The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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50.15 Acknowledgment
All figures, illustrations, tables, and descriptions of concepts,
methods, and technique included in this chapter are courtesy of
the Marten Clinic of Plastic Surgery and are used with permission.
Opinions expressed in this writing are those of the authors and
are not intended to be construed as, or used to define, a standard
of care.
Suggested Reading
[1] Marten T, Elyassnia D. Fat injection: a systemic review of injection volumes by
facial subunit³discussion article. Aesthetic Plast Surg 2018;2018(42):5
>2@ Marten T, Elyassnia D. Facial fat grafting: why, where, how, and how much.
Aesthetic Plast Surg 2018;42(5):1278–1297
>3@ Marten T, Elyassnia D. Simultaneous facelift and fat grafting: combined lifting
and filling for rejuvenation of the aging face. In: Coleman S, Mazzola R, Pu L,
eds. Fat Injection from Filling to Regeneration, 2nd ed. 1ew 2018
>4@ Marten T, Elyassnia D. Simultaneous facelift and fat grafting. In: Connell BF, Sun-
dine M-, eds. Aesthetic Rejuvenation of the Face and Neck. 1ew 2016:160–187
>5@ Marten TJ. Secondary deformities and the secondary facelift. In: 1eligan P, Rubin
-P, eds. Plastic Surgery. Vol. 2: Aesthetic, 4th ed. London, U.: Elsevier; 2018
>6@ Marten T, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg
2015;42(2):219–252
[7] Marten T-. High SMAS facelift: combined single flap lifting of the jawline, cheek,
and midface. Clin Plast Surg 2008;35(4):569–603
[8] Marten T-. Facelift. Planning and technique. Clin Plast Surg
1997;24(2):269–308
[9] Marten T-. Maintenance facelift: early facelift for younger patients. Semin Plast
Surg 2002; 16(4):375–390

51 Facial Implant Augmentation
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51 Facial Implant Augmentation
Imran Ratanshi and Michael J. Yaremchuk
Abstract
Alloplastic implant augmentation offers an accurate and pre-
dictable strategy to address facial skeletal deficiency. Silicone or
porous polyethylene implants are most common owing to their
predictable implant behavior and capacity for fine-tuning with
scalpel or contouring bur. Facial implants are commonly used to
augment the mandible, malar eminence, piriform aperture, and
infraorbital rim. Most deficiencies can be managed with ready-
made or ´off-the-shelfµ implants. However, three-dimensional
irregularities, such as postorthognathic contour imbalances,
are best addressed with custom computer-assisted designed/
manufactured (CAD/CAM) implants. This chapter will describe
principles underlying implant selection, indications for treat-
ment, and operative technique to optimize aesthetic outcome.
Keywords
facial augmentation, alloplastic implant, silicone, porous poly-
ethylene, mandible, malar, infraorbital, piriform, CAD/CAM
51.1 Indications
Since the skeletal infrastructure is fundamental to facial
appearance, patients with normal, deficient, or surgically altered
anatomy may all benefit from augmentation of their craniofacial
skeleton.
Conceptually, autogenous bone would be the best material to
restore or augment the craniofacial skeleton, because it has the
potential to be vascularized and subsequently incorporated into
the facial skeleton. However, donor site morbidity as well as the
time and operative costs associated with autogenous bone can
be significant. In addition, the inevitable resorption and the
poor handling characteristics of autogenous bone grafts limit
the quality and predictability of the aesthetic result. For these
reasons, the majority of facial skeleton augmentation is done with
alloplastic implants.
51.1.1 %DODnFe Dnd 'eÀniWiRn
Facial skeletal augmentation is most often done to enhance
facial appearance in patients whose skeletal relationships are
considered within the normal range. Definition, angularity and
´balanceµ of their facial dimensions is desired (Fig. 51.1).
51.1.2 'eÀFienFy
Skeletal osteotomies and rearrangement are usually required to
treat facial deformities that are disfiguring and are of functional
consequence to vision, breathing, and mastication. Mild midface
and mandibular hypoplasia are common in patients with normal
or orthodontically compensated occlusion. The appearance
of skeletal osteotomies and rearrangements can be simulated
through the use of facial implants in these patients. Fig. 51.2
and Fig. 51.3 demonstrate how implant surgery can mimic the
appearance of skeletal osteotomies in this group of patients.
Because the Le Fort I maxillary osteotomy and advancement is
performed beneath the infraorbital foramen, the midface skeleton
above the foramen remains deficient in its sagittal projection. The
midface skeleton is now more prominent in its lower half after Le
Fort I advancement surgery and as a result, the cheeks appear low.
Sagittal split osteotomy of the deficient mandible with advance-
ment in the sagittal plane may result in ramus asymmetry. Gaps
at the osteotomy sites after sagittal osteotomy of the mandible, or
horizontal osteotomies of the chin with advancement, can leave
visible depressions along the mandible border. Implants designed
to augment the infraorbital rim can correct the upper midface
deficiency after Le Fort I advancement. Implants designed to
Fig. 51.1 A 52-year-old woman underwent posterior mandible and chin augmentation to increase angularity at the time of rhytidectomy.
(a) Preoperative lateral view. (b) Diagrammatic representation of implant augmentation. (c) Postoperative lateral view.
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VIII Surgical Rejuvenation of the Face and Neck
Fig. 51.2 (a) Illustration of midface concavity and Class III malocclusion. The dotted line shows potential lines of osteotomy, and the arrow shows
anticipated advancement. (b) Osteotomy and advancement at the Le Fort III level provides midface projection and Class I occlusion. Note change
in soft tissue profile. (c) Illustration of midface concavity and corrected Class I occlusion. (d) Multiple midface implants provide a soft tissue profile
mimicking the effect of Le Fort III osteotomy and advancement but do not alter occlusion.
Fig. 51.3 (a) Mandibular deficiency with Class II malocclusion. Dotted line shows potential lines of osteotomy. Arrows show anticipated advance-
ment. (b) After sagittal split osteotomy with horizontal osteotomy advancement of the chin to increase chin projection. Note that the occlusion has
been corrected from Class II to Class I. Note change in soft tissue profile. (c) Mandibular deficiency with corrected Class I occlusion. (d) The visual
effect of sagittal split osteotomy and horizontal osteotomy of the chin with advancement has been simulated with mandible and chin implants.
Note that the Class I occlusion is unchanged. Note the change in soft tissue profile. Notice also that the border regularities inherent with skeletal
osteotomies are avoided when implants are used. Patients who have had orthognathic surgery to correct occlusal disharmony are often left with
contour imbalances and irregularities. Both the midface and lower face can manifest characteristic postorthognathic contour irregularities, which are
amenable to alloplastic implant improvement.
b
b
d
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a
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51 Facial Implant Augmentation
727
augment the mandible angle can camouflage angle asymmetries.
Implants can bridge the gap at sagittal and horizontal osteotomy
sites to create a regular contour of the mandible border (Fig. 51.4;
Fig. 51.5). The gap implants are routinely placed secondarily but
can also be placed at the time of primary surgery.
Because postorthognathic contour imbalances and irregular-
ities are three-dimensional (3D), computer-assisted designed/
manufactured (CAD/CAM) implants are invaluable in improving
appearance in this group of patients. Fig. 51.6 shows a 3D
computed tomography (CT) image of a patient after mandibular
osteotomies and the implants designed to create symmetry.
Computer technology has recently been introduced to plan and
guide orthognathic osteotomies as well as to design and manu-
facture custom fixation devices. :ith preoperative anticipation
and prediction of the intraoperative surgical outcome, implants
potentially can be designed to correct anticipated imbalances at
the time of the orthognathic procedure.
51.1.3 Rejuvenation
The soft tissue changes associated with facial aging occur in
concert with remodeling processes of the craniofacial skeleton.
Pessa and colleagues, as well as Shaw and .ahn, analyzed
changes in shape to the orbital rims in different age subgroups
(see Suggested Reading). Findings included curve distortions of
the superior medial upper orbit and inferolateral lower orbit.
There was also retrusion of the infraorbital rim, as illustrated
in Fig. 51.7. Alloplastic augmentation of the infraorbital rim can
restore youthful contour in an aged skeleton.
Shaw and .han also showed that retrusion of the midface
skeleton with age as demonstrated by the difference in glabella,
maxilla, and piriform angles. Morphologic changes with age were
also documented in the mandible. Alloplastic augmentation can
restore youthful skeletal contours while providing support for the
soft tissue envelope as shown earlier in Fig. 51.1.
51.2 Evaluation and Planning
Physical examination is the most important element of preoper-
ative assessment and planning. Reviewing photographic images
with the patient can be helpful when discussing aesthetic con-
cerns and goals. All faces are asymmetric. This recognition pre-
operatively is important to both the surgeon and the patient. The
patient’s asymmetry should be pointed out during the preoper-
ative consultation so that the patient can anticipate asymmetry
in the postoperative result. Preoperatively, the asymmetries
belong to the patient. Postoperatively, if not identified before the
surgery, they are attributed to the surgeon.
Fig. 51.5 Implants are available that span short gaps in inferior border contour after horizontal or sagittal ostotomy (Matrix Surgical, Atlanta, GA).
These implants may be placed at the time of osteotomy surgery or during secondary surgery. (a) Model with osteotomy gap. (b) Implant spans
osteotomy gap resulting in regular mandibular border.
Fig. 51.4 Typical facial contour sequelae after orthognathic surgery and subsequent implant correction. (a) Lateral appearance of patient after Le
Fort I advancement, sagittal split, and horizontal chin osteotomies. (b) Illustration showing skeletal movements responsible for facial contour dishar-
monies and irregularities. (c) Infraorbital rim, mandible angle, and chin implants to correct imbalances and irregularities. (d) Postop appearance after
implant correction.
b
b
d
c
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VIII Surgical Rejuvenation of the Face and Neck
51.2.1 Radiologic Examination
Most aesthetic procedures are done without preoperative radio-
logic assessment. In general, the size and position of the implant
are largely aesthetic judgments. Cephalometric X-ray images are
most often used for planning chin augmentation surgery.
CT scans provide the ability to view the skeleton in different
planes and, through computer manipulation, in three dimen-
sions. CT imaging provides digitized information that can be
transferred to CAD/CAM design software. CAD/CAM implants
provide an increased level of refinement in both reconstructive
and aesthetic applications. Full-scale (1:1) models can also be
fabricated using CAD/CAM methods for surgical planning, and
implants can be customized for the needs of the patient. The
design process can also be conducted virtually, as demonstrated
in Fig. 51.8.
51.2.2 Facial Measurements
Because implant augmentation of the facial skeleton results in
measurable changes in facial dimensions and proportions, it
is intuitively attractive and appropriate to use facial measure-
ments to evaluate the face and to guide surgery. :hile they are
commonly referenced in texts discussing facial skeletal augmen-
tation, neoclassical canons have a limited role in surgical evalu-
ation and planning. Similar to Leonardo da Vinci’s observations,
they are based on idealizations.
Medical anthropology is the accumulation of large numbers
of precise, reproducible surface measurements of various popu-
lation groups of both sexes. These data define normative values
as well as gender and ethnic differences in facial measurements
and proportions. Anthropometric landmarks, measurements, and
inclinations are useful for planning implant and other craniofacial
Fig. 51.6 Three-dimensional computed tomography (CT) images used to plan correction of mandible asymmetry after mandibular osteotomies.
(a) Image after osteotomies. (b) Image of implants designed to create symmetry.
Fig. 51.7 Pessa et al showed that in the youthful face, the cheek fat lies anterior to the cornea and the orbital fat lies slightly anterior to the orbital
rim. With aging, the cheek mass tends to lie posterior to the anterior surface of the cornea, the orbital fat moves slightly anterior, and the infraorbital
rim has a significant movement posteriorly. Hence, retrusion of the infraorbital rim with aging will make the eyes appear more prominent by changing
globe–rim relations, and it will significantly impact the appearance of the lower lid bags, particularly in those who tend toward maxillary hypoplasia.
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51 Facial Implant Augmentation
729
surgery. Frontal views of female and male faces drawn from
average anthropometric measurements for 21-year-old 1orth
American Caucasians are shown in Fig. 51.9.
51.2.3 Sexual Dimorphism
On average, all facial measurements are greater in men than in
women. In addition, the relations between measurements differ
in men and women. For example, the lower third of women’s
faces tends to be absolutely and relatively narrower than that
of men. Sex-related differences have implications for surgical
planning. Fig. 51.10 shows typical male and female skulls.
51.3 Autogenous Implant Materials
51.3.1 Bone
Autogenous bone has the potential to be revascularized and
then assimilated into the facial skeleton. For that reason, it is the
only material available to reconstruct segmental load-bearing
defects of the facial skeleton reliably. :hen used as an onlay
graft, these attributes can lead to graft resorption and unreliable
augmentation of the facial skeleton. The morbidity, time, and
cost associated with autogenous graft harvest also makes it an
unattractive material for aesthetic facial skeletal augmentation.
Fig. 51.8 Virtually planned custom midface, chin, and mandible implants. Native anatomy is shown in relief. (a) Anteroposterior craniofacial view.
(b) Lateral craniofacial view.
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VIII Surgical Rejuvenation of the Face and Neck
51.3.2 Fat
Autogenous fat grafting has become a valuable addition to the
facial aesthetic procedural armamentarium. A small augmenta-
tion of either the underlying skeleton or the overlying soft tissue
envelope may result in almost clinically imperceptible facial con-
tour. However, the resultant facial contours diverge between these
modalities as the degree of augmentation increases. A progressive
increase in the projection of the facial skeleton by osteotomy
and advancement, or with alloplastic augmentation using rigid
implant materials, results in a facial contour that is increasingly
skeletal and defined. On the other hand, a progressive increase in
the volume of the overlying soft tissue envelope results in a facial
contour that is increasingly less defined. In many clinical instances,
fat grafting can complement the result of skeletal augmentation.
51.4 Alloplastic Implant Materials
Virtually all aesthetic facial skeletal augmentation is done with
alloplastic materials. The use of synthetic material avoids donor
area morbidity while vastly simplifying the procedure in terms
of time and complexity. Implant materials used for facial skeletal
augmentation are biocompatible; that is, they have an acceptable
reaction between the material and the host. In general, the host
has little or no enzymatic ability to degrade the implant, with the
result that the implant tends to maintain its volume and shape.
Likewise, the implant has a minimal and predictable effect
on the host tissue that surrounds it. The alloplastic implants
presently used for facial reconstruction have not been shown to
have any toxic effects on the host. The host response to these
materials involves forming a fibrous capsule around the implant,
which is the body’s way of isolating the implant from the host.
The most important implant characteristic that determines the
nature of the encapsulation is the implant’s surface characteris-
tics. Smooth implants result in the formation of smooth-walled
capsules. Porous implants allow varying degrees of soft tissue
ingrowth, which results in a less dense capsule).
Solid silicone, porous polyethylene, polytetrafluoroethylene
(PTFE), and hydroxyapatite (HA) are the materials most often used
for aesthetic facial augmentation.
Fig. 51.9 Frontal view of female and male faces drawn from average anthropometric measurements for 21-year-old North American Caucasians.
Fig. 51.10 (a) Male and (b) female skull images. (Courtesy of the Atkinson Skull Collection, University of the Pacific School of Dentistry, Webster
Street, San Francisco, CA.)
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51 Facial Implant Augmentation
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51.4.1 Polysiloxane (Silicone)
Solid silicone (Implantech, Ventura, CA) or the silicone rubber
used for facial implants is a vulcanized form of polysilox-
ane. It has the following advantages: it can be (i) sterilized
by steam or irradiation, (ii) carved with either a scissors
or scalpel, and (iii) stabilized with a screw or a suture.
Because of its smooth surface, it can be removed quite easily.
Disadvantages include the tendency to cause resorption of
bone underlying it, particularly when used to augment the
chin; the potential to migrate if not fixed; and the potential
for its fibrous capsule to be visible when placed under a thin
soft tissue cover.
51.4.2 3ROyWeWrDÁuRrReWKyOene 37)(
Polytetrafluoroethylene
(PTFE;
Gore-Tex,
Implantech,
Ventura, CA) has a carbon–ethylene backbone to which are
attached four fluorine atoms. It is very chemically stable, has
a nonadherent surface, and because it is not cross-linked, it
is very flexible. Preformed implants are made with a pore
size between 10 and 30 —m, which allows for some soft tissue
ingrowth. However, it is smooth enough to be maneuvered
easily through soft tissues. This material can be fixed to
underlying structures with sutures or screws. It is easily
sterilized.
51.4.3 Polyethylene
Polyethylene is a simple carbon chain of ethylene monomer.
The high-density, porous variety (Omnipore, Matrix Surgical,
Atlanta, GA; Medpor, Stryker, .alamazoo, MI) is used for
facial implants because of its higher tensile strength. The
porosity of Omnipore or Medpor has both advantages and
disadvantages. The advantages include its tendency to allow
extensive soft tissue ingrowth, thereby lessening its tendency
to migrate and to erode underlying bone. Its firm consistency
allows it to be easily fixed with screws and contoured with
a scalpel or electrically powered bur without fragmenting.
However, its porosity causes soft tissue to adhere to it,
making placement more difficult and requiring larger pock-
ets to be made than with smooth-surfaced implants. The soft
tissue ingrowth also makes implant removal more difficult
than with smooth-surfaced implants. Despite these intrinsic
shortcomings, porous polyethylene remains the authors’
implant material of choice.
51.4.4 Hydroxyapatite
Hydroxyapatite is a calcium phosphate salt found as a major
component of bone matrix. Dense hydroxyapatite can be
produced synthetically. Porous hydroxyapatite can be entirely
synthetic or formed by chemically converting the naturally
porous calcium carbonate skeleton of marine coral. Porous
hydroxyapatite is also available as granules for injection.
Hydroxyapatite has the theoretical advantage of being oste-
oinductive and osteoconductive. These attributes have been
shown experimentally but have yet to demonstrate clinical
relevance.
51.5 Morbidity and Complications
Associated with Alloplastic
Implants
The facial implants just described are biocompatible. Extensive
review of the literature discounts any association of these
implants with carcinogenicity, systemic disease, or hypersen-
sitivity. Complications tend to be technique-related rather than
due to material selection. The senior author’s personal experi-
ence with porous polyethylene implants placed over a 10-year
period in 661 patients demonstrated a 1.6 overall complication
rate.
51.5.1 Bone Erosion
Bone erosion, which is inevitable beneath smooth implants and
visible on X-ray images, often raises concern, but it is never clini-
cally apparent. Receded bone may complicate secondary surgery
by creating an irregular skeletal surface. Rarely, an implant
positioned over a tooth root can result in bone erosion, which
may lead to dental symptoms requiring root canal surgery.
51.5.2 Infection
Implants are susceptible to bacterial colonization and infection.
If microorganisms are not eliminated rapidly from an implant
surface, they will adhere to the implant initially by nonspecific
physical forces and then by the formation of biofilms character-
ized by clustering together in an extracellular matrix attached
to the implant. Biofilms protect bacteria from host defenses
and antibiotics. Since antibiotic treatment alone is usually not
successful, facial implant–related infections are best treated by
implant removal and appropriate wound care. Implants may be
replaced in 6 to 12 months.
51.5.3 Implant Malposition
The limited skeletal exposure afforded by remote incisions,
a complex 3D skeletal topography, and potential mismatch
between the posterior surface of an implant and the facial
skeleton can lead to less than ideal implant placement. Implant
malposition is best avoided by wide subperiosteal exposure of
the area to be augmented, thus providing landmarks to guide
positioning. Once the desired location is determined, screw
fixation guarantees that the implant cannot be displaced in the
postoperative period. Screw fixation also obliterates any gaps
between the posterior surface of the implant and the skeleton.
Gaps translate into unanticipated increases in implant projec-
tion. The exact fit of CAD/CAM implants to the desired area of
augmentation make malposition less likely.
51.6 Operative Technique
51.6.1 Preparation
To facilitate intraoperative hemostasis, patients are instructed
to discontinue any medications, foods, or supplements that can

