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Rejuvenation of the Aging Neck
Rejuvenation of the Aging Neck 40 Years Experience Brunno Ristow, MD, FACS KEYWORDS Neck lift Neck lift technique Neck lift sequelae Neck lift complications Neck rejuvenation
KEY POINTS The neck is divided into 2 defined segments: (1) the submental, submandibular region, and (2) the region of the neck proper, which includes the structures caudally to this imaginary line. The understanding of neck rejuvenation depends entirely on 2 different factors. Alone, neither will produce a good neck. Combine both, and an excellent result is consistently achieved. The correction of laxity of tissues in the submental area needs direct surgery in this region and the hammock effect, produced by the bilateral elevation of the midface lift. Only with both can the rejuvenation of this region be achieved.
Editor Commentary: My friendship with Bruno Ristow exceeds 35 years, and I was delighted when he accepted my invitation to contribute to this publication. He followed the questions posed to him and presents a logical template for rejuvenating the neck. He makes the important point of proper rotation of the SMAS/platysma flap following partial transection of the platysma at the level of the cricoid cartilage. His admonition to wait up to 1 year before considering revising the neck is important to consider, because many small issues resolve themselves; larger issues require maturation of the soft tissue (similar to waiting 1 year before performing a secondary rhinoplasty.)
When the editor of this issue asked me to share my experience and the concluding thoughts resulting from my nearly 40 years of performing neck rejuvenation, I promptly and happily accepted the invitation. The reasons are simply based on experience; to me the issues have logical and direct answers based on facts. I was prompted with a series of questions to address. However, before I address the questions, I want to emphasize that the understanding of neck rejuvenation depends entirely on 2 different factors. Neither will produce a good neck alone. Combine both, and an excellent result is consistently achieved.
If a fine line is drawn from the jaw neck angle to the earlobe (Fig. 1), the neck is divided into 2 defined segments: 1. The submental, submandibular region 2. The region of the neck proper, which includes the structures caudally to this imaginary line The correction of laxity of tissues in the submental area, need, aside from the direct surgery in this region, needs the hammock effect, produced by the bilateral elevation of the midface lift. Only then, can the rejuvenation of this region be achieved. The effect of the superficial musculo-aponeurotic system (SMAS) elevation on the right and left midface, gives a strong
California Pacific Medical Center, San Francisco, CA E-mail address: [email protected] Clin Plastic Surg 41 (2014) 125–129 http://dx.doi.org/10.1016/j.cps.2013.09.004 0094-1298/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
INTRODUCTION
126
Ristow with localized submental fat and no plastymal bands, are treated with–occipital incision (Figs. 2 and 3).
WHAT ARE YOUR INDICATIONS FOR LIMITING YOUR ACCESS INCISIONS TO THE SUBMENTAL AREA OR THE LATERAL APPROACH? IN WHICH CASES DO YOU USE BOTH INCISIONS?
Fig. 1. Dividing the neck into aesthetic units and skin redraping.
sling effect to the tissues in the submental region, appropriately described as the hammock effect. Now, to address specific questions.
WHAT INCISION(S) DO YOU TYPICALLY USE IN THE THIN NECK AND THE HEAVY NECK IN BOTH YOUNG AND OLDER PATIENTS? Younger and older patients will receive very similar incisions. In the older ones, necessarily the occipital incision has to be longer. Only young patients,
Fig. 2. Pre and Post-operative Face and Necklift.
In a still youthful neck with good skin texture and only localized submental fat, a simple submental incision, 3.5 cm long, located 1 cm below the submental crease, is sufficient for effective treatment. The submental crease is released, as are the attachments to the depressors of the lip bilaterally. Silverglyde Bipolar forceps (Stryker Corporation/ Kalamazoo, MI) is the only safe approach to hemeostasis over the depressor anguli oris. The localized fat is taken out in progressive layers until the platysma muscle is exposed. If necessary, 1, 2, or 3 sutures between the thyroid cartilage and the symphisis of mentum are placed to assure an attractive jaw/neck angle. A Porex (Porex Medical Products/Ontario, CA) (1-800-521-7321, ECO043-02) drain is placed and the incision closed, everting its edges, with a 6-0 suture.
Rejuvenation of the Aging Neck
Fig. 3. Pre and Post-operative Face and Necklift.
