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Chapter 47 Combined Face Lift and Facial Fat Grafting
Clinical Caveats
Patients with significant facial atrophy will generally achieve suboptimal im-
provement from both surface treatments of facial skin and surgical lifts. The ad-
dition of fat to areas of the face that have atrophied from age or disease can pro-
duce a significant and sustained improvement in appearance that is unobtainable
by other means.
Performing fat injections in conjunction with a face lift has certain disadvantages
that must be acknowledged, including the learning curve associated with any new
procedure, an increase in operating room time, increased postoperative edema, a
longer period of recovery, and uncertainty of graft take.
Fat contains adult stem cells that are believed to elaborate growth factors and other
as yet not clearly defined cellular mediators that appear to have a regenerating ef-
fect on adjacent tissues, and it is likely that injecting fat into the face as part of a
face lift has a rejuvenating and regenerative effect on the facial skin.
Isolated fat injections are of questionable benefit to a patient with significant fa-
cial sagging and skin redundancy. Although aggressive filling of the sagging face
with fat can improve contour and produce a smoother skin surface, it generally
results in an unusually large, overfilled face that appears both unnatural and un-
feminine.
Areas in need of treatment with fat will vary from patient to patient, and plan-
ning fat injections requires looking at the face more as a sculptor and less as a tai-
lor, as we have done in the past.
Poor outcomes are typically obtained if sharp hypodermic needles are used to har-
vest and inject fat, and if fat is injected in a manner similar to that used to inject
nonautologous facial fillers. Sharp needle injection can also result in fat embo -
lization and serious related problems and is not recommended.
Donor sites are typically chosen in conjunction with the patient to improve his
or her silhouette, although ideal locations are arguably those areas of diet- and
exercise-resistant fat collections where the fat is biologically programmed to per-
sist throughout the patient’s life.
Donor sites and site markings should be photographed preoperatively to docu-
ment what was agreed on and to avoid any dispute over the patient’s preoperative
condition after surgery.
Fat should be harvested in a thoughtful and artistic manner that improves the pa-
tient’s figure. Thus it must generally be removed bilaterally and symmetrically, un-
less body contours dictate otherwise.
Continued
Clinical Caveats—cont’d
Harvested fat is generally not uniform in character: each syringe will contain a
variable amount of fat, blood, local anesthetic, and ruptured fat cells, and pro-
cessing is necessary to obtain uniform material for injection.
A common misconception in treating the hollow upper orbit is that the fat should
be injected in the preseptal portion of the eyelid itself. Volume is more properly re-
stored by placing fat in a preorbital position along the inferior margin of the supra-
orbital rim.
When injecting the upper orbit, one is working in close proximity to the eye, and
although the injection cannulas are blunt tipped, they are capable of perforating
the ocular globe.
Filling the upper cheek produces a profoundly beneficial effect on the nasolabial fold,
and treatment of the fold is more effective when combined filling of both these ar-
eas is made. If the cheek is filled, less fat is needed to improve the nasolabial fold.
A common error when injecting fat into the lips is to fill the lips in such a manner
that a large but shapeless and unnatural-appearing “sausage lip” is produced.
Injection of the geniomandibular groove with fat has a high aesthetic payoff and is
a good area for the beginning injector to gain experience with the technique.
Although not intuitively obvious, strengthening the jawline and posterior mandibu-
lar border makes patients appear more youthful, fit, and attractive.
It is wise to make small additions of fat to “safe” areas at first to gain familiarity
with the technique.
Patients should be followed carefully, outcomes critically evaluated, and the sur-
geon should constantly seek ways to improve injection techniques.
1672
Part VIII Face Lift and Neck Lift
Acknowledgment
All photos in this chapter are reproduced courtesy of Timothy J. Marten, MD,
Founder and Director, Marten Clinic of Plastic Surgery, San Francisco, California.
1673
Chapter 47 Combined Face Lift and Facial Fat Grafting
Suggested Readings
Coleman SR. Fat Injection: From Filling to Regeneration. St Louis: Quality Medical Pub-
lishing, 2009.
Connell BF, Marten TJ. Deep Layer Techniques in Cervico-facial Rejuvenation Deep Face-
lifting. New York: Thieme, 1994.
Connell BF, Marten TJ. Face Lift for the Active Man. Instructional Courses in Plastic Surgery.
St Louis: Mosby, 1991.
Connell BF, Marten TJ. Mastery of Plastic and Reconstructive Surgery. New York: Little
Brown, 1994.
Connell BF, Marten TJ. Orbicularis oculi myoplasty: surgical treatment of the crow’s feet de-
formity. In Operative Techniques in Plastic Surgery. Philadelphia: WB Saunders, 1995.
Connell BF, Marten TJ. The submental crease and elimination of the double chin deformity
at rhytidectomy. Aesthet Surg J 10:10-12, 1990.
Connell BF, Marten TJ. Surgical correction of the crow’s feet deformity. Clin Plast Surg
20:295-302, 1993.
Hartley JH Jr, Little JW, Marten TJ, et al. Customized incisions in facial rejuvenation. Aes-
thet Surg J 19:231-238, 1999.
Marten TJ. Facelift. Planning and technique. Clin Plast Surg 24:269-308, 1997.
Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and mid-
face. Clin Plast Surg 35:569-603; vi-vii, 2008.
Marten TJ. Lamellar high SMAS face and midface lift. In Nahai F, ed. The Art of Aesthetic
Surgery: Principles & Techniques. St Louis: Quality Medical Publishing, 2005.
Marten TJ. Maintenance facelift: early facelift for the younger patient. Semin Plast Surg
16:375, 2002.
Marten TJ. Secondary rejuvenation of the face. In Mathes S, ed. Plastic Surgery. Philadelphia:
Elsevier, 2006.
Marten TJ. Treatment of the full, obtuse neck. Aesthet Surg J 25:387-397, 2005.
Stuzin JM, Feldman JJ, Baker DC, Marten TJ, et al. Cervical contouring in facelift. Aesthet
Surg J 22:541-548, 2002.
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Neck Lift
FOAD NAHAI
CHAPTER 48
M
y thinking and current approach to treatment of the neck have been influ-
enced by the work of my close friends. Courtiss’s submental liposuction, Feld-
man’s corset platysmaplasty, and Connell’s modification of the subplatysmal struc-
tures, combined with the experience John Bostwick and I had with endoscopic face
and neck lifting, have all shaped my approach to the neck. Equally important has
been the experience gained through secondary neck lifts.
Courtiss demonstrated that removal of submental fat resulted in redraping and re-
contouring of the submental skin without any redundancy. Normal skin quality and
elasticity are prerequisites. Feldman’s corset platysmaplasty improved the submen-
tal contour and jawline and eliminated platysma bands. Connell’s subplatysmal ap-
proach further improved neck contour through the elimination of bulging fat, di-
gastric muscles, and submandibular glands. Our experience with endoscopic face
and neck lifts clearly established that all of the components of a neck lift could be
performed through minimal-access incisions, and if skin excision was not needed,
the standard retroauricular face-lift incision, serving only for access, could be totally
eliminated.
