- Email: [email protected]
Hyo neck lift: Preliminary report
+ Models
ANNPLA-1188; No. of Pages 7 Annales de chirurgie plastique esthétique (2016) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Hyo neck lift: Preliminary report Le hyo lift cervical C. Le Louarn 59, rue Spontini, 75116 Paris, France Received 27 November 2015; accepted 8 December 2015
KEYWORDS Neck lift; Platysma; Hyoid bone; Hyoplatysmal ligament
MOTS CLÉS Lift du cou ; Platysma ; Os hyoïde ; Ligament hyoplatysmal
Summary Background. — The aim of neck lift is to recreate an acute cervicomandibular angle. Surgical neck rejuvenation typically is associated with posterosuperior traction on the platysma (PLA) with an anterior vertical PLA corset or a digastric corset. Medium-term instability can exist with these procedures. Objectives. — A novel platysmaplasty technique called the hyo neck lift is described and its surgical efficacy is compared with those of previously described techniques. Methods. — Ten patients underwent hyo neck lift and were evaluated in a preliminary prospective study. Hyo neck lift involved horizontal suturing of the PLA towards the hyoid and then to the skin to recreate a youthful cervicomandibular angle and to place tension on the submental area. Results. — Six months postoperatively, all patients showed improvement in the definition and flattening of the submental area and in ptosis of the submandibular gland. Hyo neck lift is less invasive, without any specific dissection, like in the digastric corset. Conclusions. — The simplest way to achieve an acute cervicomandibular angle is to reattach the PLA and skin to the hyoid. Hyo neck lift is logical and efficient and produced satisfactory aesthetic and functional outcomes in this preliminary study. # 2016 Published by Elsevier Masson SAS. Résumé But. — Le but du lifting du cou est de recréer un angle cervico-mentonnier aigu. Le rajeunissement chirurgical du cou associe classiquement une traction postéro-supérieure du platysma (PLA) avec une plicature antérieure verticale de ce muscle, voire un corset digastrique. Malgré ces procédures sophistiquées, une instabilité de la correction peut exister à moyen terme. Objectif. — Une nouvelle technique appelée le hyo lift cervical est décrite et son efficacité est comparée aux autres techniques.
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.anplas.2015.12.001 0294-1260/# 2016 Published by Elsevier Masson SAS.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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C. Le Louarn Me ´thodes. — Cette technique a été réalisée chez 10 patients, qui ont permis cette étude préliminaire. Le hyo lift cervical comprend une suture horizontale du PLA sur la face antérieure de l’os hyoïde, puis de la peau sur le PLA pour recréer un angle cervico-mandibulaire aigu, jeune et applique une tension horizontale et postérieure sur la région sous-mentale. Re ´sultats. — À six mois postopératoire, tous les patients montrent une amélioration de la définition et de l’aplatissement de la région sous-mentale. Le hyo lift du cou est moins invasif, sans aucune dissection spécifique, comme il est réalisé dans le corset digastrique. Conclusion. — Le moyen le plus simple de créer un angle cervico-mandibulaire aigu est d’attacher le PLA et la peau sur l’os hyoïde. Le hyo lift cervical est logique, efficace et produit des résultats esthétiques et fonctionnels dans cette étude préliminaire. # 2016 Publié par Elsevier Masson SAS.
Although numerous techniques have been described, surgical rejuvenation of the neck usually involves lateral ptatysma suspension [1], which may be associated with a vertical platysma (PLA) corset through a submental incision [2]. In this approach, the 2 medial edges of the PLA are joined with a continuous suture. Alternatively, a vertical digastric corset may be performed after subplatysmal fat resection [3,4]. Patients presenting with concerns of skin excess around the neck and PLA bands generally are assessed with a vertical pinch test to remove the anterior vertical excess and mimic posterosuperior tightening. These assessments and surgical approaches are based on the anatomy of the lower face at rest. We recently characterized the functional anatomy of the lower face and identified a previously unknown mimetic muscle, the depressor labii lateralis (DLL) [5]. The results of our study suggest that the PLA functions to elevate the neck skin and not to provide downward jugal force or lower lip traction as previously thought. Moreover, the DLL acts as an antagonist of the PLA [5]. The depressors of the mouth descend skin from the mouth to the jawline, whereas the PLA elevates skin from the lower neck toward the jawline. These antagonistic muscles meet at the mandibular line, explaining why the aging process is so noticeable in this area [5]. Consequently, rejuvenation of the neck must elevate the skin and muscle above the jawline and descend the muscle below the jawline. Rejuvenation of the neck must elongate the PLA posteriorly, instead of shortening it anteriorly with a PLA corset. Moreover, the skin tension induced by the PLA corset goes anteriorly, in the wrong direction. Neck skin has then to be freed from the PLA to go posteriorly. We suggest that an incomplete understanding of the function of the facial muscles may be responsible for the shortcomings of existing neck lift techniques, including medium-term instability. Our functional anatomic model [5] enabled us to develop a surgical procedure, called hyo (i.e., hyoid) neck lift, that better addresses rejuvenation of the lower face. With hyo neck lift, the PLA is extended toward the anterior cervicomandibular angle and affixed to the hyoid. This surgical procedure produces a youthful lower face and neck and restores the function of the hyoplatysmal ligament (Fig. 1) [6]. We have performed hyo neck lift in our practice for 1 year and have not modified this technique from its original version during that time.