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VIII Surgical Rejuvenation of the Face and Neck
compromise the blood clotting cascade. To optimize intraoral
hygiene, professional dental examination and cleaning may be
indicated. Patients are always prescribed chlorhexidine mouth-
wash for 48 to 72 hours prior to the anticipated surgery.
:ith the exception of chin augmentation, operations are per-
formed with the patient under general anesthesia, preferably with
nasotracheal intubation. Since most operations employ intraoral
incisions, this approach optimizes access and allows optimum
preparation of the operative site as well as control of the airway
(Fig. 51.11). The operative field is infiltrated with a solution con-
taining epinephrine (1:200,000) to minimize bleeding. A throat
pack is placed, and both the skin and the oral mucosa are prepared
with a povidone–iodine solution. Antibiotics, usually cephalospo-
rins, are administered intravenously prior to the onset of surgery
and redosed intraoperatively depending on the length of surgery.
Oral antibiotics are administered for the 5 days following surgery
only if intraoral access for implant placement was employed.
51.6.2 Incisions
Incisions are always planned remote from implant placement
and never obtained through open wounds. Implants positioned
directly beneath surgical incisions are at risk for exposure,
contamination, and then loss. These operative approaches are
borrowed from craniofacial and aesthetic surgery.
Coronal incisions are used to place implants in the frontal and
temporal areas. Transconjunctival retroseptal incisions (often with
a lateral canthotomy for increased exposure) are used to access
the infraorbital rim, malar area, and internal orbit. The lateral
extent of the lower lid blepharoplasty incision provides access to
the lateral orbit and zygomatic arch. This small cutaneous incision
leaves an inconspicuous scar. It is used with the transconjunctival
approach when a lateral canthotomy is avoided. Blepharoplasty
skin–muscle flaps provide alternative access to this area.
Intraoral incisions are used to augment the midface as well as
the mandibular body and ramus. Intraoral incisions are made
with a generous labial cuff to allow watertight, reliable mucosal
closure (Fig. 51.12).
Chin area augmentation is preferably performed through a
submental incision. This approach to the chin provides optimal
exposure of the skeletal anatomy and the mental nerves. Unlike
the intraoral approach, which avoids a cutaneous scar, the sub-
mental approach does not violate the mentalis muscle. Mentalis
dysfunction can result in lower lip descent, excessive lower tooth
show, and chin pad ptosis.
51.6.3 Implant Selection
The majority of aesthetic facial skeletal augmentation is done
with silicone (Implantech, Ventura, CA) or porous polyethylene
(Omnipore, Matrix Surgical, Atlanta, GA; Medpor, Stryker,
.alamazoo, MI), implants; the latter is the senior author’s
preference. It is important to note that manufacturers provide
multiple implant shapes and sizes intended for specific anatom-
ical areas. It is unusual for the senior author to use an implant
without changing its contour (reducing it) to meet the needs of
the specific situation. Implants can be trimmed with a scalpel or
bur for precise contouring.
51.6.4 Screw Fixation
Screw fixation prevents movement of the implant, which adds
precision as well as early and late predictability to the result. By
Fig. 51.11 General anesthesia using nasotracheal intubation is ideal
for midface and mandible augmentation. Endoscopy draping of the
endotracheal tube and circuit allows it to be in the operative field and
mobile. The airway is protected and controlled. A panoramic view of
the operative area is provided.
Fig. 51.12 Surgical access to expose the posterior mandible. An intra-
oral mucosal incision is made along the ramus and posterior body of
the mandible approximately 1 cm above the sulcus on its buccal side.
Intraoral incisions to expose the midface are also made approximately
1 cm above the sulcus on the labial side.

