- Email: [email protected]
Neck lift
Scientific Forum
Neck Lift Claudio Cardoso de Castro, MD Dr. de Castro is professor and chief of the Service of Plastic Surgery, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil, and a member of the Brazilian Society of Plastic Surgery.
Background: The treatment of the aging neck is still a challenge to the plastic surgeon. Objective: The results of anatomic studies of the platysma muscle and its role in the treatment of the aging neck are presented. Methods: Dissection of 50 cadavers revealed differences in the distribution of the medial fibers of the platysma muscle in the suprahyoid region that could significantly affect surgical results. A 4-cm incision at the submental area, 0.3 to 0.4 mm behind the submental crease, and submental skin undermining permitted visualization of the medial fibers of the platysma. The medial fibers were dissected laterally and excess muscle removed. The fibers were sutured without tension to the median line, followed by a medial section at the level of the cricoid cartilage. Results: With the use of the approach described here, very good results were obtained in the treatment of patients who presented with deformities in the median line of the neck. Conclusions: Appropriate treatment of the platysma, based on anatomic analysis and facilitated by the submental approach, is the key to optimal results in the treatment of the aging neck. (Aesthetic Surg J 2003;23:165-169.)
T
he first visible signs of the aging process usually develop around the eyes, then in the neck and lower face. Alterations in the neck caused by aging vary among patients. The size and shape of the mandible, the amount and distribution of cervical fat, the location of the hyoid bone, and the thickness and anatomic variation of medial fibers of the platysma muscle change as a result of aging. To achieve the best possible aesthetic results with surgical intervention, a thorough examination of all these factors must be conducted. Skin undermining followed by traction improves the appearance of the neck. Restoration of the facial anatomy is paramount for an excellent final result. Sometimes surgical treatment in addition to skin undermining, such as removal of excess fat or treatment of the platysma muscle, is necessary to correct the appearance of the neck. Apart from resection of excess skin, 2 alternatives exist for the surgical treatment of the neck: a lateral SMAS-platysma flap, with or without cervical lipectomy; and a lateral SMAS-platysma flap or a direct approach to the medial platysma fibers, with or without cervical lipectomy. In most cases, skin dissection joins the lateral undermining and the suprahyoid region. In this article, the importance of proper treatment of fat and platysma muscle in the attenuation of neck deformities caused by the aging process is discussed.
Cervical Lipectomy When fat accumulation was present, lipectomy was performed by means of open lipoplasty and completed with scissors. Neck lipectomy was performed after traction and fixation of the lateral SMAS-platysma flaps. The fat ascended over the lower border of the mandible when the SMAS flap was pulled. The fat above the mandibular border must be preserved. When necessary, removal of subplatysmal fat was performed conservatively. A space exists between the platysma muscle and the mylohyoid muscle. If too much subplatysmal fat is resected, the platysma may scar in the mylohyoid muscle, and skin retraction in the submental area may result. This retraction is difficult to correct (Figure 1). In patients who present with excess fat in the neck, proper treatment of the excess fat yields a marvelous result. However, adequate treatment of the platysma is the key to optimal success in neck surgeries.
Platysma Muscle Since the 1980s, my interest in the anatomy and surgical importance of the platysma muscle in the treatment of the aging neck was initially aroused by articles published by Connell1 and Guerrerosantos2 on platysma and neck deformities. Because I found that articles on the AESTHETIC
SURGERY
JOURNAL
~
May/June
2003
165
Scientific Forum
A
Figure 4. A, Schematic representation of type III. B, The fibers are separated, as in type I; however, they do not decussate but go straight to the chin.
Figure 1. Result after excessive subplatysmal lipectomy. The correction of this retraction is not easy, but improvement is possible through lipofilling.
A
B
Figure 2. A, Schematic representation of type I. B, Anatomic dissection of type I. The fibers are separated in the suprahyoid region. Thickness and flaccidity vary.
B
anatomy of the platysma muscle in the standard textbooks3–5 were not sufficient to clarify the importance of platysma muscle in neckplasties, I dissected 50 cadavers preserved in formalin in an attempt to better understand the anatomy of this muscle.6 These dissections demonstrated the significance that anatomic knowledge of the medial fibers of the platysma muscle could play in the treatment of alterations of the cervical area. Dissection revealed the medial fibers to be distributed in three different ways, which I have classified as follows: Type I, in which the fibers are separated in the suprahyoid region, interlacing roughly 1 to 2 cm from the chin (Figure 2); type II, in which the fibers intermingle at the level of the thyroid cartilage, behaving as a single muscle in the suprahyoid region (Figure 3); and type III, in which the fibers do not interlace but go straight to the chin (Figure 4). In types I and III, the medial fibers are more or less separated but vary in thickness and flaccidity. In type II, the fibers interlace at the level of the cricoid cartilage and are linked in the suprahyoid region.