Methods Patients and study design Ten consecutive patients (7 women, 3 men) who underwent hyo neck lift from October 2014 to December 2014 were evaluated in a preliminary prospective study. Because of its preliminary nature, this study was not approved by an ethics committee or institutional review board. Patients were selected for this study who presented for neck lift. No additional inclusion or exclusion criteria were applied. Patients provided written, informed consent for this preliminary study. The study was conducted in accordance with guiding principles as defined by the Declaration of Helsinki.
Surgical procedures In young patients with a heavy neck, a submental incision alone was made according to the platysmaplasty technique described by Knize [8]. For patients who presented with a stable medial hyoplatysmal ligament and lateral PLA bands, preauricular and retroauricular incisions were made. For patients presenting with distension of the hyoplatysmal ligament and paramedial PLA bands, submental, preauricular, and retroauricular incisions were made. Preoperative markings designed on the skin the projection of the hyoid. Patient were in recumbent position
Figure 1 Schematic anatomy of the neck. The hyoplatysmal ligament is depicted on the body of the hyoid bone.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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Hyo neck lift: Preliminary report and the 10 cases were done under general anesthesia. Face liposuction then was performed as needed. Subcutaneous dissection proceeded laterally to join the anterior dissection at the hyoid level. This is similar to the dissection patterns of the digastric corset or the anterior PLA corset, which are performed through submental incisions. The hyoid was palpated medially above the laryngeal prominence of the thyroid cartilage. The greater cornu (i.e., the lateral extension of the hyoid body) was also palpated. Medial pressure was placed on 1 side of the greater cornu to make it more palpable on the other side. There is only supple cartilage around the hyoid, and this is the only bone in
3 the body that is not connected to another bone. Therefore, the determination of the position of the hyoid with palpation is feasible, but requires practice. In case of a patient with
Figure 4 Suturing of the platysma to the lateral extension of the hyoid (i.e., the greater cornu) in a 61-year-old man, under general anesthesia, who was depicted in Fig. 2. The suture material (size, 3-0; Quill Monoderm) is visible at the angle of the mandible.
Figure 2 The projection of the hyoid body and greater cornu on the platysma are marked in this 61-year-old man, under general anesthesia, performing a neck lift. The marking indicates the planned suturing pattern.
Figure 5 Suturing of the horizontal PLA to the hyoid presents no risk to the overlying hypoglossal nerve because the thyrohyoid branch, which descends vertically, has numerous anastomoses with the ansa cervicalis.
Figure 3 Hyoplatysmal suturing, as represented here, produces an acute cervicomandibular angle. Black arrows indicate posterior translation of the platysma.