Almost all face-lift procedures, especially those involving the SMAS, will have some
effect on the neck, particularly the jawline. For a small group of patients this may
be all that they need, whereas others will need more extensive procedures involving
a submental incision. I have found the vertical simulation test very useful in my
decision-making concerning the need for a submental incision and central neck pro-
cedures. Neck lifts are not only performed in conjunction with face lifts, but also as
separate procedures without a concomitant face lift.
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Part VIII Face Lift and Neck Lift
Not all patients’ necks have the same morphology, nor do their necks age at the same
rate or in the same way. The approach to each neck is individualized to maximize
the result. Neck lifting involves a combination of rejuvenation or reversal of the ag-
ing process and recontouring. The spectrum of procedures available to us ranges from
liposuction only to a full open neck lift, and through multiple incisions with inter-
vention in each of the three planes—superficial, intermediate, and deep. After careful
evaluation, the surgeon selects the appropriate procedure and plans the incisions,
vectors, and planes of intervention.
1677
Chapter 48 Neck Lift
Surgical Options
Liposuction only
– Suction-assisted liposuction (SAL)
– Ultrasound-assisted liposuction (UAL)
– Power-assisted liposuction (PAL)
– Laser-assisted liposuction (LAL)
Submental lift
The components of a neck lift include fat contouring, muscle and fascia plication,
subplatysmal procedures, skin redraping and redistribution, and skin excision. Fat
may be removed from under the skin, between the platysma muscles, and below the
muscle. In the superficial plane the fat may be removed through liposuction or di-
rect excision. The fat between and deep to the platysma muscles is removed by di-
rect excision, since liposuction deep to the platysma is risky and inappropriate. Mus-
cle and fascia plication involves the platysma muscle and its investing fascia. The
procedures deep to the platysma include fat removal, tangential excision of the an-
terior belly of the digastric muscles, intracapsular removal of the superficial lobe of
the submandibular gland, and release of the suprahyoid fascia.
Components of a Neck Lift
Fat contouring
– Superficial
– Deep
Muscle and fascia plication
Endoscopic neck lift
Short-scar face lift, with or without
submental incision
Full-scar face lift, with or without
submental incision
Subplatysmal procedures (deep plane)
Skin redraping and redistribution
Skin excision
Skin resurfacing
Management of skin in the neck differs from management of facial skin. To obtain
optimal results in the neck, it is not always necessary to remove excess skin. The neck
affords more options for skin redraping and redistribution, and excellent results are
possible without skin excision. The key is to assess the skin of the neck and estab-
lish whether the excess, if any, is real or apparent.
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Part VIII Face Lift and Neck Lift
Internal jugular vein
Digastric muscle
Sternocleidomastoid
muscle
External jugular vein
Anterior jugular vein
Cricothyroid muscle
Superior thyroid vein
Facial vein
Jugular arch
Internal
jugular vein
Submandibular
gland
Parotid gland
External jugular vein
Hyoid bone
Skin
Subcutaneous
fat
Platysma
muscle
Digastric
muscle
Interplatysmal fat
Subplatysmal
fat
Submandibular
gland
Within the neck, fat is found in the subcutaneous tissue between the skin and
platysma muscle. The thickness of this fat pad will vary according to the patient’s
morphology and weight. It is usually more abundant in the submental area, extend-
ing in between the platysma muscles if they are separated at this level. There is also
a collection of fat deep to the platysma muscles and superficial to the digastric mus-
cle and the submandibular gland. Dramatic neck recontouring can be achieved
through removal of neck fat in these different levels.
Preplatysmal-
subcutaneous fat
Interplatysmal fat
This operative view demonstrates en bloc
resection of preplatysmal-submental fat
and separate en bloc resection of inter-
platysmal and subplatysmal fat.
Pertinent Anatomy
Fat
Although the jowls or the jowl–fat pads extend into the neck, it is facial fat that
should be returned to the lower face where it belongs, or be excised as needed. It is
not part of the fat in the neck.
Muscle
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Chapter 48 Neck Lift
The platysma muscles separate the neck into superficial and deep compartments.
The muscles are large, thin sheets that extend from the face across the neck and down
to the clavicle. Within the submental area the anatomy of the muscle varies greatly
from individual to individual.
Cardoso de Castro’s anatomic studies led him to classify the relationship of the two
platysma muscles and their interdigitations or decussation in the submental area into
three types.
This confirms our clinical impression that in the majority of patients there is very
limited interdigitation of the muscles medially, as evidenced by the two visible
platysma bands in the aging neck. Stuzin discussed retaining ligaments that hold the
platysma against the deep cervical fascia; he described them as a series of fibrous
bands extending from the mandibular symphysis distally to the thyroid. With aging,
attenuation of this retaining ligament system allows platysmal descent, which ac-
counts not only for platysma bands but also for the increasingly oblique cervical
angle, both hallmarks of the aging neck.
TYPE I
Occurs in 75% of cases (most common).
Demonstrates a limited decussation of
the platysma muscles, extending 1 to 2 cm
below the mandibular symphysis.
TYPE II
Occurs in 15% of cases.
Demonstrates decussation of the
platysma from the mandibular symphysis
to the thyroid cartilage.
TYPE III
Occurs in 10% of cases.
Demonstrates no decussation
or interdigitations.
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Part VIII Face Lift and Neck Lift
Digastric muscle
Facial artery
Facial vein
Lingual nerve
Branches of the facial nerve
Hypoglossal nerve
Mylohyoid muscle
Submandibular gland
The anterior belly and posterior belly of the digastric muscle form two sides of the
submental triangle. The third side is the ramus of the mandible. Within this triangle
lies the submandibular gland, facial artery and vein, the lingual nerve, and the mar-
ginal mandibular branch of the facial nerve.
Submandibular Gland
Facial artery and vein
Facial nerve
Marginal mandibular nerve
Submandibular gland
Superficial thyroid vein
Thyroid gland
Omohyoid muscle
Sternohyoid muscle
Parotid
gland
Greater
auricular nerve
Accessory
nerve
Internal
jugular vein
Ansa cervicalis
nerve
Sternomastoid
muscle
Posterior belly
of digastric muscle
Anterior belly
of digastric muscle
Submandibular glands lie within the submental triangle. Whether clinically visible
glands are ptotic or simply enlarged is currently a matter of debate. The sub man di bu -
lar gland lies in close proximity to the facial artery, which crosses superficial to the
Digastric Muscle
Submental triangle
posterior portions of the gland. The marginal mandibular branch of the facial nerve
crosses the gland superficially. The safest approach to resection of the gland is in-
tracapsular, because all of these structures lie outside of the capsule of the gland.
Clinical Correlations
The platysma divides the neck into a superficial and deep compartment. My clini-
cal approach to the neck, the layered approach, includes intervention in three planes:
superficial, intermediate, and deep.
1681
Chapter 48 Neck Lift
The superficial plane includes only the subcutaneous fat, and intervention in
this plane is limited to fat contouring.
The intermediate plane includes the platysma and any fat lying between the
two muscles and the occasional lymph node. Intervention in this plane includes
resection of the fat and plication of the platysma muscle medially and laterally.
