Operative Technique in Plastic Surgery – Kevin C.Chung

■ Patients are asked to set aside 2 to 3 weeks to recover from surgery. If the
patient is doing well, they can return to light office work and casual social
activity 9 to 10 days after surgery. Patients are advised to avoid all strenuous
activity during the first 2 weeks after surgery. Two to three weeks after surgery,
they are allowed to begin light exercise and gradually work up their activity as
tolerated by 6 weeks.
■ Patients are informed that it will often take 2 to 3 months to look good in a
photo or to be seen at an important social function.
OUTCOMES
■ See FIGS 8 to 10
COMPLICATIONS
■ The most common complication is a hematoma. The incidence ranges from
2% to as high as 10%. The incidence is higher in men and patients with a
history of hypertension. Preoperative measures to reduce the risk include
control of blood pressure and avoidance of medications and supplements that
may affect bleeding. Intraoperative maneuvers include close cooperation with
the anesthesiologist to rigorously control blood pressure along with meticulous
hemostasis. Most hematomas will occur in the first 12 hours postoperatively so
close monitoring in the recovery and over the first evening is critical. This
includes proper management of pain, anxiety, blood pressure, and nausea.

FIG 8 • A. AP view. On the left, preoperative view of a
woman, age 65. She has had previous upper and lower
eyelifts performed by another surgeon. Note midface,
cheek, and jawline laxity and poor transition from lower
eyelid to malar area. On the right, same patient, 13
months after high SMAS face-lift, neck lift, hairline
lowering forehead lift, upper and lower eyelifts, perioral
dermabrasion, and fat transfer to the cheeks and lips.
No skin resurfacing, facial implants, or other ancillary
procedures were performed. The midface, cheek, and
jowl have been repositioned harmoniously and in a
uniform and balanced manner. Note smooth facial
contours, more youthful facial shape, and absence of a
pulled or a “face-lifted” appearance. B. AP view smiling.
On the left, preoperative view of a woman, age 65. She
has had previous upper and lower eyelifts performed by
another surgeon. Note that but improvement along the
jawline can be seen when the patient smiles, but
midface ptosis and cheek laxity are accentuated. On
the right, same patient, 13 months after high SMAS
face-lift, neck lift, hairline lowering forehead lift, upper
and lower eyelifts, perioral dermabrasion, and fat
transfer to the cheeks and lips. The midface, cheek,
and jowl have been repositioned harmoniously and in a
uniform and balanced manner. Note soft, natural facial

contours and the absence of a tight, pulled, or “face-
lifted” appearance. C. Oblique. On the left, preoperative
view of a woman, age 65. She has had previous upper
and lower eyelifts performed by another surgeon. Note
sagging midface, cheeks, and jowl, and infraorbital
hollowness. On the right, same patient, 13 months after
high SMAS face-lift, neck lift, hairline lowering forehead
lift, upper and lower eyelifts, preoral dermabrasion, and
fat transfer to the cheeks and lips. The midface, cheeks,
and jawline have been repositioned in a balanced and
harmonious fashion. Note also the improved transition
from lower eyelid to malar region. D. Lateral view.
Preoperative view of a woman, age 65. She has had
previous upper and lower eyelifts performed by another
surgeon. Note sagging mid-face, cheek and jowl, and
poor transition from lower eyelid to malar area. Same
patient, 13 months after high SMAS face-lift, neck lift,
hairline lowering forehead lift, upper and lower eyelifts,
perioral dermabrasion, and fat transfer to cheeks and
lips. The midface, cheek, and jowl have been
repositioned harmoniously and in a balanced manner.
Note also improved transition from lower eyelid to
cheek.

FIG 9 • A. AP view. On the left, preoperative view of a
woman, age 55. Note midface ptosis, heavy jowls, deep
nasolabial lines, and poor jawline contour. She has had
no prior plastic surgery. On the right, same patient, 1
year 6 months after high SMAS face-lift, neck lift, limited
incision forehead lift, and upper lower eyelifts, chin
augmentation, and fat transfer to the lips and cheeks.
No skin resurfacing or other ancillary procedures were
performed. Midface, cheek, and jowl have been
repositioned harmoniously and in a uniform and
balanced manner. Note smooth facial contours, more
youthful facial shape and absence of a pulled or a
“face-lifted” appearance. B. AP Frowning. On the left,
preoperative view of a woman, age 55 frowning. She
has had no prior plastic surgery. On the right, the same
patient, 1 year 6 months after High SMAS face-lift, neck
lift, limited incision forehead lift, upper and lower eye

blepharoplasties, chin augmentation, and fat transfer to
the cheeks and lips. She is trying to frown in this
photograph but is no longer able to do so due to muscle
modification performed as part of the forehead lift
procedure. C. Oblique view. On the left, preoperative
view of a woman, age 55. Note midface ptosis, sagging
cheek, and jowl, and perioral laxity. She has had no
prior plastic surgery. On the right, same patient, 1 year
6 months after High SMAS face-lift, neck lift, limited
incision forehead lift, upper and lower blepharoplasties,
chin augmentation, and fat transfer to the cheek and
lips. The midface, cheek, and jowl have been
repositioned harmoniously in a balanced manner. Note
smooth facial contours, more youthful facial shape. D.
Lateral view. On the left, preoperative view of a woman,
age 55. Note midface ptosis, sagging cheek, and jowl
and poor transition from lower eyelid to malar area. She
has had no prior plastic surgery. On the right, same
patient, 1 year 6 months after High SMAS face-lift, neck
lift, limited incision forehead lift, upper and lower
eyelifts, chin augmentation, and fat transfer to cheeks
and lips. Note restoration of attractive malar contour,
improved transition from lower eyelid to cheek,
elevation of perioral area, and well-defined jawline.

FIG 10 • A. AP view. On the left, preoperative view of
patient, age 60. Atrophy in the infraorbital, perioral, and
upper midface regions is evident. Loss of attractive
facial contour due to deep tissue ptosis can be seen in
the cheek, jowl and perioral regions. On the right, the
same patient, 14 months after high SMAS face-lift, neck
lift, closed foreheadplasty, conservative upper and
lower blepharoplasty and partial facial fat injections. Fat
injections have provided filling of the infra-orbital and
per-oral areas. Note restoration of youthful facial shape
without a tight or pulled appearance. B. AP smiling
view. On the left, preoperative view of patient, age 60.
On the right, the same patient, 14 months after high
SMAS face-lift, neck lift, closed foreheadplasty,
conservative upper and lower blepharoplasty, and
partial facial fat injections. Note natural contour is
present, even in animation. C. Oblique view. On the left,

preoperative view of patient age 60. Note lateral brow
ptosis, mid-face ptosis and loss of youthful malar,
perioral and mandibular contour. On the right, the same
patient, 14 months after high SMAS face-lift, neck lift,
closed foreheadplasty, conservative upper and lower
blepharoplasty and partial facial fat injections. Note
improved brow position, restoration of cheek fullness,
improved transition from lower lid to cheek, elevation of
ptotic perioral tissue, smooth jawline and improved
submental contour. D. Lateral view. On the left,
preoperative view of patient age 60. Note malar
flattening, perioral laxity, ptotic jowl and
cervicosubmental laxity. A prominent submandibular
gland can also be seen. On the right, the same patient,
14 months after high SMAS face-lift, neck lift, closed
foreheadplasty, conservative upper and lower
blepharoplasty and partial facial fat injections. The
protruding portion of the submandibular gland has also
been excised. Note the restoration of cheek fullness,
elevation of ptotic perioral tissue, smooth jawline and
improved cervicosubmental contour. The face has a
natural appearance, and all scars are well concealed
(Courtesy of T. J. Marten, MD, FACS).
■ A less common complication is skin slough which is most commonly the
result of tension. Skin slough resulting from underlying circulatory problems
includes smoking, acne scarring, and diabetes.
■ One of the most devastating complications after a face-lift is facial nerve
injury. Fortunately, the incidence is less than 1%. The facial nerve branches
most at risk include the buccal, frontal, and marginal mandibular.
REFERENCES
1. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve
during rhytidectomy. Plast Reconstr Surg 1980;66:675-679.

2. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg
1989;83:11.
3. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg
1992;89:441-449.
4. Marten TJ. Face lift planning and technique. Clin Plast Surg 1997;24:269-
308.
5. Marten TJ. Lamellar high SMAS face and midface lift. In: Nahai F, ed. The
Art of Aesthetic Surgery. St. Louis, MO: Quality Medical Publishing;
2005:1110-1192.

45
CHAPTERSMASectomy Face-lift
Steven M. Levine and Daniel C. Baker
DEFINITION
■ Surgery is the standard for addressing descent and laxity in the aging face.
■ SMASectomy refers to the removal of a strip of superficial
musculoaponeurotic system (SMAS) at the junction of the fixed and mobile
SMAS.
ANATOMY
■ Relevant anatomy is the recognition of the difference between fixed and
mobile SMAS. The location of this intersection varies between patients but is
roughly found on a diagonal line connected the earlobe to the lateral canthus
(FIG 1).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Beyond usual history and physical findings to indicate a patient for a face and
neck lift, the specific question to note is whether the patient has a full, wide
face or a thinner face that could benefit from SMAS being “stacked” on itself
to add volume.
■ The authors refrain from providing specific guidelines or measurements as the
ultimate decision is a function of the aesthetic sense of the surgeon.
SURGICAL MANAGEMENT
■ Surgery should be performed in an accredited operating room.
■ SMASectomy can be performed under local anesthesia with or without
sedation or general anesthesia.
Preoperative Planning

■ Consideration should be given as to whether the surgeon believes the patient
will benefit from an SMASectomy (removal of tissue) or a plication
(imbrication of tissue); however, this decision can also be made
intraoperatively.
■ The rest of the surgery is planned like any other biplanar face-lift.
Positioning
■ The patient is supine on the procedure table.
■ Usually, the head of bed is slightly elevated.
■ The authors prefer to sit for maximum stability.
Approach
■ An incision pattern is chosen (either preauricular or intratragal).
■ The skin is elevated in the subcutaneous plane after infiltration with local
anesthesia with epinephrine.
■ The SMAS is identified, and a plan is created.
FIG 1 • Although the junction of the fixed and mobile
SMAS may vary from patient to patient, it is generally
found near a line from the lobule of the ear to the lateral
canthus.

T E C H N I Q U E S
■ SMASectomy
■ The area of superficial musculoaponeurotic system (SMAS) to be removed
is best visualized after performing a lateral platysmaplasty.1
■ A lateral platysmaplasty is performed by elevating the SMAS/platysma flap
just in front of the sternocleidomastoid (SCM) muscle.
■ The author prefers to do this with a Bovie electrocautery, though any
means is acceptable.
■ The flap should be elevated to allow the SMAS/platysma to freely rotate in
a chosen vector cephalad and lateral to the surgeon’s desires.
■ The flap is then fixed to mastoid fascia with 3-0 PDS sutures and can be
reinforced to the fascia of the SCM.
■ Once this flap is secured, a bunching of tissue can be noted, usually near the
angle of the mandible.
■ This bunching is the most proximal component of the SMAS to be removed
as a dog-ear, which is in effect the SMASectomy (TECH FIG 1A).
■ Scissors can be used to spread beneath the SMAS to safely develop the
plane over the parotid fascia.
■ Care must be taken to protect the facial nerve until the distal portion of
parotid fascia.
■ To achieve a midface elevation, the SMASectomy must be carried out to the
midface, beyond the parotid fascia (TECH FIG 1B).
■ The edges of fixed and mobile SMAS are reapproximated using buried
interrupted 3-0 PDS sutures (TECH FIG 1C).
■ The SMAS is trimmed of irregularities.
■ The skin flap is redraped, trimmed, and sewn under no tension.
■ The authors prefer to leave drains, but this understandably varies between
surgeons.

TECH FIG 1 • A. Tissue bunching near the angle of
the mandible indicates a common starting point for the
SMASectomy. B. The SMASectomy is carried
anteriorly past the parotid tail to achieve midface
elevation. C. The edges of the SMAS are
reapproximated.
PEARLS AND PITFALLS
Technique
■ Doing lateral platysmaplasty prior to SMASectomy will set up the
exact starting point for the SMASectomy.
Facial
nerve
■ Facial nerve is protected over the parotid gland. Beyond the parotid
gland, it is important to note the depth of your excision and take extra
caution.

Suturing
■ Always bury knots to avoid seeing or feeling bumps through the facial
flap.
■ Always check the facial surface after each SMAS suture. If too much
or too little movement, remove suture and replace.
POSTOPERATIVE CARE
■ Cool packs are also used to reduce swelling.
■ Strict blood pressure control is enforced postoperatively.
■ Patients are instructed to avoid lifting or bending for 2 weeks.
■ The authors prefer to place patients in a face and/or neck compressive dressing
for at least 4 to 6 hours after surgery but up to 24 hours.
■ Drains are usually removed at 48 hours.
■ All patients are seen by the surgeon the following morning and then again
multiple times over the following week.
■ Sutures are usually removed at 1 week.
OUTCOMES
■ SMASectomy can achieve excellent jawline contour and midface elevation.
■ The amount of midface elevation is dependent on how high the SMAS is
operated on during the procedure.
COMPLICATIONS
■ Bruising and hematoma are the most common complications.
■ Hematomas in males are twice as common as they are in females.
■ Facial nerve injury should be exceedingly rare with these techniques and
should only be temporary when observed.
REFERENCE
1. Baker DC. Lateral SMASectomy, plication and short scar facelifts: indications
and techniques. Clin Plast Surg. 2008;35(4):533–550, vi.
doi:10.1016/j.cps.2008.06.003.

46
CHAPTER
Indications and Technique
for Deep Plane Face-lift
Thomas A. Mustoe
DEFINITION
■ Facial aging is caused by relaxation and descent of the deeper layers of the
face, including the subcutaneous fat, and the underlying superficial fascial
layer that encompasses the superficial muscles as well as the skin.
■ Because these layers are closely adherent, the deep plane face-lift recognizes
the principles that in order to properly correct the relaxation and descent, all
layers must be addressed with complete release, even tension, and avoidance of
excess tension on the skin to achieve reliably a natural appearance.
ANATOMY
■ The critical anatomy to understand is the makeup of the superficial
musculoaponeurotic system (SMAS) or fascia, which is a thin fascia layer just
deep to the subcutaneous fat. It is contiguous with the platysma muscle and is
continuous to the inferior surface of the orbicularis oculi muscle.
■ There are retaining ligaments that are collagen attachments passing from the
SMAS to the deeper tissues, which in the midface region are just lateral to the
origin of the zygomaticus major muscle (the zygomatic retaining ligaments)
and in the region of the superior most portion of the platysma muscle
(masseteric retaining ligaments).
■ In the neck, the retaining ligaments or deep attachments are along the posterior
border of the SMAS, just anterior to the greater auricular nerve, and run
obliquely down the neck where they have attachments to the
sternocleidomastoid muscle. There are also attachments in the region of the
anteroinferior portion of the parotid gland.
■ For the SMAS to be completely mobile, all of these attachments must be