Operative Procedure
A
B
Figure 3. A, Schematic representation of type II. B, Example of type II. The platysma behaves as a single muscle in the suprahyoid region.
166
Aesthetic
Surgery
Journal
~
May/June
A 4-cm incision was made at the submental area, 0.3 mm to 0.4 mm behind the submental crease. The submental skin undermining was connected to the previous dissection of the lateral aspects of the face. The medial fibers were then visualized and the diagnosis of the anatomic variation of the platysma, as well as its flaccidity and thickness, was established. The medial fibers were dissected laterally, and muscle excess was assessed and removed. The fibers were sutured without tension to the median line. This was followed by a medial section at the level of the cricoid cartilage to achieve a better readaptation of the muscle fibers7 (Figure 5). When medial flaccid-
2003
Volume 23, Number 3
Scientific Forum
A
D
G
E B
Figure 5. A, Schematic representation of the evaluation of the medial fibers. B and C, Perioperative evaluation of the muscle excess. D and E, Schematic representation and perioperative view of the sutures of the fibers to the median line. F, Medial section. G, Final aspect.
C
F
ity is improperly treated, a remnant muscular band may result (Figure 6). Surgery on the medial fibers of the platysma was performed after treatment of the lateral SMAS-platysma, although some surgeons prefer to reverse the order of these procedures.6
Results Some alterations of the neck can be corrected through traction of SMAS-platysma lateral flaps8–10; however, when sagging of the medial aspect is present, the submental approach is mandatory.11 Excellent results have been achieved with this approach (Figures 7-9). I have never received a complaint about the submental scar and have never regretted making this incision. I believe that in Neck Lift
some cases in which the submental incision was not used, the results would have been better had it been employed.
Discussion The evolution of procedures aimed at achieving facial rejuvenation has helped deepen our knowledge of the anatomy of the face and neck.10,12,13 In turn, anatomic studies have opened the way for the development of more sophisticated rhytidoplasty procedures and better results. However, complications may occur with the use of these more sophisticated techniques unless the surgeon is familiar with the relevant anatomy. With regard to neck-lift procedures in particular, an understanding of platysma muscle anatomy permits safe AESTHETIC
SURGERY
JOURNAL
~
May/June
2003
167
Scientific Forum
A
B
C
D
Figure 6. A and C, Preoperative views of a 60-year-old woman with marked deformities of the neck. B and D, Postoperative appearance 6 months after neck lift. There is improvement, but excess muscle remains, caused by improper treatment of medial flaccidity (arrows).
B
A
Figure 7. A, Preoperative view of a 47-year-old patient showing deformities of the medial fibers of the neck. B, Postoperative view 8 months after rhytidoplasty with extended SMAS-platysma flaps and a direct approach to the medial fibers of the platysma muscle.
dissection and optimal correction of deformities of the cervical area caused by the aging process. The main advantage of the described submental approach is that it provides the surgeon with direct visualization of the medial fibers of the platysma muscle, which in turn allows the proper diagnosis of any anatomic variation, as well as an easier approach to the excess muscle. It also facilitates the revision of the cervical lipectomy. The submental incision is inconspicuous, and patient satisfaction is not adversely affected. 168
Aesthetic
Surgery
Journal
~
May/June
2003
Conclusion Appropriate treatment of the platysma, based on anatomic analysis and facilitated by the submental approach, is the key to optimal results in treatment of the aging neck.■
References 1. Connell BC. The value of platysma muscle flaps. Ann Plast Surg 1978;1:34-43.
Volume 23, Number 3
Scientific Forum
A
B
Figure 8. A, Preoperative view of a 39-year-old patient with neck deformities whose weight loss resulted in a more aged appearance. B, Postoperative view 1 year after a face lift with extended treatment of the medial fibers of the platysma.
A
B
Figure 9. A, Preoperative view of a 50-year-old patient who desired improvement of the appearance of her neck. She had undergone a face lift 10 years earlier. B, Postoperative view 1 year after a secondary face lift with extended SMAS-platysma flaps in which a direct approach to the medial fibers of the platysma was taken.