The deep plane includes the subplatysmal fat, the digastric muscles, and the
submandibular gland. The resection of the subplatysmal fat is relatively safe;
however, the anterior veins of the neck may course within the fat.
Tangential excision of the anterior belly of the digastric muscle is also relatively safe
and bloodless. The dissection of the submandibular gland has to be performed cau-
tiously and within the capsule. Resection of the superficial lobe is relatively safe, be-
cause this portion of the gland is well away from the facial vessels, facial nerve, and
lingual nerve. Dissections beyond this superficial lobe or extracapsular dissection of
the gland are more likely to lead to vascular injury with profuse bleeding and nerve
injuries. The suprahyoid fascia also lies in the deep plane. This fascia is occasionally
released to further improve on the cervical angle in patients with a high hyoid.
Intermediate plane
Deep plane
Superficial plane
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Part VIII Face Lift and Neck Lift
Fat removal has the most dramatic effect on neck contouring. Therefore it is impor-
tant to determine the accurate location of fat in the neck, whether it is only under
the skin or also between and below the platysma muscles.
Focus of Neck Evaluation
Fat
Muscles
Submandibular gland
Evaluation of the location of submental neck fat, pinch-
ing the submental area at rest
Subcutaneous versus subplatysma fat is assessed by
pinching the submental area during contraction
To differentiate between subcutaneous and subplatysmal fat, the surgeon pinches
the submental area with the patient at rest and then after contraction of the platysma
muscle. If the amount of fat within the pinch diminishes on contraction of the mus-
cle, a significant amount of fat lies deep to the muscle, indicating that subcutaneous
fat removal alone may not result in an ideal contour. If there is subplatysmal fat, an
open procedure for defatting below the platysma is indicated, and subcutaneous fat
removal or liposuction will yield a suboptimal result.
Skin
Neck-face interface
Preoperative Assessment
Careful evaluation of the neck and its relationship to the lower third of the face will
lead to selection of the appropriate procedure to meet the patient’s goals. This eval-
uation also helps to determine incisions, vectors, and planes of intervention. In or-
der of importance in neck recontouring and rejuvenation, I assess the fat, muscles,
submandibular gland, and finally, the skin for skin excess and skin elasticity. The
jowls and the jawline, the interface of the neck and face are also evaluated.
The platysma and digastric muscles are evaluated. The platysma bands may be visi-
ble at rest or on animation only. The location of the bands and the distance between
them is noted. Transcutaneous evaluation of the digastrics may not always be possi-
ble, especially in a heavy neck. The digastric muscles are best evaluated during the
procedure, after the subcutaneous fat is removed.
If flexion of the neck results in a bulge, it may be appropriate to consider digastric
muscle excision. Occasionally the digastric muscle may be visible transcutaneously,
especially in candidates for a secondary neck lift. The submandibular gland is often
visible transcutaneously, presenting as a bulge within the submental triangle. In a
heavy neck it may not be visible, and intraoperative evaluation may be necessary be-
fore the surgeon decides about the gland.
Skin
The length of the skin incision in neck lifting reflects the location of the excess skin
to be removed. If there is no excess, the entire neck procedure is performed through
minimal incisions. I evaluate whether the skin excess is real or apparent, and if it is
real, where that excess lies. The success of short-scar procedures relies not only on
1683
Chapter 48 Neck Lift
Evaluation of excess skin of the neck and platysma bands with the patient at rest
Evaluation of platysma bands on animation
assessment of the location of skin excess, but also on the quality and elasticity of the
skin. The vertical simulation test is invaluable in evaluating skin quality and skin
excess. Normal skin elasticity is essential for all short-scar procedures. Patients who
have inelastic, sun-damaged skin must have the full retroauricular incision for a
good result.
Apparent excess skin will redrape after recontouring below the skin, such as sub-
mental skin following fat removal in all three planes, as well as digastric and sub-
mandibular gland excisions. The skin must have sufficient elasticity to redrape. It is
the long side of the triangle redraping into the two shorter sides, thus eliminating
the apparent skin excess.
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Part VIII Face Lift and Neck Lift
Skin redraping is shown after fat removal and platysma plication through a sub-
mental incision. A short preauricular incision was made to tighten the SMAS to im-
prove on the jowls and the jawline. No neck skin was excised.
Real excess skin usually extends below the thyroid cartilage and posteriorly beyond
the sternocleidomastoid muscle. If there is real excess skin or if skin quality is poor,
a full retroauricular incision is essential.
This patient demonstrates skin excess beyond the thyroid cartilage and behind the
sternocleidomastoid muscle, as well as poor skin elasticity, as evidenced by the sun-
damaged appearance. A full face-lift incision, including a retroauricular extension,
is required for an optimal result.
Vectors
Skin evaluation influences my choice of vectors. The vertical vector applied to the
neck in combination with a face lift, through SMAS and skin elevation, will define
and improve the jawline. The more diagonal vector required for skin resection in the
retroauricular area will define and improve the lower and lateral neck.
Neck-Face Interface
If there is significant jowling and descent of the neck-face interface, an isolated neck
lift procedure will not address that problem and will lead to a suboptimal result. In
such patients a lower face and neck lift is a more appropriate operation. In selected
patients, judicious liposuction of the jowl fat will improve the jawline.
Planes of Intervention
Through clinical evaluation of the neck I determine the planes of intervention. If only
subcutaneous fat excision is needed, liposuction in the superficial plane would be
the procedure of choice. If platysma bands have to be dealt with, an intermediate
plane intervention is planned. If subplatysmal fat removal, modification of the di-
gastric muscles, or submandibular gland excision are required, intervention in the
deep plane is planned. It is not rare to perform procedures in all three planes.
1685
Chapter 48 Neck Lift
Jowls
Submandibular
gland
Platysma bands
Excess skin
1686
Part VIII Face Lift and Neck Lift
Fat
Muscles
Neck Lift Options: Components of Neck Lift
Sub-
No
Aged
Sub-
Inter-
Sub-
mandibular
Real
Poor
Neck-Face
cutaneous
platysmal
platysmal
Platysma
Digastric
Gland
Excess
Excess Quality
Interface
Liposuction
only
Submental
neck lift
Endoscopic
neck lift
Short-scar
face and
neck lift
Full-scar
face and
neck lift
Choosing the Best Option
Skin
Preoperative Planning and Decision-Making
I currently have five options for neck recontouring or rejuvenation, ranging from li-
posuction to a full-scar face and neck lift:
1. Liposuction
2. Submental neck lift
3. Endoscopic neck lift
4. Short-scar face and neck lift
5. Full-scar face and neck lift
In the superficial plane, liposuction alone results in significant contour improvement
and relies on normal skin quality for redraping. The other four options allow inter-
vention in the intermediate or platysmal plane as well as access to the plane below
the platysma. In combination with a face lift, the face-neck interface, jawline, and
jowls are rejuvenated. The full-scar face and neck lift is the only option that includes
retroauricular skin excision. The chart below represents surgical options, along with
each of the components of the neck lift that apply to that approach.