Figure 6 Suturing of the skin to the platysma parallel with previous suturing of the platysma to the hyoid (Fig. 4) in this 61year-old man, under general anesthesia, who was depicted in Fig. 2.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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heavy neck, an ultrasound examination can help to precisely locate the hyoid. The entire hyoid was marked on the PLA to ensure correct placement of the running suture (Fig. 2). The PLA was fastened horizontally to the hyoid with absorbable barbed sutures (size, 3—0; Quill Monoderm, reverse cutting, diamond point, Angiotech, Reading, PA, USA) running medially on the hyoid body and then, laterally, on the greater cornu (Fig. 3). For more precise suturing, the first surgical bite was medial and through the submental opening on the middle of the body of the hyoid with 1 of the 2 needles. After a first pass of 14 cm, the middle of the thread prevented movement of the other thread because the barbs run in opposite directions. Therefore, an initial knot was not necessary. Suturing then proceeded with multiple passes of the needle (spacing, approximately 1 cm) to progressively attach the PLA to the hyoid. After nearly 3 passes, suturing was continued through the preauricular skin opening, to be able to reach easily the lateral part of the hyoid. Suturing was stopped at the posterior extremity of the greater cornu, just beneath the angle of the mandible, without making a knot (Fig. 4). This process required 5 cm of thread. On the contralateral side, the first surgical bite was performed with the
other needle in the same location on the middle of the hyoid body. Multiple passes of the needle then proceeded from the bone to the PLA to the posterior extremity of the contralateral greater cornu. This procedure restored the complete hyoplatysmal ligament. Care was taken to avoid placing a surgical bite through the hypoglossal nerve, which controls the tongue and is located at least 1 cm above the greater cornu (Fig. 5). Therefore, it was necessary to suture parallel to and completely against the hyoid. Surgical bites were made near the bone at each pass, and the tip of the needle touched the hyoid. This suturing technique placed downward tension on the lateral PLA and minimized ptosis of the submandibular gland. At the level of the greater cornu, it was possible to contact the thyrohyoid branch of the hypoglossal nerve, which descends vertically (Fig. 5). Such contact is not damaging because the thyrohyoid branch has numerous anastomoses with the ansa cervicalis. After fixation of the PLA to the hyoid, the same type of suture was applied to loosely attach the skin horizontally against the PLA (Fig. 6). Suturing proceeded parallel to the suture line that fastened the PLA to the hyoid. Hyo neck lift includes dissection of the neck along the PLA, leaving
Figure 7 (A, C, E) This 45-year-old woman presented with moderate skin excesses of the upper eyelid, medial face, jawline, and neck. She underwent upper eyelid blepharoplasty, concentric malar lift, and hyo neck lift. (B, D, F) Six months postoperatively, the cervicomandibular angle has been displaced posterosuperiorly. As a result, the submental area, including the distance between the chin and the cervicomandibular angle, has been increased. Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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Hyo neck lift: Preliminary report subdermal fatty tissues attached to the skin. Therefore, this second suture line involved the subdermis, not the dermis, and transferred the skin slightly posteriorly. This step created a cervicomandibular angle that was well defined and had appropriate skin tension. Dead space at the neck level then was closed and no drain was necessary. At the parotid level, no drain was needed because quilting sutures were placed. To stabilize PLA position on the hyoid during healing process, botulinum toxin injections were performed. Three spots of injection of 3 units of Vistabel (Allergan, Weston, Florida, USA) were realized in the PLA each side (18 units both sides), along the suture PLA to hyoid, from the midline to the greater cornu.
Results The average age of the patients was 61 years (range, 45— 73 years). Postoperatively, patients did not experience sensations of submental anterior tightening [3,4,7], and myorelaxants were not needed. The skin and PLA were fixed to the hyoid without any retrograde pressure, similar to the results of digastric corset. Because only moderate tension is needed with hyo neck lift to advance the hyoid, postoperative pain was minimal. For this preliminary report, all patients received follow-up for 6 months. Additional follow-up is
5 ongoing, and a subsequent report is planned that will describe the results of this clinical series after 12 months of follow-up. No patients indicated complications of hyo neck lift during 6 months of follow-up. Postoperatively, all patients had improved definition of the submental area and improvement in submandibular gland ptosis. Results were assessed in the postoperative period visually, photographically, and by assessing patient satisfaction. Patient satisfaction was higher (80% of satisfied patients, 20% of moderately satisfied) than surgical satisfaction (70% satisfied, 30% moderately satisfied) because of the 3 first cases, through visual and photographical analysis, due to the learning curve, and the decision to use botulinum toxin injection to favor healing of the PLA in good position. Three patients who presented for hyo neck lift are described in Figs. 7—9.
Discussion The present study describes the results of hyo neck lift, a novel technique based on functional anatomic studies of the lower face [5]. The patient depicted in Fig. 7 who presented with limited PLA bands is considered a simple case; she could have experienced satisfactory surgical outcomes with nearly any neck lift technique, including subcutaneous lift without involving the superficial muscular aponeurotic system.