Most patients who need their neck rejuvenated need a retroauricular occipital incision. Whenever the structures (skin/muscle) are aged, this redraping becomes necessary. The vectors of redraping allow for little variation. Generally, they are at 90 from the neck (see Fig. 1).
WHAT IS YOUR APPROACH TO DEFATTING THE NECK? WHICH FATTY LAYERS DO YOU RESECT (IE, SUBCUTANEOUS, INTERPLATYSMAL, SUBPLATYSMAL FAT)? WHAT ROLE DOES LIPOSUCTION PLAY IN YOUR TECHNIQUE, EITHER ALONE OR IN COMBINATION WITH OPEN TECHNIQUES? I choose to elevate the skin of the neck with the appropriate final thickness of the subcutaneous fat. I gauge this by feeling the dissecting scissors on my right hand and my fifth finger on my left hand to feel the thickness of the flap of the skin being elevated. I find this method accurate and equally precise as transillumination. After the final positioning of the platysma, with the sling to the occipital region (or the small flap described by Tord Skoog1), I defat the layer overlaying the platysma (Fig. 4). (Transillumination is used to evaluate the uniform thickness
of the flaps at the end of the procedure, just prior to closure.)
HOW DOES THE PRESENCE OF VISIBLE PLATYSMA MUSCLE BANDS ALTER YOUR APPROACH? DO YOU UNDERMINE, PLICATE, TRANSECT, PARTIALLY RESECT, OR BACKCUT PLATYSMAL MUSCLE BANDS? Visible platysma muscle bands are always treated. The central strip of platysma is removed; submental fat is grasped with a brown forceps and resected. This leaves platysmal edges on both sides, generally separated by 2 cm. These edges are sutured together in the midline; usually 3 sutures with inverted knots of 3-0 nylon between the thyroid cartilage and the symphisis of the mentum are sufficient. The continuity of the bands is interrupted at the level of the cricoid cartilage, for 2.5 cm in each direction, with a triangle of the muscle removed. Laterally, I also routinely partially divide the platysma muscle. I follow the anterior border of the sternocleidomastoideus muscle, approximately 5 cm (or more if necessary) toward the direction of the cricoid cartilage. The platysma/SMAS flap resulting from the midface dissection is then
127
128
Ristow
Fig. 4. Pre and Post-operative Face and Necklift.
transposed to the retroauricular/occipital region. I do not plicate the platysma, as I suspect this may contribute to the later formation of recurring bands.
DISCUSS SUBMAXILLARY GLAND REDUCTION A good platysma/SMAS sling, with the midline anchoring sutures, provides significant submandibular support. Given reported complications and drawbacks (eg, dry mouth, halitosis, fistulas, and rare nerve injuries), I have not engaged in the partial resection of the glands. Also, after explanation to prospective patients of the issues involved, I have observed that patients will not accept this procedure.
DO YOU PARTIALLY RESECT THE ANTERIOR BELLIES OF THE DIGASTRIC MUSCLES? Yes, I do partially resect the anterior bellies of the digastric, but only if they are responsible for extra bulk. I electrocoagulate the excessive volume.
DO YOU FEEL THERE IS A NEED TO DRAIN NECKS? Yes, I drain all necks. A major and difficult problem is to have any remaining blood after surgery. Avoidance of this complication is of paramount importance.
DO YOU USE FIBRIN GLUE IN THE NECK? No, I do not use fibrin glue in the neck. I am concerned about the manufacturers’ disclaimers of possible transmission of disease.
BRIEFLY MENTION EXPECTED SEQUELAE OF YOUR TECHNIQUE AND COMPLICATIONS THAT YOU HAVE OBSERVED AND HOW YOU TREATED THEM Collections of undrained blood and rare banding of the platysma are difficult issues. They require time for reabsorption, patience, good relations with one’s patients, and, extremely rarely, excision of the offending band. Lesser issues may respond to BOTOX and judicious injections of diluted Triamcinolone Acetonide.
Rejuvenation of the Aging Neck MENTION YOUR TIMING FOR ANY REVISIONS OF A NECK LIFT I would wait 1 year if it all possible. Revisions, however, have practically not existed, following the technical precautions aforementioned. Unfortunately, I have seen very poor results from surgery done elsewhere, frequently, not amendable to improvement. Too much fat removed from the
subcutaneous layer and the excessive electrocoagulation are often the culprits.
