Multidimensional Evaluation and Surgical Approaches to Neck Rejuvenation

Neck aging is still a challenging problem despite that many procedures and techniques have been described over the years.^1–8 A result that looks good in the early postoperative period can be followed a few weeks or months later with frustrating subcutaneous indurations, skin flaccidity, contour irregularities due to preexisting salivary gland ptosis, digastric “malposition” hypertrophy or subplatysma fat that has not been addressed during the initial surgery. Despite the emphasis of many surgeons on the platysma banding, recurrence of this problem is limited to patients with thin necks.

Not all necks are alike. Aesthetic problems of the cervical area are influenced by the following:

• Age
• Inherent skin elasticity
• Subcutaneous and subplatysma fat accumulation
• Volume and quality of the skeletal support of the mandible from the chin to the gonial angle
• Natural height of the cervical spine
• Presence of arthritic changes on the cervical spine that modifies its height and curvature
• Body mass index (BMI)

Aging of the neck is greatly influenced by the acquired or inherent anatomic, aesthetic, and metabolic milieu. An aging neck in the preexisting presence of low BMI with a long slender neck with a normal curvature and excellent mandibular support is going to be completely different from the aging neck in a patient with high BMI, short neck, and poor skeletal support. Between these 2 extremes are a wide variety of conditions that need to be individualized to treat the patient adequately.

In the first situation (low BMI, long slender neck, normal curvature, mandibular support), simpler techniques, such as a cervicofacial lift from the lateral approach, will work well. In the second situation (high BMI, short neck, poor skeletal support), this simple procedure as is proposed by many surgeons will give at best a mediocre result and, at worst, it will make more apparent the underlying anatomic issues with associated aesthetic deformities.

This simple analysis will explain why you cannot compare techniques when you apply them to different anatomic and clinical situations. Any 2 techniques have to be compared when you apply them to similar clinical situations.

Obesity

Obesity is an ever-increasing problem in the United States and in most of the industrialized world with 60 million obese adults in the United States. Likewise, there is increasing rate of obesity in children and teenagers. Since 1980, overweight rates have doubled among children and tripled among adolescents (Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006). That is the population that plastic surgeons will be seeing as patients when they approach middle and old age, not to mention the current middle-age and aging population. Obesity affects not only the trunk but also to a significant degree the face and neck. Those patients develop accumulation of subcutaneous fat not only on the anterior neck but also on the posterior neck. They also develop fat accumulation deep to the platysma muscle more than average-weight people. Overweight and obese patients also present more jowling. Obesity is a condition essential to consider during preoperative planning.

Bulging Digastric Muscle

Bulging of the anterior belly of digastric muscle is another problem not routinely approached during cervicoplasty. This bulging can be due to hypertrophy or malposition of the muscle. I do not know why hypertrophy occurs. Malposition of the anterior belly of the digastric is related to the low-lying position of the hyoid bone. This is seen in patients with obtuse-firm necks and in patients with microgenia.

Salivary Gland Ptosis

Salivary gland ptosis is another complex problem that affects many patients and makes it difficult to obtain a nice contour on the neck during cervicoplasty. Salivary gland ptosis can happen in patients with thin or heavy necks. Preoperatively it is easier to spot this problem in thin necks. Patients with heavy necks can camouflage minor or large degrees of salivary gland ptosis. This can be a trap for the inexperienced surgeon because, if you overlook diagnosing this condition, postoperatively you will have an unsatisfied patient who will claim that you missed removal of “a lump” of fat tissue, which obviously it is not. Postoperative explanations to an angry patient do not go well and correction of this problem is more complicated at this stage.

Cervical Spine Degeneration

A problem not recognized in the etiology of aesthetic problems of the neck during aging is the gradual shortening of the cervical spine due to arthritic changes and the natural shrinkage or herniations of the intervertebral discs. Those
changes are common to the entire length of the spinal column and the cervical spine is not spared of these degenerative processes. This will shorten the entire cervical cylinder, which, in turn, will push the deep neck and floor of the mouth structures to the areas of least resistance, which are the submandibular and submental triangles. As a consequence, the salivary glands, digastric/mylohyoid muscles and the subplatysma fat will “herniate” anteriorly and inferiorly. The more superficial neck envelope, skin, and platysma muscle will also become more redundant in the vertical and horizontal dimensions.

Mandible Skeletal Support

The size of the skeletal support of the mandible also influences how one ages on the lower face and neck. Poor support at the chin, mandibular body, and angle will allow drift of lower face structures into the neck, blunting the submandibular trough and making more obtuse the cervicomental angle. They will also make more apparent the bulging of the submental/submandibular structures.