divided.1
■ Immediately underneath the SMAS are the branches to the facial nerve.
■ In the neck, the cervical branch comes out from the parotid and up into the
platysma anterior to the retaining ligaments at the anteroinferior edge of the
platysma and can be safely preserved while fully releasing the SMAS.1
■ The marginal mandibular branch is well protected underneath the masseteric
fascia.
■ The major buccal branch runs just above the Stensen duct and is underneath
the very thin deep fascia overlying the buccal fat pad, which is more easily
penetrated, meaning that nerve is less well protected but easily seen.
■ The zygomatic branch runs underneath the zygomaticus major muscle and
thus is protected.
■ Finally, the frontal branch becomes more superficial above the zygomatic arch.
Dividing the SMAS at the level of the arch protects the frontal branch while
still allowing elevation of the malar fat pad with the SMAS if the dissection
extends below the inferior edge of the orbicularis oculi muscle to preserve
innervation to that muscle.
NATURAL HISTORY
■ The aging process with relaxation of the SMAS and fat as well as overlying
skin is progressive, with loss of collagen fibers and increasing viscoelasticity of
the overlying skin.2,3
■ However, the aging process is genetically highly variable. In patients of Asian
background, for instance, the skin is somewhat thicker, and the retaining
ligaments are stronger, and so development of jowls and malar descent is less
pronounced with age.
■ In addition, there is loss of facial fat with age particularly around the mouth,
and to a variable degree in the cheeks, so that facial rejuvenation usually
includes some degree of volume restoration, particularly around the mouth.
■ Fat also accumulates in the submental region, and in some patients (small
percentage), a true excess accumulates in the jowl region, which when
combined with loss of fat in the prejowl perioral area accentuates the loss of a
firm jawline.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The characteristic features of the aging face are development of jowls, malar
descent, loss of facial fat, accumulation of submental fat, relaxation of the

orbicularis muscle and overlying skin, and relaxation of the platysma muscle
and overlying skin.
■ In many patients, the relaxation of tissues is more pronounced in one region
than another.
NONOPERATIVE MANAGEMENT
■ Although nonoperative management of the aging face with fillers and fat, as
well as noninvasive and minimally invasive techniques using laser, focused
ultrasound, and radiofrequency, has increased greatly, there are limitations.
■ More advanced relaxation of the skin and deeper tissues can only be corrected
with a face-lift.
SURGICAL MANAGEMENT
■ The author performs a deep plane rhytidectomy in all patients who are
candidates for face-lift, even those with changes limited to the neck and/or
jowls, without significant changes in the midface.
■ What does vary is the extent of the dissection. In patients who are mainly
concerned about the neck and jowls with early aging changes, undermining and
release of the SMAS in the midface can be quite limited without extending out
to the masseteric and zygomatic retaining ligaments, but a deep plane
dissection is still done in the neck.
■ The incisions can also be limited with a postauricular incision limited to the
sulcus, and the preauricular retrotragal incision also limited. With a more
limited dissection, the recovery period is accelerated.
■ Although the submental fat, including subplatysmal fat, and superficial release
of skin attachments is always addressed with fine handheld cannulas through
two or three 2-mm incisions, as the author’s experience has increased, a
submental incision is never done except in the occasional patient 6 months
postoperatively who is bothered by persistent platysmal bands in the
postoperative period.
■ The main steps of the procedure are as follows:
■ Make a retrotragal incision with superior and postauricular extensions.
■ Raise a superficial skin flap, which is elevated above the zygomatic arch to
the lateral border of the orbicularis oculi muscle, and below that over the
lateral cheek over several centimeters.
■ Incise the SMAS at the level of the zygomatic arch, extending out to the
orbicularis oculi muscle and in front of the ear. A portion of the SMAS is then

elevated lateral to the retaining ligaments.
■ The postauricular dissection is carried out deep to the superficial fascia over
the investing fascia of the sternocleidomastoid muscle.
■ The sub-SMAS dissection is then extended in a wide arc in front of and
inferior to the ear until all of the retaining ligaments are released, and the
SMAS slides easily along with the overlying skin.
■ Deep sutures are placed anchoring and repositioning the SMAS.
■ Excess skin and SMAS are cut, and final skin suturing is complete.
■ The neck is addressed as described above with blunt undermining and
liposuction with the use of fine cannulas.
■ The other side is performed in identical fashion.
Preoperative Planning
■ The patient should be medically cleared for surgery, including a recent normal
electrocardiogram.
■ If the electrocardiogram is abnormal, consideration of specific cardiac
clearance may be indicated including other studies such as a stress test.
■ Hypertension must be well controlled, and clonidine is routinely given as a
preoperative dose of 0.1 to 0.3 mg to minimize postoperative hypertension,
which is a major risk factor for postoperative hematoma.
■ Smoking must be stopped at least 3 weeks prior to surgery, and if there is any
concern about smoking cessation, strong consideration should be given to
measuring nicotine levels.
■ The risks are discussed prior to surgery including hematoma, infection, skin
necrosis, facial nerve injury, and the limitations of loss of elasticity, which
means that some relaxation of tissues is inevitable in the postoperative period
and must be viewed as a limitation rather than a failure of the procedure.
Positioning
■ Positioning is straightforward in the supine position, with the head slightly
elevated (10 degrees is sufficient) to enhance venous return.
■ The head should be placed on a flat surface for easy turning.
Approach
■ Usually, a full-length incision as described below is used, but when aging
changes are early, the incision can be limited behind the ear to the postauricular
sulcus and in front of the ear to the level of the superior edge of the tragus and

to the top of the ear without extending underneath the sideburn.
T E C H N I Q U E S
■ Modified Deep Plane Rhytidectomy with Midface
Elevation and Elimination of Submental Incision
Markings and Incisions
■ The markings are consistent whether male or female and can be shortened
for short scar technique or face-lifts with more limited dissection and less
tissue rearrangement.
■ The essential steps are an extension above the helix into the hair directly
vertically; a V-shaped extension along the sideburn, stopping at the anterior
point where the hair is no longer growing down to hide the incision; a
retrotragal incision, taking care to have sharp angles rather than curves at the
superior edge and incision of the tragus; and a postauricular incision that
curves up high on the mastoid and into the hairline at approximately the
superior edge of the tragus (TECH FIG 1A).
■ In a subcutaneous plane, the cheek skin is elevated to the lateral edge of the
orbicularis oculi muscle (TECH FIG 1B).
■ An incision is made through the SMAS at the level of the zygomatic arch
(high enough to allow the midface to come up as part of the SMAS) and in
front of the ear, and the SMAS elevation is begun extending to the extent of
the previous subcutaneous dissection (TECH FIG 1C).
SMAS Dissection
■ The dissection is begun behind the ear below the level of the superficial
fascia and further inferior with exposure of the vestigial postauricular muscle,
the greater auricular nerve, and the investing fascia of the
sternocleidomastoid muscle (TECH FIG 2A).
■ Sharp dissection is carried around the ear lobule, connecting the anterior
sub-SMAS dissection with the posterior dissection and taking care to elevate
the entire SMAS, which extends to the greater auricular nerve.
■ The parotid fascia is exposed, and the SMAS is clearly demarcated by its
dense collagen content (TECH FIG 2B,C).

