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Rejuvenation of the Anterior Neck
Rejuvenation of the Anterior Neck The When and Why Jayson Terres, MD, DDS, FACS, FAACS KEYWORDS Rejuvenation Anterior neck Liposculpture Cervicoplasty KEY POINTS Rejuvenation of the anterior neck region requires a complex artistic interpretation of the patient’s desires and potential anticipated outcomes. Whether it is a minimal invasive liposculpture procedure to a full cervicoplasty with chin augmentation and full facelift, the outcome will be optimal if the anticipated areas of complaints are fully addressed. Understanding the patient’s relative aging process will ultimately lead to the correct proposed treatment.
Introduction
Effects on aging/variability of neck types
One of the most common complaints of the cosmetic patient is the neck region. Excessive skin, muscle laxity, and increased fatty deposition are all factors that lead to an unwanted aging effect. Nevertheless, the esthetic improvement of the anterior neck complex remains one of the most challenging aspects of facial rejuvenation.1e13 This area is often one of the first places people complain of during the “aging” process: whether it is an early accumulation of unwanted fatty deposition, an increased prominence of platysma banding, decreased definition in the cervicomental angle, or loss of skin-muscle tone. There are several combinations of these complaints among a wide variety of ages (Fig. 1). It is important to understand what the patients’ primary concerns are and which proposed treatment would give a maximum outcome. It is also important to have an artistic eye and predict the patient’s outcome for their desired procedures to ensure that the other local facial structures will not hamper treatment results. Preoperative understanding of the patient’s desired outcome is paramount in selecting the appropriate surgery. Younger patients that still possess good skin elasticity may be able to have a simple liposculpture procedure, whereas an older patient having the same procedure may not be as pleased with the outcome due to unmasked jowling that is now more apparent or possibly the insufficient intrinsic contractility of skin. Complete fat removal in neck tissue does not lend itself to the optimal result (Fig. 2). An understanding of the patient’s current anatomic state will then most commonly dictate what type of procedure will be performed. These procedures can range from simple liposculpture, to direct lipectomy, platysmaplasty, or complete cervicoplasty encompassing a combined facelift (Box 1).
The anterior neck region is more of a sweeping topographic landscape with smooth undulations versus its more flat upper facial counterparts.1e5 A youthful-appearing facial and neck region has a smooth textured appearance, well-defined cervicomental angle, and appropriate suspended fullness. Ellenbogen1 has long established the visual aspects of a youthful neck appearance. A youthful neck appearance has been classified as having a cervicomental angle between 105 and 120 with a distinct mandibular border and smooth nonbanded overlying skin draping (Fig. 3).2 However, as our aging process begins, the initial tone and texture of the more superficial structures is the first visible structure change. Further substructural changes within muscle then give way. It is this laxity of suspensory neck muscles in combination of increased fatty deposits and inferior gravitational movement of the patient’s jowls that account for aging of the neck region. Furthermore, the accumulation of excessive fat deposits is increased with aging, weight gain, and certain medical conditions. Several classification systems have been introduced to characterize this process. I have adapted the Baker classification system,3 as its 4 subtypes seem to encompass most of my patients’ aging attributes (Box 2, Fig. 4). In addition, there other components that this author thinks can potentiate this aging appearance over time, such as submandibular gland ptosis and mandibular bony atrophydboth of which contribute to a poor cervicomental angle and loss of volume. They can further pose some difficulties to the surgeon, as the decision needs to be made in regards to which procedure or procedures should be performed to maximize outcome and achieve the highest success with the patient’s expectations.
Patient expectations The author has nothing to disclose. Maxillofacial Trauma, Mother Frances Health System, Tyler, TX, USA E-mail address: [email protected] Atlas Oral Maxillofacial Surg Clin N Am 22 (2014) 25–36 1061-3315/14/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cxom.2013.10.001
In evaluating the patient’s anterior neck region, several factors come into play. First and foremost is the patient’s biggest concern, their chief complaint. In my presurgical consultations,
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Fig. 1 Note the difference in neck structural types. Patient on the left exhibits mild submental lipomatosis, whereas the patient on the right has redundant tissue, lipomatosis, and banding. Also, note the second patient has much more prominent jowls and mandible notching.
I always explain to the patient that we both must see their issuedif I cannot, this becomes a flag to me, or if I see something that the patient does not complain of, I will point it out, because I can see a potential issue that may become exacerbated in the future if the wrong surgery is performed. In listening to my patients, I often hear that they do not want anything too invasive or they only want a few days of down time or they do not want a facelift, just fix their sagging neck. Well, as I like to explain to my patients, there is the “right answer” for their problem and then there is the “right procedure” for their problem. What I mean by this is, for example, if a 60-year-old patient comes into my office and wants his/her neck “tightened” and his/her eyes “lifted”d what he/she likely needs is a brow lift, upper/lower eyelid lift, full face/neck lift, laser resurfacing, and possibly chin and cheek implants. They need 2 to 3 weeks of downtime to achieve this simple complaint. Explaining this to a patient that liposuction and a blepharoplasty will not provide an optimal outcome on her/him (like it did on a 40-year-old friend) can be difficult. Therefore, even though the optimal procedure for this type of patient would be a more classic complete facial rejuvenation, I may tailor the surgery to meet my patient’s more specific requests. I am not advocating a “quick-fix procedure,” but think it is very important to keep all of the patient’s expectations in mind to the best of my abilities. At
this point, I may recommend staged surgeries or give the patient a complete understanding of why the “quicker” procedure would not be most beneficial for her/him (Figs. 5 and 6).
Indications for neck rejuvenation Given the complexity and variability of the anterior neck region, most treatment options will be individualized for each patient. Age, gender, race, social history, habits, and genetics all play major roles in the aging process. Table 1 provides a brief description of the problem areas and their respective treatments and is a basic guide for what would be necessary to correct the problem. Often it is the combination of 2 or more of these procedures that is necessary to maximize outcomes. An in-depth description of neck subregions is described later in this article.
Surgical anatomy concepts The anatomy of the neck is complex and in itself is the subject of full textbooks. The anatomy of the platysma has been extensively studied4,5 and a brief summary will not do it any justice, although a brief overview and some important landmarks to aid with the rejuvenation surgical aspect have been included.
Box 1. Terms
Fig. 2 This patient had prior neck liposuction. The result was oversculpture and now a more visualized platysma band (arrow).
Liposculpture: classic liposuction, but in the neck the artistic ability to “sculpt” fatty areas, removing more in certain areas and less in others to maximize cosmetic appearance Direct lipectomy: removal of fat under direct vision (can be with lipocannula, surgical scissors, bovie, etc) Platysmaplasty: retightening the platysma muscle in the anterior neck regions. Various methods are used, whether it is a single or double layered “corset” approachdwith or without back cuts Complete cervicoplasty: encompasses direct removal of fat, platysmaplasty, and possibly facelift (short incision, superficial musculo-aponeurotic system (SMAS), or deep plane)
Rejuvenation of the Anterior Neck
Fig. 3
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Note the youthful, smooth neck contour and acceptable chin neck angle.
