Bridging vessels are identified and cauterized with bipolar cautery as needed. While elevating the flaps, several millimeters of subcutaneous fat are preserved to prevent dermal adhesion to the underlying muscle as well as to protect the dermal plexus. A headlight or lighted facelift retractor can be helpful with the lateral most extents of this dissection. Liposculpting is performed in a similar manner to conventional facelift and to address any focal areas of fat. Subplatysmal lipodystrophy and/or submandibular gland ptosis may also be addressed, if needed, by elevating the platysma off the deep cervical fascia from medial to lateral. Care is taken during debulking of ptotic submandibular glands to preserve the marginal mandibular nerve and avoid the facial vessels. If indicated, maneuvers such as debulking and plication of the anterior bellies of the digastric muscles or placement of a chin implant may also be accomplished at this time. After the fat contours have been addressed, a median platysmaplasty is performed. A 3-0 polydioxanone suture (PDS) suture is used to approximate the medial edges of the platysma. The initial suture is placed at the level of the desired cervical point marked preoperatively, and a running simple stitch is used to approximate the medial edges of the platysma up to the mandibular symphysis. Care is taken not to recruit excessive amounts of platysma and fat into this suture, to avoid excessive bulk in the central neck. Upon reaching the mandibular symphysis, the suture is run back down to the cervical point for an additional layer of strength and is then tied. Next, a 1-cm notch is cut from the medial edges of the platysma bilaterally, inferior to the cervical point. This prevents postoperative banding of the free edges of the inferior aspect of the platysma. This process is the same as conventional midline platysmaplasty described earlier in this chapter. With the shaping of the preplatysmal fat, platysma, and, if necessary, subplatysmal fat complete, attention is turned to the Z-plasty closure of the neck incision. The wound is temporarily closed in a simple vertical line with simple interrupted sutures (Fig. 8.27). The mark at the cervical point is once again verified and 172
used as the central limb for Z-plasty. An incision is made diagonally, at 30 degrees to the cervical point line, on each neck flap, creating the triangular flaps to be transposed (Fig. 8.28). The temporary sutures are then removed, and the wound is closed in layers, with 4-0 and 5-0 Monocryl in the deep layer and tension-free 6-0 running, locking Prolene in the skin (Fig. 8.29). Care and time should be given to the ends of the incision. Despite the primary Z-plasty, some degree of standing cone deformity may occur at the superior and inferior extents of the incision, requiring additional careful tailoring of the skin of these areas, with possible Burrows’ triangle excisions. With meticulous attention to hemostasis throughout the procedure and before closing, no drain is necessary. The wound is dressed with bacitracin and a nonadherent dressing and a facelift-type fluffy pressure dressing is applied, concluding the procedure. The patient is examined in office on postoperative day one, the dressing is discontinued, and sutures are removed on postoperative day seven. The patient is allowed to shower and pat the wound dry beginning on postoperative day one.
Case Presentations Figs. 8.30 to 8.34 show before and after cases of direct neck excision Z-plasty.
Complications Complications for this procedure are similar to facelift incisions and it is not uncommon for patients to undergo steroid injection for scar improvement, laser or light therapy for incision erythema, and scar revision for cone deformities at the incision edges. Major complications are rare.
Conclusion Direct excision of the neck is a targeted procedure that specifically addresses the multifactorial issues, which together created
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Fig. 8.27. The left image (A) shows the Z-plasty markings 30 degrees to the cervical line, one each flap and the right image (B) shows the Z-plasty incisions after release of the temporary sutures. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.333. Page 179)
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Fig. 8.28. The left image (A) shows the Z-plasty incisions in position and the right image (B)shows them transposed. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.334. Page 180)
cervical ptosis and laxity. It is not a substitute for a conventional facelift but rather an alternative. The curved and concave surface of the neck is notorious for poor scarring and banding with total vertical or horizontal incisions, but when the wound tension is shifted via Z-plasty, extremely aesthetic incisions can be crafted in the cervicomental region. All the patients treated were happy with their outcomes and valued the procedure and result over conventional facelift. In summary, direct neck excision is an effective technique that yields high rates of patient satisfaction when performed on patients with specific aging changes and desires. Although not as
comprehensive as conventional facelift, the surgery, anesthesia, recovery and cost are markedly less than that of a facelift. This procedure can be a viable alternative to conventional facelift for: • Patients with cervicomental aging and minimal jowling • Patients who only desire improvement of their neck • Patients without the finances, recovery window, or medical clearance for conventional facelift • Patients wanting to avoid the stigma of facelift incisions or hairline changes associated with facelift surgery. Like any surgical procedure, this technique is not applicable to all patients but rather a more select group. If the patient has the 173
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Fig. 8.29. The left image (A) shows closure of the subcutaneous layer and the right image (B) shows final suture closure. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.335. Page 180)
Fig. 8.30. This male patient is shown 60 days after direct excision Z-plasty. The patient also had open sculpting of the jowls and a chin placed through the main incision. Photo courtesy of Dr. Mike Nayak. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.336. Page 181)
aging changes compatible with this procedure and a thorough understanding of the benefits and drawbacks, this surgery has merit for both the patient and surgeon.