Figure 8 (A, C, E) This 61-year-old man presented with ptosis of the neck, jugal region, frontal region and mid-face. This patient constituted a difficult case due to extensive skin laxity that was not caused by weight loss. He underwent hyo neck lift, concentric malar lift, and upper eyelid blepharoplasty and frontal lift. (B, D, F) Six months postoperatively, skin excess is no longer visible over the neck and frontal face, the neck looks youthful and natural, and there is no ptosis of the ear lobe. Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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However, medium-term instability is a concern with neck lift. Often, PLA bands reappear within 6 months after a standard neck lift, even in an uncomplicated case. Thanks to the hyo neck lift, no reoccurrence of the PLA bands is visible at 6 months in this case. For more extensive and challenging cases, such as those depicted in Figs. 8 and 9, recurrence of PLA bands and skin ptosis is a major concern, and skin redraping is a challenge in the submental area. With hyo neck lift, subcutaneous skin suture to the PLA and hyoid ensure optimal submental tightening. Hyo neck lift is logical and efficient and can be mastered relatively quickly. As with previously described neck lift techniques, hyo neck lift utilizes the subcutaneous plane for neck dissection. The process of affixing the PLA to the hyoid is a novel surgical maneuver that is unique to hyo neck lift. However, other neck lift approaches involve PLA manipulations, such as sectioning and traction [9]. Dissection is limited with hyo neck lift compared to digastric corset [4]. Moreover, muscle transfer is limited with hyo neck lift compared to the vertical suture rows associated with the PLA corset. In a study by Feldman [10], 4 of 75 patients (5%) experienced transient weakness of the depressor muscles of the lower lip with PLA corset.
Neither Labbe et al. [4] nor Feldman [10,11], in the description of their last technical evolution, claim they would attach the PLA to the hyoid: they are concerned with actions on digastric muscles. With hyo neck lift, the submandibular area can be substantially tightened and postoperative definition of the neck appears natural (Figs. 8 and 9). In contrast, even digastric corset can fail to eliminate visible submandibular volume and skin excess [4]. Our preliminary results indicate that placement of 2 rows of horizontal sutures in the well-exposed PLA surface improves the short-term (6 months) outcomes of neck lift and avoids postoperative complications, such as an excessively tight vertical PLA corset. A more protracted monitoring period is needed to validate the long-term stability of hyo neck lift.
Limitations This study was limited by a small patient group and a follow-up period of 6 months. Additional follow-up is needed to confirm whether the anterior and lateral PLA fixations to the hyoid can stably prevent recurrence of PLA bands, skin excess, and submental bulging. It is unclear whether different types of
Figure 9 (A, C, E) This 61-year-old woman presented with ptosis of the neck, jugal region, and mid-face. She underwent hyo neck lift, concentric malar lift, and upper eyelid blepharoplasty. (B, D, F) Six months postoperatively, flattening and elongation of the submental area are visible. Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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Hyo neck lift: Preliminary report necks (from thin and long to short and heavy) will require modified surgical maneuvers and whether the procedure will prevent recurrence of PLA bands and submental bulging over time. If variable aesthetic outcomes are noted at 12 months of follow-up, this procedure could be modified by stapling, instead of suturing, the PLA to the hyoid.
7
[2]
[3] [4]
Conclusions The aim of neck lift is to recreate an acute cervicomandibular angle. The simplest way is to achieve this outcome is by reattaching the PLA and skin to the hyoid, which is the only bone in this anatomic region and is located at the most posterior point of the cervicomandibular angle. Hyo neck lift is straightforward and efficient and allows for the reconstitution of a new hyoplatysmal ligament.
[5]
[6]
[7]
Disclosure of interest [8]
The author declares that he has no competing interest. [9]
References [1] Labbé D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of
[10] [11]
30 cases. Plast Reconstr Surg 2006;117(6):2001—7 [discussion, 2008—2010]. Feldman JJ. Corset Platysmaplasty. In: Feldman JJ, editor. Neck lift. St Louis, MO: Quality Medical Publishing; 2006 . p. 307—62. Ramirez OM, Robertson KM. Comprehensive approach to rejuvenation of the neck. Facial Plast Surg 2001;17(2):129—40. Labbé D, Giot JP, Kaluzinski E. Submental area rejuvenation by digastric corset: anatomical study and clinical application in 20 cases. Aesthetic Plast Surg 2013;37(2):222—31. Le Louarn C. A new approach to functional anatomy of the lower face: roles of the hyoplatysmal ligament, the platysma, and the depressor labii lateralis. Ann Chir Plast 2016. http:// dx.doi.org/10.1016/j.anplas.2015.12.002. Brandt MG, Hassa A, Roth K, Wehrli B, Moore CC. The hyoplatysmal ligament: characterization and biomechanical properties. Arch Facial Plast Surg 2012;14(5):369—71. Giampapa V1, Bitzos I, Ramirez O, Granick M. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fine points for improving outcomes. Aesthetic Plast Surg 2005; 29(5):341—50. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg 1998;101(2):473—81. Patel BC. Aesthetic surgery of the aging neck: options and techniques. Orbit 2006;25(4):327—56. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg 1990; 85(3):333—43. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg 2014;134(6):1173—83.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