The anatomic structure of the anterior neck is a complex laminate, made up of layers of skin and soft tissue (fat, fascia, muscle) that encompass nerves, vessels, and lymphatics.6 When performing full neck rejuvenation, it is paramount to stay in the right plane, which will not only give the surgeon an optimal outcome but also keep you away from any troubled areas (ie, nerves or great vessels). There are several classic descriptions of the series of “muscle triangles” described by their relative locations and particular borders.7 The complexity of the neck anatomy can be overwhelming and not the basis of this surgical anatomic discussion. Rather, anatomic esthetic subunits, what they encompass, and how to correct them are the focused on. Feldman7 describes the anatomic face as a set of 5 regional esthetic subunits, with the neck being one. It can be described as an undulating trapezoid; the neck extends from below the mandibular border, down toward the collarbones and posteriorly to the occiput region, just anterior to the trapezius muscles. He then further divides into 8 smaller subunits: (1) jawline bands, (2) chin subunit, (3) submental zone, (4) vertical midline strip, (5) middle neck lowland, (6) lateral neck highland, (7) small musclulomandibular triangle, and (8)
Box 2. Patient types Type I patients have slight cervical skin laxity with submental fat and early jowls Type II patients have moderate cervical skin laxity, moderate jowls and submental fat Type III patients have moderate cervical laxity, but with significant jowling and active platysmal banding Type IV patients have loose, redundant cervical skin and folds below the cricoid, significant jowls, and active bands
postauricular hinterland. The analysis of these subunits as a whole must take into account the varying degrees of the patient’s skin tone texture and tightness, along with the underlying support structure (muscle) and any laxity it may have developed, and finally, the varying degrees of fat deposition (Fig. 7). The first area, the jawline bands, is a very common complaint of “ jowling.” The degree of facial jowling and the prejowl notch will dictate the amount of fatty tissue in the area that needs to be removed and the degree of subcutaneous release of the mandibular ligament, which will also lead into the chin subunit. Identifying the patient for chin augmentation can accomplish several esthetic goals. First, an improvement in the cervicomental angle, and second, camouflaging a prejowl notch. (Even in patients who do not need anterior-posterior chin advancement, I use a prejowl implant with no anterior-posterior projection to aid in a deep prejowl notch.) The next 2 areas of concern are the submental zone and vertical midline strip. These areas are going to give the most information about the rejuvenation process of the neck, whether it is a young patient with good skin overtone and moderate lipomatosis or an elderly patient with skin laxity, muscle banding, and severe lipomatosis. This region dictates minimal invasive liposculpture to submentalplasty to complete cervicomentalplasty with combined facelift. The region contains both supra- and subplatysma fat structure, platysma muscles, hyoid bone, anterior jugular vein, and its communicating branches. The 2 leading edges of the platysma will have some decussation in most patients, and a small percentage will have none, although it is this area where redundant tissue (both muscle and fat) will be excised and tightened (Fig. 8). The deeper muscle structures, such as the anterior digastric muscles, may also need to be trimmed or tighteneddbut I usually find this is on a prior operated neck where other overlying structures have been repositioned or removed in excess.
Fig. 4
Note neck classification types AeD.
Fig. 5 This younger male patient was able to achieve a very good cosmetic resultdliposculpture with a chin implant with minimal downtime.
Fig. 6 This older female patient requested “liposuction” to her neck; after careful discussion, it was deemed that a combined facelift and cervicoplasty would be needed to achieve her expectations along with a 2-week downtime period.
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Problem Area
Treatment
1. Subcutaneous fat
Liposculpture or direct lipectomydage dependent
2. Excessive skin
Direct excision with redraping (isolated neck/or facelift)
3. Subplatysma fat
Direct excision with platysma tightening
4. Platysma bands
Platysma plication with inferior back cut
there is no excessive parotid tissuedif present, I prefer to leave the gland structure but will remove excessive fatty tissue to improve the clinical cervicomental angle. The final area is the postauricular hinterland; the region is just posterior to the auricle, where the final resting place of newly suspended tissue resides. Passive tissue will give the most optimal results. Excessive removal will lead to wound breakdown and widened scar bands. Too little removal can leave “tissue rolls” that may take several months to soften and often patients will complain of lumpy tissue.
5. Retrogenia
Alloplastic implant or orthognathic surgery
Nonsurgical techniques
6. Poor neck angle
Combinations of all the above
Table 1
Problem areas and treatments
The midneck lowland region is an important clinical area that needs to be thoroughly examined before a final treatment is proposed. The midneck lowland region is the region where excessive jowling and submandibular salivary gland distinction must be made. Not only is this an area of excessive lipomatosis, but also the submandibular gland can be prominent and easily camouflaged by excess fat. Palpation of this area from both an intraoral and an extraoral approach can provide great insight as to whether the gland will require a partial resection, suspension, or oversew in the supporting muscle. The lateral neck highland area is the topographic area overlying the sternocleidomastoid muscle and is the most difficult area for cutaneous flap elevation. The fascia fibers overlying the muscle structure are in greatest number here and make dissection challenging. However, it is of great importance to dissect enough tissue away to ensure a proper skin “redraping”; otherwise a gathered tissue appearance will give a noticeable “operated” neck. The final 2 described areas are small triangle regions. The first area is the musculomandibular triangle, just inferior to the earlobe. This area can be somewhat problematic because inferior earlobe distortions from improper suspension can be quite visible. The classic “pixie-ear” deformity from an isolated neck lift or complete face and neck lift is formed from improper suspension of tissue and excessive skin pull (Fig. 9). This area can also be affected if there is too much fatty tissue left behind, causing a blunting of the posterior border of the mandible. Careful attention is also warranted to ensure that
Fig. 7
There are several nonsurgical modalities for improving the aging neck. These techniques can include anything from neck muscle exercises, botulism injections, and skin tightening with lasers, radiofrequency, or even chemical peeling. In my opinion these are very patient-specific and yield only temporary results. Some are discussed, because they remain popular requests among patients.
Botulinum toxin Chemodenervation with Botulinum toxin (Botox, Dysport, and others) will help with static platysma bands. Muscle atrophy can ensure and a loss of prominence can improve the anterior neck appearance.8 Dynamic bands can also be treated with Botox injections. Softening of these “active” muscle bands can delay the formation of static platysma lines with repeated injections. Just as Botox reduces dynamic and static line formation in the forehead and glabella regions, it can be helpful in the anterior neck as well. However, due to differences in the affected muscle structures, overlying skin tone, textures, and subunit attachments, the benefits are usually not as great as those seen in the forehead area.
Laser resurfacing Laser resurfacing to the anterior neck can improve the tone and texture of the skin and to some degree collagen tightening will also occur. However, these treatments must take into account the skin difference from the upper facial units: the amount of sebaceous type tissue and the skin epidermal and
The subdivisions of the neck as described by Feldman.
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Fig. 8 The lines represent the platysma muscle. On the right is the planned surgical corset and inferior back cuts with a “double-layer” closure.
dermal depth differences. Unfortunately, the neck has an inconsistent and dramatically less pilosebaceous unit than the face, and therefore, is less able to recover from the same depth of treatment as the face.9 There is an increase in scarring, pigmentation changes, as well as delayed healing. Laser resurfacing the neck must be done with caution not to create severe skin damage. The other issue that I have with this treatment (when done alone) is that it does not usually address the underlying issue, which most commonly is an abundance of fatty deposition and muscle laxity. Other new nonsurgical or “minimal-risk” neck rejuvenation procedures often promise great results with minimal or no downtime. Please do not be misguided by these claims, because the Fountain of Youth does not exist with “no down time and no pain.” My recommendation to my patients when asked if I do any of these types of procedures is that the evidence just is not there. I always tell them to request several before-and-after photographs of “actual” patients with longterm follow-up photographs (at least a year)dI am waiting to see them.