REFERENCE 1. Tord Skoog I. Plastic Surgery - New Methods and Refinement. Stockholm, Sweden: Almquist & Wiksell International; 1974.
129
KEY POINTS The neck is divided into 2 defined segments: (1) the submental, submandibular region, and (2) the region of the neck proper, which includes the structures caudally to this imaginary line. The understanding of neck rejuvenation depends entirely on 2 different factors. Alone, neither will produce a good neck. Combine both, and an excellent result is consistently achieved. The correction of laxity of tissues in the submental area needs direct surgery in this region and the hammock effect, produced by the bilateral elevation of the midface lift. Only with both can the rejuvenation of this region be achieved.
Editor Commentary: My friendship with Bruno Ristow exceeds 35 years, and I was delighted when he accepted my invitation to contribute to this publication. He followed the questions posed to him and presents a logical template for rejuvenating the neck. He makes the important point of proper rotation of the SMAS/platysma flap following partial transection of the platysma at the level of the cricoid cartilage. His admonition to wait up to 1 year before considering revising the neck is important to consider, because many small issues resolve themselves; larger issues require maturation of the soft tissue (similar to waiting 1 year before performing a secondary rhinoplasty.)
When the editor of this issue asked me to share my experience and the concluding thoughts resulting from my nearly 40 years of performing neck rejuvenation, I promptly and happily accepted the invitation. The reasons are simply based on experience; to me the issues have logical and direct answers based on facts. I was prompted with a series of questions to address. However, before I address the questions, I want to emphasize that the understanding of neck rejuvenation depends entirely on 2 different factors. Neither will produce a good neck alone. Combine both, and an excellent result is consistently achieved.
If a fine line is drawn from the jaw neck angle to the earlobe (Fig. 1), the neck is divided into 2 defined segments: 1. The submental, submandibular region 2. The region of the neck proper, which includes the structures caudally to this imaginary line The correction of laxity of tissues in the submental area, need, aside from the direct surgery in this region, needs the hammock effect, produced by the bilateral elevation of the midface lift. Only then, can the rejuvenation of this region be achieved. The effect of the superficial musculo-aponeurotic system (SMAS) elevation on the right and left midface, gives a strong
California Pacific Medical Center, San Francisco, CA E-mail address: [email protected] Clin Plastic Surg 41 (2014) 125–129 http://dx.doi.org/10.1016/j.cps.2013.09.004 0094-1298/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
INTRODUCTION
126
Ristow with localized submental fat and no plastymal bands, are treated with–occipital incision (Figs. 2 and 3).
WHAT ARE YOUR INDICATIONS FOR LIMITING YOUR ACCESS INCISIONS TO THE SUBMENTAL AREA OR THE LATERAL APPROACH? IN WHICH CASES DO YOU USE BOTH INCISIONS?
Fig. 1. Dividing the neck into aesthetic units and skin redraping.
sling effect to the tissues in the submental region, appropriately described as the hammock effect. Now, to address specific questions.
WHAT INCISION(S) DO YOU TYPICALLY USE IN THE THIN NECK AND THE HEAVY NECK IN BOTH YOUNG AND OLDER PATIENTS? Younger and older patients will receive very similar incisions. In the older ones, necessarily the occipital incision has to be longer. Only young patients,
Fig. 2. Pre and Post-operative Face and Necklift.
In a still youthful neck with good skin texture and only localized submental fat, a simple submental incision, 3.5 cm long, located 1 cm below the submental crease, is sufficient for effective treatment. The submental crease is released, as are the attachments to the depressors of the lip bilaterally. Silverglyde Bipolar forceps (Stryker Corporation/ Kalamazoo, MI) is the only safe approach to hemeostasis over the depressor anguli oris. The localized fat is taken out in progressive layers until the platysma muscle is exposed. If necessary, 1, 2, or 3 sutures between the thyroid cartilage and the symphisis of mentum are placed to assure an attractive jaw/neck angle. A Porex (Porex Medical Products/Ontario, CA) (1-800-521-7321, ECO043-02) drain is placed and the incision closed, everting its edges, with a 6-0 suture.
Rejuvenation of the Aging Neck
Fig. 3. Pre and Post-operative Face and Necklift.
Most patients who need their neck rejuvenated need a retroauricular occipital incision. Whenever the structures (skin/muscle) are aged, this redraping becomes necessary. The vectors of redraping allow for little variation. Generally, they are at 90 from the neck (see Fig. 1).