ANNPLA-1188; No. of Pages 7 Annales de chirurgie plastique esthétique (2016) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Hyo neck lift: Preliminary report Le hyo lift cervical C. Le Louarn 59, rue Spontini, 75116 Paris, France Received 27 November 2015; accepted 8 December 2015
KEYWORDS Neck lift; Platysma; Hyoid bone; Hyoplatysmal ligament
MOTS CLÉS Lift du cou ; Platysma ; Os hyoïde ; Ligament hyoplatysmal
Summary Background. — The aim of neck lift is to recreate an acute cervicomandibular angle. Surgical neck rejuvenation typically is associated with posterosuperior traction on the platysma (PLA) with an anterior vertical PLA corset or a digastric corset. Medium-term instability can exist with these procedures. Objectives. — A novel platysmaplasty technique called the hyo neck lift is described and its surgical efficacy is compared with those of previously described techniques. Methods. — Ten patients underwent hyo neck lift and were evaluated in a preliminary prospective study. Hyo neck lift involved horizontal suturing of the PLA towards the hyoid and then to the skin to recreate a youthful cervicomandibular angle and to place tension on the submental area. Results. — Six months postoperatively, all patients showed improvement in the definition and flattening of the submental area and in ptosis of the submandibular gland. Hyo neck lift is less invasive, without any specific dissection, like in the digastric corset. Conclusions. — The simplest way to achieve an acute cervicomandibular angle is to reattach the PLA and skin to the hyoid. Hyo neck lift is logical and efficient and produced satisfactory aesthetic and functional outcomes in this preliminary study. # 2016 Published by Elsevier Masson SAS. Résumé But. — Le but du lifting du cou est de recréer un angle cervico-mentonnier aigu. Le rajeunissement chirurgical du cou associe classiquement une traction postéro-supérieure du platysma (PLA) avec une plicature antérieure verticale de ce muscle, voire un corset digastrique. Malgré ces procédures sophistiquées, une instabilité de la correction peut exister à moyen terme. Objectif. — Une nouvelle technique appelée le hyo lift cervical est décrite et son efficacité est comparée aux autres techniques.
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.anplas.2015.12.001 0294-1260/# 2016 Published by Elsevier Masson SAS.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
+ Models
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C. Le Louarn Me ´thodes. — Cette technique a été réalisée chez 10 patients, qui ont permis cette étude préliminaire. Le hyo lift cervical comprend une suture horizontale du PLA sur la face antérieure de l’os hyoïde, puis de la peau sur le PLA pour recréer un angle cervico-mandibulaire aigu, jeune et applique une tension horizontale et postérieure sur la région sous-mentale. Re ´sultats. — À six mois postopératoire, tous les patients montrent une amélioration de la définition et de l’aplatissement de la région sous-mentale. Le hyo lift du cou est moins invasif, sans aucune dissection spécifique, comme il est réalisé dans le corset digastrique. Conclusion. — Le moyen le plus simple de créer un angle cervico-mandibulaire aigu est d’attacher le PLA et la peau sur l’os hyoïde. Le hyo lift cervical est logique, efficace et produit des résultats esthétiques et fonctionnels dans cette étude préliminaire. # 2016 Publié par Elsevier Masson SAS.
Although numerous techniques have been described, surgical rejuvenation of the neck usually involves lateral ptatysma suspension [1], which may be associated with a vertical platysma (PLA) corset through a submental incision [2]. In this approach, the 2 medial edges of the PLA are joined with a continuous suture. Alternatively, a vertical digastric corset may be performed after subplatysmal fat resection [3,4]. Patients presenting with concerns of skin excess around the neck and PLA bands generally are assessed with a vertical pinch test to remove the anterior vertical excess and mimic posterosuperior tightening. These assessments and surgical approaches are based on the anatomy of the lower face at rest. We recently characterized the functional anatomy of the lower face and identified a previously unknown mimetic muscle, the depressor labii lateralis (DLL) [5]. The results of our study suggest that the PLA functions to elevate the neck skin and not to provide downward jugal force or lower lip traction as previously thought. Moreover, the DLL acts as an antagonist of the PLA [5]. The depressors of the mouth descend skin from the mouth to the jawline, whereas the PLA elevates skin from the lower neck toward the jawline. These antagonistic muscles meet at the mandibular line, explaining why the aging process is so noticeable in this area [5]. Consequently, rejuvenation of the neck must elevate the skin and muscle above the jawline and descend the muscle below the jawline. Rejuvenation of the neck must elongate the PLA posteriorly, instead of shortening it anteriorly with a PLA corset. Moreover, the skin tension induced by the PLA corset goes anteriorly, in the wrong direction. Neck skin has then to be freed from the PLA to go posteriorly. We suggest that an incomplete understanding of the function of the facial muscles may be responsible for the shortcomings of existing neck lift techniques, including medium-term instability. Our functional anatomic model [5] enabled us to develop a surgical procedure, called hyo (i.e., hyoid) neck lift, that better addresses rejuvenation of the lower face. With hyo neck lift, the PLA is extended toward the anterior cervicomandibular angle and affixed to the hyoid. This surgical procedure produces a youthful lower face and neck and restores the function of the hyoplatysmal ligament (Fig. 1) [6]. We have performed hyo neck lift in our practice for 1 year and have not modified this technique from its original version during that time.