Surgical managementdnoninvasive versus invasive There are both invasive and noninvasive surgical treatments used to correct the anterior neck region. This set of procedures includes combinations of liposculpture/direct lipectomy, removing or altering neck musculature, and the redraping of excessive skin and removal as necessary.
Liposculpture (liposuction) Liposculpture (liposuction) is a common procedure performed very routinely not only on the face but also on multiple areas of the body. It can be done very safely and effectively if done properly. In young patients (Baker type I) this is an excellent treatment modality. The younger patient often still has very good intrinsic contractility strength in their skin, which will allow for good elastic recoil after the unwanted fatty deposits are removed. Liposculpture (liposuction) can be done with
Fig. 9 This patient was treated by another surgeon and underwent a chin implant and an isolated “neck lift.” She presented with a complaint of minimal improvement and worsening of problem areas. Note how improper suspension of neck structures leads to ear stress (long arrow). There was no addressing the midline structures. Also, the chin implant stopped short of the mandibular notch and accentuates this area more (shorter arrow). The patient had minimal improvement with her cervicomental angle and thus was not pleased with her outcome.
Rejuvenation of the Anterior Neck minimal anesthesia and a relatively uneventful postoperative course. However, whereas liposuction does have a role in cosmetic surgery of the submental area, it is not a comprehensive procedure and does not address all of the anatomic components leading to submental fullness.10
Direct lipectomy Direct lipectomy is performed in younger patients with more neck fullness caused by excessive fatty deposition, but still good skin tone (Baker type I and some IIsdthis is difficult to judge and clinical experience is the only way to determine if you can achieve adequate results in these types of patients). Again, anesthesia is the surgeon’s preference. However, these are commonly done through a slightly larger incision than general liposculpture, and both lipocannulas and facelift scissors are used for direct fat removal.
Platysmal plication Once muscle laxity has occurred, whether the patient demonstrates a single- or double-banded structure in the anterior neck, the platysma needs to be tightened (Baker type IIeIII). There are too many ways to list on how this is performed, but the procedure involves a submental crease exposure, fatty cutaneous plane, and direct visualization of the platysma muscle. Excessive muscle tissue is removed in the midline, and 2 leading edges are clearly identified. The subplatysma fat can be removed here as deemed necessary; then the muscle is closed overlying this area and is done in 1 or 2 layers. Various back cuts have been described.2,5,7 The complete surgical details are presented later in this article. At this point the options for isolated posterior neck tightening or the addition of a formal facelift are done. The addition of a chin implant can be considered as well.
Cervicoplastyddirect lipectomy, platysmal plication, SMAS elevation The goal of this procedure is to provide an improvement in the cervicomental angle, smooth and uniform skin contour, and a decrease in the amount of unwanted fatty tissue deposits. It is most important not to overdo any particular portion or unwanted asymmetries or uneven skin texture may hamper your overall results. My surgical techniques are very similar for all my “complete-neck” or cervicoplasty rejuvenation patients. These patients usually fit the Baker type IIIeIV classification and I still perform almost the same surgical procedure with the exception of an additional suture corsets layer in the last group. A rhytidectomy in conjunction with a neck rejuvenation procedure is my preferred operation for almost all my patients. The addition of the SMAS elevation with neck rejuvenation allows for a smoother and controlled elevation and repositioning of the soft tissues, especially aiding in the lateral neck area. Performing anterior neck surgery alone can sometimes accentuate jowling and lateral neck fullness as well as place more of an unwanted visual focus on the patient’s other aging facial features.7 There are surgeons who claim that the posterior neck pull after an anterior plication does not make sense, and the increased in posterior tension will have an increased likelihood of midline failure but this is not what I usually see. I think the posterior resuspension
31 needs to be done carefully and not “overly” tightened to give a good harmonious neck contour. I do not always do a submentalplasty corset. There are some patients who present with such severe jowling that requires a large “pull-up” of SMAS tissue and in these cases if I can just perform anterior midline resection of excessive laxed muscle tissue and remove excessive fat, I can maximize their lift and fix the jowling without being held back by an excessive midline platysma tightening.
Operative techniques All of my surgical patients are seen in my accredited ambulatory surgery center. I use varying depths of anesthesia, but my usual routine is done with an laryngeal mask airway and general anesthetic gas (sevoflurane). Of course, all of the following procedures can be done with IV sedation, or a general anesthetic, and some people will do with PO sedation and local anestheticdbut this is not my preferred method.
Operative steps: noninvasive and invasive Noninvasive liposculture In the preoperative setting, I mark the desired area for liposculpture with the patient in an upright position; using a mirror, I have the patient directly visualize the anticipated areas while I mark them. I then outline key anatomic areasd mandible border, hyoid, muscle structures, and nerve course. I use 3 small incisions, one submental, and the other 2 just behind the earlobes. After I complete these markings, I recline the patient into the anticipated surgical position and reinspect my markings. Once in the operating room, a standard sterile drape and preparation (hibiclens prep is my preferred choice) is completed. The surgical sites are infiltrated with a small amount of 1% lidocaine and then the anterior neck is infiltrated with tumescent solution (my mixture is 0.01% lidocaine with 1 part per million epinephrine) (Fig. 10). I use 3 small stab incisions when doing liposculpture alone, but if I plan for a direct lipectomy, the submental incision is extended to 3 cm in the shadow just posterior to the submental skin crease. Starting from the submental incision, bluntly dissect in a subcutaneous plane, overlying the platsyma with one hand and hold the neck skin with the other using the cannula in a starburst pattern. It is very important to maintain the same plane; this dissection is relatively easy, so do not overforce it! After fanning the anterior region of the neck, do the same procedure from each of the lateral areasdkeeping in mind relative anatomic structures, nerve courses, and vascular position. After the dissection is completed, a lipocannula is used to “sculpt the neck,” with continual sweeping motion with direct visualization of the cannula underlying the skin. (There are several types of cannulas for this procedure. I tend to use both flat spatulas and round cannulas or varying sizes. I also use cannulas attached to wall suction or with a syringe and Johnnylock device [Fig. 11].) You can turn the suction opening “toward” the skin surface, but it is only recommended doing this in certain areas where the fatty deposits are thicker or more irregular. The goal is NOT to remove all the fat, just unnecessary fat, and provide a smooth plane of dissection above the platysma muscle to allow an even redraping of skin tissue. I do occasionally have to do subplatysma fat liposculpture in the
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Fig. 10 Tumescence solution being infiltrated into subcutaneous tissue. After 12 minutes, tissue blanching in the picture on the right can be noted.