51 Facial Implant Augmentation
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applying the implant to the skeleton, screw fixation eliminates
any gaps between the implant and the recipient bed. Gaps are
potential sites for hematoma or seroma accumulation. Gaps
provide an unanticipated increase in implant projection, thereby
resulting in an effective increase in augmentation and risk for
migration and malposition. Screw immobilization of the implant
allows in-place contouring of the implant at the recipient site,
which can enable creation of a clinically imperceptible transition
between the implant and the recipient skeleton.
51.6.5 Hemostasis
Several maneuvers are employed to minimize bleeding and its
sequelae. These include infiltration of the operative field with
epinephrine-containing solution prior to the onset of surgery.
Dissection is performed in the subperiosteal plane. The majority
of dissection is done with the needle-tipped electrocautery.
1euro Pattie sponges (Medtronic, Minneapolis, M1) soaked in
epinephrine are placed in one area of the dissection while the
surgeon moves to another area. :ounds are never closed until
hemostasis is achieved. Suction drains are always used when the
posterior mandible is stripped of its overlying masseter muscle
These drains are placed below the mandible in the most depen-
dent position to maximize efficacy. Mildly compressive dressings
are applied over the area of surgical dissection. Prophylactic
anticoagulation is not used in conjunction with facial implant
surgery by the senior author.
51.7 Midface Implants
51.7.1 Piriform Aperture
Augmentation of the piriform aperture area is usually performed
to move the lower midface profile from one of concavity to relative
convexity, mimicking the visual effect of Le Fort I advancement
(Fig. 51.13). A deficiency in lower midface projection is common
in patients with surgically corrected clefts. Retrusion of the
lower midface may occur when upper and lower jaw fractures
are reduced with respect to occlusion only and not to preinjury
3D skeletal anatomy above the occlusal level. It may also occur
after comminuted maxillary fracture reduction and fixation if
the surgery is inadequate to resist soft tissue deformity forces
accompanying massive edema. Paranasal augmentation can help
restore the preinjury lower face convexity. Augmentation of the
alveolus and lower lateral paranasal area will improve lip and
nasal relationships and overall facial balance. It is often a useful
adjunct during the rhinoplasty procedure. Augmenting the skel-
eton in this area can alter the projection of the nasal base, the
nasolabial angle, and the vertical plane of the lip.
Operative Technique
Piriform aperture (or paranasal) implants are designed as right and
left crescents. An upper gingivobuccal sulcus incision is made just
lateral to the piriform aperture to avoid placing incisions directly
over the implant. The incision is made at least 1 cm above the
sulcus to provide an adequate cuff of mucosa inferiorly to allow
layered closure (Fig. 51.14). The lip elevators can be seen after
the mucosa is incised. These muscles are not divided but rather
are retracted during the exposure of the maxilla. Subperiosteal
dissection exposes the area to be augmented. The borders of
the piriform aperture, the infraorbital nerve, and the root of the
canine tooth should be identified during surgery. Defining the
bony edges of the piriform aperture provides bony landmarks
that help facilitate precise and symmetric implant placement.
The implant may compromise the nasal airway if positioned
beyond the medial bony edge of the aperture. Identification of
the nerve avoids inadvertent retractor or implant damage to the
structure. The root of the canine tooth will be visible as a distinct
bulge just lateral to the piriform aperture. The implant will, in
part, lie directly over it. The surgeon must avoid damaging these
Fig. 51.13 Influence of a paranasal implant on position of the nasal base, nasolabial angle, and vertical plane of the lip. (a) Profile view of patient with
lower midface concavity and acute nasolabial angle. (b) Profile view shows that augmentation of the piriform aperture area creates a convex profile
and opens the nasolabial angle.
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VIII Surgical Rejuvenation of the Face and Neck
structures if screw fixation is used to immobilize the implant.
The incision is closed in layers. Because of the relatively small
area of dissection, no drains are used.
Clinical Example
A 20-year-old woman underwent rhinoplasty and paranasal
augmentation. Increasing midface convexity visually decreased
the projection of the nose (Fig. 51.15).
51.7.2 Cheek (Malar Eminence)
Prominent malar bones are considered attractive. The lack of
anthropometric and cephalometric landmarks makes analysis
and augmentation of the malar area largely subjective. Malar
deficiency is often part of a generalized midface deficiency for
which malar augmentation alone may be inadequate or, even,
inappropriate. Clinical experience has shown that when malar
projection is deemed inadequate, malar augmentation is most
effective when it re-creates the contours of a normal skeleton
with prominent anterior projection. The availability of 3D CT
scans has enabled the senior author to correlate the underlying
skeletal topography with the overlying soft tissue envelope.
:ith this information, the senior author places the point of max-
imum projection just at, or slightly lateral to, the intersection of a
vertical line placed through the lateral canthus and a horizontal
line traversing the infraorbital foramen.
Fig. 51.15 This 20-year-old woman underwent rhinoplasty and paranasal augmentation. (a) Preoperative frontal, lateral, and oblique views.
(b) Postoperative frontal, lateral, and oblique views.
Fig. 51.14 Diagrammatic overview of paranasal implant surgery. The
incision is made on the labial side of the buccal sulcus and lateral to the
area to be augmented. The gold area indicates the area of subperios-
teal dissection. Note proximity of infraorbital nerve. Note that the root
of the canine tooth lies below the area to be augmented. It must be
avoided during screw immobilization of the implant.
a
b

51 Facial Implant Augmentation
735
Implant Design
Malar implants should reproduce the normal contours of the
facial skeleton. Myriad implant designs of both porous polyeth-
ylene (Matrix Surgical USA, Atlanta, GA; Stryker, .alamazoo,
MI) and silicone (Implantech, Ventura, CA) are available. An
intraoperative photograph in Fig. 51.16 shows a typical shape
and placement of a malar implant.
Implant projection varies from 3 to 5 mm. The thickness of the
overlying soft tissue envelope will influence selection of implant
projection. The silhouettes of large implants can become visible
as the overlying cheek tissues atrophy and sag with time. The
capsule formation that accompanies smooth-surfaced implants
further exaggerates the tendency toward implant visibility.
Asymmetric implant placement is not uncommon after malar
implant surgery. This reflects limited exposure of a complex
surface topography and the impossibility of seeing both operative
sites simultaneously for comparison.
Certain implant designs do not mimic the contours of the
midface skeleton. For example, submalar implants are designed
to be placed over and below the origin of the masseter muscle³a
location where there is no midface skeleton³in an attempt to
provide cheek fullness. The lower midface fullness result is an
unnatural midface: one with too much lower midface fullness,
which actually detracts from malar definition and projection.
Operative Technique
Exposure of the area to be augmented is key. To that end, both
eyelid and intraoral approaches are employed. A transcon-
junctival retroseptal incision with lateral canthotomy is
the senior author’s preferred eyelid approach. An upper
gingivobuccal sulcus incision is made over the premolars. The
incision is made at least 1 cm above the sulcus to provide an
adequate inferior cuff of mucosa for closure. The lip elevators
can be seen after the mucosa is incised. These muscles are
not divided but rather are separated in their longitudinal
orientation and retracted during the exposure of the zygoma
and lower maxilla.
Subperiosteal dissection exposes the area to be augmented.
Laterally, the dissection extends just beyond the zygomaticotem-
poral suture. Medially, at this level, it extends to the infraorbital
foramen, where the infraorbital nerve is visualized. This requires
elevation of the zygomaticus major and zygomaticus minor muscles
from their origins and the sacrifice of the zygomaticofacial nerve.
The levator anguli oris (caninus) lies deep to the zygomatic muscles.
Its origins are usually separated from the canine fossa of the maxilla
immediately inferior to the infraorbital foramen. The lip elevators
and the infraorbital nerve are retracted to provide exposure.
After skeletal exposure, the implants are modified to meet the
specific needs of the reconstruction. As noted previously, sym-
metric implant placement is challenging. Implants are available
with registration features that aid in implant positioning (Matrix
Surgical USA, Atlanta, GA).
As with placement in other craniofacial skeletal locations, the
implant is fixed to the skeleton with screws for several reasons.
Doing so allows precise, stable positioning of the implant and
adapts the posterior surface of the implant to the anterior surface
of the malar bone, thereby obliterating gaps between the implant
and the malar bone (gaps between the implant and the bone will
result in an undesirable increase in augmentation in the gap area).
Immobilizing the implant with screws allows final in-place con-
touring of the implant to ensure proper implant projection and an
imperceptible transition between the implant and the bone.
Before the incisions are closed, the infraorbital nerve is iden-
tified to be confident that any early postoperative complaints of
decreased sensation in the distribution of the infraorbital nerve
can be attributed to the trauma of soft tissue retraction and not
implant compression.
51.7.3 Infraorbital Rim
The relationship between the globe and the orbital rims will
determine whether the eyes appear prominent or deep-set.
Because the infraorbital rim and upper midface skeleton support
the lower eyelids and the cheek soft tissues, their projection has
an impact on lid and cheek position. Patients with deficient skel-
etons are more likely to undergo premature lower lid and cheek
descent with aging. This lack of skeletal support predisposes to
lower lid malposition after blepharoplasty and limits the efficacy
and longevity of midface lift procedures.
Globe–Rim Relations
The relationship of the globe to the orbital rims is a primary
determinant of the appearance of the upper third of the face.
-elks and -elks categorized globe–orbital rim relationships and
the tendency for the development of lower lid malposition after
blepharoplasty (Fig. 51.17). On sagittal view, they placed a line or
´vectorµ between the most anterior projection of the globe and
the malar eminence and lid margin. A positive vector relationship
exists when the most anterior projection of the globe lies behind
the soft tissues overlying the midface skeleton in the parasagittal
plane. A negative vector relationship exists when the most ante-
rior projection of the globe lies ahead of the soft tissues overlying
the midface skeleton in the parasagittal plane. This relation
Fig. 51.16 Typical shape and position of a malar implant. Implants
are carved to meet the needs of the patient. Most often, its length is
adjusted so that it extends from the zygomaticotemporal suture to just
beneath the infraorbital foramen.

736
VIII Surgical Rejuvenation of the Face and Neck
reflects a deficiency in midface projection. They warned, similar
to Rees and LaTrenta, that patients whose orbital morphology
has a negative vector relationship are morphologically prone
to lid malposition after lower blepharoplasty. Augmentation of
the infraorbital rim with an alloplastic implant in patients with
midface deficiency can bring it into a better relationship with the
globe, thereby reversing the negative vector.
Indications for Reversing the Negative Vector
Infraorbital rim augmentation is part of the strategy for
normalizing the appearance in patients with midface skeletal
deficiency. It can be adapted for negative vector patients who
are first seeking improvement in their periorbital appearance or
for those whose lid malposition and round eye appearance have
been exaggerated by previous lower blepharoplasty.
Eye prominence results from a deficiency in skeletal projection
and correlates with a more inferior position of the lower lid
(resulting in scleral show) and a more medial position of the lateral
canthus. Descent of the lower lid increases the height of the palpe-
bral fissure, while the more medial position of the lateral canthus
decreases its width. Hence, patients with poorly projecting upper
midface skeletons have ´round eyes,µ as compared with the long
narrow eyes characteristic of young people with a normal perior-
bital morphology. Furthermore, in the skeletally deficient, the lack
of infraorbital rim projection and cheek prominence often allows
their lower lid fat compartments to be visible, giving them ´early
bags.µ Patients with this morphology can benefit from reversing
their negative vector at the time of their blepharoplasty together
with resuspension of their midface soft tissue envelope (Fig. 51.18).
1egative vector patients who develop lid malposition after con-
ventional blepharoplasty can have their lid position and palpebral
Fig. 51.17 Jelks and Jelks categorized globe–orbital rim relationships by placing a line or “vector” between the most anterior projection of the
globe and the soft tissues overlying the midface skeleton in the parasagittal plane. (a) Positive vector relationship. (b) Negative vector relationship.
(c) “Reversed” negative vector relationship resulting from increasing the sagittal projection of the infraorbital rim with an implant.
Fig. 51.18 (a) Frontal and (b) lateral views of a woman with midface skeletal morphology (negative vector) predisposing to lower lid and cheek
descent, resulting in a “round eye” appearance with prominent bags. On lateral view, the artist has drawn in the underlying deficient facial skeleton.
a
b
c
b
a