OPERATIVE TECHNIQUE
Liposuction
The best candidates for liposuction recontouring of the neck are usually younger pa-
tients with normal-quality skin and localized excess submental fat. Clinical evalua-
tion of the platysmal muscles and subplatysmal fat is the key to patient selection. In
addition to the pinch test described earlier, the patient’s neck is examined at rest and
on animation for the presence of platysma bands.
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Chapter 48 Neck Lift
No visible platysma bands at rest
Platysma bands visible on animation
If platysma bands are present at rest, the patient would be best served by a submental
lift. If bands are visible on animation but not at rest, removal of the subcutaneous
fat will expose the bands, and these patients are also best served by an alternative
approach that would eliminate the platysma bands. Liposuction will unmask un-
derlying platysma bands or deep plane fullness. The best way to avoid this is a com-
plete and detailed evaluation of the neck before selecting liposuction as the proce-
dure of choice for neck contouring.
Technique
Liposuction of the neck may be performed with the patient under local or general
anesthesia. I prefer general anesthesia if additional procedures are planned. The pa-
tient is placed supine on the operating table with the neck in full extension. Through
an access incision in the submental area and optional incisions behind each earlobe,
the neck is infiltrated with a wetting solution. My preference is Ringer’s lactate so-
lution with 250 mg of lidocaine and 1 mg of epinephrine added to each liter. I find
Platysma bands visible at rest
that 100 ml of this solution is more than adequate for anesthesia, vasoconstriction,
and sufficient wetting of the tissues for UAL. I usually wait 12 to 15 minutes fol-
lowing infiltration for full anesthetic effect and vasoconstriction.
Ultrasound-Assisted Liposuction
For UAL of the neck, I use a short 2 or 3 ml solid probe with a power setting of
5 and either continuous or pulse mode with the LySonix UAL device (Mentor Corp.,
Santa Barbara, CA). The UAL phase is usually no longer than 2 to 3 minutes. This
is followed by aspiration with a flat 2 or 3 ml cannula. I prefer UAL over SAL in the
neck, because in my hands it yields a smoother result.
Suction-Assisted Liposuction
My choice of cannula for suction-assisted liposuction of the neck is a flat 2 or 3 ml
single-hole cannula. The suction is started through the submental incision with the
hole always toward the deep tissue, never toward the skin. It is important to leave at
least 3 to 5 cc of fat on the deep surface of the skin to avoid postoperative irregu-
larities. Removal of an excessive amount of fat or oversuctioning under the dermis
will lead to adherence of the skin to the underlying platysma, resulting in tethering
and banding.
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Part VIII Face Lift and Neck Lift
Excessive fat removal in the subcutaneous plane to mask or correct problems deep
to the platysma is a common error that is often difficult to reverse, as seen in this
woman. Overaggressive fat removal from her neck and submental area has unmasked
platysma bands and prominent digastric muscles.
In SAL of the neck the cannula is passed slowly through separate tunnels, fanning
out from the submental incision. I make it a point to never make more than one or
two passes in each tunnel, because repeated passes within a tunnel will lead to over-
suction and irregularities. If suction of the jawline and lateral neck is also indicated,
a separate incision behind each earlobe is made for access. This also allows a criss-
crossing of the tunnels in the submental area. It is best to err on the side of leaving too
much fat behind rather than oversuctioning. The endpoint is judged by direct ob-
servation of the recontouring effect and by pinching the skin and subcutaneous tis-
sues. I also roll my fingers along the skin with gentle pressure to look for irregular-
ities to ensure that the fat removal has been uniform.
No drains are required for liposuction of the neck, but compression is applied with
either foam tape or an elastic garment.
1689
Chapter 48 Neck Lift
1690
Part VIII Face Lift and Neck Lift
Results
This patient underwent liposuction of her neck 4 years earlier. The redraping of her
excess neck skin in the submental area is apparent. No skin excision was performed.
This young woman underwent UAL of the submental area and neck; she still has some
persistence of her jowls, but the jawline and submental area have been improved.
This patient underwent liposuction of the submental area and transoral chin aug-
mentation with a solid silicone implant. Improvement of facial proportions is demon-
strated, with a more pleasing jawline and neck-jaw angle.
1691
Chapter 48 Neck Lift
Liposuction of the submental area and neck unmasked this patient’s platysma bands,
which are more noticeable on the right than on the left. A better result would have
been achieved through a submental neck lift, including platysma plication.
Submental Neck Lift
The submental neck lift includes an incision in the submental area, variable under-
mining of the neck, and intervention in each plane of the neck as indicated. The sub-
mental neck lift may be performed as an isolated procedure for recontouring of the
submental area and neck or in combination with a short- or full-scar face lift. The
degree of skin undermining will vary from individual to individual, depending on
the clinical appearance of the neck, skin quality, and skin excess.
Technique
An isolated submental neck lift is not a common procedure in my practice. The sub-
mental approach described here is usually performed in combination with a face lift.
The procedure is performed with the patient under general anesthesia; the patient is
placed supine with the neck extended. The neck is infiltrated with a dilute lidocaine
and epinephrine solution, usually 0.25% lidocaine with epinephrine 1:400,000. The
incision is made just posterior to the submental crease. The dissection is then con-
tinued anteriorly under the crease to release it from the underlying tissues. If indi-
cated, this dissection progresses forward and laterally to release the mandibular lig-
aments. Subcutaneous defatting is then performed. I prefer to do this directly rather
than through liposuction. With the scissors, I elevate the skin with a 3 to 5 mm layer
of fat.
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Part VIII Face Lift and Neck Lift
1693
Chapter 48 Neck Lift
If procedures are planned deep to the platysma, the platysma on each side is ele-
vated, and any fat in between and deep to the platysma is directly excised as needed.
If interplatysmal or subplatysmal fat excision is planned or performed, it is very im-
portant to leave an adequate subcutaneous layer of fat to avoid a submental de-
pression. There is often a very small lymph node or two in the fatty layer, between
and deep to the platysma, which is usually included in this resection.
Central undermining
Lateral undermining
Extent of undermining laterally varies from patient to patient
Mylohyoid
muscle
Platysma muscle
Digastric
muscle
Fat deep to
platysma muscle
Once the platysma has been elevated and the fat deep to it removed, the anterior
belly of the digastric muscle on each side can easily be visualized. The anterior bellies
of the digastric muscles may be tangentially excised, totally excised, or the two pli-
cated in the midline.
The skin is undermined in this plane
toward the thyroid cartilage and later-
ally as needed. Then this submental fat
is resected from the superficial surface
of the platysma. In thin individuals in
whom no fat removal is planned, the
dissection starts directly over the pla -
tysma, leaving all the fat on the deep
surface of the skin.
Platysma muscle elevated to expose fat and digastric muscle
1694
Part VIII Face Lift and Neck Lift
Digastric
muscle
Mylohyoid
muscle
Most commonly I do a tangential excision. This starts anteriorly at the origin of the
muscle. A hemostat is passed halfway through the thickness of the muscle.