anterior region as well in more full-neck patients, remembering not to overreduce or you could make the underlying structures (thyroid cartilage, digastric muscles, hyoid bone) more apparent. My surgical approach is exactly the same for direct lipectomy, except following the initial liposculpture, I open the submental incision to 2.5 to 3 cm and use a lighted retractor to remove any excessive fatty deposits with direct vision. One small 6-0 nylon suture is used to close each of the access incisions (more for direct lipectomy) and soft gauze pads are opened and placed in the anterior neck and an elastic head wrap is placed. My typical protocol is for the patient to wear the head wrap for 1 week for 24 hours except when showering and then an additional week only at night (Box 3). Invasive cervicoplasty As discussed earlier, there is great variability between individual neck types. The proposed surgical technique is a common standard procedure that will encompass the rejuvenation process for most of these types. Certain steps may be omitted or overly emphasized pending the individual patient. As previously described, the anterior neck is a harmonious topographic architecture that needs to be smooth. I like to think of it as a lump of clay on a potter’s wheel; the clay is spun and the potter smooths it centrally and brings its up. This technique is our goal for neck surgical rejuvenation; smooth out the tissues and “bring them up.” Platysma laxity, submental lipomatosis, and cervical lipomatosis cannot be adequately addressed solely through a preauricular incision. The goal of achieving an improved and cosmetically enhanced
cervicomental angle is done by the anterior midline platysma plication, inferior muscle release, and its facial component that allows for a superior lateral anchor that minimizes tension of the anterior corset (Fig. 12).11 The initial portion of this is the same as mentioned above for liposculpture, using the extended 3-cm incision just posterior to the submental crease. The anterior neck is completely exposed using facelift scissors with both a vertical and a horizontal motion. The surgical plane established will vary on neck and patient type but usually extends to below the cricoid (again, inferior extension varies in each patient), carried out laterally to the posterior angle of the mandible (Fig. 13). Using lighted retractors, any bulbous fatty deposits are directly removed, and hemostasis is achieved. This exposure will allow for an adequate platysmaplasty. Under direct vision the medial leading edges of the platysma are freed from the underlying subplatsyma fat and digastric muscles and grasped and brought to the midline. Excessive muscle and fat are excised and the leading edges are imbricated together with 1 to 2 layers of running suture. A release is performed low in the neck to allow for adequate muscle redrape. This technique will tighten the platysma and improve the cervicomental angle. I directly visualize the areas where the submandibular glands are and pending any herniation or enlarged gland tissue I will either place a row of support sutures, or if the gland is easily visualized, I will just remove a portion of it. Some authors do describe an intraoral resuspension,2,5,12 but rarely have I had to do this. Although this procedure can be very beneficial in younger patients, I find that most patients will require lateral neck
Box 3. Quick summary
Fig. 11 Standard liposuction cannulas, one with a lock-syringe device and the other for wall suction.
1. 2. 3. 4. 5. 6.
Mark patient Tumescence through 3 small incisionsdwait 15 min Dissect with flat cannula Liposculpt with 4e5 mm flat/round cannula Closure Wrap with head dressing for 1 wk
Rejuvenation of the Anterior Neck
Fig. 12
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Preoperative markings for combined neck rejuvenation with SMAS lift.
approaches to maximize their expected outcome. I almost always combine complex neck rejuvenation with a facelift procedure and by doing so it will allow the surgeon to address the neck as well as any unwanted jowling or other aging issues. My preferred adjunctive facelift procedure is an SMAS elevation whereby a portion of the SMAS flap is elevated superior and another is transposed posterior to the ear to affect lateral neck contour (Fig. 14). This portion of the SMAS is secured to the mastoid fascia with permanent suture. One technical point is
clear: cervical rhytidectomy suspension with a predominantly superior vector will serve to sharpen the jawline and crisply define the face-to-neck transition (Fig. 15).11
Chin implant Patients who are retrognathic and/or retrogenic are good candidates for chin augmentation. Whether the surgery relies on an artistic appreciation of facial harmony or a formal
Fig. 13 (A) Surgical access for anterior neck. (B) Exposure opening for direct lipectomy and anterior platysma plication. (C) Surgical access for SMAS lift component. (D) Connection of face and neck flaps.
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Fig. 14 Sequential operative technique for anterior neck rejuvenation (direct lipectomy, platysma plication with back cut, and SMAS elevation). (A) Note extensive cutaneous elevation. (B) SMAS with direct platysma pull. (C) Marking SMAS for partial resection and posterior plication. (D) SMAS resection.
soft/hard tissue cephalometric analysis is completed, chin augmentation can have a profound effect on cervicomental enhancement. Whether a formal horizontal mandibular osteotomy is carried out or an alloplastic implant is placedd both can dramatically improve a poor cervicomental angle and provide an optimal esthetic and functional outcome.14,15
Submandibular gland The submandibular gland is the one area that that I admittedly overlooked when I first began doing full face and neck rejuvenation procedures over 10 years ago. Basically, it just was not an issue in most of my early procedures. Now, though, this is one of the key areas that I make certain to address before any procedure is done, from basic liposculpture to full facial rejuvenation. The reason for doing so is that after a very well-orchestrated surgery, if the gland becomes a visualized problem, it becomes the only thing the patient focuses on. That being said, there are a few ways to ensure that the gland does not become as issue. I routine will place overlying mattress suspension sutures in the platysma to create a substructural support if the gland is not overly large. I also perform a partial gland resection if the superior head of the gland is excessively prominent or noticeably herniating through the underlying muscle. Finally, gland suspension with suspension sutures with a combined intraoral approach can be done if the gland itself is thought to be excessively large or not amenable to the other listed procedures.12
Fat grafting Patients who have already had a prior facelift with neck combination and have a noted middling “trough” appearance are candidates for fat grafting. Esthetic surgeons have been performing facial rejuvenation that usually involves excision and resuspension, but there are many times that restoring facial volume (lost with aging) with provide similar or better results.13 In the anterior neck region, the usual patient is someone that had an overaggressive resection of the supra-/ subplatysma fat, now with lax platysma or a howled out area with a tethered skin appearance. I perform my routine open neck from a submental incision and identify and free up the anterior leading edges of the platysma; if they are connected in the midline, I separate them and do a direct fat graft into the subplatsyma area and then perform a double-layered closure of the muscle. Grafting between the platysma and cutaneous layer is then a clinical decision. It has been my experience that the more uniform the grafted fat, the better the outcome. I routinely overfill by about 15% to 20%. Pitfallsdareas that are often overlooked Low hyoid Subplatysma fat content The chindchin augmentation can improve cervicomental angle, soften or decrease to mandible prejowl notch Submandibular gland Elderly patients almost always require full cervicoplasty to achieve optimal results
Rejuvenation of the Anterior Neck
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Fig. 15 All patients (AeC) shown underwent a full anterior neck rejuvenation with SMAS facelift. All result photographs are 1-year postoperative.
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Summary Rejuvenation of the anterior neck region requires a complex artistic interpretation of the patient’s desires and potential anticipated outcomes. Whether it is a minimally invasive liposculpture procedure or a full cervicoplasty with chin augmentation and full facelift, the outcome will be optimal if the anticipated areas of complaints are fully addressed. Understanding the patient’s relative aging process will ultimately lead to the correct proposed treatment.
References 1. Ellenbogen RK. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg 1980;66(6):826e37. 2. Ramirez OM. Advanced considerations determining procedure selection in cervicoplasty. Clin Plast Surg 2008;35(4):670e90. 3. Baker DC. Lateral SMASectomy, plication and short scar facelifts: indications and techniques. Clin Plast Surg 2008;35(4):533e50. 4. Vistnes LM, Souther SG. The platysma muscle. Anatomic considerations for aesthetic surgery of the anterior neck. Clin Plast Surg 1983;10:441.