Methods Patients and study design Ten consecutive patients (7 women, 3 men) who underwent hyo neck lift from October 2014 to December 2014 were evaluated in a preliminary prospective study. Because of its preliminary nature, this study was not approved by an ethics committee or institutional review board. Patients were selected for this study who presented for neck lift. No additional inclusion or exclusion criteria were applied. Patients provided written, informed consent for this preliminary study. The study was conducted in accordance with guiding principles as defined by the Declaration of Helsinki.
Surgical procedures In young patients with a heavy neck, a submental incision alone was made according to the platysmaplasty technique described by Knize [8]. For patients who presented with a stable medial hyoplatysmal ligament and lateral PLA bands, preauricular and retroauricular incisions were made. For patients presenting with distension of the hyoplatysmal ligament and paramedial PLA bands, submental, preauricular, and retroauricular incisions were made. Preoperative markings designed on the skin the projection of the hyoid. Patient were in recumbent position
Figure 1 Schematic anatomy of the neck. The hyoplatysmal ligament is depicted on the body of the hyoid bone.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
+ Models
ANNPLA-1188; No. of Pages 7
Hyo neck lift: Preliminary report and the 10 cases were done under general anesthesia. Face liposuction then was performed as needed. Subcutaneous dissection proceeded laterally to join the anterior dissection at the hyoid level. This is similar to the dissection patterns of the digastric corset or the anterior PLA corset, which are performed through submental incisions. The hyoid was palpated medially above the laryngeal prominence of the thyroid cartilage. The greater cornu (i.e., the lateral extension of the hyoid body) was also palpated. Medial pressure was placed on 1 side of the greater cornu to make it more palpable on the other side. There is only supple cartilage around the hyoid, and this is the only bone in
3 the body that is not connected to another bone. Therefore, the determination of the position of the hyoid with palpation is feasible, but requires practice. In case of a patient with
Figure 4 Suturing of the platysma to the lateral extension of the hyoid (i.e., the greater cornu) in a 61-year-old man, under general anesthesia, who was depicted in Fig. 2. The suture material (size, 3-0; Quill Monoderm) is visible at the angle of the mandible.
Figure 2 The projection of the hyoid body and greater cornu on the platysma are marked in this 61-year-old man, under general anesthesia, performing a neck lift. The marking indicates the planned suturing pattern.
Figure 5 Suturing of the horizontal PLA to the hyoid presents no risk to the overlying hypoglossal nerve because the thyrohyoid branch, which descends vertically, has numerous anastomoses with the ansa cervicalis.
Figure 3 Hyoplatysmal suturing, as represented here, produces an acute cervicomandibular angle. Black arrows indicate posterior translation of the platysma.