51 Facial Implant Augmentation
737
fissure shape improved by increasing their skeletal support with
alloplastic augmentation of the infraorbital rim together with
midface soft tissue elevation and lateral canthopexy.
In addition to a deficiency in sagittal skeletal projection, eye
prominence may also result from excess of orbital soft tissue
volume, as seen in thyroid-induced Graves’ ophthalmopathy.
Infraorbital rim augmentation together with midface soft tissue
elevation can be a useful adjunct to orbital decompression in
patients with Graves’ disease.
Preoperative Evaluation
A disproportion in sagittal globe–rim relations is usually obvi-
ous, and correction is made by clinical judgment.
Implant Design
Implants are designed to augment the sagittal projection of the
infraorbital rim. Implants can provide up to 5 mm of anterior
projection. They have malar components of various surface areas
and can be segmented for easier placement and conformation to
the underlying skeleton (Matrix Surgical, Atlanta, GA). They are
fixed with screws to eliminate movement and apply the implant
to the skeleton. Implants are trimmed to meet the specific needs
of the patient (Fig. 51.19).
Operative Technique
Infraorbital rim augmentation requires exposure of the entire
midface skeleton and concomitant elevation of the midface soft
tissue envelope in the subperiosteal plane (Fig. 51.20).
The infraorbital rim and adjacent anatomy must be exposed
sufficiently to ensure ideal implant placement, smooth implant
facial skeleton transition, and screw fixation. A lower lid blepha-
roplasty incision of the surgeon’s preference exposes the infraor-
bital rim. It is important to identify the infraorbital nerve, which
exits from the infraorbital foramen about 8 mm below the margin
of the orbit. This may be 3 to 6 mm in patients with significant
maxillary hypoplasia, who are the most common candidates for
this surgery. The orbicularis oculi and the origins of the lip eleva-
tors are separated from the underlying skeleton in a subperiosteal
plane to expose the infraorbital rim.
Together with the lid incision, an intraoral sulcus incision is
used to free the midface soft tissue envelope in a subperiosteal
plane. Adequate elevation of the soft tissue envelope requires its
separation from the masseter tendon.
The implant is carved to fit the specific needs of the patient.
Segmenting the implant may facilitate placement of the implant
through limited skeletal access. The implant is fixed to the skeleton
with titanium screws to allow precise application of the implant
to the surface of the skeleton.
After the implant is positioned, sutures are used to elevate
and secure the malar midface and lid soft tissues. Through
the intraoral incision, two figure-of-eight sutures are used to
purchase the midface soft tissues. These sutures incorporate
the incised periosteum, the origins of the released lip elevators,
and cheek subcutaneous tissue. A suture placed at the midpupil
level approximately 3 cm beneath the pupil is passed through
the lower lid incision and secured to the rim implant. Another
suture is placed in the lateral aspect of the malar fat pad (placed
approximately 3 cm beneath the lateral canthus) and is tied to
a drill hole placed in the lateral orbital rim. The elevated sub–
orbicularis oculi fat (SOOF) and adjacent musculature now rest
on the augmented skeleton and help to support the freed and
elevated lid margin. A negative vector patient who underwent
infraorbital rim augmentation for periorbital rejuvenation is
shown in Fig. 51.21.
In negative vector patients with postblepharoplasty lid
retraction, lateral canthopexy is added to rim augmentation with
midface lift. A ´bridge of boneµ lateral canthopexy is performed
to narrow the palpebral fissure and to provide additional support
for the elevated lower lid margin. Through the lateral extent of
an upper lid blepharoplasty incision, both limbs of the lateral
canthus are purchased with a figure-of-eight suture. If scarring
limits the upward mobility of the lateral canthus, the lateral thirds
of the middle lamellae are incised with the needle tip electrocau-
tery. Two drill holes are placed in the lateral orbital rim just above
and 1 to 2 mm below the zygomaticofrontal suture. Each end of
the suture is then passed from within the orbit through the drill
holes in the lateral orbital rim. The sutures are tied over the bridge
of bone between the two holes. The inferior drill hole placement
determines the lateral canthal position, which should be 2 to 3
mm above the plane of the medial canthi.
Fig. 51.19 Implants designed specifically for infraorbital rim sagittal augmentation (Matrix Surgical, Atlanta, GA). (a) Oblique view. (b) Overhead
view.
b
a

738
VIII Surgical Rejuvenation of the Face and Neck
The bridge of bone canthopexy is preferred for several reasons.
Drill holes placed in the lateral orbital rim can be placed after
precise measurement, allowing for predictable and symmetric
lateral canthus positioning. The bridge of bone provides a secure
fixation point. The passing of the canthopexy stitch from inside
the orbit to outside applies the lid to the globe. This maneuver
avoids the lid–globe dysjunction in the lateral commissure that is
common when canthopexy sutures are tied to the outer surface
of the lateral orbit.
A patient who underwent infraorbital rim augmentation, mid-
face elevation, and lateral canthopexy is presented in Fig. 51.22.
51.8 Lower Face
51.8.1 Chin
Chin augmentation with implants is the most frequently per-
formed facial implant surgery. Although it is often considered a
relatively trivial surgical procedure, asymmetry, lip dysfunction,
and poor transition between implant and native mandible are not
uncommon. Effective preoperative planning requires an under-
standing of the patient’s desires, recognition of the impact of
previous facial surgery or orthodontic treatment on the patient’s
appearance, and careful facial examination. This careful preopera-
tive analysis, together with refinements in surgical technique and
implant design, will help optimize the surgical outcome. :hen
chin augmentation is considered as an adjunct to rhinoplasty or
neck rejuvenation, preoperative analysis should be as rigorous as
it is when chin deficiency alone is the presenting complaint.
Fig. 51.20 Overview of operation to increase projection of infraorbital
rim and “reverse the negative vector” in patients with upper midface
skeletal deficiency. A transconjunctival retroseptal incision (broken
blue line) with the lateral extent of a lower lid blepharoplasty incision
(solid red line) to expose the infraorbital rim is illustrated. This approach
preserves the integrity of the lateral canthus and, hence, the palpebral
fissure. A lateral canthotomy would increase exposure but is accom-
panied by a greater risk of palpebral fissure distortion. An intraoral
incision is used to access the lower midface skeleton and to identify
and protect the infraorbital nerve. The lower lid and midface soft
tissues are freed by subperiosteal dissection in the area shown in gold.
Fig. 51.21 The woman shown in Fig. 51.18 who underwent infraorbital rim augmentation and midface lift. No fat was removed from the lower lids.
(a) Preoperative frontal view. (b) One year postoperative frontal view. Note that without direct manipulation of lower lid fat, the “early bags” are
meliorated but not eliminated. (c) Preoperative lateral with artist rendition of underlying facial skeleton. (d) One-year postoperative lateral view with
artist’s rendition of augmented facial skeleton.
b
d
a
c

51 Facial Implant Augmentation
739
Physical Examination
Physical examination must include analysis of both the skeleton
and its soft tissue envelope. The lower third of the face must
relate appropriately to the upper two-thirds. :ithin the lower
third, the position of the lips and depth of the labiomental sulcus
are affected by the projection of the chin.
Imaging
In contrast to orthognathic surgery, where cephalometric X-ray
studies are intrinsic to the preoperative planning, preoperative
X-ray images can be helpful but are not mandatory for implant
surgery. Plain X-ray images may be helpful during revision sur-
gery after previous osteotomies.
Three-dimensional CT scans and the models that can be gener-
ated from their data are the gold standard for planning surgery to
ameliorate facial skeletal asymmetries. Custom implants can be
made using these data.
Anthropometric Assessment
1ormative data are helpful in analyzing the chin and planning its
augmentation, not only in its sagittal but also in its vertical and
horizontal projections.
SDgiWWDO 3rRMeFWiRn 3rRÀOe VieZ
The anthropometric studies of Farkas showed that the mean
inclination of the facial profile as defined by a line from the
glabella to the pogonion was ï3 “ 3.4ƒ in men and ï4.1 “ 3.0ƒ in
women (Fig. 51.23).
These data show that men’s chins project more than women’s and
that “normal” chin projection is considerably less than that deter-
mined ´idealµ by subjective criteria. This does not mean that aug-
mentation beyond one standard deviation would be unattractive in
any given individual, but it may look too large, especially in a woman.
Subjective criteria for an ideal profile are at variance from those
obtained by objective analyses. Ignoring sexual dimorphism,
artists usually portray a larger chin than normally exists in reality.
Lip–Chin Relations
There is a consensus among authors that the chin should rest
slightly posterior to the lower lip and the lower lip posterior to
the upper lip.
Labiomental Angle
The inclination of labiomental angle must be evaluated when
considering an increase in the sagittal projection of the chin.
Fig. 51.22 A 52-year-old woman had undergone previous browlift, rhytidectomy, and upper and lower lid blepharoplasty. Lower lid retraction was
treated by multiple canthopexies, spacer grafts, and full-thickness skin grafts. Dry eye symptoms persisted. Infraorbital rim augmentation, midface
lift, and lateral canthopexy resolved her symptoms. Her brows and hairline were repositioned. (a) Preoperative frontal view. (b) Postoperative frontal
view. (c) Preoperative lateral view. (d) Postoperative lateral view.
b
d
a
c

740
VIII Surgical Rejuvenation of the Face and Neck
There is a considerable variability in this inclination. In general,
the inclination is more acute in men than it is in women. :hen
the angle is already acute, chin augmentation will make it more
acute, thereby deepening the labiomental angle. Such deepening
is usually dysaesthetic.
Vertical Projection (Height)
On average, the distance from the base of the nose (subnasion) to
the mouth opening (stomion) is half the distance from subnasion
to gnathion. In order words, the height of the mandible in the
midline should account for approximately two-thirds of the
lower face height, or subnasion to gnathion (Fig. 51.24).
The vertical height of the chin can be increased with implants
in three ways. (1) An illusion of increased length can be obtained
by moving the most projecting part of the chin inferiorly by
implant positioning. Real increases in vertical projection require
(2) CAD/CAM implants or (3) horizontal osteotomy with a spacer
of desired height between the proximal and distal chin segments.
Horizontal Projection (Chin Width)
The width of the chin should be appropriate for the vertical pro-
jection. This is the rationale for extended chin implants, which
allow a transition between the augmented chin point and the
anterior mandibular body.
Predicting the Soft Tissue Response to Skeletal
Augmentation
The soft tissue–to–hard tissue change in patients undergoing
alloplastic augmentation of the chin averages between 77.7 and
90. This reflects the variability in the thickness of the chin soft
tissue envelope. The thicker the overlying soft tissue envelope, the
less its surface response to the underlying skeletal augmentation.
Surgical Anatomy
Structures susceptible to iatrogenic injury during chin augmen-
tation include the mental nerve as well as the lower lip retractors
and elevators. Their anatomy is depicted in Fig. 51.25.
Mental Nerve
The inferior alveolar nerve, a branch of the mandibular nerve,
enters the mandibular canal with the inferior alveolar vessels
Fig. 51.23 The inclination of the facial profile as defined by a line from the glabella (g) to the pogonion (pg). The broken line is drawn perpendicular
to the Frankfort horizontal line (Porion, Po, to Orbitale, Or) at an inclination of 0°. The solid red line represents the mean inclination of the study
group. The shaded area encompasses one standard deviation (SD). (a) The mean inclination in 100 young North American white men was −3 “
3.4°. (b) The mean inclination in 100 young North American white women was −4.1 “ 3°. In both men and women, note that the chin rests slightly
posterior to the lower lip and the lower lip lies slightly posterior to the upper lip. These data show that men’s chins project more than women’s and
that “normal” chin projection is considerably less than that determined “ideal” by subjective criteria. This does not mean that augmentation beyond
one standard deviation would be unattractive in any given individual, but that it may look too large, especially in a woman.
Fig. 51.24 In both male and female faces, the height of the mandible
in the midline, from stomion to gnathion (sto–gn), should account for
two-thirds of the lower face height, from subnasion to gnathion (sn–gn).
b
a