Terres 5. De Castro CC. Anatomy of the neck and procedure selection. Clin Plast Surg 2008;35:625. 6. Burnham MA. Facial nerve anatomy relevant to cosmetic surgery. Oral Maxillofac Surg Clin North Am 2000;12(4):613e21. 7. Feldman JJ. Neck lift. St Louis (MO): Quality Medical Publishing; 2006. 8. Brandt FS, Boker A. Botulinum toxin for the treatment of neck lines. Dermatol Clin 2004;22:159e66. 9. Toft KM, Blackwell KE, Keller GS. Submentoplasty. Facial Plast Surg Clin North Am 2000;8(2):183e92. 10. Fattahi T. Submental liposuction versus formal cervicoplasty: which one to choose? J Oral Maxillofac Surg 2012;70(12):2854e8. 11. Wachholz JH. Surgical treatment of the heavy face and neck. Facial Plast Surg Clin North Am 2009;17(4):603e11. 12. Sullivan PK, Hoy EA. Minimal invasive facial rejuvenation. In: Nahai F, Nahai FR, editors. Necklift vs neck rejuvenation. New York: Saunders; 2009. p. 99e109. 13. Saboeiro AP, Coleman SR. Minimally invasive facial rejuvenation: fat rejuvenation with structural fat grafting. New York: Saunders; 2009. p. 89e98. 14. Lee NR. Genioplasty techniques. Oral Maxillofac Surg Clin North Am 2000;12(4):755e63. 15. Niamtu J. Alloplastic chin augmentation. Oral Maxillofac Surg Clin North Am 2000;12(4):765e9.
Introduction
Effects on aging/variability of neck types
One of the most common complaints of the cosmetic patient is the neck region. Excessive skin, muscle laxity, and increased fatty deposition are all factors that lead to an unwanted aging effect. Nevertheless, the esthetic improvement of the anterior neck complex remains one of the most challenging aspects of facial rejuvenation.1e13 This area is often one of the first places people complain of during the “aging” process: whether it is an early accumulation of unwanted fatty deposition, an increased prominence of platysma banding, decreased definition in the cervicomental angle, or loss of skin-muscle tone. There are several combinations of these complaints among a wide variety of ages (Fig. 1). It is important to understand what the patients’ primary concerns are and which proposed treatment would give a maximum outcome. It is also important to have an artistic eye and predict the patient’s outcome for their desired procedures to ensure that the other local facial structures will not hamper treatment results. Preoperative understanding of the patient’s desired outcome is paramount in selecting the appropriate surgery. Younger patients that still possess good skin elasticity may be able to have a simple liposculpture procedure, whereas an older patient having the same procedure may not be as pleased with the outcome due to unmasked jowling that is now more apparent or possibly the insufficient intrinsic contractility of skin. Complete fat removal in neck tissue does not lend itself to the optimal result (Fig. 2). An understanding of the patient’s current anatomic state will then most commonly dictate what type of procedure will be performed. These procedures can range from simple liposculpture, to direct lipectomy, platysmaplasty, or complete cervicoplasty encompassing a combined facelift (Box 1).
The anterior neck region is more of a sweeping topographic landscape with smooth undulations versus its more flat upper facial counterparts.1e5 A youthful-appearing facial and neck region has a smooth textured appearance, well-defined cervicomental angle, and appropriate suspended fullness. Ellenbogen1 has long established the visual aspects of a youthful neck appearance. A youthful neck appearance has been classified as having a cervicomental angle between 105 and 120 with a distinct mandibular border and smooth nonbanded overlying skin draping (Fig. 3).2 However, as our aging process begins, the initial tone and texture of the more superficial structures is the first visible structure change. Further substructural changes within muscle then give way. It is this laxity of suspensory neck muscles in combination of increased fatty deposits and inferior gravitational movement of the patient’s jowls that account for aging of the neck region. Furthermore, the accumulation of excessive fat deposits is increased with aging, weight gain, and certain medical conditions. Several classification systems have been introduced to characterize this process. I have adapted the Baker classification system,3 as its 4 subtypes seem to encompass most of my patients’ aging attributes (Box 2, Fig. 4). In addition, there other components that this author thinks can potentiate this aging appearance over time, such as submandibular gland ptosis and mandibular bony atrophydboth of which contribute to a poor cervicomental angle and loss of volume. They can further pose some difficulties to the surgeon, as the decision needs to be made in regards to which procedure or procedures should be performed to maximize outcome and achieve the highest success with the patient’s expectations.
Patient expectations The author has nothing to disclose. Maxillofacial Trauma, Mother Frances Health System, Tyler, TX, USA E-mail address: [email protected] Atlas Oral Maxillofacial Surg Clin N Am 22 (2014) 25–36 1061-3315/14/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cxom.2013.10.001
In evaluating the patient’s anterior neck region, several factors come into play. First and foremost is the patient’s biggest concern, their chief complaint. In my presurgical consultations,
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Fig. 1 Note the difference in neck structural types. Patient on the left exhibits mild submental lipomatosis, whereas the patient on the right has redundant tissue, lipomatosis, and banding. Also, note the second patient has much more prominent jowls and mandible notching.
I always explain to the patient that we both must see their issuedif I cannot, this becomes a flag to me, or if I see something that the patient does not complain of, I will point it out, because I can see a potential issue that may become exacerbated in the future if the wrong surgery is performed. In listening to my patients, I often hear that they do not want anything too invasive or they only want a few days of down time or they do not want a facelift, just fix their sagging neck. Well, as I like to explain to my patients, there is the “right answer” for their problem and then there is the “right procedure” for their problem. What I mean by this is, for example, if a 60-year-old patient comes into my office and wants his/her neck “tightened” and his/her eyes “lifted”d what he/she likely needs is a brow lift, upper/lower eyelid lift, full face/neck lift, laser resurfacing, and possibly chin and cheek implants. They need 2 to 3 weeks of downtime to achieve this simple complaint. Explaining this to a patient that liposuction and a blepharoplasty will not provide an optimal outcome on her/him (like it did on a 40-year-old friend) can be difficult. Therefore, even though the optimal procedure for this type of patient would be a more classic complete facial rejuvenation, I may tailor the surgery to meet my patient’s more specific requests. I am not advocating a “quick-fix procedure,” but think it is very important to keep all of the patient’s expectations in mind to the best of my abilities. At
this point, I may recommend staged surgeries or give the patient a complete understanding of why the “quicker” procedure would not be most beneficial for her/him (Figs. 5 and 6).
Indications for neck rejuvenation Given the complexity and variability of the anterior neck region, most treatment options will be individualized for each patient. Age, gender, race, social history, habits, and genetics all play major roles in the aging process. Table 1 provides a brief description of the problem areas and their respective treatments and is a basic guide for what would be necessary to correct the problem. Often it is the combination of 2 or more of these procedures that is necessary to maximize outcomes. An in-depth description of neck subregions is described later in this article.
Surgical anatomy concepts The anatomy of the neck is complex and in itself is the subject of full textbooks. The anatomy of the platysma has been extensively studied4,5 and a brief summary will not do it any justice, although a brief overview and some important landmarks to aid with the rejuvenation surgical aspect have been included.
Box 1. Terms
Fig. 2 This patient had prior neck liposuction. The result was oversculpture and now a more visualized platysma band (arrow).