Figure 6 Suturing of the skin to the platysma parallel with previous suturing of the platysma to the hyoid (Fig. 4) in this 61year-old man, under general anesthesia, who was depicted in Fig. 2.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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heavy neck, an ultrasound examination can help to precisely locate the hyoid. The entire hyoid was marked on the PLA to ensure correct placement of the running suture (Fig. 2). The PLA was fastened horizontally to the hyoid with absorbable barbed sutures (size, 3—0; Quill Monoderm, reverse cutting, diamond point, Angiotech, Reading, PA, USA) running medially on the hyoid body and then, laterally, on the greater cornu (Fig. 3). For more precise suturing, the first surgical bite was medial and through the submental opening on the middle of the body of the hyoid with 1 of the 2 needles. After a first pass of 14 cm, the middle of the thread prevented movement of the other thread because the barbs run in opposite directions. Therefore, an initial knot was not necessary. Suturing then proceeded with multiple passes of the needle (spacing, approximately 1 cm) to progressively attach the PLA to the hyoid. After nearly 3 passes, suturing was continued through the preauricular skin opening, to be able to reach easily the lateral part of the hyoid. Suturing was stopped at the posterior extremity of the greater cornu, just beneath the angle of the mandible, without making a knot (Fig. 4). This process required 5 cm of thread. On the contralateral side, the first surgical bite was performed with the
other needle in the same location on the middle of the hyoid body. Multiple passes of the needle then proceeded from the bone to the PLA to the posterior extremity of the contralateral greater cornu. This procedure restored the complete hyoplatysmal ligament. Care was taken to avoid placing a surgical bite through the hypoglossal nerve, which controls the tongue and is located at least 1 cm above the greater cornu (Fig. 5). Therefore, it was necessary to suture parallel to and completely against the hyoid. Surgical bites were made near the bone at each pass, and the tip of the needle touched the hyoid. This suturing technique placed downward tension on the lateral PLA and minimized ptosis of the submandibular gland. At the level of the greater cornu, it was possible to contact the thyrohyoid branch of the hypoglossal nerve, which descends vertically (Fig. 5). Such contact is not damaging because the thyrohyoid branch has numerous anastomoses with the ansa cervicalis. After fixation of the PLA to the hyoid, the same type of suture was applied to loosely attach the skin horizontally against the PLA (Fig. 6). Suturing proceeded parallel to the suture line that fastened the PLA to the hyoid. Hyo neck lift includes dissection of the neck along the PLA, leaving
Figure 7 (A, C, E) This 45-year-old woman presented with moderate skin excesses of the upper eyelid, medial face, jawline, and neck. She underwent upper eyelid blepharoplasty, concentric malar lift, and hyo neck lift. (B, D, F) Six months postoperatively, the cervicomandibular angle has been displaced posterosuperiorly. As a result, the submental area, including the distance between the chin and the cervicomandibular angle, has been increased. Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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Hyo neck lift: Preliminary report subdermal fatty tissues attached to the skin. Therefore, this second suture line involved the subdermis, not the dermis, and transferred the skin slightly posteriorly. This step created a cervicomandibular angle that was well defined and had appropriate skin tension. Dead space at the neck level then was closed and no drain was necessary. At the parotid level, no drain was needed because quilting sutures were placed. To stabilize PLA position on the hyoid during healing process, botulinum toxin injections were performed. Three spots of injection of 3 units of Vistabel (Allergan, Weston, Florida, USA) were realized in the PLA each side (18 units both sides), along the suture PLA to hyoid, from the midline to the greater cornu.
Results The average age of the patients was 61 years (range, 45— 73 years). Postoperatively, patients did not experience sensations of submental anterior tightening [3,4,7], and myorelaxants were not needed. The skin and PLA were fixed to the hyoid without any retrograde pressure, similar to the results of digastric corset. Because only moderate tension is needed with hyo neck lift to advance the hyoid, postoperative pain was minimal. For this preliminary report, all patients received follow-up for 6 months. Additional follow-up is
5 ongoing, and a subsequent report is planned that will describe the results of this clinical series after 12 months of follow-up. No patients indicated complications of hyo neck lift during 6 months of follow-up. Postoperatively, all patients had improved definition of the submental area and improvement in submandibular gland ptosis. Results were assessed in the postoperative period visually, photographically, and by assessing patient satisfaction. Patient satisfaction was higher (80% of satisfied patients, 20% of moderately satisfied) than surgical satisfaction (70% satisfied, 30% moderately satisfied) because of the 3 first cases, through visual and photographical analysis, due to the learning curve, and the decision to use botulinum toxin injection to favor healing of the PLA in good position. Three patients who presented for hyo neck lift are described in Figs. 7—9.
Discussion The present study describes the results of hyo neck lift, a novel technique based on functional anatomic studies of the lower face [5]. The patient depicted in Fig. 7 who presented with limited PLA bands is considered a simple case; she could have experienced satisfactory surgical outcomes with nearly any neck lift technique, including subcutaneous lift without involving the superficial muscular aponeurotic system.