■ The sub-SMAS dissection is then extended beyond the parotid gland
anteriorly to expose the masseteric fascia. This is easily done and is avascular
except for an occasional perforating vessel (TECH FIG 2D,E).
TECH FIG 1 • A. Skin markings for face-lift. B.
Subcutaneous dissection over the cheek. C. Initial
SMAS elevation over the cheek.

Greater auricular nerve Sternocleido Mastoid fascia Parotid glans SMAS Jugulodigastic lympf nodes and fat SGM Parotid gland Posterior edge of SMAS - Greater auricular nerve Masseteric fascia Parotid fascia

TECH FIG 2 • A. Initial dissection in the neck with
exposure of greater auricular nerve. B. Initial elevation
of SMAS over parotid and extending posteriorly. C.
Exposure of parotid fascia with transition zone
between parotid and SCM. D. Completion of
dissection over parotid with exposure of masseteric
fascia. E. Inferior view of completion of dissection over
parotid extending posteriorly. The arrow is indicating
the retaining ligament at the anterior border of the

parotid gland. F. Extension of sub-SMAS dissection
over the midface with exposure of zygomaticus major
and inferior edge of orbicularis oculi. G. Extension of
sub-SMAS dissection in the neck with inferior release
of posterior edge of SMAS and exposure of external
jugular vein and inferior course of greater auricular
nerve. H. Another view of extension of sub-SMAS
dissection in the neck with visible collagen
attachments (retaining ligaments) at anteroinferior
edge of the parotid. I. Exposure of cervical branch of
facial nerve coming out of anteroinferior edge of
parotid and coursing superficially up into deep surface
of platysma.
■ The dissection is carried superiorly over the midface, with release of the
zygomatic and masseteric retaining ligaments, exposure of the zygomaticus
major muscle, and extending under the inferior edge of the orbicularis oculi
muscle so that elevation of the SMAS includes the cheek mass and tightens
the orbicularis muscle (TECH FIG 1F).
■ The dissection is then extended beyond the anteroinferior edge of the parotid
with release of the neck retaining ligaments, and exposure of the external
jugular vein, and inferior path of the greater auricular nerve (TECH FIG
1G,H).
■ With release of the attachments beyond the parotid that allow full
mobilization of the neck, the cervical branch of the facial nerve can
sometimes be seen coursing up into the platysma (TECH FIG 1I).
■ Inferiorly, the dissection is variable, depending on the extent of neck
mobilization, but generally goes to where the greater auricular nerve
crosses the posterior border of the SCM and over the investing fascia of the
entire SCM posteriorly.
Closure and Completion
■ The closure begins with placing two 3-0 PDS sutures from the midface area
(above the zygomaticus major into inferior edge of orbicularis muscle and
then back to temple) (TECH FIG 3A).
■ Next, the corner of the SMAS is sutured in a posterosuperior direction into

deep tissues just above the anterior helical rim (TECH FIG 3B,C).
■ The skin is rotated superiorly and, depending on skin laxity, may have a
more posterior vector than the SMAS that is rotated primarily in a superior
direction.
■ Excess skin is excised avoiding a dog-ear at the anterior edge of the
sideburn, and closure is begun (TECH FIG 3D).
■ Posteriorly, two or more sutures are placed from the SMAS-skin composite
flap up to the mastoid (TECH FIG 3E).

TECH FIG 3 • A. Placement of suture above
zygomaticus major into inferior edge of orbicularis and

into fatty tissues of the cheek mass. B. Suture placed
into superolateral corner of elevated SMAS, which will
be elevated in a primarily superior vector. C. Suture
from corner of SMAS being tied down to deep tissues
at superoanterior edge of the ear. D. Closure at
sideburn after trimming of excess skin, which has
been rotated in a superoposterior direction. E.
Posterior suture behind the ear grasping SMAS as
part of SMAS-skin composite layer, which will be tied
posterosuperiorly to mastoid fascia. F. View after
suturing of SMAS is complete and initiation of
postauricular suture line along the hairline with
separate cut into the hairline. G. Trimming skin
anteriorly along helix and tragus. Skin is under no
tension. H. Completed skin closure. I. Submental
liposuction being performed after the first side of the
face is closed, through stab incision.
■ Skin closure is initiated posteriorly. The length of the incisions is controlled
by cuts into the hair with superior rotation and an extension of variable length
along the edge of the hairline (TECH FIG 3F).
■ In selected patients with minimal neck laxity, a short scar technique is
utilized by confining the scar to the postauricular sulcus and accepting
some pleating.
■ The skin is then trimmed and defatted along the tragus, and the posterior
skin is excised (TECH FIG 3G,H).
■ Submental liposuction is carried out with a handheld fine cannula, and
subplatysmal liposuction is also performed when there is significant
subplatysmal fat.
■ The cannula is used to undermine the entire neck down to the sternal notch
and separate skin-platysma attachments. This step is always performed
even if there is no submental fat (TECH FIG 3I).
■ The same procedure is then carried out on the contralateral neck and face.

PEARLS AND PITFALLS
Skin
elevation
over the
cheek
■ When there are significant crow’s-feet, extending dissection over
orbicularis to orbital rim will reduce wrinkles.
SMAS
dissection,
midface
■ In patients with minimal midface descent, the dissection can be
limited to the posterior edge of the zygoma to minimize swelling and
avoid more dangerous parts of the dissection.
SMAS
dissection
of the neck
■ The extent of the dissection is dictated by the amount of neck laxity,
but it is important to capture all of SMAS in the region of the ear
lobule to aid in closure.
Hemostasis
■ It is important to get hemostasis several times prior to closure to
minimize hematoma risk.
Closure
■ All tension should be borne through the SMAS. Skin closure should
be absolutely tension-free.
POSTOPERATIVE CARE
■ Drains can be used, though the author does not find them necessary. The area
of potential concern for the accumulation of fluid is behind the ear, and this
problem is minimized by the use of several sutures behind the ear from the
neck flap to the mastoid area to help in fixation and minimize dead space (ie,
they serve as quilting sutures).
■ The head is elevated with an extra pillow or by placing a cushion underneath
the mattress at the head of the bed.
■ The head is wrapped overnight as a convenience to absorb fluid and blood
leaking through the incision line, and then the patient is instructed to shampoo
and wash the area. The incisions have ointment applied to them twice daily
until the sutures are removed 7 days after surgery. The preauricular sutures are
absorbable.
OUTCOMES
■ The final outcome is about 3 months after surgery, when virtually all swelling
is resolved and tissue relaxation has occurred. The aging process of course
continues but at its normal, gradual pace.