Liposculpture: classic liposuction, but in the neck the artistic ability to “sculpt” fatty areas, removing more in certain areas and less in others to maximize cosmetic appearance Direct lipectomy: removal of fat under direct vision (can be with lipocannula, surgical scissors, bovie, etc) Platysmaplasty: retightening the platysma muscle in the anterior neck regions. Various methods are used, whether it is a single or double layered “corset” approachdwith or without back cuts Complete cervicoplasty: encompasses direct removal of fat, platysmaplasty, and possibly facelift (short incision, superficial musculo-aponeurotic system (SMAS), or deep plane)
Rejuvenation of the Anterior Neck
Fig. 3
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Note the youthful, smooth neck contour and acceptable chin neck angle.
The anatomic structure of the anterior neck is a complex laminate, made up of layers of skin and soft tissue (fat, fascia, muscle) that encompass nerves, vessels, and lymphatics.6 When performing full neck rejuvenation, it is paramount to stay in the right plane, which will not only give the surgeon an optimal outcome but also keep you away from any troubled areas (ie, nerves or great vessels). There are several classic descriptions of the series of “muscle triangles” described by their relative locations and particular borders.7 The complexity of the neck anatomy can be overwhelming and not the basis of this surgical anatomic discussion. Rather, anatomic esthetic subunits, what they encompass, and how to correct them are the focused on. Feldman7 describes the anatomic face as a set of 5 regional esthetic subunits, with the neck being one. It can be described as an undulating trapezoid; the neck extends from below the mandibular border, down toward the collarbones and posteriorly to the occiput region, just anterior to the trapezius muscles. He then further divides into 8 smaller subunits: (1) jawline bands, (2) chin subunit, (3) submental zone, (4) vertical midline strip, (5) middle neck lowland, (6) lateral neck highland, (7) small musclulomandibular triangle, and (8)
Box 2. Patient types Type I patients have slight cervical skin laxity with submental fat and early jowls Type II patients have moderate cervical skin laxity, moderate jowls and submental fat Type III patients have moderate cervical laxity, but with significant jowling and active platysmal banding Type IV patients have loose, redundant cervical skin and folds below the cricoid, significant jowls, and active bands
postauricular hinterland. The analysis of these subunits as a whole must take into account the varying degrees of the patient’s skin tone texture and tightness, along with the underlying support structure (muscle) and any laxity it may have developed, and finally, the varying degrees of fat deposition (Fig. 7). The first area, the jawline bands, is a very common complaint of “ jowling.” The degree of facial jowling and the prejowl notch will dictate the amount of fatty tissue in the area that needs to be removed and the degree of subcutaneous release of the mandibular ligament, which will also lead into the chin subunit. Identifying the patient for chin augmentation can accomplish several esthetic goals. First, an improvement in the cervicomental angle, and second, camouflaging a prejowl notch. (Even in patients who do not need anterior-posterior chin advancement, I use a prejowl implant with no anterior-posterior projection to aid in a deep prejowl notch.) The next 2 areas of concern are the submental zone and vertical midline strip. These areas are going to give the most information about the rejuvenation process of the neck, whether it is a young patient with good skin overtone and moderate lipomatosis or an elderly patient with skin laxity, muscle banding, and severe lipomatosis. This region dictates minimal invasive liposculpture to submentalplasty to complete cervicomentalplasty with combined facelift. The region contains both supra- and subplatysma fat structure, platysma muscles, hyoid bone, anterior jugular vein, and its communicating branches. The 2 leading edges of the platysma will have some decussation in most patients, and a small percentage will have none, although it is this area where redundant tissue (both muscle and fat) will be excised and tightened (Fig. 8). The deeper muscle structures, such as the anterior digastric muscles, may also need to be trimmed or tighteneddbut I usually find this is on a prior operated neck where other overlying structures have been repositioned or removed in excess.
Fig. 4
Note neck classification types AeD.
Fig. 5 This younger male patient was able to achieve a very good cosmetic resultdliposculpture with a chin implant with minimal downtime.
Fig. 6 This older female patient requested “liposuction” to her neck; after careful discussion, it was deemed that a combined facelift and cervicoplasty would be needed to achieve her expectations along with a 2-week downtime period.
Rejuvenation of the Anterior Neck
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Problem Area
Treatment
1. Subcutaneous fat
Liposculpture or direct lipectomydage dependent
2. Excessive skin
Direct excision with redraping (isolated neck/or facelift)
3. Subplatysma fat
Direct excision with platysma tightening
4. Platysma bands
Platysma plication with inferior back cut
there is no excessive parotid tissuedif present, I prefer to leave the gland structure but will remove excessive fatty tissue to improve the clinical cervicomental angle. The final area is the postauricular hinterland; the region is just posterior to the auricle, where the final resting place of newly suspended tissue resides. Passive tissue will give the most optimal results. Excessive removal will lead to wound breakdown and widened scar bands. Too little removal can leave “tissue rolls” that may take several months to soften and often patients will complain of lumpy tissue.
5. Retrogenia
Alloplastic implant or orthognathic surgery
Nonsurgical techniques
6. Poor neck angle
Combinations of all the above
Table 1
Problem areas and treatments
The midneck lowland region is an important clinical area that needs to be thoroughly examined before a final treatment is proposed. The midneck lowland region is the region where excessive jowling and submandibular salivary gland distinction must be made. Not only is this an area of excessive lipomatosis, but also the submandibular gland can be prominent and easily camouflaged by excess fat. Palpation of this area from both an intraoral and an extraoral approach can provide great insight as to whether the gland will require a partial resection, suspension, or oversew in the supporting muscle. The lateral neck highland area is the topographic area overlying the sternocleidomastoid muscle and is the most difficult area for cutaneous flap elevation. The fascia fibers overlying the muscle structure are in greatest number here and make dissection challenging. However, it is of great importance to dissect enough tissue away to ensure a proper skin “redraping”; otherwise a gathered tissue appearance will give a noticeable “operated” neck. The final 2 described areas are small triangle regions. The first area is the musculomandibular triangle, just inferior to the earlobe. This area can be somewhat problematic because inferior earlobe distortions from improper suspension can be quite visible. The classic “pixie-ear” deformity from an isolated neck lift or complete face and neck lift is formed from improper suspension of tissue and excessive skin pull (Fig. 9). This area can also be affected if there is too much fatty tissue left behind, causing a blunting of the posterior border of the mandible. Careful attention is also warranted to ensure that
Fig. 7
There are several nonsurgical modalities for improving the aging neck. These techniques can include anything from neck muscle exercises, botulism injections, and skin tightening with lasers, radiofrequency, or even chemical peeling. In my opinion these are very patient-specific and yield only temporary results. Some are discussed, because they remain popular requests among patients.
Botulinum toxin Chemodenervation with Botulinum toxin (Botox, Dysport, and others) will help with static platysma bands. Muscle atrophy can ensure and a loss of prominence can improve the anterior neck appearance.8 Dynamic bands can also be treated with Botox injections. Softening of these “active” muscle bands can delay the formation of static platysma lines with repeated injections. Just as Botox reduces dynamic and static line formation in the forehead and glabella regions, it can be helpful in the anterior neck as well. However, due to differences in the affected muscle structures, overlying skin tone, textures, and subunit attachments, the benefits are usually not as great as those seen in the forehead area.
Laser resurfacing Laser resurfacing to the anterior neck can improve the tone and texture of the skin and to some degree collagen tightening will also occur. However, these treatments must take into account the skin difference from the upper facial units: the amount of sebaceous type tissue and the skin epidermal and
The subdivisions of the neck as described by Feldman.