51 Facial Implant Augmentation
741
through the mandibular foramen, which is located in the inner
aspect of the ramus of the mandible. The nerve and vessels course
obliquely from the ramus to the body, where it exits as the mental
nerve through the mental foramen, which is located at the level of
the first or second premolar. Vertically, the mental foramen was
located almost halfway from the tip of the alveolar process to the
lower border of the mandible. The potential location of this nerve
is important to recognize when placing screws or performing hor-
izontal osteotomies of the mandible. After exiting the foramen,
the mental nerve divides into two or three branches to supply
sensation to the mucosa and the skin of the lower lip and chin.
Mentalis Muscle
The mentalis muscle is an elevator of the central lower lip. It
arises from the mandible at the level of the root of the lower
lateral incisor and therefore defines the inferior limits of the
sulcus intraorally. It fans inferiorly as a truncated cone whose
base inserts on the skin and therefore dimples the skin when
elevating and protruding the lower lip. It is the most frequently
damaged muscle during chin surgery. If it is divided and improp-
erly repaired or stripped from its origin and allowed to descend
to a more inferior position, the result is inferior malposition of
the lower lip, with increased lower incisor show and deepening
of the sulcus as well as inferior displacement of the chin pad.
Lip Depressor Muscles
The depressor anguli oris (triangularis), the depressor labii inferio-
ris (quadratus), and platysma are all depressors of the lower lip. The
depressor labii inferioris and depressor anguli oris arise from the
oblique line of the mandible to merge with orbicularis oris and skin
of the lower lip. The platysma muscle sends fibers that originate
from the mandible beneath the oblique line and merge with the lip
depressors. Subperiosteal dissection separates these muscles as a
continuum from the bone. Failure to stay in the subperiosteal plane
may cause damage, usually short-lived, to these muscles. Clinically
this injury mimics that of marginal mandibular branch palsy, since
the marginal branch innervates the lower lip depressors.
Implant Selection
The goal of surgery is to create an anatomically correct, gender-
appropriate, stable mandible contour that satisfies the aesthetic
goals of the patient. The design and composition of the implant
should help accomplish this. Myriad designs of various materials
are available. In general, female chins tend to be narrower and
tapered while male chins are wider and square (see Fig. 51.10).
Porous polyethylene implants come in two pieces: a right half
and a left half. Segmentation facilitates placement of the relatively
long and stiff implant. The two-piece design also provides flexibil-
ity in positioning the lateral extensions of the implant, ensuring
that it mimics the inclination of the patient’s mandibular body.
A tab insert joins the right and left halves of the chin implant.
Registration tabs are meant to align with the inferior border of the
mandible to ensure symmetric placement (Fig. 51.26).
Silicone rubber implants are designed as one piece. The material’s
flexibility allows it to be inserted through relatively small access inci-
sions. A one-piece implant, particularly one with lateral extensions,
is unlikely to have an arc, projection, and inclination appropriate
for every mandible (Fig. 51.27). These implants can be divided into
three pieces for greater ease of insertion. Use of a stair-step, rather
than a straight line, can help better align the implants correctly.
Fig. 51.25 Shows the anatomy of the lower lip elevators and retractors as well as the path of the mental nerve. These structures are susceptible to
injury during chin augmentation. (a) Frontal view. (b) Lateral view.
b
a

742
VIII Surgical Rejuvenation of the Face and Neck
Operative Technique
The technique presented here employs porous polyethylene
implants (Fig. 51.28). They employ right and left components
joined by a midline connecting feature. The design demon-
strated here also has registration features, which aid in implant
alignment. The fundamentals of the technique are applicable for
implants of any material or design.
Anesthesia
Chin augmentation with implants may be performed under local
or general anesthesia.
Submental Approach
The chin and the anterior mandible are accessed through a sub-
mental incision. :ide subperiosteal dissection is performed. The
upper limits of the dissection is the origin of the mentalis muscle.
Laterally, the mental foramen with its exiting nerve and the infe-
rior border of the mandible body are exposed. Lateral dissection
extends approximately 1 cm beyond the area of augmentation.
The submental approach and extended dissection avoid damage
to the mentalis muscle, allow visualization of the mental nerve,
and provide a panoramic view of the complex and varying
contours of the mandible to enable precise implant placement.
The technique of intraoral placement of chin implants avoids
a cutaneous scar but provides limited exposure to the menton
while compromising the mentalis muscle. As a result, the intra-
oral approach is often associated with implant malposition and
lower lip dysfunction resulting from mentalis muscle division or
detachment.
Fig. 51.26 The two-piece design and registration tabs allows the implant to mimic inclination of mandible. (a) Registration tab guides alignment
with inferior border of mandible. (b) Central connecting tab acts as a hinge between implant segments, allowing border alignment.
Fig. 51.27 The arc, the inclination of the limbs, and the contour of
the posterior surface of an extended one-piece implant may all be
inappropriate for the shape of a mandible. This three-dimensional
computed tomography image demonstrates a clinical example. Note
how the inferior borders of the lateral extensions of the one piece
extended implant fail to align with the inferior border of the mandible.
A two-piece design allows adaptation of each of these parameters
for a given mandible. When placed through the submental approach,
the two-piece implant limits asymmetry in the horizontal plane. With
one-piece implants, asymmetry in horizontal positioning increases as
one proceeds laterally.
Fig. 51.28 Screw fixation of the implant to the mandible prevents
implant movement and obliterates gaps between the implant and
anterior surface of the mandible. Screw fixation also allows in-place
contouring of the implant to ensure desired contour and an impercep-
tible implant-to-skeleton transition.
b
a

51 Facial Implant Augmentation
743
Implant Positioning
Marking the midline of the pogonion aids in symmetric implant
placement. The midline can be marked with a marker, drill hole,
or temporary screw. This is useful for implants of any design or
material. It may be beneficial to contour prominences on the
native mandible to allow better congruence between the poste-
rior surface of the implant and the mandible surface. The senior
author’s preference is a two-piece porous polyethylene implant
with registration tabs incorporated at the inferior border of the
implant. Right and left portions of the implant are placed and
then positioned. The registration tab dictates lateral positioning.
The connecting tab joins the two implant segments in the mid-
line and also acts as a hinge to allow the implant to adjust to
the unique inclination of the mandible border. The connecting
bar also allows the width of the implant to be varied as dictated
by the space between implant right and left segments. In most
instances, there will be a gap between the medial aspects of the
implant halves.
Screw Fixation and Closure
The implant is fixed to the skeleton with screws. The wound is
closed in layers. A mildly compressive dressing is placed imme-
diately once the operation is complete and is removed in 48 to
72 hours.
Clinical Examples
Patients who have undergone primary chin augmentation using
the techniques just described are shown in Fig. 51.29 and Fig.
51.30.
51.8.2 Mandible Angle
Indications
Patients with normal, deficient, or surgically altered anatomy
may all benefit from implant augmentation of the mandibular
body, angle, and ramus.
Most patients who desire mandible augmentation have lower
face horizontal dimensions that relate to the upper and middle
thirds of the face within a normal range. These patients, usually
men, perceive a wider lower face as desirable. Mandibular body
and ramus augmentation in women with normal-dimensioned
mandibles should be done conservatively, with the intention of
providing definition.
Another group of patients who benefit from mandible augmen-
tation are those with skeletal mandibular deficiency who have had
their dental relationships normalized through orthodontic tooth
movement. The anatomy associated with mandibular deficiency
can be camouflaged with implants. The addition of an extended
chin implant will camouflage the poorly projecting chin.
A third group of patients who may benefit from alloplastic aug-
mentation of the mandible are patients who have had their Class
II dental malocclusion due to mandibular deficiency corrected by
sagittal split osteotomy with advancement of the distal segment.
Fig. 51.29 A 50-year-old woman underwent chin augmentation with a 3-mm two-piece porous polyethylene implant combined with rhytidectomy.
It was placed to lower the most projecting point of the chin. (a) Preoperative frontal and (b) lateral views. Postoperative (c) frontal, (d) lateral, and (e)
oblique views.
b
d
e
a
c

744
VIII Surgical Rejuvenation of the Face and Neck
This skeletal rearrangement often results in asymmetries and
border irregularities. Mandible implants, particularly those that
are computer-designed to fit the particular needs of the patient,
can improve contour and symmetry in these circumstances.
Physical Examination
Physical examination is the most important element in preop-
erative assessment and planning. Reviewing life-size anterior
and lateral photographs with the patient can be helpful when
discussing aesthetic concerns and goals.
Imaging
Posteroanterior (PA) and lateral cephalograms provide data that
can help the surgeon determine how the dimension of the implant
might be altered to best suit the patient. However, 3D CT scans
and the models obtained from their data can be invaluable when
attempting to correct asymmetries associated with congenital,
posttraumatic, or postsurgical deformities. In general, the size
and position of the implant are largely aesthetic judgments.
Surgical Anatomy
Skeleton
The mandible consists of the tooth-bearing body and the ramus,
which extends upward from the angle. The ramus, including the
angle (gonion), is covered on its external surface by the masseter
muscle. The oblique line runs forward and downward from
the anterior border of the ramus. It affords attachment for the
depressor labii inferioris and depressor anguli oris. The platysma
is attached near the inferior border of the mandible. The bucci-
nator muscle is attached to the outer lip of the superior border of
the mandible as far forward as the first molar tooth (Fig. 51.31).
Musculature
Only the masseter and, indirectly, the medial pterygoid, as part
of the mandibular sling, are encountered during mandibular
augmentation. The masseter and the medial pterygoid muscle
are so positioned that they form a sling around the inferior
border of the mandible and therefore suspend the angle of
the mandible. :hen placing a mandibular angle implant, it is
necessary to separate the superficial portion of the masseter
and its sling component from the mandible in a subperiosteal
plane. Tearing the periosteum at the inferior border may disrupt
the sling mechanism and allow the freed masseter to ride up,
causing a depression in the soft tissues overlying the angle. This
depression is exaggerated when the muscle is contracted.
The buccinator is another muscle that is encountered during
exposure of the mandible during mandibular augmentation. The
buccinator is the principal muscle of the cheek. It forms the lateral
wall of the oral cavity and is incised when exposing the posterior
mandible (Fig. 51.31).
Fig. 51.30 A 31-year old man underwent chin augmentation with a 7-mm projection two-piece porous polyethylene implant. A submental lipectomy was
also performed. (a) Preoperative frontal and (b) lateral views. (c) Postoperative frontal, (d) lateral, and (e) oblique views.
b
d
e
a
c

51 Facial Implant Augmentation
745
Inferior Alveolar Nerve
The inferior alveolar nerve is a branch of the mandibular nerve
(cranial nerve V3). It enters the mandibular canal with the infe-
rior alveolar vessels through the mandibular foramen, which is
located in the inner aspect of the ramus of the mandible approx-
imately halfway between its anterior and posterior borders. It
is important to visualize the path of the inferior alveolar nerve
when placing screws to immobilize mandibular implants.
Implant Design
Ramus and body implants are capable of changing the shape of
the mandible in three dimensions: bigonial width (go–go), ramus
height from gonion to condylar process (go–cdl), and body length
from gonion to gnathion (go–gn). Fig. 51.32 demonstrates basic
implant designs for the mandible angle. The implant usually
extends from the posterior vertical border of the mandible to the
oblique line. The flange at the implant’s inferior border allows
the implant to register to the mandible border (Fig. 51.33).
Fig. 51.31 Mandible anatomy. (a) Surface topography. (b) Muscle origins and insertions.
Fig. 51.33 Illustration of mandibular body and angle implant used in combination with a chin implant. This combination is often used for patients
with Class II mandibular deficiency.
Fig. 51.32 Mandible angle implants of increasing lateral projection
(Matrix Surgical, Atlanta, GA) used to increase lower facial width.
b
a