■ An estimate to patients is that the tissue relaxation that existed preoperatively
in the neck and face will be corrected by 80%, which of course varies
depending on the intrinsic viscoelastic properties of the individual patient’s
skin and SMAS.
■ Some patients (5% to 10%, skewed toward older patients with more advanced
tissue relaxation and greater viscoelastic properties) will not be fully satisfied
with the results and elect to undergo an early second face-lift (less than 2 years
after the first one).3
COMPLICATIONS
■ Hematoma is the most common complication and occurs about 1% of the time,
virtually always within the first 24 hours and usually due to labile blood
pressure in the postoperative period that is more common in the elderly, and is
minimized but not completely prevented by the use of clonidine preoperatively.
■ Infection is very rare and has been localized to an area of wound breakdown.
This has been minimized by postoperative wound hygiene.
■ Marginal skin necrosis behind the ear has been a rare occurrence, easily
treated with local wound care, due to the enhanced blood supply of the
dissection deep to the superficial fascia and preservation of SMAS skin
attachments (composite dissection).
■ Although the facial nerve is at risk, I have had no permanent injuries.
Neuropraxia of the cervical branch of the facial nerve (pseudomarginal
mandibular paralysis) has occurred in 1 of 200 patients earlier in my
experience but with much less frequency in the last 10 years with full
understanding of the anatomy of the cervical branch. I have had one incidence
of neuropraxia of the buccal branch due to thermal injury and one case of
frontal branch neuropraxia in my personal series of more than 1500 cases. All
cases of neuropraxia have resolved within 2 to 3 months.
REFERENCES
1. Saulis AS, Lautenschlager EP, Mustoe TA. Biomechanical and viscoelastic
properties of skin, SMAS, and composite flaps as they pertain to rhytidectomy.
Plast Reconstr Surg. 2002;110:590-598.
2. Mustoe TA, Rawlani V, Zimmerman H. Modified deep plane rhytidectomy
with lateral approach to the neck: an alternative to submental incision and
dissection. Plast Reconstr Surg. 2011;127:357-370.
3. Rawlani V, Mustoe TA. The staged facelift: addressing the biomechanical

limitations of the primary facelift. Plast Reconstr Surg. 2012; 130(6):1305-
1314.

47
CHAPTERIsolated Neck Lift
Alan Matarasso and Sammy Sinno
DEFINITION
■ The appearance of neck aging can occur as early as the late 30s.
■ Differences in the quality of skin above and below the mandible can contribute
to neck aging independently. The neck changes may occur prior to facial aging,
which can be particularly disconcerting to patients.
■ Recent advances allow the neck to be rejuvenated in a spectrum of methods
that include neck lift, minimally invasive surgical procedures (submentalplasty
and liposuction), and nonsurgical methods depending upon the indications and
goals.
■ The most comprehensive treatment of the aging neck requires an isolated neck
lift.
ANATOMY
■ The youthful neck is characterized by a distinct mandibular border with the
relative absence of jowls, subhyoid depression, visible thyroid cartilage bulge,
distinct border to the sternocleidomastoid (SCM) muscle, and a cervicomental
angle between 105 and 120 degrees (FIG 1).1
■ The aging neck is manifested by attenuation of retaining ligaments from the
medial platysma, which leads to platysma edge shortening and banding.
Additionally, there can be accentuation of preplatysmal or subplatysmal fat,
laxity of skin with texture changes, hypertrophy of the digastric muscles, and
hypertrophied and/or ptotic submandibular glands.

FIG 1 • Relevant neck anatomy.
■ Treatment options vary based on individualized patient assessment of key
anatomic landmarks and treatment goals.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Ideal candidates for an isolated neck surgery procedure are those who want to
address neck rejuvenation without the need to concomitantly treat the midface
with a face-lift.
■ During the initial consultation, it is essential to evaluate the patient’s goals and
expectations and to reconcile them with the surgeon’s evaluation and treatment
plan. Furthermore, it is important to discuss relevant procedures that may play
a role in enhancing the result of neck surgery, such as chin augmentation,
buccal fat pad removal, salivary gland treatment, skin quality enhancement, or
midface treatments.2,3
■ When evaluating the patient and discussing the surgical options, the patient
should be educated on the algorithm to discuss the surgical treatments available
to treat the various soft tissue components of the aging neck.
■ More advanced cases of the aging neck are treated with a neck lift that
encompasses liposuction as indicated and submentalplasty along with wide

skin flap undermining, elevation, and skin excision.
■ Less severe cases can be treated with minimally invasive surgical procedures,
including liposuction for fatty necks or submentalplasty that applies liposuction
and midline platysma muscle treatment.
■ Nonsurgical methods including Ultherapy (Ulthera, Mesa, AZ), among other
“tightening” energy-based systems, Kybella (Allergan, Weston, FL), and Botox
(Allergan, Weston, FL) can be used to improve the appearance of the neck
skin, fat, and muscle, respectively, albeit with a different result than a surgical
procedure.
IMAGING
■ No imaging other than routine preoperative clearance imaging is needed.
SURGICAL MANAGEMENT: NECK LIFT
Preoperative Planning
■ A traditional neck lift encompasses improvement in the area from the jawline
down to the clavicle.
■ The quality and quantity of skin are noted.
■ If patients desire improvement in the jowls as well as the neck, an “extended”
neck lift can be considered, which addresses the same areas as neck surgery
and incorporates improvement in the jowl region. This is accomplished by
extending the neck lift incision slightly cephalically toward the tragus, which
allows jawline skin advancement, SMAS tightening, and jowl liposuction.
Positioning
■ The patient is placed in the supine position for this procedure.
Approach
■ The isolated neck lift procedure is performed under general anesthesia
administered by an anesthesiologist.
■ Perioperative antibiotics are used, and TED stockings or sequential
compression devices are placed for the entirety of the case.
■ Antibiotic ointment is placed in the nostrils and cotton soaked in Betadine is
placed in each ear canal.

T E C H N I Q U E S
■ Isolated Neck Lift
■ The surgical field is infiltrated with local anesthetic solution containing 1 mL
of 1:1000 epinephrine, 100 mL of 1% lidocaine, and 200 mL of normal
saline.
■ After waiting for the effect of the local anesthetic, we begin with liposuction
of the subcutaneous fat as indicated. A 2.4-mm Mercedes cannula is used for
the neck liposuction, and a 1-8 mm Mercedes cannula is used for the jowl
area. Additional liposuction is conducted with a spatula tip cannula.
■ After completion of liposuction, a submental incision is made just above or
below the natural submental crease if treatment of the platysmal muscle is
indicated (submentalplasty).
■ Wide undermining of the neck skin is performed with the aid of a lighted
fiber-optic retractor and the assistant placing countertraction on the skin.
■ Medial platysmal bands are identified. In patients who have loose redundant
or hypertrophic anterior platysmal bands, a strip of excess platysmal muscle
is excised.
■ After the platysmal band is resected, submuscular fat can be identified and
treated in patients who will benefit from a reduction. This is carried out by
directly excising small amounts of fat and melting the remainder with a ball
tip electrocautery.
■ Attention is then returned to the platysmal muscle. Various options for the
repair of the midline platysmal muscle repair have been described.4 The
muscle is approximated with interrupted 3-0 Mersilene (Ethicon, San
Lorenzo, PR) sutures (TECH FIG 1A).
■ Once the anterior neck treatment is completed, the patient’s head is turned
and the surgery continues on the right side of the neck where the incisions are
made. The skin flaps are incised and undermined under direct vision sharply
and with face-lift scissors. The neck is completely undermined from side to
side by connecting the dissection with the prior submental plane.
■ The lateral border of the platysma is located and evaluated.
■ If the platysma is lax or redundant, it is undermined with sharp and blunt
dissection at least 3 to 4 cm below the angle of the mandible, back cut, and

sutured to the sternocleidomastoid (SCM) fascia with 3-0 Mersilene suture
(Ethicon, San Lorenzo, PR) while avoiding placing excessive tension on
the midline repair.
■ In other cases, the platysma is plicated to the SCM at 3 to 4 points
including the lower superficial musculoaponeurotic system (SMAS) for
jowl improvement (TECH FIG 1B).
TECH FIG 1 • A. Plication of medial platysma borders.
B. Suturing of the lateral border of the platysma to
sternocleidomastoid fascia.
■ Final hemostasis is achieved by electrocautery, and Jackson-Pratt drains
(Cardinal Health, Dublin, OH) soaked in Betadine are placed and brought out
through the wound and sutured.
■ Excess skin is elevated, advanced, redraped, and excised so as to optimize
the result and preserve the integrity of the hairline.
■ The hair-bearing region is closed with staples, and the area between the hair-
bearing region and postauricular incision is closed with half-buried
absorbable sutures.
■ The postauricular crease is closed with 3-0 nylon sutures; the lower
preauricular area, if opened for an extended neck lift, is closed with a 5-0
nylon suture.
■ The submental region is the last area inspected for hemostasis after closing
both sides of the neck incision. The submental incision is closed with a
subcuticular 5-0 Prolene and 5-0 interrupted nylon (Ethicon, San Lorenzo,
PR).