2. Guerrerosantos J, Spaillat L, Morales F. Muscular lift in cervical rhytidoplasty Plast Reconstr Surg 1974;54:127-131.
my: its importance and anatomical basis. Ann Plast Surg 1980;4:370375.
3. Gardner E, Gray D J, O´Hahilley R. Anatomia [in Portuguese], 2nd ed. Guanabara Rio de Janeiro: Koogan, 1967:772.
12. Whetzel TP, Stevenson TR. The contribution of the SMAS to the blood supply in the lateral face flap. Plast Reconstr Surg 1997;100:10111018.
4. Locklart RD, Hamilton GF, Fyle FW. Anatomy of the Human Body, 2nd ed. London: Faber & Faber, 1965:155.
13. Yousif NJ, Mendelson BC. Anatomy of the midface. Clin Plast Surg 1995;22:227-237.
5. Testut L. Traité d´Anatomie Humaine. 5th ed. Vol I. Paris: Octaine Doin, 1904:737.
Accepted for publication January 23, 2003.
6. Cardoso de Castro C. The anatomy of the platysma muscle. Plast Reconstr Surg 1980;66:680-687.
Reprint requests: Claudio Cardoso de Castro, MD, Rua Carlos Gois, 375/307, 22440.040 Leblon, Rio de Janeiro, Brazil; e-mail: [email protected]/br.
7. Aston JS. Platysma-SMAS cervical rhytidoplasty. Clin Plast Surg 1983;10:507-520.
Copyright © 2003 by The American Society for Aesthetic Plastic Surgery, Inc.
8. Feldmann JJ. Corset platysmaplasty. Plast Reconstr Surg 1990;85:333-343.
doi:10.1067/maj.2003.37
1090-820X/2003/$30.00 + 0
9. McKinney P, Tresley EE. The “maxi-SMAS” management of the platysma bands in rhytidectomy. Ann Plast Surg 1984;12:260-267. 10. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989;83:11-16. 11. Cardoso de Castro C, Aboudib Jr JH. Extensive and lower face lipecto-
Neck Lift
AESTHETIC
SURGERY
JOURNAL
~
May/June
2003
169
Neck Lift Claudio Cardoso de Castro, MD Dr. de Castro is professor and chief of the Service of Plastic Surgery, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil, and a member of the Brazilian Society of Plastic Surgery.
Background: The treatment of the aging neck is still a challenge to the plastic surgeon. Objective: The results of anatomic studies of the platysma muscle and its role in the treatment of the aging neck are presented. Methods: Dissection of 50 cadavers revealed differences in the distribution of the medial fibers of the platysma muscle in the suprahyoid region that could significantly affect surgical results. A 4-cm incision at the submental area, 0.3 to 0.4 mm behind the submental crease, and submental skin undermining permitted visualization of the medial fibers of the platysma. The medial fibers were dissected laterally and excess muscle removed. The fibers were sutured without tension to the median line, followed by a medial section at the level of the cricoid cartilage. Results: With the use of the approach described here, very good results were obtained in the treatment of patients who presented with deformities in the median line of the neck. Conclusions: Appropriate treatment of the platysma, based on anatomic analysis and facilitated by the submental approach, is the key to optimal results in the treatment of the aging neck. (Aesthetic Surg J 2003;23:165-169.)
T
he first visible signs of the aging process usually develop around the eyes, then in the neck and lower face. Alterations in the neck caused by aging vary among patients. The size and shape of the mandible, the amount and distribution of cervical fat, the location of the hyoid bone, and the thickness and anatomic variation of medial fibers of the platysma muscle change as a result of aging. To achieve the best possible aesthetic results with surgical intervention, a thorough examination of all these factors must be conducted. Skin undermining followed by traction improves the appearance of the neck. Restoration of the facial anatomy is paramount for an excellent final result. Sometimes surgical treatment in addition to skin undermining, such as removal of excess fat or treatment of the platysma muscle, is necessary to correct the appearance of the neck. Apart from resection of excess skin, 2 alternatives exist for the surgical treatment of the neck: a lateral SMAS-platysma flap, with or without cervical lipectomy; and a lateral SMAS-platysma flap or a direct approach to the medial platysma fibers, with or without cervical lipectomy. In most cases, skin dissection joins the lateral undermining and the suprahyoid region. In this article, the importance of proper treatment of fat and platysma muscle in the attenuation of neck deformities caused by the aging process is discussed.