746
VIII Surgical Rejuvenation of the Face and Neck
Operative Technique
In anticipation of implant surgery, the patient is instructed to
optimize oral–dental hygiene. Chlorhexidine mouthwashes are
prescribed for 72 hours preoperatively.
Anesthesia
It is the senior author’s preference to perform mandibular aug-
mentation under general anesthesia (nasotracheal intubation
is ideal). This provides a panoramic view of the operative field.
The airway is protected while the oral cavity can be optimally
prepared. The face and oral cavity are prepared with an iodine
solution after placement of a throat pack. The operative site
is infiltrated with 1:200,000 epinephrine solution to provide
hemostasis.
Incisions
A generous intraoral mucosal incision is made to expose the
ramus and body of the mandible. It is made at least 1 cm above
the sulcus on its buccal side (Fig. 51.34). The anterior ramus
and body of the mandible are freed from their soft tissues. It
is important to free both the inferior and posterior borders of
the mandible of soft tissue attachments so as to allow implant
placement.
Freeing of the inferior border inevitably violates the pterygo-
masseteric sling. Care should be taken not to divide the sling,
which results in postoperative elevation of the muscle and
midramus bulging with masseter muscle contraction. As deter-
mined by preoperative assessment, the implant is trimmed
with a scalpel or mechanical bur before its placement on the
mandible.
Implant Positioning and Fixation
To ensure the desired placement, certain implants are
designed with registration tabs that align with the inferior
border of the mandible (Matrix Surgical USA, Atlanta, GA). To
ensure its desired position and to apply it to the surface of the
mandible without gaps, the implant is fixed to the mandible
with titanium screws. A long, guarded drill facilitates screw
hole drilling. :ith vigorous retraction, implant fixation can
be done through the intraoral incision (Fig. 51.35). Clamping
the implant to the mandible maintains implant position during
screw fixation.
Screws are placed to avoid the anticipated path of the inferior
alveolar nerve before its exit from the mental foramen. Screws
immobilize the implant and eliminate any gaps resulting from the
lack of congruence between the posterior surface of the implant
and the anterior surface of the mandible. Reduction of promi-
nences on the surface of the mandible minimizes gaps between
the implant and the skeleton. It is crucial to soften any transitions
between the implant and the mandible, particularly where the
implant extends beyond the anterior mandibular border’s inferior
edge. Any step-offs between the implant and the mandible in
this area may be visible in thin patients. Screw fixation of the
implants allows scalpel or mechanical bur final contouring with
the implants in place.
After hemostasis is appropriate, the wound is irrigated (anti-
biotic irrigation is a rational adjunct to decrease bacterial con-
tamination in this operation performed through intraoral access).
The incision is closed in two layers with absorbable sutures. Care
is taken to evert the mucosal edges. A small suction drain is left
in until the next morning. I prefer one with a trocar that allows
the skin exit site to be located behind the ear lobule. An elastic
Fig. 51.34 Intraoral mucosal incision is made along ramus and
posterior body of mandible. It is made approximately 1 cm above the
sulcus on its buccal side.
Fig. 51.35 Screw fixation of the implant to the mandible through an
intraoral approach.

51 Facial Implant Augmentation
747
tape external dressing is used to help apply the soft tissues to the
implant and avoid hematoma formation.
Patients are administered broad-spectrum antibiotics (ordi-
narily cephalosporins) intravenously immediately before the pro-
cedure. Oral antibiotics are administered for 5 days postoperatively.
A liquid diet is prescribed for the first 3 days postoperatively
and a soft diet for the next 5 days. Frequent mouthwashes are
advised, as well as very careful tooth brushing.
Clinical Example
A clinical example is shown in Fig. 51.36.
51.9 Concluding Thoughts
Alloplastic augmentation of the facial skeleton provides a pre-
dictable alteration of skeletal contours. The use of computer
planning and manufacture brings added sophistication to this
modality.
Clinical Caveats
• Access incisions are always made remotely from planned or
previous underlying implants.
• For chin augmentation, an extraoral, submental approach is
preferred to an intraoral incision, as it optimizes exposure and
avoids injury to the mentalis muscle.
• Screw fixation of the implant is essential to avoid implant
migration. It obliterates gaps between the implant and skel-
eton, thereby making implant projection more predictable.
• Drains are frequently placed to minimize dead space and
assist with fluid egress.
• Custom CAD/CAM implants should be considered in circum-
stances of 3D deformities, particularly if bilateral or from
previous orthognathic surgery
Suggested Reading
[1] Aiache AE. Mandibular angle implants. Aesthetic Plast Surg 1992;16(4):349–354
>2@ Doumit G, Abouhassan :, ment of Graves ophthalmopathy. Plast Reconstr Surg 2014;134(3):519–526
>3@ Farkas LG, Hreczko TA, .atic M-. Craniofacial norms in 1orth American Cauca-
sians from birth (one year) to young adulthood. In: Farkas LG, ed. Anthropometry
of the Head and Face, 2nd ed. 1ew >4@ Hazani R, Rao A, Ford R, of chin implants. Plast Reconstr Surg 2013;131(4):869–872
>5@ Huggins R-, Mendelson BC. Biologic behavior of hydroxyapatite used in facial
augmentation. Aesthetic Plast Surg 2017;41(1):179–184
>6@ -elks G:, -elks EB. The influence of orbital and eyelid anatomy on the palpebral
aperture. Clin Plast Surg 1991;18(1):183–195
[7] Lee -H, .aban LB, contour with computer-designed/computer-manufactured alloplastic implants.
Plast Reconstr Surg 2018;142(3):747–755
[8] Pessa -E, =adoo VP, Mutimer .L, et al. Relative maxillary retrusion as a natural
consequence of aging: combining skeletal and soft-tissue changes into an inte-
grated model of midfacial aging. Plast Reconstr Surg 1998;102(1):205–212
[9] Rees TD, LaTrenta GS. The role of the Schirmer’s test and orbital morpholo-
gy in predicting dry-eye syndrome after blepharoplasty. Plast Reconstr Surg
1988;82(4):619–625
>10@ Shaw RB -r, .ahn DM. Aging of the midface bony elements: a three-dimensional
computed tomographic study. Plast Reconstr Surg 2007;119(2):675–681, discus-
sion 682–683
[11] Sinno S, =ide BM. Chin ups and downs: avoiding bad results in chin reoperation.
Aesthet Surg J 2017;37(3):257–263
Fig. 51.36 A 30-year-old man with Class I dental occlusion and mandibular deficiency desired improvement in jaw angle width and lower border
definition, as well as chin projection. A mandible ramus and posterior body augmentation with the implants was performed with a chin augmentation.
(a) Preoperative anterior, (b) oblique, and (c) lateral views. (d) Postoperative anterior, (e) oblique, and (f) lateral views.
b
e
f
c
a
d

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VIII Surgical Rejuvenation of the Face and Neck
>12@ Taylor CO, Teenier T-. Evaluation and augmentation of the mandibular angle
region. Facial Plast Surg Clin North Am 1994;3:329
>13@ Terino EO. Alloplastic facial contouring: surgery of the fourth plane. Aesthetic
Plast Surg 1992;16(3):195–212
>14@ Thomas MA, angle surgery. Aesthet Surg J 2009;29(6):473–476
>15@ :hitaker LA. Aesthetic augmentation of the posterior mandible. Plast Reconstr
Surg 1991;87(2):268–275
>16@ Plast Reconstr Surg 1998;102(5):1676–1684, discussion 1685
[17] [18] 2001;107(6):1585–1592, discussion 1593–1595
[19] plasty. Plast Reconstr Surg 2003;111(1):441–450, discussion 451.452
>20@ tion. Plast Reconstr Surg 2003;112(5):1422–1432, discussion 1433–1434
>21@ prone.” Plast Reconstr Surg 2004;114(4):980–987
>22@ 2005;29(3):141–147, discussion 148
>23@ 2008;121(2):620–628
>24@ roplasty and midfacial results. Plast Reconstr Surg 2009;124(6):2151.2160
>25@ 2009;29(4):323–329
>26@ Matros E, Momoh A, tions for rejuvenation and reconstruction using implants. Facial Plast Surg
2009;25(4):252–259
>27@ Sharabi SE, Hatef DA, .oshy -C, Hollier LH -r, the missing link in the facial aging puzzle" Aesthetic Plast Surg 2010;34(5):603–611
>28@ Shaw RB -r, .atzel EB, .oltz PF, et al. Aging of the facial skeleton: aesthetic impli-
cations and rejuvenation strategies. Plast Reconstr Surg 2011;127(1):374–383
>29@ skeleton: an occasional adjunct or alternative to orthognathic surgery. Plast
Reconstr Surg 2011;127(5):2021–2030
>30@ rhinoplasty. Clin Plast Surg 2016;43(1):187–193
>31@ chin reoperation. Aesthet Surg J 2017;37(3):264–265

52 Neck Lift
749
52 Neck Lift
Foad Nahai
Abstract
Options for rejuvenation and contouring the neck range from
liposuction to extensive procedures including subplatysmal
resection of fat, digastric muscle reduction, and excision of the
superficial lobe of the submandibular gland.
Keywords
neck lift, submental lift, digastric muscle excision, submandibu-
lar gland excision
52.1 Introduction
My thinking and current approach to treatment of the neck
have been influenced by the work of my close friends. Courtiss’s
submental liposuction, Feldman’s corset platysmaplasty, and
Connell’s modification of the subplatysmal structures, combined
with the experience -ohn Bostwick and I have had with endo-
scopic 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 recontouring of the submental skin
without any redundancy. 1ormal skin quality and elasticity are
prerequisites. Feldman’s corset platysmaplasty improved the
submental contour and jawline and eliminated platysma bands.
Connell’s subplatysmal approach further improved neck con-
tour through the elimination of bulging fat, digastric muscles,
and submandibular glands. Our experience with endoscopic
face- and neck lifts clearly established that all of the compo-
nents of a neck lift could be performed through minimal-access
incisions, and if skin excision was not needed, the standard
retroauricular facelift incision, serving only for access, could be
totally eliminated.
Almost all facelift procedures, especially those involving the
superficial musculoaponeurotic system (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 procedures. Other factors I take into account in deciding
whether to make a submental incision include modifications of
the platysma in the midline and subplatysmal procedures. 1eck
lifts are performed not only in conjunction with facelifts but also
as separate procedures without a concomitant facelift.
1ot 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. 1eck lifting
involves a combination of rejuvenation or reversal of the aging
process and recontouring. Volume management superficial and
deep to the platysma are integral parts of neck contouring. The
spectrum of procedures available to us ranges from liposuction
only to a full open neck lift, and through multiple incisions with
intervention in each of the three planes³superficial, intermedi-
ate, and deep. After careful evaluation, the surgeon selects the
appropriate procedure and plans the incisions, vectors, and planes
of intervention (Fig. 52.1).
Surgical Options
• Liposuction only
̑ Suction-assisted liposuction (SAL)
̑ Ultrasound-assisted liposuction (UAL)
̑ Power-assisted liposuction (PAL)
̑ Laser-assisted liposuction (LAL)
• Submental lift
• Endoscopic neck lift
• Short-scar facelift, with or without submental incision
• Full-scar facelift, with or without submental incision
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 direct excision. The fat between and deep to the platysma
muscles is removed by direct excision, since liposuction deep to
the platysma is risky and inappropriate. Muscle and fascia pli-
cation involves the platysma muscle and its investing fascia. The
procedures deep to the platysma include fat removal, tangential
excision of the anterior belly of the digastric muscles, intracap-
sular 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
• Subplatysmal procedures (deep plane)
• Skin undermining
̑ 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

750
VIII Surgical Rejuvenation of the Face and Neck
possible without skin excision. The key is to assess the skin of the
neck and establish whether the excess, if any, is real or apparent.
In patients with deeply etched transverse lines, undermining of
the skin is necessary to improve those lines. Rarely, peels and/or
fillers and fat may improve these lines.
52.2 Pertinent Anatomy
52.2.1 Fat
:ithin 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, weight, and genetics.
It is usually more abundant in the submental area, extending 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 muscle and the submandibular gland.
Dramatic neck recontouring can be achieved through removal of
neck fat in these different levels (Fig. 52.2).
The operative view shown in Fig. 52.3 demonstrates en bloc
resection of preplatysmal–submental fat and separate en bloc
resection of interplatysmal and subplatysmal 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.
Fig. 52.1 Different morphologies of the aging neck demand an
individualized approach to neck rejuvenation.
Fig. 52.2 (a) Anatomy of the neck. (b) Distribution of fat within the neck.
b
a

52 Neck Lift
751
52.2.2 Muscle
Platysma
The platysma muscles separate the neck into superficial and
deep compartments. These muscles are large, thin sheets that
extend from the face across the neck and down to the clavicle.
:ithin 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 (Fig. 52.4).
This confirms our clinical impression that in the majority of
patients there is very limited interdigitation of the muscles medi-
ally, 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. :ith aging, attenuation of this retaining ligament
system allows platysmal descent, which accounts not only for
platysma bands but also for the increasingly oblique cervical
angle, both of which are hallmarks of the aging neck. :hile these
anatomical descriptions are useful additions to our knowledge
of the intricate anatomy, treatment of platysma bands remains a
challenging problem with much debate as how best to eliminate
the bands. 1eurotoxins also offer an alternative to surgical modi-
fication of the platysma.
Digastric Muscle
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. :ithin this triangle lie the submandibular gland,
the facial artery and vein, the lingual nerve, and the marginal
mandibular branch of the facial nerve (Fig. 52.5).
Fig. 52.4 Classification of platysma anatomy, as defined by the relationship of the two muscles in the submental area. Type I: In 75% of cases (most
common), there is a limited decussation of the platysma muscles, extending 1 to 2 cm below the mandibular symphysis. Type II: In 15% of cases,
decussation of the platysma extends from the mandibular symphysis to the thyroid cartilage. Type III: In 10% of cases, there is no decussation or
interdigitations.
Fig. 52.3 Intraoperative view of en bloc resection of preplatysmal and
submental fat and separate resection of interplatysmal fat.