Digastric muscle
Platysma muscle
Digastric muscle
Platysma muscle
The tips are then spread, and with electrocautery the muscle fibers are transversely
divided so that at least half the thickness of the muscle is tangentially excised by dis-
secting posteriorly along the muscle to its tendinous junction. On the rare occasions
when I resect the entire anterior belly, the origin is divided first with electrocautery
and then the tendinous junction.
Once the anterior belly of the digastric muscle has been dealt with, an enlarged sub-
mandibular gland is easily visualized. Even if a decision has already been made to
dissect the gland, the neck is flexed and the contour assessed before proceeding with
partial gland excision. The most important step in resecting the gland is to incise the
capsule and to perform the resection piecemeal. This will greatly decrease the risk
of bleeding and damage to the surrounding nerves.
1695
Chapter 48 Neck Lift
Once the gland is visualized, I grasp it with an Allis forceps or place a 3-0 suture
through the gland and pull the gland into view. The capsule is incised with needle-
tip cautery; then the gland is resected piecemeal. If there is any bleeding, the vessels
are easily cauterized. Occasionally the small artery feeding the gland is encountered
and must be suture ligated. Once the gland has been suitably reduced in size, the neck
is again flexed and the effect on neck contour assessed. Gland excision proceeds in
this manner until the desired contour is achieved.
Submandibular
gland
Retracted platysma muscle
Submandibular
gland
Retracted platysma muscle
Removed
portion of
submandibular
gland
Retracted platysma muscle
After these deeper procedures are completed, the platysma muscles are plicated in
the midline. I prefer interrupted sutures with permanent material. The tail end of a
suction drain is left deep to the platysma before completing the midline plication.
Occasionally I plicate the platysma in two layers. The second layer is sutured with
an absorbable material.
For an isolated submental lift, the procedure at this stage is almost complete. Neck un-
dermining extends laterally on either side until effective skin draping is seen. If there
is any skin redundancy, the undermining is extended until this excess is eliminated.
Any remaining contour irregularities are dealt with through direct fat excision, if
possible. Otherwise, liposuction is done with a small, flat 2 or 3 mm cannula. A suc-
tion drain is routinely placed in the neck. The skin is closed in two layers—4-0
Monocryl for the dermis and intracuticular 5-0 Monocryl for the skin. Tapes and
dressings are applied.
Postoperative Care
Patients undergoing an isolated submental lift may be allowed to go home on the
same day as surgery. Those undergoing a face lift in combination will remain
overnight in our facility. A compression tape or garment is worn for several days
postoperatively. The drain is removed the next day after surgery.
1696
Part VIII Face Lift and Neck Lift
Piecemeal excision of superficial lobe
of submandibular gland
1697
Chapter 48 Neck Lift
Preoperative evaluation of this man demonstrated platysma bands on animation,
with fat superficial and deep to the platysma muscle. He had an indistinct neck-jaw
angle. He underwent a submental neck lift, including subplatysmal fat excision and
digastric excision. No subcutaneous fat was removed so that a smooth contour re-
mained. He also had chin augmentation with an anatomic solid silicone implant.
Postoperative views demonstrate improved contour without skin irregularities.
Endoscopic Neck Lift
Technique
The submental neck lift described earlier has almost entirely replaced our original
endoscopic neck-lift procedure. This procedure was essentially the same through the
submental incision. Additional incisions were then made behind each earlobe, and
the endoscope aided in the wide undermining of the neck skin from one sternoclei-
domastoid muscle to the other. Endoscopic visualization also facilitated hemostasis.
A headlight and a Deaver or lighted retractor through the submental incision have
now replaced the endoscope.
Result
1698
Part VIII Face Lift and Neck Lift
A similar procedure was performed on this patient, who exhibited platysma bands
and apparent excess skin in the submental area.
This patient underwent an endoscopic neck lift, including platysma plication and
neck suspension sutures through a 4 cm submental incision and a 1 cm retroauric-
ular incision on each side. There was no skin excision.
Results
1699
Chapter 48 Neck Lift
Short-Scar Face and Neck Lift
The ideal candidate for a short-scar face and neck lift is a patient who has no excess
neck skin with jowls and aging of the neck-face interface. The short-scar approach,
with a vertical upward vector on the SMAS and slight diagonal vector on the skin,
will improve the jawline. If needed, neck recontouring through liposuction or through
a submental approach may be performed at the same time. With the submental ap-
proach, I connect the face and neck dissection in the subcutaneous plane. The tech-
nical aspects of the procedure for the neck were described earlier.
Jowls
Submandibular
gland
No platysma bands
No excess skin
1700
Part VIII Face Lift and Neck Lift
Technique
A prehairline incision is made below the
sideburn and a preauricular intratragal
incision down to and around the earlobe.
The skin flap is elevated and the dissec-
tion connected with the neck dissection,
which usually extends to the posterior
border of the sternocleidomastoid.
Incision follows
lateral border of
platysma muscle
Zygomatic
prominence
Angle of
the mandible
The sub-SMAS dissection is then initiated
at the junction of the adherent and mo-
bile SMAS. A diagonal incision is made in
the SMAS, extending from the zygomatic
prominence medially toward the angle of
the mandible laterally. The dissection then
continues along the lateral border of the
platysma.
The SMAS-platysma flap is mobilized by blunt dissection and then pulled upward
in the face and posteriorly in the neck. Usually in a heavy face, a portion of the ele-
vated SMAS and platysma is resected; in thin faces, it is plicated with permanent su-
ture material. My preference is 3-0 Mersilene. The lateral plication of the platysma
will further define the neck. This lateral plication is always performed regardless of
whether a submental approach and medial platysmal plication is performed. I place
a drain in all face lifts. The drain is brought out behind the earlobe.
1701
Chapter 48 Neck Lift
The facial skin is pulled directly upward with a slight diagonal vector posteriorly.
The excess skin is resected and an anchoring suture of 3-0 PDS is placed at the base
of the concha. The excess skin is then trimmed, tailored around the tragus, and in-
set. A two-layer closure of 4-0 Monocryl to the dermis and running 6-0 rapid-
absorbing catgut to the epidermis completes the procedure. Dressings are applied,
and the patient remains overnight in our facility.
1702
Part VIII Face Lift and Neck Lift
Results
This woman underwent a short-scar face lift that included a submental incision with
platysma plication. She is seen 4 years postoperatively.
The preoperative views of this patient demon-
strate apparent excess skin in the submental area,
jowls, and platysma bands on animation. She un-
derwent a short-scar face and neck lift, includ-
ing a submental incision with submental fat re-
moval and platysma plication. The postoperative
view demonstrates neck recontouring, improve-
ment of jowling, and no retroauricular scars.
This ideal candidate underwent a short-scar face lift through a submental incision
with subplatysmal intervention, including partial excision of the submandibular
gland. A lower lid blepharoplasty was also performed. The postoperative result
demonstrates improvement of the submental area and jawline.