Submentoplasty Submentoplasty describes a procedure where the soft tissues of the submental region are treated to improve neck and chin aesthetics. Like many of these truncated procedures, submentoplasty represents a compromise only applicable to very select patient populations. This procedure generally works best on younger patients with significant submental excess (usually fat coupled with 174
recessive chin) but without significant skin excess (see before and pictures in this chapter). As discussed earlier in the diagnostic section this procedure is also more dramatic on patients who have an acute cervicomental angle and is less effective on patients with an obtuse cervicomental angle (Fig. 8.35). In addition, this procedure is less effective on patients who have significant jowling. To recap the aforementioned, any patient with significant submental fullness, skin excess, and jowling, is a candidate for facelift surgery and not submentoplasty. As I have said numerous times in this textbook, if a surgeon attempts to perform a smaller procedure on a patient who needs a bigger procedure, both parties will be
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Fig. 8.31. The same patient shown in the left lateral view. Photo courtesy of Dr. Mike Nayak. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.337. Page 181)
Fig. 8.32. The same patient is shown in the left three-quarter view. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.338. Page 182)
disappointed. An estimation of result can be made by retracting the submental soft tissues posteriorly (Fig. 8.36). Some patients (and surgeons) do not understand how a concavity can be made from a convexity. Basically, when considering surface area and contour, it takes the same amount of tissue for a concavity or convexity in the submental region (Fig. 8.37).
Surgical Technique The submentoplasty procedure is basically the same as the submental treatment described in the submental part of the facelift chapter. It concerns: • Submental incision • Submental liposuction • Possible deep platysmal lipectomy
• Platysmal plication (or platysectomy) • Possible periincisional skin excision. The goal of the procedure is to debulk the region and redrape the skin, thus creating a more youthful neck and cervicomental angle. The first step is to inject tumescent anesthesia and for all of the area to blanch. A routine submental incision is made at or below the submental crease. The incision should be small enough to be aesthetic and large enough to allow access without traumatizing the skin margins. Aggressive submental liposuction is performed in this area commensurate with the amount of preplatysmal fat present. At this point the platysma is generally visualized and I prefer to excise several centimeters of muscle on each side the platysmal midline. This exposes the subplatysmal fat which lies between the mandibular border and the anterior bellies of the 175
Fig. 8.33. This female patient is shown 6 months after direct neck excision Z-plasty and open jowl sculpting. Photo courtesy of Dr. Mike Nayak. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.339. Page 182)
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Fig. 8.34. The same patient shown in Fig. 8.33 is shown here. The aesthetic scar is a trade-off for avoiding traditional facelift. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.340. Page 183)
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Fig. 8.35. This image illustrates how the angulation of the neck anatomy and submental region will affect a final result. Patients with acute cervicomental angles will have better results than patients with obtuse cervicomental angles (A-F). (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.18. Page 44)
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Fig. 8.36. Retracting the soft tissues in the submental region can be useful to estimate a result by exposing the submental anatomic outlines (A, B).
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Fig. 8.37. The left image (A) shows a dotted outline of a patient with submental ptotic tissues. The right image (B) shows a line of the same length on a patient with a corrected submental region. Although the tissue outline has changed, the length of the outline remains the same or similar.
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Fig. 8.38. After tumescent anesthesia and submental incision, a subcutaneous dissection is performed in the same manner as platysmaplasty (A, B).
Fig. 8.39. Submental liposuction is performed in all aspects of the anterior and lateral neck and inferior mandibular border. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.73. Page 70)
Fig. 8.40. Many submentoplasty patients have excess deep subplatysmal fat which can be recontoured if necessary. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.74. Page 70)
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Fig. 8.41. The left image (A) shows the medial borders of the platysmal muscle. The center image (B) shows a 2-0 Vicryl suture securing the medial borders of each platysma muscle and the right image (C) shows the shoestring type platysmaplasty bringing the medial borders of the platysma together moving the neck superiorly and posteriorly.
Fig. 8.42. A silicone chin implant can be a dramatic addition in conjunction with submentoplasty. The left image (A) shows a silicone implant and a measurement of the patient’s midline. The right image (B) shows the silicone implant placed on the anterior mandible and secured with a single titanium screw. (From Niamtu, J. Cosmetic Facial Surgery, 2nd ed. (2018). Philadelphia, PA: Elsevier. Fig. 3.76. Page 71)
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Fig. 8.43. Liposuction and/or buccal fat reduction can also make significant contributions to the final result in conjunction with a submentoplasty (A, B).
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Fig. 8.44. This patient is shown before (A) and 24 hours after (B) submentoplasty. This is an out-of-town patient and no final follow-up photos were available.
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Fig. 8.45. This patient is shown before (A) and 24 hours after (B) submentoplasty, jowl liposuction, chin implant, and buccal fat reduction.
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Fig. 8.46. The same patient as shown in Fig. 8.45 is shown in the lateral view before (A) and 90 days after (B) her surgery.
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Fig. 8.47. This patient is shown in the lateral view before (A) and 90 days after (B) submentoplasty, jowl liposuction, chin implant, and buccal fat reduction.
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B Fig. 8.48. The same patient as shown in Fig. 8.47 is shown in the three-quarter view (A, B).
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B Fig. 8.49. This patient is shown in the frontal view before (A) and 90 days after (B) submentoplasty.
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B Fig. 8.50. This patient is shown in the lateral view before (A) and 90 days after (B) submentoplasty.
digastric muscle. If this is excessive, it is reduced with scissors and/ or shrunk back with radiowave or cautery. Some patients may need significant reduction of the subplatysmal fat whereas others do not require any treatment. Care is always used so as not to create an over correction (Cobra deformity [see Fig. 8.34]). Concomitant jowl liposuction can be performed either through this
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incision or through stab incisions in inferior lobe region. Many of these patients have full faces and may also benefit from simultaneous and buccal fat reduction. Figs. 8.38 to 8.43 show key intraoperative steps in submentoplasty. Figs. 8.44 to 8.50 show before and after submentoplasty cases.