Preoperative planning

A careful and comprehensive analysis is important for a good surgical planning. The patient should be made aware of all the issues outlined in the overview: amount of superficial and deep cervical fat, quality of the skeletal support around the chin and mandible, how thick or thin is the entire cervical cylinder, what structures are bulging, if there is
salivary gland ptosis or not, how much of skin redundancy exists, the presence or absence of platysma bands, and so forth. Based on these findings, a surgical proposal will be made.

You will need to outline the need to augment the skeletal support, and you will discuss how to treat the deep neck structures and how you will approach the neck. Will you use the lateral approach only or will you also need to use the
anterior approach? How will you treat the platysma and skin? These are important considerations because the best cervicoplasty will not give a good result in the absence of good skeletal support. If the patient has heavy, deep structures, a standard cervicoplasty will still have the outcome of a heavy neck postoperatively. Because the management of the salivary gland ptosis is the most complicated and time-consuming proposition, patients need to understand very well the pros and cons of that approach. Many times patients make surgical decisions based on economical factors. He or she has to understand that postoperatively there will be some residuals and sometimes more apparent issues, such as bulging of the salivary gland that he or she did not notice preoperatively (Figs. 1 and 2).

Fig. 1. This patient scheduled for a biplanar facial rejuvenation presents deep neck fullness associated to a salivary gland ptosis and enlargement. She elected not to have salivary gland surgery.

Fig. 2. Postoperatively, despite the improvement obtained at every other level, she presents accentuation of the salivary gland fullness.

When you add more complicated procedures to the standard cervicofacial lift, these will increase the operative time and cost. This is particularly true if you add chin and gonial angle augmentation and a deep cervicoplasty. On many occasions, the components of the planned surgeries may need to be staged to get the best results and avoid prolonged anesthesia time.

Standard preoperative cardiovascular risk evaluation, avoidance of blood thinners, control of hypertension, and so forth is directed in all patients. Arrangements for postoperative care under a health care provider, usually a certified nurse with experience in plastic surgery postoperative care is made, particularly if a deep cervicoplasty is done, because of the potential of postoperative bleeding.

Recovery time and time to return to work depends on the extent of the surgery. This can vary from 1 to 4 weeks.

Surgical technique

Lateral and Anterior Approach

Most of my patients are approached through lateral and anterior incisions. This is irrespective of age and amount of work you need to do. The reason is that most patients need some work on the anterior neck: platysma, submental fat, and so forth. I have better control of those structures from the submental incision. The submental incision is usually made 1.0 to 1.5 cm posterior to the submental crease. This incision also allows me to perform a subcutaneous/subdermal dissection from this incision to the anterior lower chin and separate the attachments of the skin to the submental crease and prejowl ligaments. This dissection tends to be bloody and I can control this subdermal bleeding better from this approach. This dissection allows better redraping of the perimental skin. This submental incision also allows you to advance the platysma medially and move the skin in the opposite direction. Logistically, you cannot do that if you use the lateral approach exclusively.

Fig. 3. The submental incision for the anterior approach is made 1.0 to 1.5 cm posterior to the submental crease.

Fig. 4. A wide subcutaneous undermining is done via the submental approach. At least 0.5 cm subcutaneous fat thickness should be preserved under the dermis.

Fig. 5. Showing the interlocked Giampapa cervical suture suspension (GSS).

Lateral Approach

Obviously, there will be exceptions in which there is not a need to do these maneuvers and you can handle everything from the lateral approach.

The lateral approach exclusively is indicated in patients with the following:

• Smooth submental crease area
• Absence of submental bulge
• Absence of platysma bands
• Absence of visible prejowl dimples

Fig. 6. The Ramirez Pursestring suture suspension. This is a variation of the GSS. The double row of sutures are woven into the platysma. This maneuver recruits muscle over the salivary gland for enhanced support while it takes care of the platysma redundancy.

On the other hand, I use the submental incision exclusively in young or middle-age patients who do not have too much excess of skin and most of the problems are in the submental area (Figs. 3 and 4). The rest of the neck can be remodeled with liposuction and a suture suspension applied through a retroauricular/mastoid miniincision, as described by Giampapa and DiBernardo (Fig. 5).⁹ If there is excess skin, this can be redraped posteriorly with through-andthrough skin undermining using mini-incisions in the retroauricular/occipital scalp and applying the
Ramirez modification of the Giampapa suture suspension (Fig. 6). This requires an endoscope for accurate dissection and control of bleeding.¹⁰ Mentopexy and/or chin implants will also dictate the need for an anterior incision.