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VIII Surgical Rejuvenation of the Face and Neck
52.2.3 Submandibular Gland
Submandibular glands lie within the submental triangle.
:hether clinically visible glands are ptotic or simply enlarged
is currently a matter of debate. The submandibular gland lies in
close proximity to the facial artery, which crosses superficial to
the 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 intracapsular, because
all of these structures lie outside of the capsule of the gland (Fig.
52.6).
52.2.4 Clinical Correlations
The platysma divides the neck into a superficial and a deep
compartment. My clinical approach to the neck, the layered
Fig. 52.5 Anatomy of the submental triangle.
Fig. 52.6 The submandibular gland and surrounding structures.

52 Neck Lift
753
approach, includes intervention in three planes: superficial,
intermediate, and deep (Fig. 52.7):
• The superficial plane includes only the subcutaneous fat, and
intervention in this plane is limited to fat contouring.
• The intermediate plane includes the platysma muscles, any
fat lying between them, 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 sub-
mandibular gland has to be performed cautiously and within the
capsule. Resection of the superficial lobe is relatively safe, because
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 sup-
rahyoid fascia also lies in the deep plane. This fascia is occasionally
released to improve further on the cervical angle in patients with
a high hyoid.
52.3 Preoperative Assessment
Careful evaluation of the neck and its relationship to the lower
third of the face will lead to selection of the appropriate proce-
dure with which to meet the patient’s goals. This evaluation also
help determine incisions, vectors, and planes of intervention.
In order 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.
Focus of Neck Evaluation
• Fat
• Muscles
• Submandibular gland
• Skin
• Neck–face interface
• Jawline and jowls
52.3.1 Fat
Fat removal has the most dramatic effect on neck contouring.
Therefore it is important 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.
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 (Fig. 52.8). If
the amount of fat within the pinch diminishes on contraction of
the muscle, 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.
Fig. 52.7 (a) The superficial, (b) intermediate, and (c) deep planes of the neck.
a
b
c

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VIII Surgical Rejuvenation of the Face and Neck
52.3.2 Muscle and Submandibular Gland
The platysma and digastric muscles are evaluated. The pla-
tysma bands may be visible 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
possible, especially in a heavy neck. The digastric muscles are
best evaluated during the procedure, after the subcutaneous fat
is removed (Fig. 52.9).
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 before the surgeon decides about the
gland.
52.3.3 Skin
The length of the skin incision in neck lifting reflects the location
of the excess skin to be removed and whether deeply etched
transverse neck lines need to be addressed surgically through
undermining. 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 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. 1ormal
skin elasticity is essential for all short-scar procedures. Patients
who have inelastic, sun-damaged skin must have the full retro-
auricular incision for a good result.
Apparent excess skin will redrape after recontouring below the
skin, such as submental skin following fat removal in all three
planes, as well as digastric and submandibular 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.
Fig. 52.10 shows skin redraping after fat removal and platysma
plication through a submental incision in a patient with apparent
excess skin. A short preauricular incision was made to tighten the
SMAS so as to improve on the jowls and the jawline. 1o 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.
The patient shown in Fig. 52.11 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 facelift incision, including a retroau-
ricular extension, is required for an optimal result.
52.3.4 Vectors
Skin evaluation influences my choice of vectors. The vertical
vector applied to the neck in combination with a facelift, 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.
52.3.5 Neck–Face Interface
If there is significant jowling and descent of the neck–face
interface with blunting of the jawline, an isolated neck lift
procedure will not address those problems 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. I feel that a
better option is to reposition the jowls through a facelift incision
and SMAS elevation.
Fig. 52.8 The location of submental neck fat is assessed by pinching
the fat at rest and observing its movement with contraction of the
platysma.
Fig. 52.9 Evaluation of excess skin of the neck and platysma bands
(a) with the patient at rest and (b) on animation.
b
a

52 Neck Lift
755
52.3.6 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 is the procedure of choice.
If platysma bands have to be dealt with, an intermediate plane
intervention is planned. If subplatysmal fat removal, modifica-
tion of the digastric muscles, or submandibular gland excision is
required, intervention in the deep plane is planned. It is not rare
to perform procedures in all three planes.
52.4 Preoperative Planning and
Decision Making
I currently have five options for neck recontouring or rejuvena-
tion, ranging from liposuction to a full-scar face- and neck lift:
1. Liposuction
2. Submental neck lift
3. Endoscopic or limited-incision 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 enable intervention in the
intermediate or platysmal plane as well as access to the plane
below the platysma. In combination with a facelift, 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.
Table 52.1 represents surgical options, along with each of the
components of the neck lift that apply to that approach.
52.5 Operative Technique
52.5.1 Liposuction
The best candidates for liposuction recontouring of the neck are
usually younger patients with normal-quality skin and localized
excess submental fat. Clinical evaluation of the platysma 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 (Fig.
52.12).
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 underlying platysma bands or deep plane fullness.
The best way to avoid this is a complete and detailed evaluation
of the neck before selecting liposuction as the procedure 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 patient is placed supine
on the operating table with the neck in full extension. Through
an access incision in the submental area and optional incisions
Fig. 52.10 (a,c) Preop and (b,d) postop photos (top) and diagrams
(bottom) following fat removal and platysma plication through a
submental incision. The superficial musculoaponeurotic system was
tightened through a short preauricular incision to contour the jawline.
No neck skin was excised, but the effect of skin redraping is significant.
Fig. 52.11 Patient with skin excess beyond the thyroid cartilage and
behind the sternocleidomastoid muscle, as well as generally poor skin
elasticity.
c
d
a
b

756
VIII Surgical Rejuvenation of the Face and Neck
behind each earlobe, the neck is infiltrated with a wetting
solution. My preference is Ringer’s lactate solution with 250 mg
of lidocaine and 1 mg of epinephrine added to each liter. I find
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 following 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 mL of fat on the deep surface of the skin so as to avoid
postoperative irregularities. 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.
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 the woman shown in Fig. 52.13.
Overaggressive fat removal from her neck and submental area has
unmasked platysma bands and prominent digastric muscles.
Fig. 52.12 A detailed and dynamic evaluation of the neck is necessary to identify the best operative approach. (a) Platysma bands visible at rest,
(b) no visible platysma bands at rest, (c) platysma bands visible on animation.
Table 52.1 Choosing the best option for neck lift
Neck lift options: components of neck lift
Fat
Muscles
Skin
Planes or layers
of the neck
Subcutaneous
Interplatysmal
Subplatysmal
Platysma
Digastric
Submandibular
gland
No Real
Excess
Excess
Poor
quality
Aged neck–
face interface
Liposuction
only
¥
Submental
neck lift
¥
¥
¥
¥
¥
¥
¥
Endoscopic
limited incision
neck lift
¥
¥
¥
¥
¥
¥
¥
Short-scar face
and neck lift
¥
¥
¥
¥
¥
¥
¥
¥
Full-scar face
and neck lift
¥
¥
¥
¥
¥
¥
¥
¥
¥
a
b
c

52 Neck Lift
757
In SAL of the neck the cannula is passed slowly through sepa-
rate tunnels, fanning out from the submental incision (Fig. 52.14).
I make it a point never to make more than one or two passes in
each tunnel, because repeated passes within a tunnel will lead to
oversuction 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 crisscrossing 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 observation of the recontouring effect and by pinching the
skin and subcutaneous tissues. I also roll my fingers along the skin
with gentle pressure to look for irregularities to ensure that the fat
removal has been uniform.
1o drains are required for liposuction of the neck, but compres-
sion is applied with either foam tape or an elastic garment.
Results
The patient shown in Fig. 52.15 underwent liposuction of her
neck and is shown preoperatively and 4 years postoperatively.
The redraping of her excess neck skin in the submental area is
apparent. 1o skin excision was performed.
The young woman shown in Fig. 52.16 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.
The patient shown in Fig. 52.17 underwent liposuction of the
submental area and transoral chin augmentation with a solid sili-
cone implant. Improvement of facial proportions is demonstrated,
with a more pleasing jawline and neck–jaw angle.
Fig. 52.13 Overaggressive fat removal from the neck and submental
area has unmasked platysma bands and prominent digastric muscles.
Fig. 52.14 The liposuction cannula is passed through separate tunnels
fanning out from the submental incision.
Fig. 52.15 (a,c) Preop and (b,d) 4-year postop photos following liposuction of the neck without skin excision.
a
b
c
d

758
VIII Surgical Rejuvenation of the Face and Neck
Liposuction of the submental area and neck unmasked platysma
bands, more noticeable on the right than on the left, in the patient
shown in Fig. 52.18. A better result would have been achieved
through a submental neck lift, including platysma plication.
52.5.2 Submental Neck Lift
The submental neck lift includes an incision in the submental
area, variable undermining of the neck, and intervention in
each plane of the neck as indicated. The submental 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 facelift. 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 submental approach described here is usually
performed in combination with a facelift.
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 continued anteriorly under the crease to
release it from the underlying tissues. If indicated, this dissection
progresses forward and laterally to release the mandibular liga-
ments. Subcutaneous defatting is then performed. I prefer to do
this directly rather than through liposuction. :ith the scissors, I
elevate the skin with a 3- to 5-mm layer of fat.
The skin is undermined in this plane toward the thyroid carti-
lage and laterally 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
Fig. 52.16 (a,c) Preop and (b,d) postop photos following liposuction of the submental area and neck. The submental and jawline contours are
improved.
Fig. 52.17 (a,c) Preop and (b,d) postop photos following
liposuction of the submental area and transoral alloplastic chin
augmentation.
a
b
c
d
a
c
b
d

52 Neck Lift
759
over the platysma, leaving all the fat on the deep surface of the
skin (Fig. 52.19).
If procedures are planned deep to the platysma, the platysma
on each side is elevated, and any fat in between layers of or deep
to the platysma is directly excised as needed. If interplatysmal
or subplatysmal fat excision is planned or performed, it is very
important to leave an adequate subcutaneous layer of fat to avoid
a submental depression. There is often a very small lymph node or
two in the fatty layer, between layers of or deep to the platysma,
which is usually included in this resection.
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 (Fig. 52.20). The anterior bellies of the
digastric muscles may be tangentially excised, totally excised, or
the two plicated in the midline.
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 (Fig. 52.21). 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 dissecting 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 (Fig. 52.22).
Once the anterior belly of the digastric muscle has been dealt
with, an enlarged submandibular gland is easily visualized. Even
if a decision has already been made to dissect the gland, the neck
Fig. 52.18 (a,c) Preop and (b,d) postop photos following liposuction of the submental area and neck. The procedure has unmasked platysma
bands.
Fig. 52.19 Undermining performed in a submental neck lift.
Fig. 52.20 The platysma muscle is elevated to expose fat and digastric
muscle.
a
b
c
d

760
VIII Surgical Rejuvenation of the Face and 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.
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 (Fig. 52.23; Fig. 52.24). If there is any bleed-
ing, 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.
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. 1eck undermining 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 suction drain is
routinely placed in the neck. The skin is closed in two layers: 4–0
poliglecaprone (Monocryl, Ethicon, Somerville, 1-) for the dermis
and intracuticular 5–0 Monocryl for the skin. Tapes and dressings
are applied.
Fig. 52.21 (Left) The digastric muscle is tangentially excised. (Right)
A hemostat passed halfway through the digastric muscle guides the
extent of resection.
Fig. 52.22 At least half the thickness of the digastric muscle is
excised by transverse myotomies at the muscle’s origin and tendinous
insertion.
Fig. 52.23 Exposure and partial resection of the submandibular gland.
Fig. 52.24 Piecemeal excision of superficial lobe of submandibular
gland.