Full-Scar Face and Neck Lift
The best candidates for a full-scar face and neck lift are individuals with aging
changes of the face and neck, especially the neck-face interface, with inelastic skin
and excess lower and posterior neck skin. The vertical simulation test is most useful
for selecting short or long scars. The procedure is similar to the operation described
previously, with the exception that the skin incision is continued around the earlobe
up to the level of the tragus or higher and then across into the occipital hair.
1703
Chapter 48 Neck Lift
Jowls
Submandibular
gland
Platysma bands
Excess skin
This patient demonstrates jowls,
a visible submandibular gland,
platysma bands, and excess skin
below the thyroid.
The vertical vector on the SMAS will improve her
jowls, and the redraping of the apparent submen-
tal skin excess will improve the submental area.
1704
Part VIII Face Lift and Neck Lift
With rather long sideburns, this patient is a candidate for the classic face-lift inci-
sion, extending from the temporal area into the occipital hair. The postoperative view
demonstrates neck recontouring.
Technique
Occasionally, in individuals with unusually lax skin with sig-
nificant excess skin in the lower neck, this incision is modified
so that at the level of the tragus or just below, it will cross to
the hairline and follow the occipital hairline downward and pos-
teriorly. This modification allows resection of more of the neck
skin without altering the occipital hairline. There is more ex-
tensive skin undermining with this incision, extending beyond
the posterior border of the sternocleidomastoid muscle and be-
hind the ear. Management of the SMAS and platysma was de-
scribed previously, as was the anterior closure of the wounds.
A second anchoring suture of 3-0 PDS is placed through the skin flap and into the
mastoid fascia at the level of the earlobe. The excess skin behind the ear is resected
in stages, aligning the hairline first and then resecting the skin. I close the hair-bearing
scalp with staples and two layers of Monocryl, including a final intracuticular layer
behind the ear. When closing behind the ear, it is important to include the deep fas-
cia in the retroauricular sulcus within the closure; this will prevent outward migra-
tion of the retroauricular scar. Dressings and postoperative management are the same
as described earlier.
Results
1705
Chapter 48 Neck Lift
This middle-aged woman, seen preoperatively and 5 years postoperatively, under-
went an endoscopic brow lift, upper and lower lid blepharoplasty, face and neck lift
with platysma plication, and CO2 laser resurfacing of the forehead and perioral area.
The split-face view demonstrates that brow position has been maintained and pla -
tys ma bands have been eliminated.
1706
Part VIII Face Lift and Neck Lift
This middle-aged patient underwent a face and neck lift, with upper and lower lid
blepharoplasty. No subcutaneous fat was removed from her neck. Her improved con-
tour is the result of subplatysmal procedures, including digastric and submandibu-
lar gland excision.
This woman had a lower lid blepharoplasty, face and neck lift, including a submen-
tal incision, subplatysmal fat removal, and platysma plication. Her postoperative re-
sult demonstrates smooth recontouring of the neck.
This patient in her sixties is shown 3 years after a full-scar face lift, a neck lift with no
fat removal, a temporal brow lift, an upper lid blepharoplasty, a lower lid bleph -
aroplasty including fat preservation, orbicularis redraping, and canthopexy. An
oblique view of her in her twenties is included. The only flaws in an otherwise good
result at 3 years are the wrinkles around her lateral brow and central neck. This is
related more to skin quality than to the effectiveness of her face and neck lift. A resur-
facing procedure at this stage would be beneficial.
1707
Chapter 48 Neck Lift
This middle-aged patient underwent a face and neck lift, including subplatysmal fat
removal and platysma plication. No subcutaneous fat was removed to maintain a
5 mm layer of fat over the platysma. The improved neck contour is the result of sub-
platysmal procedures and platysma plication.
Problems and Complications
The most common error I see in neck recontouring is overoperating in the superfi-
cial plane to mask or improve intermediate or deep plane problems. The tendency is
to overdo the removal of subcutaneous fat, rather than dealing with problems re-
lated to interplatysmal or subplatysmal fat, the digastric muscle, and submandibu-
lar gland. Reluctance to deal with the deeper layers in the neck leads to suboptimal
contouring. The excessive removal of subcutaneous fat leads to adherence of the de-
nuded dermis directly onto the platysma muscle, contraction bands, and unusual
skin tethering that is most obvious on movements involving the platysma. Although
correction of untreated subplatysmal contour problems is relatively straightforward,
improvement of skin-platysma adhesions is very difficult.
1708
Part VIII Face Lift and Neck Lift
Preoperatively, this patient demonstrated neck irregularities, reflecting overzealous
subcutaneous fat removal in a previous surgery rather than a subplatysmal proce-
dure to recontour the neck. The problem was further compounded by skin dyschro-
mias resulting from CO2 laser resurfacing. Excision of digastric muscles and sub-
mandibular glands improved her contour; however, the problem of adhesions of skin
directly to the platysma is extremely difficult to overcome.
I have found that full mobilization of the skin off the platysma with secondary re-
draping offers some improvement. Autologous fat, dermis grafts, and acellular dermal
matrix are suitable options for improvement of such problems.
Another common error with neck lifts is related to vectors. The preferred vectors in-
clude an upward vector in the face and a diagonal posterior vector. Excessive poste-
rior traction on the neck without adequate vectors of elevation anteriorly along the
jawline will lead to a banding or a “hammock effect” whereby the lower and poste-
rior neck are effectively tightened, but laxity remains in the submental area, jowls,
and neckline.
1709
Chapter 48 Neck Lift
This patient, who had undergone two previous face lifts, demonstrates the inappro-
priate vectors and planes of intervention employed during her previous face lifts. She
is shown 1 and 2 years after a tertiary face and neck lift, with redirection of SMAS
and skin vectors and subplatysmal recontouring.
Secondary problem areas include the following:
Skin
Fat
Platysma
Digastric muscles
Submandibular glands
Inappropriate vectors
1710
Part VIII Face Lift and Neck Lift
Skin problems following neck lifts are usually related to failure of adequate redrap-
ing as a consequence of insufficient undermining or poor skin quality. Most often,
however, the cause is undercorrection or failure to correct the jowls, jawline, and the
neck-face interface. Correction requires a face lift with appropriate management of the
facial skin.
Fat problems are related to overexcision or underexcision. Overexcision is most of-
ten performed in the subcutaneous plane; this can be avoided through the use of
smaller cannulas, turning the hole away from the skin, limiting the passes in each
tunnel, and striving to leave a uniform 3 to 5 mm thickness of fat deep to the skin.
Underremoval of fat is most often seen deep to the platysma and adjacent to the sub-
mental incision itself. These can be avoided through proper planning and appropri-
ate management of each plane or layer of the neck.
The most frequently encountered problem with the platysma is the persistence of
platysma bands. These occur when the bands are not dealt with primarily or when
the plication sutures fail. Solutions include reoperation to plicate or resect as indi-
cated, or temporary treatment with botulinum toxin injections. Alternative ap-
proaches such as transcutaneous division of platysma bands, as advocated by Gon-
zalez, and stairstep division of the platysma, as described by Saylan, are appropriate
options.
A persistent bulge following neck contouring in the submental area most often is the
anterior belly of the digastric muscle, which may have been unmasked when subcu-
taneous fat was removed. Correction is relatively straightforward, entailing digastric
excision through a submental incision.