Neck Fat and Neck Bulge

Neck defatting is done by direct trimming with scissors via the submental approach. I do liposuction only when an entirely closed approach is used or as a way to debulk a heavy subcutaneous fat accumulation and I do the fine contouring with the scissors. The decision to resect interdigastric/subplatysma fat is usually made intraoperatively.

Fig. 7. When approaching the deep neck compartment the platysma is opened vertically from pogonium to cricoid cartilage level.

Fig. 8. This anatomical preparation shows the deep cervical fat compartment. This typically has a trapezoidal shape and extends beyond the level of the salivary glands laterally. Red dots indicate level of platysma muscle division. Blue mark on the specimen: bony attachment of playsma muscle. White dotted line indicate the boundaries of the deep cervical fat. ABD, anterior belly of digastric; DC Fat, Deep Cervical fat; PM, platysma muscle lifted above and over the mandible.

Fig. 9. After the interdigastric and the rest of the deep cervical fat resection the anterior belly of digastrics (ABD) can be sutured as a corset in the midline. A: before the digastric corset. B: after the digastric corset.

You can predict a high probability of doing this in the heavy, short neck. After the superficial fat is resected, an assessment of the contour of the neck is made. If there is bulging, a decision to open the platysma in the midline is made and a graduated approach to deal with the deep subplatysma structures is made starting with the deep fat (Fig. 7). This fat is not confined to the interdigastric region only. It has a trapezoidal shape and it extends laterally up to the area underlying the salivary glands (Fig. 8).¹¹ If you resect only the central part you will develop a hollowed out submental area.

Next, the contour of the digastric against the mylohyoid muscle is assessed. If the digastric is bulging, the first step is a trial of advancement of this muscle toward the midline. If that fills the gap and the contour is improved, then a corset of the anterior belly of the digastrics (ABD) with inverted sutures using 3-0 nylon is made (Fig. 9). If that does not improve it, then a tangential shaving of the superficial portion of the ABD is done. If preoperatively enlarged ptotic salivary glands are detected or during surgery the glands are bulging, the superficial lobe of the gland is removed on each side (Fig. 10).

Fig. 10. This drawing depicts the partial salivary gland resection via the central subplatysma approach.

Cervicoplasty

To perform deep cervicoplasty, long slender instruments are needed. I usually use 2 lighted retractors and commonly do bleeding control with small hemoclips.

• The platysma muscle is closed after they are advanced to the midline.
• If the platysma is thin, I do not resect the redundancy. I will overlap or fold the edges as I apply the interrupted sutures from the mentum to the hyoid.
• In cases of platysma banding, I usually do 2 Z-plasties of the anterior 4 cm of the muscle. I handle the redundant muscle with the Ramirez pursestring woven suture suspension and/or I resect the muscle in the lowest part of the dissected area.
• I leave 2 mm butterfly drains connected to a vacutainer tubes, one on each side of the subplatysma plane and one on each side of the superficial plane. I do not use fibrin glue. I advance the drains on the second or third day and I usually remove them on the fifth or sixth day, a bit longer than the standard. This allows me to suction all the potential seroma that may form.
• Following these steps, you can obtain reliable and consistent excellent results (Figs. 11–14).

Fig. 11. Preoperative view of this 55-year-old female. She has obtuse cervicomental angle with skin and platysma muscle redundancy and bands.

Fig. 12. Postoperative view after a complete biplanar endoscopic assisted mask (BEAM) facial rejuvenation.

Observe the smooth, clean and well defined neck and cervicomental angle. The patient had a bidirectional approach to the neck rejuvenation. The platysma corset was complemented with the Ramirez Woven Suture Suspension.

Fig. 13. Before and after of a patient with a TEAM (triplanar endoscopic-assisted mask) facial rejuvenation. This included the subplatysma deep cervicoplasty with partial salivary excision on the left.

Fig. 14. Before and after of a patient with the TEAM facial rejuvenation. The obtuse neck treatment required subplatysma deep neck cervicoplasty with DC fat excision and a geniomandibular Ramirez (RZ) medpor chin implant.

Sequela and complications

Complications and sequelae following cervicoplasty can range from a simple nuisance to a devastating problem.