Figure 8 (A, C, E) This 61-year-old man presented with ptosis of the neck, jugal region, frontal region and mid-face. This patient constituted a difficult case due to extensive skin laxity that was not caused by weight loss. He underwent hyo neck lift, concentric malar lift, and upper eyelid blepharoplasty and frontal lift. (B, D, F) Six months postoperatively, skin excess is no longer visible over the neck and frontal face, the neck looks youthful and natural, and there is no ptosis of the ear lobe. Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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However, medium-term instability is a concern with neck lift. Often, PLA bands reappear within 6 months after a standard neck lift, even in an uncomplicated case. Thanks to the hyo neck lift, no reoccurrence of the PLA bands is visible at 6 months in this case. For more extensive and challenging cases, such as those depicted in Figs. 8 and 9, recurrence of PLA bands and skin ptosis is a major concern, and skin redraping is a challenge in the submental area. With hyo neck lift, subcutaneous skin suture to the PLA and hyoid ensure optimal submental tightening. Hyo neck lift is logical and efficient and can be mastered relatively quickly. As with previously described neck lift techniques, hyo neck lift utilizes the subcutaneous plane for neck dissection. The process of affixing the PLA to the hyoid is a novel surgical maneuver that is unique to hyo neck lift. However, other neck lift approaches involve PLA manipulations, such as sectioning and traction [9]. Dissection is limited with hyo neck lift compared to digastric corset [4]. Moreover, muscle transfer is limited with hyo neck lift compared to the vertical suture rows associated with the PLA corset. In a study by Feldman [10], 4 of 75 patients (5%) experienced transient weakness of the depressor muscles of the lower lip with PLA corset.
Neither Labbe et al. [4] nor Feldman [10,11], in the description of their last technical evolution, claim they would attach the PLA to the hyoid: they are concerned with actions on digastric muscles. With hyo neck lift, the submandibular area can be substantially tightened and postoperative definition of the neck appears natural (Figs. 8 and 9). In contrast, even digastric corset can fail to eliminate visible submandibular volume and skin excess [4]. Our preliminary results indicate that placement of 2 rows of horizontal sutures in the well-exposed PLA surface improves the short-term (6 months) outcomes of neck lift and avoids postoperative complications, such as an excessively tight vertical PLA corset. A more protracted monitoring period is needed to validate the long-term stability of hyo neck lift.
Limitations This study was limited by a small patient group and a follow-up period of 6 months. Additional follow-up is needed to confirm whether the anterior and lateral PLA fixations to the hyoid can stably prevent recurrence of PLA bands, skin excess, and submental bulging. It is unclear whether different types of
Figure 9 (A, C, E) This 61-year-old woman presented with ptosis of the neck, jugal region, and mid-face. She underwent hyo neck lift, concentric malar lift, and upper eyelid blepharoplasty. (B, D, F) Six months postoperatively, flattening and elongation of the submental area are visible. Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001
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Hyo neck lift: Preliminary report necks (from thin and long to short and heavy) will require modified surgical maneuvers and whether the procedure will prevent recurrence of PLA bands and submental bulging over time. If variable aesthetic outcomes are noted at 12 months of follow-up, this procedure could be modified by stapling, instead of suturing, the PLA to the hyoid.
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[2]
[3] [4]
Conclusions The aim of neck lift is to recreate an acute cervicomandibular angle. The simplest way is to achieve this outcome is by reattaching the PLA and skin to the hyoid, which is the only bone in this anatomic region and is located at the most posterior point of the cervicomandibular angle. Hyo neck lift is straightforward and efficient and allows for the reconstitution of a new hyoplatysmal ligament.
[5]
[6]
[7]
Disclosure of interest [8]
The author declares that he has no competing interest. [9]
References [1] Labbé D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of
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30 cases. Plast Reconstr Surg 2006;117(6):2001—7 [discussion, 2008—2010]. Feldman JJ. Corset Platysmaplasty. In: Feldman JJ, editor. Neck lift. St Louis, MO: Quality Medical Publishing; 2006 . p. 307—62. Ramirez OM, Robertson KM. Comprehensive approach to rejuvenation of the neck. Facial Plast Surg 2001;17(2):129—40. Labbé D, Giot JP, Kaluzinski E. Submental area rejuvenation by digastric corset: anatomical study and clinical application in 20 cases. Aesthetic Plast Surg 2013;37(2):222—31. Le Louarn C. A new approach to functional anatomy of the lower face: roles of the hyoplatysmal ligament, the platysma, and the depressor labii lateralis. Ann Chir Plast 2016. http:// dx.doi.org/10.1016/j.anplas.2015.12.002. Brandt MG, Hassa A, Roth K, Wehrli B, Moore CC. The hyoplatysmal ligament: characterization and biomechanical properties. Arch Facial Plast Surg 2012;14(5):369—71. Giampapa V1, Bitzos I, Ramirez O, Granick M. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fine points for improving outcomes. Aesthetic Plast Surg 2005; 29(5):341—50. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg 1998;101(2):473—81. Patel BC. Aesthetic surgery of the aging neck: options and techniques. Orbit 2006;25(4):327—56. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg 1990; 85(3):333—43. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg 2014;134(6):1173—83.
Please cite this article in press as: Le C. Hyo neck lift: Preliminary report. Ann Chir Plast Esthet (2016), http://dx.doi.org/10.1016/ j.anplas.2015.12.001