Bulging in the submental triangle results from an enlarged submandibular gland. Most
often this was present preoperatively and was not dealt with or was unmasked by sub-
cutaneous defatting. Correction entails a submental approach and partial excision.
Appropriate vectors in the neck include an upward vector in the submental area
where the skin redrapes, an upward vector along the jawline, and a diagonally pos-
terior vector behind the ear. For an optimal result, a balance must be struck among
these vectors. Excessive traction in any one of these vectors without appropriate coun-
tertraction in the others will result in banding or a hammock effect. Correction in-
cludes reoperation and remobilization with more balanced traction.
1711
Chapter 48 Neck Lift
Concluding Thoughts
The neck does not always have to be opened in order to be recontoured and rejuve-
nated, nor is it necessary to operate deep to the platysma in every patient. A full pre-
operative assessment of the three planes, together with intraoperative evaluation,
will indicate the procedure or procedures that will most effectively recontour the neck.
Clinical Caveats
The surgeon should avoid overoperating in the subcutaneous plane to overcome
deeper problems.
For optimal results, the deeper planes must be approached and modified directly.
For liposuction, cannulas of 3 mm or smaller in diameter should be used.
Patients must be evaluated for platysma bands and subplatysmal fat before lipo-
suction.
Liposuction may unmask preexisting platysma bands.
Liposuction should be avoided in patients who have fat superficial and deep to the
platysma, because results will likely be suboptimal.
The number of liposuction passes should be limited to one or two in each tunnel.
The cannula hole should be turned away from the dermis.
Undermining widely is recommended to achieve adequate skin redraping.
Stretched, inelastic skin will not redrape and must be resected.
Recontouring the neck without addressing the lower third of the face will yield
suboptimal results.
At least 3 to 5 mm of subcutaneous fat should be left on the skin flap.
Subplatysmal fat should be removed rather than overresection of subcutaneous fat.
The need for digastric or submandibular gland excision should be evaluated in-
traoperatively.
Submandibular gland excision is performed within the capsule of the gland.
Submandibular gland excision is approached in a piecemeal fashion.
The surgeon must maintain harmony between the lower third of the face and the
jawline.
Resurfacing (20% TCA) should be considered to improve skin quality in the neck.
1712
Part VIII Face Lift and Neck Lift
Annotated Bibliography
Connell BF, Shamoun JM. The significance of digastric muscle contouring for rejuvenating
the submental area of the face. Plast Reconstr Surg 99:1586-1590, 1997.
The authors present the technique of partial resection (tangential excision) of the ante-
rior belly of the digastric muscle. They also discuss the benefits of this procedure; they
have found that it results in a well-contoured submental area, prevents residual fullness,
is easy to perform, and averts the need for secondary neck-contouring procedures.
Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Re-
constr Surg 66:826-837, 1980.
The authors suggest visual criteria for achieving and assessing success in platysma cer-
vical lift. They think it is now possible to satisfy these criteria in most patients, even
those with a low-lying hyoid. They also discuss techniques for restoring a youthful neck.
Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg 85:333-343, 1990.
Contemporary surgery to rejuvenate the aging neck commonly includes some type of
platysma modification. Corset platysmaplasty was developed to avoid postoperative im-
perfections. The author discusses the rationale and surgical technique for this proce-
dure. A number of case examples are also presented.
Fuente del Campo A. Midline platysma muscular overlap for neck restoration. Plast Recon-
str Surg 102:1710-1714; discussion 1715, 1998.
The author describes a variation of platysmaplasty, consisting of the overlapping (double-
breasted fashion) of the platysma muscles in the midline, solely through a submental
approach. This variation allows excellent platysmal suspension and neck recontouring,
eliminating the need for posterior traction of the platysma muscle and in many cases
avoiding the need for cervical incisions.
Guerrerosantos J. Neck lift. Simplified surgical techniques, refinements, and clinical classifi-
cation. Clin Plast Surg 10:379-404, 1983.
The author describes his classification of the aging neck and his approach for rejuvena-
tion of the neck. This article includes the original description of suspension sutures de-
signed to improve on the jaw line and neck jaw angle.
Nahai F. Reconsidering neck suspension sutures. Aesthet Surg J 24:365-367, 2004.
In this article I note that in my experience the suspension sutures only temporarily im-
prove and mask problems that lie deep to the platysma. The suspension sutures are de-
signed to tighten the platysma and thus temporarily correct the deep problems. I have
found that a direct approach to the fat digastric muscle and submandibular gland deep
to the platysma provides longer lasting results. For this reason, I tend to limit the use of
suspension sutures in my practice, and I prefer to approach these deeper tissues directly.
1713
Chapter 48 Neck Lift
Suggested Readings
Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy:
evolution and application. Aesthetic Surg J 21:14-26, 2001.
Biggs TM, Koplin L. Direct alternatives for neck skin redundancy in males. Clin Plast Surg
10:423-428, 1983.
de Castro CC. The anatomy of the platysma muscle. Plast Reconstr Surg 66:680-683, 1980.
Connell BF. Male face lift. Aesthet Surg J 22:385-396, 2002.
Connell BF, Gaon A. Surgical correction of aesthetic contour problems of the neck. Clin Plast
Surg 10:491-505, 1983.
Connell BF, Marten TJ. Facelift. In Cohen M, ed. Mastery of Plastic Surgery. Boston: Little
Brown, 1994.
Connell BF, Semlacher RA. Contemporary deep layer facial rejuvenation. Plast Reconstr Surg
100:1513-1523, 1997.
Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg 76:882-889, 1985.
Cronin TD, Biggs TM. The T-Z-plasty for the male “turkey gobbler” neck. Plast Reconstr
Surg 47:534-538, 1971.
Eaves FE, Nahai F, Bostwick J III. The endoscopic neck lift. Oper Tech Plast Reconstr Surg
2:145, 1995.
Feldman JJ. Corset platysmaplasty. Clin Plast Surg 19:369-382, 1992.
Feldman JJ. Neck Lift. St Louis: Quality Medical Publishing, 2006.
Franco T. Face-lift stigmas. Ann Plast Surg 15:379-385, 1985.
Fulton JE, Saylan Z, Helton P, et al. The S-lift facelift featuring the U-suture and O-suture
with skin resurfacing. Dermatol Surg 27:18-22, 2001.
Giampapa VC, Di Bernardo BE. Neck contouring with suture suspension and liposuction:
an alternative for the early rhytidectomy candidate. Aesthetic Plast Surg 19:217-223,
1995.
Gonzalez R. Composite platysmaplasty and closed percutaneous platysma myotomy: a sim-
ple way to treat deformities of the neck caused by aging. Aesthet Surg J 29:344-354,
2009.
Gradinger GP. Anterior cervicoplasty in the male patient. Plast Reconstr Surg 106:1146-1154;
discussion 1155, 2000.
Gryskiewicz JM. Submental suction-assisted lipectomy without platysmaplasty. Plast Re-
constr Surg 112:1393-1405; discussion 1406-1407, 2003.