• Injury to one or more branches of the marginal mandibular nerve (MMN) can be devastating to the patient. Luckily this is rarely permanent. Recovery of the nerve can be hastened with electrical myoneural stimulation. Avoidance of aggressive liposuction or avoidance of monopolar cautery around the trajectory of the MMN will minimize this risk.
• Acute hematoma in a closed compartment can be a life-threatening complication. Any hypertension should be controlled and patients should be watched carefully, particularly in the first 24 hours. During surgery, hemostasis should be precise with bipolar or coaxial suction coagulator. A large or medium-size vessel should be ligated with sutures or hemoclips.
• Subdermal/subcutaneous indurations due to seromas or hematomas can be resolved with serial injections of diluted triamcinolone. Prevention of seromas includes prevention of hematomas and the use of close-system small drains for several days.
• Contour irregularities from residual fat accumulations can be corrected with liposuction by using small cannulas. This can be prevented with meticulous contouring with the sharp scissors.
• Skin necrosis resulting from smoking or excessive tension requires a secondary correction after the area has been allowed to heal and the skin left to soften for several months. Prevention includes perioperative avoidance of smoking and control of skin tension during closure.
• Residual bulging due to anterior belly of digastric hypertrophy and or salivary gland ptosis requires a secondary deep cervicoplasty. Avoidance of these problems requires a good preoperative assessment and surgical planning.
• Small areas of residual platysma banding can be improved with botox injections. Large areas will require secondary platysmaplasty. To avoid residual platysma banding, the appropriate technique should be used: muscle z-plasty, muscle back cut, and so forth.

In general, the timing of any revision is better done after you wait the longest. The minimum is 6 months, ideally 12 months. However, psychological issues may determine earlier revision.

Summary

Correction of aesthetic and anatomic deformities of the neck due to aging is a complex proposition, and the planning and approach depends on the findings during your initial examination. Surgical techniques need to be adapted to the
problems you encounter.¹² More than any area of the body, an in-depth knowledge of the anatomy is mandatory. The surgery can be very simple or highly technical. Surgeons should have in their armamentarium all the available surgical techniques to provide the best aesthetic result. The deep cervicoplasty is not the same as the superficial cervicoplasty; it is completely a different surgical dimension. Deep cervicoplasty is not for the occasional facial rejuvenative surgeon. You require experience in diagnosing neck problems, executing the proper surgical maneuvers, and effectively tackling acute and late complications.

References:

1. Owsley JQ Jr. SMAS-platysma facelift. A bidirectional cervicofacial rhytidectomy. Clin Plast Surg 1983; 10(3): 429–40.
2. Labbe D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study an analysis of 30 cases. Plast Reconstr Surg 2006; 117(6): 2001–7.
3. Millard DR Jr, Garst WP, Beck RL, et al. Submental and submandibular lipectomy in conjunction with face lift, in the male or female. Plast Reconstr Surg 1972; 49(4): 385–91.
4. Fuente del Campo A. Midline platysma muscular overlap for neck restoration. Plast Reconstr Surg 1998; 102(5): 1710–4.
5. Ramirez OM. Cervicoplasty: non-excisional anterior approach. Plast Reconstr Surg 1997; 99: 1576–85.
6. Ramirez OM, Robertson KM. Comprehensive approach to rejuvenation of the neck. Facial Plast Surg 2001; 17(2): 129–40.
7. Giampapa VC, Bitzos I, Ramirez OM, et al. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fine points for improving outcomes. Aesthetic Plast Surg 2005; 29(5): 341–50.
8. Giampapa VC, Bitzos I, Ramirez OM, et al. Longterm results of suture suspension platysmaplasty for neck rejuvenation: a 13-year follow-up evaluation. Aesthetic Plast Surg 2005; 29(5): 332–40.
9. Giampapa VC, DiBernardo BE. Neck recontouring with suture suspension and liposuction: an alternative for the early rhytidectomy candidate. Aesthetic Plast Surg 1995; 19(3): 217–23.
10. Ramirez OM. Cervicoplasty without skin excision. In: Shiffman MA, Mirrafati SJ, Lam SM, et al, editors. Simplified facial rejuvenation. Berlin: Springer Verlag; p. 613–20 Chapter 80.
11. Ramirez OM. Advanced considerations determining procedure selection in cervicoplasty. Part one: anatomy and aesthetics. Clin Plast Surg 2008; 35(4): 679–90.
12. Ramirez OM. Advanced considerations determining procedure selection in cervicoplasty. Part two: surgery. Clin Plast Surg 2008; 35(4): 691–709.

Oscar M. RAMIREZ, MD, Plastic Surgeon – Leading Physicians of the World (USA)

Reprinted from Elsevier