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Fig. 8 The lines represent the platysma muscle. On the right is the planned surgical corset and inferior back cuts with a “double-layer” closure.
dermal depth differences. Unfortunately, the neck has an inconsistent and dramatically less pilosebaceous unit than the face, and therefore, is less able to recover from the same depth of treatment as the face.9 There is an increase in scarring, pigmentation changes, as well as delayed healing. Laser resurfacing the neck must be done with caution not to create severe skin damage. The other issue that I have with this treatment (when done alone) is that it does not usually address the underlying issue, which most commonly is an abundance of fatty deposition and muscle laxity. Other new nonsurgical or “minimal-risk” neck rejuvenation procedures often promise great results with minimal or no downtime. Please do not be misguided by these claims, because the Fountain of Youth does not exist with “no down time and no pain.” My recommendation to my patients when asked if I do any of these types of procedures is that the evidence just is not there. I always tell them to request several before-and-after photographs of “actual” patients with longterm follow-up photographs (at least a year)dI am waiting to see them.
Surgical managementdnoninvasive versus invasive There are both invasive and noninvasive surgical treatments used to correct the anterior neck region. This set of procedures includes combinations of liposculpture/direct lipectomy, removing or altering neck musculature, and the redraping of excessive skin and removal as necessary.
Liposculpture (liposuction) Liposculpture (liposuction) is a common procedure performed very routinely not only on the face but also on multiple areas of the body. It can be done very safely and effectively if done properly. In young patients (Baker type I) this is an excellent treatment modality. The younger patient often still has very good intrinsic contractility strength in their skin, which will allow for good elastic recoil after the unwanted fatty deposits are removed. Liposculpture (liposuction) can be done with
Fig. 9 This patient was treated by another surgeon and underwent a chin implant and an isolated “neck lift.” She presented with a complaint of minimal improvement and worsening of problem areas. Note how improper suspension of neck structures leads to ear stress (long arrow). There was no addressing the midline structures. Also, the chin implant stopped short of the mandibular notch and accentuates this area more (shorter arrow). The patient had minimal improvement with her cervicomental angle and thus was not pleased with her outcome.
Rejuvenation of the Anterior Neck minimal anesthesia and a relatively uneventful postoperative course. However, whereas liposuction does have a role in cosmetic surgery of the submental area, it is not a comprehensive procedure and does not address all of the anatomic components leading to submental fullness.10
Direct lipectomy Direct lipectomy is performed in younger patients with more neck fullness caused by excessive fatty deposition, but still good skin tone (Baker type I and some IIsdthis is difficult to judge and clinical experience is the only way to determine if you can achieve adequate results in these types of patients). Again, anesthesia is the surgeon’s preference. However, these are commonly done through a slightly larger incision than general liposculpture, and both lipocannulas and facelift scissors are used for direct fat removal.
Platysmal plication Once muscle laxity has occurred, whether the patient demonstrates a single- or double-banded structure in the anterior neck, the platysma needs to be tightened (Baker type IIeIII). There are too many ways to list on how this is performed, but the procedure involves a submental crease exposure, fatty cutaneous plane, and direct visualization of the platysma muscle. Excessive muscle tissue is removed in the midline, and 2 leading edges are clearly identified. The subplatysma fat can be removed here as deemed necessary; then the muscle is closed overlying this area and is done in 1 or 2 layers. Various back cuts have been described.2,5,7 The complete surgical details are presented later in this article. At this point the options for isolated posterior neck tightening or the addition of a formal facelift are done. The addition of a chin implant can be considered as well.
Cervicoplastyddirect lipectomy, platysmal plication, SMAS elevation The goal of this procedure is to provide an improvement in the cervicomental angle, smooth and uniform skin contour, and a decrease in the amount of unwanted fatty tissue deposits. It is most important not to overdo any particular portion or unwanted asymmetries or uneven skin texture may hamper your overall results. My surgical techniques are very similar for all my “complete-neck” or cervicoplasty rejuvenation patients. These patients usually fit the Baker type IIIeIV classification and I still perform almost the same surgical procedure with the exception of an additional suture corsets layer in the last group. A rhytidectomy in conjunction with a neck rejuvenation procedure is my preferred operation for almost all my patients. The addition of the SMAS elevation with neck rejuvenation allows for a smoother and controlled elevation and repositioning of the soft tissues, especially aiding in the lateral neck area. Performing anterior neck surgery alone can sometimes accentuate jowling and lateral neck fullness as well as place more of an unwanted visual focus on the patient’s other aging facial features.7 There are surgeons who claim that the posterior neck pull after an anterior plication does not make sense, and the increased in posterior tension will have an increased likelihood of midline failure but this is not what I usually see. I think the posterior resuspension
31 needs to be done carefully and not “overly” tightened to give a good harmonious neck contour. I do not always do a submentalplasty corset. There are some patients who present with such severe jowling that requires a large “pull-up” of SMAS tissue and in these cases if I can just perform anterior midline resection of excessive laxed muscle tissue and remove excessive fat, I can maximize their lift and fix the jowling without being held back by an excessive midline platysma tightening.
Operative techniques All of my surgical patients are seen in my accredited ambulatory surgery center. I use varying depths of anesthesia, but my usual routine is done with an laryngeal mask airway and general anesthetic gas (sevoflurane). Of course, all of the following procedures can be done with IV sedation, or a general anesthetic, and some people will do with PO sedation and local anestheticdbut this is not my preferred method.
Operative steps: noninvasive and invasive Noninvasive liposculture In the preoperative setting, I mark the desired area for liposculpture with the patient in an upright position; using a mirror, I have the patient directly visualize the anticipated areas while I mark them. I then outline key anatomic areasd mandible border, hyoid, muscle structures, and nerve course. I use 3 small incisions, one submental, and the other 2 just behind the earlobes. After I complete these markings, I recline the patient into the anticipated surgical position and reinspect my markings. Once in the operating room, a standard sterile drape and preparation (hibiclens prep is my preferred choice) is completed. The surgical sites are infiltrated with a small amount of 1% lidocaine and then the anterior neck is infiltrated with tumescent solution (my mixture is 0.01% lidocaine with 1 part per million epinephrine) (Fig. 10). I use 3 small stab incisions when doing liposculpture alone, but if I plan for a direct lipectomy, the submental incision is extended to 3 cm in the shadow just posterior to the submental skin crease. Starting from the submental incision, bluntly dissect in a subcutaneous plane, overlying the platsyma with one hand and hold the neck skin with the other using the cannula in a starburst pattern. It is very important to maintain the same plane; this dissection is relatively easy, so do not overforce it! After fanning the anterior region of the neck, do the same procedure from each of the lateral areasdkeeping in mind relative anatomic structures, nerve courses, and vascular position. After the dissection is completed, a lipocannula is used to “sculpt the neck,” with continual sweeping motion with direct visualization of the cannula underlying the skin. (There are several types of cannulas for this procedure. I tend to use both flat spatulas and round cannulas or varying sizes. I also use cannulas attached to wall suction or with a syringe and Johnnylock device [Fig. 11].) You can turn the suction opening “toward” the skin surface, but it is only recommended doing this in certain areas where the fatty deposits are thicker or more irregular. The goal is NOT to remove all the fat, just unnecessary fat, and provide a smooth plane of dissection above the platysma muscle to allow an even redraping of skin tissue. I do occasionally have to do subplatysma fat liposculpture in the
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Fig. 10 Tumescence solution being infiltrated into subcutaneous tissue. After 12 minutes, tissue blanching in the picture on the right can be noted.