■ Antibiotic ointment is placed on the wounds. A three-layer face-lift dressing
consisting of gauze and SurgiNet (Won Industry, Gyeonggi-do, Korea) is
placed on the patient.
PEARLS AND PITFALLS
Neck
aging
■ Occurs in conjunction and often more rapidly or can be more apparent
than facial aging.
■ It is a result of changes in the skin, platysma, and fat of the neck.
Other structures such as the digastric muscle and submandibular
glands can also contribute to neck aging.
■ Nonsurgical treatments offer improvement when directed at the
appropriate layer of tissue.
■ Liposuction and submentalplasty can produce significant results in
patients with appropriate skin.
■ The most comprehensive treatment of the aging neck is a surgical
neck lift.
Medial
platysma
treatment
■ After any platysma redundancy is removed, it is repaired in the
midline, which, when completed, resembles the Eiffel Tower.
■ The platysma is back cut at the level of the cricoid cartilage.
■ The hyoid fascia can be incorporated as a potential means of reducing
recurrent platysma banding, which can be a formidable issue.
Lateral
platysma
treatment
■ If the platysma is lax or redundant, it is undermined at least 3 to 4 cm
below the angle of the mandible, back cut, and sutured to the SCM
fascia.
■ In other cases, the platysma is plicated to the SCM at three points
including the lower SMAS for jowl improvement.
POSTOPERATIVE CARE
■ Attempts should be made to keep the neck extended in a semisniffing position
to avoid skin flap ischemia.
■ Dressing and drains are removed on the first postoperative day, and suture
lines are treated with antibiotic ointment. The drain tracts are “milked” of
excess fluid.
■ Staples and sutures are removed within the first 10 days.
■ Return to normal activities usually occurs progressively from 2 to 6 weeks.

During that time, patients should avoid excessive sun exposure or nonsurgical
facial treatments.
■ Firm scars are treated with massage and occasionally ultrasound therapy, as
these tend to resolve with time.
OUTCOMES
■ Isolated surgical treatment for the aging neck is a viable option for a subset of
patients who either do not require or may not wish to have a concurrent
treatment of the midface. Optimal aesthetic results can be achieved by tailoring
the procedure to the underlying anatomy and expectations of the patient (FIG
2). Ultimately, judicious patient selection and education will provide for the
greatest satisfaction in patients undergoing isolated neck lift surgery.
COMPLICATIONS
■ Complications can vary depending on the extent of the procedure that is
performed. Most frequent complications include seroma and hematoma.
■ Although skin necrosis is infrequent, it can be a significant complication when
it occurs. We use dimethyl sulfoxide or nitroglycerin ointment for these issues.
■ Facial nerve injuries are less common than in face-lifts but can occur. Most
often, the marginal mandibular branch and the cervical branch are placed at
risk during the procedure if the overlying platysma muscle is breached; this is
more frequent in secondary surgery. It has a tendency to occur when defatting
just lateral to the submental incision caudal to the mandible.
FIG 2 • Preoperative (A) and postoperative (B) views of
patient who underwent isolated neck lift. Note the
drastic improvement in cervical contour.
REFERENCES
1. Matarasso A. Managing the components of the aging neck: from liposuction
to submentalplasty, to neck lift. Clin Plast Surg. 2014;41(1):85-98.
2. de Castro CC, Aboudib JH Jr, Roxo AC. Updating the concepts on neck lift
and lower third of the face. Plast Reconstr Surg. 2012;130(1):199-205.
3. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg.
2014;134(6):1173-1183.

4. de Souza Pinto EB. Importance of cervicomental complex treatment in
rhytidoplasty. Aesthetic Plastic Surg. 1981;5(1):69-75.

48
CHAPTERSubplatysmal Neck Lifting
Dino Elyassnia and Timothy Marten
DEFINITION
■ A well-contoured neck is an artistic imperative to an attractive appearance.
■ A good neckline conveys a sense of youth, health, and vitality and lends an
appearance of sensuality and beauty (FIG 1).
■ Neck improvement is of high importance to almost every patient seeking facial
rejuvenation, and the results of our face-lift procedures are largely judged by
the outcome of the neck.
■ Traditional neck lift techniques do not adequately address many aspects of
aging in the submental region, and it is not enough in most situations to limit
treatment to preplatysmal lipectomy alone or with postauricular skin excision.
Subplatysmal problems will contribute significantly to aging and require
treatment in most cases if optimal results are to be obtained (FIG 2).
ANATOMY
■ It is critical to understand the distribution of fat in the cervicosubmental
region. Cervical fat is present in three distinct layers—preplatysmal,
subplatysmal, and deep interdigastric fat.
■ Subplatysmal fat will be evident as a centrally situated triangular shaped fat
pad with its base lying at the hyoid and tip near the mentum (see TECH FIG
1A). The two sides of the triangle will lie along each digastric muscle. Deeper
interdigastric fat is situated in between and deep to the plane tangent to the
anterior bellies of the digastric muscles.
■ The submandibular gland (SMG) is a lobulated, pink to tan-colored structure
covered by a smooth capsule. It sits in confined space with the anterior belly of
the digastric muscle lying medial, the mandibular border lateral, and the

mylohyoid muscle deep (see TECH FIG 2A). The superficial and deep lobes
are separated by the mylohyoid muscle.
■ Important neurovascular structures will all lie extracapsular to the gland, so
intracapsular dissection is safe. The marginal mandibular nerve will lie
superior and lateral to the SMG. The facial artery and vein will lie in close
proximity with the vein passing superficial and the artery deep to the gland. An
intraglandular perforator artery arising from a branch of the facial artery will
be found within the posterior portion of the superficial lobe in a central
location.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Success or failure in treating the neck lies in the ability of the surgeon to
identify the anatomic basis of patient problems and to form a sound surgical
plan for their correction.
■ A focused history should include all previous cosmetic treatments for the neck
including previous neck lift or noninvasive treatments like Thermage, Ulthera,
Kybella, etc.
■ Obtain any history of dry mouth or Sjogren syndrome as this is a relative
contraindication to reduction of the prominent SMG.
■ The cervicosubmental region of each patient must be carefully examined both
at rest and during platysmal activation to distinguish between soft adynamic
cervical bands and dynamic hard bands. This is best accomplished by asking
the patient to “push the jaw forward and tighten the neck.” Soft bands change
little during activation and are predominantly a problem of loose skin or
platysmal laxity, whereas hard bands become tight or exaggerated and indicate
a problem of platysma hyperfunction (FIG 3).
■ Evaluating the location of fat in the neck is also made easier by palpating the
neck with and without platysmal activation. Fat lying predominantly in a
preplatysmal position will generally feel “soft” and remain in the examiner’s
grasp upon platysmal activation. However, fat in a subplatysmal location will
have a firmer feel and will tend to be pulled superiorly out of the examiner’s
grasp when the platysma is contracted (FIG 4).
■ SMGs are usually palpable as firm, smooth, discrete, mobile masses in the
lateral submental triangle. Large glands requiring treatment are most readily
visible in the secondary face-lift patient who has had prior aggressive
lipectomy; however, they can be more hidden in the primary patient with a full
neck and must be palpated to ascertain their size and need for treatment (FIG