Cervical Lipectomy When fat accumulation was present, lipectomy was performed by means of open lipoplasty and completed with scissors. Neck lipectomy was performed after traction and fixation of the lateral SMAS-platysma flaps. The fat ascended over the lower border of the mandible when the SMAS flap was pulled. The fat above the mandibular border must be preserved. When necessary, removal of subplatysmal fat was performed conservatively. A space exists between the platysma muscle and the mylohyoid muscle. If too much subplatysmal fat is resected, the platysma may scar in the mylohyoid muscle, and skin retraction in the submental area may result. This retraction is difficult to correct (Figure 1). In patients who present with excess fat in the neck, proper treatment of the excess fat yields a marvelous result. However, adequate treatment of the platysma is the key to optimal success in neck surgeries.
Platysma Muscle Since the 1980s, my interest in the anatomy and surgical importance of the platysma muscle in the treatment of the aging neck was initially aroused by articles published by Connell1 and Guerrerosantos2 on platysma and neck deformities. Because I found that articles on the AESTHETIC
SURGERY
JOURNAL
~
May/June
2003
165
Scientific Forum
A
Figure 4. A, Schematic representation of type III. B, The fibers are separated, as in type I; however, they do not decussate but go straight to the chin.
Figure 1. Result after excessive subplatysmal lipectomy. The correction of this retraction is not easy, but improvement is possible through lipofilling.
A
B
Figure 2. A, Schematic representation of type I. B, Anatomic dissection of type I. The fibers are separated in the suprahyoid region. Thickness and flaccidity vary.
B
anatomy of the platysma muscle in the standard textbooks3–5 were not sufficient to clarify the importance of platysma muscle in neckplasties, I dissected 50 cadavers preserved in formalin in an attempt to better understand the anatomy of this muscle.6 These dissections demonstrated the significance that anatomic knowledge of the medial fibers of the platysma muscle could play in the treatment of alterations of the cervical area. Dissection revealed the medial fibers to be distributed in three different ways, which I have classified as follows: Type I, in which the fibers are separated in the suprahyoid region, interlacing roughly 1 to 2 cm from the chin (Figure 2); type II, in which the fibers intermingle at the level of the thyroid cartilage, behaving as a single muscle in the suprahyoid region (Figure 3); and type III, in which the fibers do not interlace but go straight to the chin (Figure 4). In types I and III, the medial fibers are more or less separated but vary in thickness and flaccidity. In type II, the fibers interlace at the level of the cricoid cartilage and are linked in the suprahyoid region.
Operative Procedure
A
B
Figure 3. A, Schematic representation of type II. B, Example of type II. The platysma behaves as a single muscle in the suprahyoid region.
166
Aesthetic
Surgery
Journal
~
May/June
A 4-cm incision was made at the submental area, 0.3 mm to 0.4 mm behind the submental crease. The submental skin undermining was connected to the previous dissection of the lateral aspects of the face. The medial fibers were then visualized and the diagnosis of the anatomic variation of the platysma, as well as its flaccidity and thickness, was established. The medial fibers were dissected laterally, and muscle excess was assessed and removed. The fibers were sutured without tension to the median line. This was followed by a medial section at the level of the cricoid cartilage to achieve a better readaptation of the muscle fibers7 (Figure 5). When medial flaccid-
2003
Volume 23, Number 3
Scientific Forum
A
D
G
E B
Figure 5. A, Schematic representation of the evaluation of the medial fibers. B and C, Perioperative evaluation of the muscle excess. D and E, Schematic representation and perioperative view of the sutures of the fibers to the median line. F, Medial section. G, Final aspect.
C
F
ity is improperly treated, a remnant muscular band may result (Figure 6). Surgery on the medial fibers of the platysma was performed after treatment of the lateral SMAS-platysma, although some surgeons prefer to reverse the order of these procedures.6
Results Some alterations of the neck can be corrected through traction of SMAS-platysma lateral flaps8–10; however, when sagging of the medial aspect is present, the submental approach is mandatory.11 Excellent results have been achieved with this approach (Figures 7-9). I have never received a complaint about the submental scar and have never regretted making this incision. I believe that in Neck Lift
some cases in which the submental incision was not used, the results would have been better had it been employed.