anterior region as well in more full-neck patients, remembering not to overreduce or you could make the underlying structures (thyroid cartilage, digastric muscles, hyoid bone) more apparent. My surgical approach is exactly the same for direct lipectomy, except following the initial liposculpture, I open the submental incision to 2.5 to 3 cm and use a lighted retractor to remove any excessive fatty deposits with direct vision. One small 6-0 nylon suture is used to close each of the access incisions (more for direct lipectomy) and soft gauze pads are opened and placed in the anterior neck and an elastic head wrap is placed. My typical protocol is for the patient to wear the head wrap for 1 week for 24 hours except when showering and then an additional week only at night (Box 3). Invasive cervicoplasty As discussed earlier, there is great variability between individual neck types. The proposed surgical technique is a common standard procedure that will encompass the rejuvenation process for most of these types. Certain steps may be omitted or overly emphasized pending the individual patient. As previously described, the anterior neck is a harmonious topographic architecture that needs to be smooth. I like to think of it as a lump of clay on a potter’s wheel; the clay is spun and the potter smooths it centrally and brings its up. This technique is our goal for neck surgical rejuvenation; smooth out the tissues and “bring them up.” Platysma laxity, submental lipomatosis, and cervical lipomatosis cannot be adequately addressed solely through a preauricular incision. The goal of achieving an improved and cosmetically enhanced
cervicomental angle is done by the anterior midline platysma plication, inferior muscle release, and its facial component that allows for a superior lateral anchor that minimizes tension of the anterior corset (Fig. 12).11 The initial portion of this is the same as mentioned above for liposculpture, using the extended 3-cm incision just posterior to the submental crease. The anterior neck is completely exposed using facelift scissors with both a vertical and a horizontal motion. The surgical plane established will vary on neck and patient type but usually extends to below the cricoid (again, inferior extension varies in each patient), carried out laterally to the posterior angle of the mandible (Fig. 13). Using lighted retractors, any bulbous fatty deposits are directly removed, and hemostasis is achieved. This exposure will allow for an adequate platysmaplasty. Under direct vision the medial leading edges of the platysma are freed from the underlying subplatsyma fat and digastric muscles and grasped and brought to the midline. Excessive muscle and fat are excised and the leading edges are imbricated together with 1 to 2 layers of running suture. A release is performed low in the neck to allow for adequate muscle redrape. This technique will tighten the platysma and improve the cervicomental angle. I directly visualize the areas where the submandibular glands are and pending any herniation or enlarged gland tissue I will either place a row of support sutures, or if the gland is easily visualized, I will just remove a portion of it. Some authors do describe an intraoral resuspension,2,5,12 but rarely have I had to do this. Although this procedure can be very beneficial in younger patients, I find that most patients will require lateral neck
Box 3. Quick summary
Fig. 11 Standard liposuction cannulas, one with a lock-syringe device and the other for wall suction.
1. 2. 3. 4. 5. 6.
Mark patient Tumescence through 3 small incisionsdwait 15 min Dissect with flat cannula Liposculpt with 4e5 mm flat/round cannula Closure Wrap with head dressing for 1 wk
Rejuvenation of the Anterior Neck
Fig. 12
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Preoperative markings for combined neck rejuvenation with SMAS lift.
approaches to maximize their expected outcome. I almost always combine complex neck rejuvenation with a facelift procedure and by doing so it will allow the surgeon to address the neck as well as any unwanted jowling or other aging issues. My preferred adjunctive facelift procedure is an SMAS elevation whereby a portion of the SMAS flap is elevated superior and another is transposed posterior to the ear to affect lateral neck contour (Fig. 14). This portion of the SMAS is secured to the mastoid fascia with permanent suture. One technical point is
clear: cervical rhytidectomy suspension with a predominantly superior vector will serve to sharpen the jawline and crisply define the face-to-neck transition (Fig. 15).11
Chin implant Patients who are retrognathic and/or retrogenic are good candidates for chin augmentation. Whether the surgery relies on an artistic appreciation of facial harmony or a formal
Fig. 13 (A) Surgical access for anterior neck. (B) Exposure opening for direct lipectomy and anterior platysma plication. (C) Surgical access for SMAS lift component. (D) Connection of face and neck flaps.
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Fig. 14 Sequential operative technique for anterior neck rejuvenation (direct lipectomy, platysma plication with back cut, and SMAS elevation). (A) Note extensive cutaneous elevation. (B) SMAS with direct platysma pull. (C) Marking SMAS for partial resection and posterior plication. (D) SMAS resection.
soft/hard tissue cephalometric analysis is completed, chin augmentation can have a profound effect on cervicomental enhancement. Whether a formal horizontal mandibular osteotomy is carried out or an alloplastic implant is placedd both can dramatically improve a poor cervicomental angle and provide an optimal esthetic and functional outcome.14,15
Submandibular gland The submandibular gland is the one area that that I admittedly overlooked when I first began doing full face and neck rejuvenation procedures over 10 years ago. Basically, it just was not an issue in most of my early procedures. Now, though, this is one of the key areas that I make certain to address before any procedure is done, from basic liposculpture to full facial rejuvenation. The reason for doing so is that after a very well-orchestrated surgery, if the gland becomes a visualized problem, it becomes the only thing the patient focuses on. That being said, there are a few ways to ensure that the gland does not become as issue. I routine will place overlying mattress suspension sutures in the platysma to create a substructural support if the gland is not overly large. I also perform a partial gland resection if the superior head of the gland is excessively prominent or noticeably herniating through the underlying muscle. Finally, gland suspension with suspension sutures with a combined intraoral approach can be done if the gland itself is thought to be excessively large or not amenable to the other listed procedures.12
Fat grafting Patients who have already had a prior facelift with neck combination and have a noted middling “trough” appearance are candidates for fat grafting. Esthetic surgeons have been performing facial rejuvenation that usually involves excision and resuspension, but there are many times that restoring facial volume (lost with aging) with provide similar or better results.13 In the anterior neck region, the usual patient is someone that had an overaggressive resection of the supra-/ subplatysma fat, now with lax platysma or a howled out area with a tethered skin appearance. I perform my routine open neck from a submental incision and identify and free up the anterior leading edges of the platysma; if they are connected in the midline, I separate them and do a direct fat graft into the subplatsyma area and then perform a double-layered closure of the muscle. Grafting between the platysma and cutaneous layer is then a clinical decision. It has been my experience that the more uniform the grafted fat, the better the outcome. I routinely overfill by about 15% to 20%. Pitfallsdareas that are often overlooked Low hyoid Subplatysma fat content The chindchin augmentation can improve cervicomental angle, soften or decrease to mandible prejowl notch Submandibular gland Elderly patients almost always require full cervicoplasty to achieve optimal results
Rejuvenation of the Anterior Neck
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Fig. 15 All patients (AeC) shown underwent a full anterior neck rejuvenation with SMAS facelift. All result photographs are 1-year postoperative.
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Summary Rejuvenation of the anterior neck region requires a complex artistic interpretation of the patient’s desires and potential anticipated outcomes. Whether it is a minimally invasive liposculpture procedure or a full cervicoplasty with chin augmentation and full facelift, the outcome will be optimal if the anticipated areas of complaints are fully addressed. Understanding the patient’s relative aging process will ultimately lead to the correct proposed treatment.
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