5).
FIG 1 • Patient seen before and after neck lift. A good
neckline conveys a sense of youth, health, fitness,
sensuality, and beauty. The patient has also undergone
a face-lift, foreheadplasty, eyelid surgery, and fat
injections.
FIG 2 • Patient seen before and after neck lift. A careful
evaluation of the preoperative photo shows platysmal
laxity, excess subplatysmal fat, large submandibular
glands, and digastric muscle hypertrophy. Removing
subcutaneous fat and tightening skin over these
anatomic problems do not correct them and cannot
produce the type of improvement shown here.
■ A small subgroup of patients will present with large, bulky anterior bellies of
their digastric muscles that are evident on visual exam as linear paramedian
submental fullness. These are most often seen in the secondary face-lift patient

who has had prior aggressive lipectomy (FIG 6). However, in the typical
primary patient, it is difficult to assess their size; thus, the decision to treat
these muscles is usually made intraoperatively.
IMAGING
■ Typically, radiographs are not necessary in facial rejuvenation surgery.
■ All patients should have standardized photographs taken preoperatively, and
any markings made preoperatively on patients should be photographed as well.
■ These photos should be used intraoperatively to help guide treatment.
NONOPERATIVE MANAGEMENT
■ Some limited options exist to treat isolated problems in the neck.
■ Neuromodulators can be used to treat dynamic platysmal bands. Some have
reported success using neuromodulators to partially reduce the size of SMGs,
but results have been mixed at best.
■ Deoxycholic acid (Kybella) is an injectable medication recently approved for
reduction of submental fat. Also, CoolSculpting has been approved for the
same treatment. At this point, it is unclear if these treatments are only affecting
the subcutaneous fat or also having an impact on subplatysmal fat. Significant
reduction of subcutaneous fat is likely not appropriate for most patients in the
typical face and neck lift age group. Thus, like submental liposuction, use of
these newer treatments should probably be limited to younger patients with
discrete subcutaneous fat excess in the submental area.
FIG 3 • Dynamic assessment of the cervicosubmental
region. The neck is examined in repose (A) and as the
platysma is contracted (B). Dynamic platysma muscle
irregularities are often referred to as “platysma bands.”
SURGICAL MANAGEMENT
■ Traditional neck lift techniques that focus on preplatysmal lipectomy, skin
excision, and platysmaplasty do not adequately address many aspects of aging
in the submental region. For many patients, subplatysmal fat accumulation,
SMG enlargement, and digastric muscle hypertrophy will contribute

significantly to the neck deformity and necessitate additional treatment.1,2
■ In all but the unusual or young patient, the majority of cervical fat accumulates
in a subplatysmal location, and little if any will need to be removed from the
preplatysmal layer. As patients age, fat stores generally shift from a
preplatysmal location to a subplatysmal one. The small amount of
subcutaneous fat present must be preserved to maintain a soft appearance to the
neck.
■ Large SMGs often contribute to the appearance of a full, “obtuse,” and
“lumpy” neck. Glands protruding inferiorly to a plane tangent to the ipsilateral
digastric and the mandibular border are likely to be problematic if excess
cervical fat is removed, platysma is tightened, and excess skin is removed.
These glands warrant reduction, and the protruding portion can be
incrementally resected through the submental incision.
FIG 4 • Assessing the location of cervicosubmental fat.
A. Submental “waddle” is grasped with the face and
neck in repose. B. The patient is then asked to activate
the platysma muscle. In this example, fat is pulled
superiorly from the examiner’s grasp indicating a
predominantly sub platysmal position. Fat lying
predominantly in a subcutaneous, preplatysmal position
would tend to remain within the examiner’s grasp when
the platysma is activated.

FIG 5 • Prominent submandibular glands.
Submandibular glands are usually evident as protruding
masses in the lateral submental triangle, lateral to the
anterior belly of the ipsilateral digastric muscle. A.
Patient with residual prominent submandibular gland
after face-lift and submental liposuction. His prior
procedure has made the prominent glands more
obvious. B. Patient with residual prominent
submandibular gland after “weekend neck lift.”
Aggressive resection of subcutaneous fat has exposed
the prominent gland.
■ The decision to perform SMG reduction should be made in conjunction with
the patient after appropriate discussion of the benefits versus risks. Patients
should know that the procedure may prolong submental induration and carries
a small but unlikely risk of bleeding, sialoma, salivary fistula, and dry mouth.
Patients should also be informed, however, that only the protruding portion is
excised and the majority of the gland is left in place.
■ Once treatment of subplatysmal fat and SMGs has been performed, the
anterior bellies of the digastric muscles should be evaluated. If the muscle
bellies are deemed to be prominent intraoperatively, subtotal digastric
myectomy should be performed. Failure to evaluate bulging of these muscles
after other modifications of the submental region can lead to an unexpected
and objectionable submental bulge postoperatively.

FIG 6 • Prominent anterior belly of the digastric muscle.
The patient has had prior face and neck lift. The
anterior belly of the digastric muscle can be seen as
objectionable linear paramedian fullness in the
submental region that spoils an otherwise good result.
Prominent digastric muscles often go unnoticed at the
time of the primary procedure due to the fact that they
are frequently hidden by cervical fat and lax platysma
muscle. (Courtesy of T. J. Marten, MD, FACS.)
Preoperative Planning
■ All patients undergo a preoperative physical evaluation, and patients with
significant medical problems must be cleared by their internist.
■ Patients are required to avoid all medications or supplements that increase the
risk of bleeding for 2 weeks prior to surgery.
■ The majority of our neck lifts are performed under deep sedation administered
by an anesthesiologist using a laryngeal mask airway (LMA). This allows the
patient to be heavily sedated but still maintains spontaneous breathing without
compromise of the airway.
■ The flexible LMA is also particularly useful in neck surgery. When this device
along with the breathing circuit is draped separately, it can be moved side to
side during surgery giving unobstructed access to the submental region.
Positioning
■ The patient is placed in the supine position, and a surgical scrub of the entire
scalp, face, ears, nose, neck, shoulders, and upper chest is performed with full-

strength (1:750) benzalkonium chloride. The patient’s head is then placed
through the opening of a split sheet leaving the entire head and neck region
unobstructed from the clavices up. No “turban” or “head wrap” is used to allow
total access.
■ In addition, the breathing circuit is draped separately from the patient as
described above.
Approach
■ Whether performing a neck lift alone or in combination with a face-lift, a
submental incision is used to access the subplatysmal space.
■ This incision should be placed posterior to the submental crease at a point
roughly half the distance between the mentum and hyoid. This is usually 1 to 2
cm posterior to the submental crease and measures 3 to 3.5 cm in length (FIG
7). It can be longer as long as it remains concealed under the mandible after
skin flaps are shifted superiorly.
■ Placing the incision posterior to the submental crease provides better access to
the submental region, prevents accentuating a “witch’s chin,” and still heals in
an inconspicuous scar.
FIG 7 • Plan for the submental incision. The submental
portion of the face-lift incision (solid line) should be
placed posterior to the submental crease (dotted line),
approximately one-half the distance between the
mentum and hyoid (arrows). Usually, this corresponds
to a point about 1.5 cm posterior to the submental
crease.