Discussion The evolution of procedures aimed at achieving facial rejuvenation has helped deepen our knowledge of the anatomy of the face and neck.10,12,13 In turn, anatomic studies have opened the way for the development of more sophisticated rhytidoplasty procedures and better results. However, complications may occur with the use of these more sophisticated techniques unless the surgeon is familiar with the relevant anatomy. With regard to neck-lift procedures in particular, an understanding of platysma muscle anatomy permits safe AESTHETIC
SURGERY
JOURNAL
~
May/June
2003
167
Scientific Forum
A
B
C
D
Figure 6. A and C, Preoperative views of a 60-year-old woman with marked deformities of the neck. B and D, Postoperative appearance 6 months after neck lift. There is improvement, but excess muscle remains, caused by improper treatment of medial flaccidity (arrows).
B
A
Figure 7. A, Preoperative view of a 47-year-old patient showing deformities of the medial fibers of the neck. B, Postoperative view 8 months after rhytidoplasty with extended SMAS-platysma flaps and a direct approach to the medial fibers of the platysma muscle.
dissection and optimal correction of deformities of the cervical area caused by the aging process. The main advantage of the described submental approach is that it provides the surgeon with direct visualization of the medial fibers of the platysma muscle, which in turn allows the proper diagnosis of any anatomic variation, as well as an easier approach to the excess muscle. It also facilitates the revision of the cervical lipectomy. The submental incision is inconspicuous, and patient satisfaction is not adversely affected. 168
Aesthetic
Surgery
Journal
~
May/June
2003
Conclusion Appropriate treatment of the platysma, based on anatomic analysis and facilitated by the submental approach, is the key to optimal results in treatment of the aging neck.■
References 1. Connell BC. The value of platysma muscle flaps. Ann Plast Surg 1978;1:34-43.
Volume 23, Number 3
Scientific Forum
A
B
Figure 8. A, Preoperative view of a 39-year-old patient with neck deformities whose weight loss resulted in a more aged appearance. B, Postoperative view 1 year after a face lift with extended treatment of the medial fibers of the platysma.
A
B
Figure 9. A, Preoperative view of a 50-year-old patient who desired improvement of the appearance of her neck. She had undergone a face lift 10 years earlier. B, Postoperative view 1 year after a secondary face lift with extended SMAS-platysma flaps in which a direct approach to the medial fibers of the platysma was taken.
2. Guerrerosantos J, Spaillat L, Morales F. Muscular lift in cervical rhytidoplasty Plast Reconstr Surg 1974;54:127-131.
my: its importance and anatomical basis. Ann Plast Surg 1980;4:370375.
3. Gardner E, Gray D J, O´Hahilley R. Anatomia [in Portuguese], 2nd ed. Guanabara Rio de Janeiro: Koogan, 1967:772.
12. Whetzel TP, Stevenson TR. The contribution of the SMAS to the blood supply in the lateral face flap. Plast Reconstr Surg 1997;100:10111018.
4. Locklart RD, Hamilton GF, Fyle FW. Anatomy of the Human Body, 2nd ed. London: Faber & Faber, 1965:155.
13. Yousif NJ, Mendelson BC. Anatomy of the midface. Clin Plast Surg 1995;22:227-237.
5. Testut L. Traité d´Anatomie Humaine. 5th ed. Vol I. Paris: Octaine Doin, 1904:737.
Accepted for publication January 23, 2003.
6. Cardoso de Castro C. The anatomy of the platysma muscle. Plast Reconstr Surg 1980;66:680-687.
Reprint requests: Claudio Cardoso de Castro, MD, Rua Carlos Gois, 375/307, 22440.040 Leblon, Rio de Janeiro, Brazil; e-mail: [email protected]/br.
7. Aston JS. Platysma-SMAS cervical rhytidoplasty. Clin Plast Surg 1983;10:507-520.
Copyright © 2003 by The American Society for Aesthetic Plastic Surgery, Inc.
8. Feldmann JJ. Corset platysmaplasty. Plast Reconstr Surg 1990;85:333-343.
doi:10.1067/maj.2003.37
1090-820X/2003/$30.00 + 0
9. McKinney P, Tresley EE. The “maxi-SMAS” management of the platysma bands in rhytidectomy. Ann Plast Surg 1984;12:260-267. 10. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989;83:11-16. 11. Cardoso de Castro C, Aboudib Jr JH. Extensive and lower face lipecto-
Neck Lift
AESTHETIC
SURGERY
JOURNAL
~
May/June
2003
169