Guerrerosantos J. Surgical correction of the fatty fallen neck. Ann Plast Surg 2:389-396,
1979.
Guyuron B. Problem neck, hyoid bone and submental myotomy. Plast Reconstr Surg 90:830-
837; discussion 838-840, 1992.
Guyuron B, Jackowe D, Iamphongsai S. Basket submandibular gland suspension. Plast Re-
constr Surg 122:938-943, 2008.
Kamer FM, Minoli JJ. Postoperative platysmal band deformity. A pitfall of submental lipo-
suction. Arch Otolaryngol Head Neck Surg 119:193-196, 1993.
1714
Part VIII Face Lift and Neck Lift
Knipper P, Mitz V, Maladry D, et al. Is it necessary to suture the platysma muscles on the
midline to improve the cervical profile? An anatomic study using 20 cadavers. Ann Plast
Surg 39:566-572, 1997.
Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg
101:473-481, 1998.
Labbé D, Franco RG, Nicholas J. Platysma suspension and platysmaplasty during neck lift:
Anatomical study and analysis of 30 cases. Plast Reconstr Surg 117:2001-2007, 2006.
Labbé D, Nicolas J. The anatomic basis of platysma suspension. In Tonnard PL, Verpaele
AM, eds. Short-Scar Face Lift: Operative Strategies and Techniques. St Louis: Quality
Medical Publishing, 2007.
McKinney P. Management of platysmal bands. Plast Reconstr Surg 110:982-984, 2002.
Morrison W, Salisbury M, Beckham P, et al. The minimal facelift: liposuction of the neck
and jowls. Aesthetic Plast Surg 25:94-99, 2001.
Prabhat A, Dyer WK II. Improving surgery on the aging neck with an adjustable expanded
polytetrafluoroethylene cervical sling. Arch Facial Plast Surg 5:491-501, 2003.
Saylan Z. Serial notching of the platysma bands. Aesthetic Surg J 21:412-417, 2001.
Saylan Z. The S-lift: less is more. Aesthet Surg J 19:406-409, 1999.
Singer DP, Sullivan PK. Submandibular gland I: an anatomic evaluation and surgical ap-
proach to submandibular gland resection for facial rejuvenation. Plast Reconstr Surg
112:1150-1154; discussion 1155-1156, 2003.
Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified
S-lift. Plast Reconstr Surg 109:2074-2086, 2002.
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Chapter 48 Neck Lift
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Reoperative Rhytidectomy
JAMES C. GROTTING, WILLIAM J. VINYARD
CHAPTER 49
P
lastic surgeons today are seeing more and more patients returning to the prac-
tice, or presenting for the first time, with requests for facial rejuvenation after
previous facial procedures. Primary face-lift patients’ concerns are more generalized;
the concerns of reoperative aesthetic patients vary but tend to be very specific. A sec-
ondary face-lift patient will often return and have common complaints such as “My
creases (nasolabial folds) are back,” “My neck is loose again,” and “My kids ask me
what I’m mad about when I’m not mad at all.” Reoperative aesthetic patients are
unique in that they already know what they’re getting into. They wouldn’t have re-
turned to the surgeon if they were not prepared to have a correction. Generally, they
will not be dissuaded by fear of pain, fear of anesthesia, or financial issues.
Every facial rejuvenation patient asks, “How long will my face lift last, Doctor?” Al-
though it isn’t possible to answer a query like that with precise accuracy, all plastic
surgeons know that a face lift does not last forever. Patients must understand that
surgery will turn the clock back for them, but the inexorable march of time will catch
up with them once again. Patients will always look better than if they had not un-
dergone the operation, although continued aging still occurs. Having a face lift is a
very big decision for most patients. Yet having a second or third procedure is be-
coming much more common.
Educating patients about the possible need to “shore things up” at a future time
helps to keep patients within a practice and helps grow one’s experience with sec-
ondary procedures. If the patient’s tissues have lost all elasticity and the subcuta-
neous fatty layer is full, the chances of requiring an early secondary correction are
high.
There are generally five categories of patients who require reoperation. The first cat-
egory is patients with complications following primary face-lifting. The second is
those seeking adjunctive procedures to improve or enhance the previous results. These
adjunctive procedures may not require traditional lifting procedures: the patient may
only require less-invasive procedures to rejuvenate the face. The third category con-
sists of individuals requesting reoperation for continued facial aging. In this group
of patients, only a “tuck-up” procedure may be required. The fourth category is pa-
tients for whom the surgeon has previously planned a staged approach. There are
two subsets to this: the first group consists of younger patients who require only min-
imal procedures, such as lipocontouring of the jowls or submental areas, and who
subsequently undergo more traditional lifting procedures as they age. The other group
comprises some of the most difficult patients to provide satisfactory results for in
1718
Part VIII Face Lift and Neck Lift
1719
Chapter 49 Reoperative Rhytidectomy
one procedure. These patients tend to be older, with doughy skin, fatty facial tissue,
and severe neck laxity that extends below the thyroid cartilage and into the sternal
notch. They usually require early postoperative tightening procedures in the neck,
even as early as 1 year. We find it best to counsel these patients preoperatively about
their risk of early recurrence. The fifth category includes those who have not had any
complications but are dissatisfied with the results they obtained from their primary
facial rejuvenation procedure.
How is reoperative facial surgery different? Often there are asymmetries created by
the previous operation that need to be addressed. The anatomy is different; the fa-
cial nerve can be in an unexpected place. This is especially true in a thin patient who
has had multiple previous procedures. It is very easy to get into the wrong plane and
damage the facial nerve; scar tissue and fibrotic adhesions create this altered anatomy.
In addition, changes in the blood supply may dictate a new approach. In one way,
the previously undermined skin flap can be considered a delayed flap, which is safe
to reelevate, but in other situations it can be quite tenuous, especially in a patient
who smokes.
In this chapter we will discuss the various reasons that patients request reoperative
facial rejuvenation, the diagnosis and management of complications seen in primary
rhytidectomy, aesthetic evaluation for reoperative facial rejuvenation, the anatomic
differences that must be considered in secondary rhytidectomy, secondary face-lift
procedure options, the prevention and correction of the “overoperated” look, and
how to maintain the results of facial rejuvenation.
Reasons for Reoperative Rhytidectomy
Continued Signs of Aging
The inevitable signs of aging can be mitigated, but not halted. A patient may have
previously been happy with the results of a primary rhytidectomy, but as the years
pass, facial aging continues. The patient’s genetics and sun exposure influence the
aging process. As we discuss later in this chapter, the appearance of the face as it ages
is different in patients who have already had facial rejuvenation surgery. Therefore
the approach to correcting facial aging is different in primary versus secondary
rhytidectomy patients.
This 58-year-old woman had undergone a subperiosteal face lift and an open brow
lift 14 years earlier. She felt that she had lost the rejuvenating glow of her primary
face lift. Patients such as this want to maintain a certain look and are excellent can-
didates for secondary face-lifting. She is shown 1 year after undergoing a secondary
face lift with an extended SMAS dissection and endoscopic brow lift.
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Part VIII Face Lift and Neck Lift