T E C H N I Q U E S
■ Skin Flap Elevation
■ First, sensory nerve blocks are performed using 0.25% bupivacaine with
epinephrine 1:200 000. This allows the neck to be injected with a reduced
degree of stimulation. This same solution is used to infiltrate the submental
incision.
■ Next, areas of subcutaneous dissection are generously infiltrated with 0.1%
lidocaine with epinephrine 1:1 000 000. Infiltration of the neck and
submental region is carried out with a 1.6-mm multihole blunt-tipped
infiltration cannula via a stab incision at the earlobe or jawline. No direct
infiltration is needed beneath the platysma if the subcutaneous tissues are
infiltrated generously.
■ The submental incision is made as described above (see Approach). The
surgeon should stand at the head of the table, and with the assistant retracting
the skin edges with a pair of 10-mm double-pronged skin hooks, skin
undermining is done using Metzenbaum scissors.
■ Subcutaneous dissection is carried out leaving the majority of preplatysmal
fat on the platysma surface so that fat excision and sculpting will be easier to
perform if needed at the end of the procedure. However, in contrast to the
face-lift skin flap, a slightly thicker layer of fat should be preserved on the
cervical skin flap to help avoid a hard or over-resected appearance to the
submental area.
■ A retrograde dissection should be made subcutaneously up onto the inferior
chin to ensure release of the submental crease and mandibular retaining
ligaments. Some bleeding should be expected with this necessary maneuver.
Subcutaneous dissection is continued inferiorly and laterally, and if an
“extended neck lift” or face lift is being performed, the submental dissection
will join the lateral skin flap dissection from a postauricular incision. If this
lateral dissection is being performed, care must be taken to avoid injury to the
greater auricular nerve.
■ Cervical Lipectomy

■ The focus of cervical lipectomy in most cases should be subplatysmal fat
(TECH FIG 1). The subplatysmal space is entered by incising the
superficially situated fascia between the medial platysma muscle borders
using a Metzenbaum scissors. A combination of blunt and sharp scissors
technique is used to isolate each muscle edge. The muscle edge is then
grasped and retracted by the assistant using a skin hook or Allis forceps.
■ The dissection is then carried laterally over the anterior belly of the digastric
muscle hugging the undersurface of the platysma in a relatively avascular
plane. Subplatysmal fat should be left on the deep surface of the neck and not
raised with the platysma flap to facilitate fat removal as it is technically more
difficult to resect fat from the undersurface of the platysma muscle.
■ The plane tangent to the anterior bellies of the digastric muscles with the
neck neutral or slightly flexed should be used as the landmark for
subplatysmal fat removal. All fat lying superficial to this plane should be
removed theoretically. If fat excision is made with the neck extended,
inadvertent overexcision can occur. Any fat situated deep to this plane
(interdigastric fat) should not be removed and the temptation to totally “clean
out” the deep cervical space resisted, or else a significant submental
depression will result.
TECH FIG 1 • Subplatysmal fat. A. Illustration of the
triangular shaped subplatysmal fat located in the

submental space with its tip near the mentum and
base at the hyoid bone. B. Cadaveric demonstration
of subplatysmal fat. The arrow is pointing to the
subplatysmal fat. The right and left borders of the
platysma have been elevated clearly displaying the
submental space. The subplatysmal fat pad can be
seen overlying the digastric muscles to the upper right
and left of the triangle with the hyoid bone at the base
of the triangle. C. Cadaveric demonstration of
subplatysmal fat. The two upper arrows point to the
anterior bellies of the right and left digastric muscles
and the lower arrow points to the subplatysmal fat
pad. In this photo, the fat pad has been reflected
downward but still attached at its base. The hyoid is
now visible along with the interdigastric space. There
is a small amount of deep cervical fat visible between
the two upper arrows. D. Intraoperative demonstration
of the subplatysmal fat specimen lying over the
submental space from which it was removed. The
patient’s chin is pointing superiorly with the neck to the
right of the photo.
■ If large SMGs or anterior bellies of the digastric muscles are present and it is
elected that they not be treated, subplatysmal fat removal should be more
conservative if accentuation of these problems is to be avoided. Also, fibrous
fat in the prehyoid region should not be arbitrarily removed, especially in
women, as accentuation and masculinization of the larynx can occur.
■ Subplatysmal fat should be removed incrementally by paying close attention
to the new contours created. This is typically carried out with an extended
Bovie and suction to evacuate smoke.
■ In almost all cases, it is best to leave the subcutaneous fat layer untouched
until all other maneuvers are completed including advancement of SMAS
flaps (if concomitant face-lift is being performed). Little if any subcutaneous
fat will require excision in most cases for patients in the typical face or neck

lift age group. When necessary, this can be completed under direct vision
using Metzenbaum scissors or a small suction cannula (“open” liposuction)
once correction of deep layer neck problems has been made and prior to
closure.
■ Submandibular Gland Reduction
■ Prominent SMGs will be encountered as subplatysmal dissection is carried
over the anterior belly of the digastric muscle. The prominent gland will
appear as a smooth pink to tan-colored mass covered by a smooth capsule
(TECH FIG 2).
■ Reduction is begun by incising the capsule overlying the gland
inferomedially just lateral to the anterior belly of the digastric muscle. The
gland will be evident once exposed in this manner due to its distinctive
lobulated appearance. Its inferior portion can be grasped and easily separated
from adjacent tissue inside its capsule using a gentle blunt scissors spreading
technique.
■ A key step in the safe performance of the procedure is adequate mobilization
of the gland, which will make both gland resection and the control of any
intraglandular bleeding easier. Although all vital structures are outside the
capsule, care should be taken when mobilizing the gland superolaterally as
both the facial vein and marginal mandibular branch of the facial nerve and
in close proximity.
■ Once adequately mobilized, the inferior portion of the gland is grasped and
pulled gently inferiorly and medially out of its fossa and away from adjacent
structures. The redundant portion is subsequently incised incrementally under
direct vision in a medial to lateral direction using an extended cautery.
Excision of the excess part of the gland should be performed in such a
manner that the portion protruding inferior to the plane tangent to the
ipsilateral mandibular border and the anterior belly of the digastric muscle
will be removed. It is usually best that the initial resection is conservative and
that the gland is incrementally reduced as needed. Never is it necessary or
appropriate to remove an entire gland, which will result in a depression or
other contour deformity and could precipitate dry mouth.
■ Proper instrumentation and personnel are needed to perform this procedure.
An extended cautery along with long insulated forceps is necessary along

with a fiber-optic headlight (our preference) or retractor and suction. Also,
two assistants will be needed for retraction, passing of instruments, etc. If a
smoke evacuator is used, a second suction should be set up in the event that
bleeding is encountered.
■ SMG reduction must not be performed without proper preparation as
mentioned above, and considerable caution as intraglandular vessels is often
encountered and can produce brisk bleeding. These vessels are more
commonly encountered when larger resections are made. Typically, bleeding
will occur from both the gland and the specimen side, and this is usually best
controlled by quickly moving the cautery back and forth between each end of
the cut vessel. If bleeding is brisk and not easily controlled with simple
cautery, the cut edge of the gland should be compressed with forceps and the
vessel isolated and cauterized. In the unlikely event that bleeding cannot be
controlled by these means, the submandibular fossae should be packed with
gauze and digital pressure applied firmly for several minutes.