WHAT IS YOUR APPROACH TO DEFATTING THE NECK? WHICH FATTY LAYERS DO YOU RESECT (IE, SUBCUTANEOUS, INTERPLATYSMAL, SUBPLATYSMAL FAT)? WHAT ROLE DOES LIPOSUCTION PLAY IN YOUR TECHNIQUE, EITHER ALONE OR IN COMBINATION WITH OPEN TECHNIQUES? I choose to elevate the skin of the neck with the appropriate final thickness of the subcutaneous fat. I gauge this by feeling the dissecting scissors on my right hand and my fifth finger on my left hand to feel the thickness of the flap of the skin being elevated. I find this method accurate and equally precise as transillumination. After the final positioning of the platysma, with the sling to the occipital region (or the small flap described by Tord Skoog1), I defat the layer overlaying the platysma (Fig. 4). (Transillumination is used to evaluate the uniform thickness
of the flaps at the end of the procedure, just prior to closure.)
HOW DOES THE PRESENCE OF VISIBLE PLATYSMA MUSCLE BANDS ALTER YOUR APPROACH? DO YOU UNDERMINE, PLICATE, TRANSECT, PARTIALLY RESECT, OR BACKCUT PLATYSMAL MUSCLE BANDS? Visible platysma muscle bands are always treated. The central strip of platysma is removed; submental fat is grasped with a brown forceps and resected. This leaves platysmal edges on both sides, generally separated by 2 cm. These edges are sutured together in the midline; usually 3 sutures with inverted knots of 3-0 nylon between the thyroid cartilage and the symphisis of the mentum are sufficient. The continuity of the bands is interrupted at the level of the cricoid cartilage, for 2.5 cm in each direction, with a triangle of the muscle removed. Laterally, I also routinely partially divide the platysma muscle. I follow the anterior border of the sternocleidomastoideus muscle, approximately 5 cm (or more if necessary) toward the direction of the cricoid cartilage. The platysma/SMAS flap resulting from the midface dissection is then
127
128
Ristow
Fig. 4. Pre and Post-operative Face and Necklift.
transposed to the retroauricular/occipital region. I do not plicate the platysma, as I suspect this may contribute to the later formation of recurring bands.
DISCUSS SUBMAXILLARY GLAND REDUCTION A good platysma/SMAS sling, with the midline anchoring sutures, provides significant submandibular support. Given reported complications and drawbacks (eg, dry mouth, halitosis, fistulas, and rare nerve injuries), I have not engaged in the partial resection of the glands. Also, after explanation to prospective patients of the issues involved, I have observed that patients will not accept this procedure.
DO YOU PARTIALLY RESECT THE ANTERIOR BELLIES OF THE DIGASTRIC MUSCLES? Yes, I do partially resect the anterior bellies of the digastric, but only if they are responsible for extra bulk. I electrocoagulate the excessive volume.
DO YOU FEEL THERE IS A NEED TO DRAIN NECKS? Yes, I drain all necks. A major and difficult problem is to have any remaining blood after surgery. Avoidance of this complication is of paramount importance.
DO YOU USE FIBRIN GLUE IN THE NECK? No, I do not use fibrin glue in the neck. I am concerned about the manufacturers’ disclaimers of possible transmission of disease.
BRIEFLY MENTION EXPECTED SEQUELAE OF YOUR TECHNIQUE AND COMPLICATIONS THAT YOU HAVE OBSERVED AND HOW YOU TREATED THEM Collections of undrained blood and rare banding of the platysma are difficult issues. They require time for reabsorption, patience, good relations with one’s patients, and, extremely rarely, excision of the offending band. Lesser issues may respond to BOTOX and judicious injections of diluted Triamcinolone Acetonide.
Rejuvenation of the Aging Neck MENTION YOUR TIMING FOR ANY REVISIONS OF A NECK LIFT I would wait 1 year if it all possible. Revisions, however, have practically not existed, following the technical precautions aforementioned. Unfortunately, I have seen very poor results from surgery done elsewhere, frequently, not amendable to improvement. Too much fat removed from the
subcutaneous layer and the excessive electrocoagulation are often the culprits.
REFERENCE 1. Tord Skoog I. Plastic Surgery - New Methods and Refinement. Stockholm, Sweden: Almquist & Wiksell International; 1974.
129