52 Neck Lift
761
Postoperative Care
Patients undergoing an isolated submental lift may be allowed to
go home on the same day as surgery. Those undergoing a facelift
in combination will remain overnight in our facility. A compres-
sion tape or garment is worn for several days postoperatively.
The drain is removed the next day after surgery.
Result
Preoperative evaluation of the man shown in Fig. 52.25 demon-
strated 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. 1o subcutaneous fat was removed,
so that a smooth contour remained. He also had chin augmenta-
tion with an anatomic solid silicone implant. Postoperative views
demonstrate improved contour without skin irregularities.
52.5.3 Endoscopic or Limited-Incision
Neck Lift
Technique
The submental neck lift described earlier has almost entirely
replaced our original endoscopic neck lift procedure. This pro-
cedure 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 sternocleidomastoid 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.
Results
The patient shown in Fig. 52.26 underwent an endoscopic neck
lift, including platysma plication and neck suspension sutures
through a 4-cm submental incision and a 1-cm retroauricular
incision on each side. There was no skin excision.
A similar procedure was performed on the patient shown in
Fig. 52.27, who exhibited platysma bands and apparent excess
skin in the submental area.
52.5.4 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 but has 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 (Fig. 52.28). If needed, neck recontouring
through liposuction or through a submental approach may be
performed at the same time. :ith the submental approach,
I connect the face and neck dissections in the subcutaneous
plane. The technical aspects of the procedure for the neck were
described earlier.
Technique
A prehairline incision is made below the sideburn, and a pre-
auricular intratragal incision is made down to and around the
earlobe (Fig. 52.29a).
The skin flap is elevated and the dissection connected with the
neck dissection, which usually extends to the posterior border of
the sternocleidomastoid (Fig. 52.29b,c).
The sub-SMAS dissection is then initiated at the junction of
the adherent and mobile SMAS. A diagonal incision is made in
the SMAS, extending from the zygomatic prominence toward the
angle of the mandible. The dissection then continues along the
lateral border of the platysma (Fig. 52.30a–c).
The SMAS-platysma flap is mobilized by blunt dissection and
then pulled upward in the face and posteriorly in the neck (Fig.
52.30d). Usually in a heavy face, a portion of the elevated SMAS
and platysma is resected; in thin faces, it is plicated with perma-
nent or absorbable suture material (Fig. 52.30e). My preference is
3–0 PDS. 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 facelifts. The drain is brought out
behind the earlobe.
Fig. 52.25 (a,c) Preop and (b,d) postop photos following submental neck lift, including subplatysmal fat and digastric excision, and chin augmentation.
a
b
c
d

762
VIII Surgical Rejuvenation of the Face and Neck
The facial skin is redraped directly upward with a slight diagonal
vector posteriorly. The excess skin is resected and an anchoring
suture of 3–0 polydioxanone is placed at the base of the concha.
The excess skin is then trimmed, tailored around the tragus, and
inset (Fig. 52.31). 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.
Results
The woman shown in Fig. 52.32 underwent a short-scar facelift
that included a submental incision with platysma plication. She
is seen 4 years postoperatively.
The preoperative views of the patient shown in Fig. 52.33a
demonstrate jowls and apparent excess skin in the submental area;
she also exhibited platysma bands on animation. She underwent a
short-scar face- and neck lift, including a submental incision with
submental fat removal and platysma plication. The postoperative
view demonstrates neck recontouring, improvement of jowling,
and no retroauricular scars (Fig. 52.33b).
The ideal candidate shown in Fig. 52.34 underwent a short-scar
facelift through a submental incision with subplatysmal interven-
tion, 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.
52.5.5 Full-Scar Face- and Neck Lift
The best candidates for a full-scar face- and neck lift are indi-
viduals 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 scar. 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.
The patient shown in Fig. 52.35 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 submental skin excess
Fig. 52.26 (a,c) Preop and (b,d) postop photos following endoscopic neck lift, including platysma plication and neck suspension sutures.
Fig. 52.27 (a,c) Preop and (b,d) postop photos following endoscopic neck lift with platysma plication.
a
a
b
b
c
c
d
d

52 Neck Lift
763
Fig. 52.30 (a) The sub–superficial musculoaponeurotic system (SMAS) dissection is initiated at the junction of the adherent and mobile SMAS. (b)
A diagonal incision is made in the SMAS, extending from the zygomatic prominence toward the angle of the mandible. (c) The dissection continues
along the lateral border of the platysma. (d) The SMAS–platysma flap is mobilized and then pulled upward in the face and posteriorly in the neck. (e)
A portion of the flap is resected in heavy faces and plicated in thinner faces.
Fig. 52.28 (a) The ideal candidate for a short-scar face- and neck lift
has no excess neck skin but exhibits jowls and aging of the neck-face
interface. (b) The short-scar approach imparts a vertical vector of
elevation on the superficial musculoaponeurotic system and a slight
diagonal vector on the skin. (c) The short-scar facelift incision.
Fig. 52.29 (a) Markings for prehairline and preauricular intratragal inci-
sions. (b) The superficial musculoaponeurotic system (SMAS)-platysma
flap is elevated upward in the face and (c) posteriorly in the neck.
a
b
c

764
VIII Surgical Rejuvenation of the Face and Neck
will improve the submental area (Fig. 52.36a). :ith rather long
sideburns, this patient is a candidate for the classic facelift inci-
sion, extending from the temporal area into the occipital hair (Fig.
52.36b). The postoperative view, compared with the preoperative
view, demonstrates neck recontouring (Fig. 52.36c,d).
Technique
Occasionally, in individuals with unusually lax skin with signif-
icant 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 poste-
riorly (Fig. 52.37). This modification allows resection of more
of the neck skin without altering the occipital hairline. There is
more extensive skin undermining with this incision, extending
beyond the posterior border of the sternocleidomastoid muscle
and behind the ear. Management of the SMAS and platysma was
described 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
Fig. 52.33 (a,c,e) Preop and (b,d,f) postop photos of patient who underwent a short-scar face- and neck lift, including a submental incision with
submental fat removal and platysma plication. (e,f) Photos demonstrate no retroauricular scars.
Fig. 52.31 (a) The facial skin is pulled directly upward with a slight
diagonal vector posteriorly. (b) Excess skin is resected and the flap
inset.
Fig. 52.32 (a) Preop and (b) 4-year postop photos of patient who
underwent a short-scar facelift that included a submental incision with
platysma plication.
a
a
b
b
a
e
b
f
d
c

52 Neck Lift
765
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. :hen closing behind the ear, it
is important to include the deep fascia in the retroauricular sulcus
within the closure; this will prevent outward migration of the
retroauricular scar. Dressings and postoperative management are
the same as described for the short-scar face- and neck lift.
Results
The middle-aged woman shown in Fig. 52.38, seen preopera-
tively and 5 years postoperatively, underwent an endoscopic
brow lift, upper and lower lid blepharoplasty, face and neck lift
with platysma plication, and CO2 laser resurfacing of the fore-
head and perioral area. The split-face view demonstrates that
brow position has been maintained and platysma bands have
been eliminated.
The middle-aged patient shown in Fig. 52.39 underwent a
face- and neck lift, with upper and lower lid blepharoplasty. 1o
Fig. 52.36 (a) The vertical vector on the superficial musculoaponeu-
rotic system will improve her jowls, and the redraping of the apparent
submental skin excess will improve the submental area. (b) With
rather long sideburns, this patient is a candidate for the classic face-lift
incision, extending from the temporal area into the occipital hair. (c)
Preoperative view. (d) The postoperative view demonstrates neck
recontouring.
Fig. 52.34 (a,c) Preop and (b,d) postop photos of patient who underwent a short-scar facelift through a submental incision with subplatysmal
intervention, including partial excision of the submandibular gland.
Fig. 52.35 This patient demonstrates jowls, a visible submandibular
gland, platysma bands, and excess skin below the thyroid, making her
a good candidate for a full-scar face- and neck lift.
a
b
d
c

766
VIII Surgical Rejuvenation of the Face and Neck
subcutaneous fat was removed from her neck. Her improved con-
tour is the result of subplatysmal procedures, including digastric
and submandibular gland excision.
The woman shown in Fig. 52.40 had a lower lid blepharoplasty,
face and neck lift, including a submental incision, subplatysmal
fat removal, and platysma plication. Her postoperative result
demonstrates smooth recontouring of the neck.
The patient in her 60s in Fig. 52.41 is shown before and 3 years
after a full-scar facelift, a neck lift with no fat removal, a temporal
brow lift, an upper lid blepharoplasty, a lower lid blepharoplasty
including fat preservation, orbicularis redraping, and canthopexy.
An oblique view of her in her 20s is included. The only flaws in an
otherwise good result at 3 years are the wrinkles around her lat-
eral brow and central neck. These are related more to skin quality
than to the effectiveness of her face and neck lift. A resurfacing
procedure at this stage would be beneficial.
Fig. 52.37 Incision for a full-scar facelift continues around the ear up
to about the level of the tragus or just below, crosses to the hairline,
and follows the occipital hairline inferiorly and posteriorly.
Fig. 52.38 (a,d) Preop and (b,e) 5-year postop photos of patient
who underwent 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. Split-face view
(c) demonstrates appropriate brow position and elimination of
platysma bands.
Fig. 52.39 (a,c) Preop and (b,d) postop photos of patient who underwent face- and neck lift including digastric and submandibular gland excision
and upper and lower lid blepharoplasty.
a
b
d
c
e
a
b
c
d

52 Neck Lift
767
Fig. 52.40 (a,c) Preop and (b,d) postop photos of patient who underwent lower lid blepharoplasty, face- and neck lift, including a submental
incision, subplatysmal fat removal, and platysma plication.
Fig. 52.41 (a,c) Preop and (b,d) 3-year postop photos of patient in her 60s who underwent full-scar facelift, neck lift with no fat removal, temporal
brow lift, and upper and lower lid blepharoplasty. (e,f) Patient is shown in her 20s for comparison.
a
a
b
b
c
c
e
d
d
f

768
VIII Surgical Rejuvenation of the Face and Neck
The middle-aged patient shown in Fig. 52.42 underwent a face
and neck lift, including subplatysmal fat removal and platysma
plication. 1o subcutaneous fat was removed to maintain a 5-mm
layer of fat over the platysma. The improved neck contour is the
result of subplatysmal procedures and platysma plication.
52.6 Problems and Complications
The most common error I see in neck recontouring is overoperat-
ing in the superficial plane to mask or improve intermediate- or
deep-plane problems. The tendency is to overdo the removal
of subcutaneous fat rather than deal with problems related to
interplatysmal or subplatysmal fat, the digastric muscle, and
submandibular gland. Reluctance to address the deeper layers in
the neck leads to suboptimal contouring. The excessive removal
of subcutaneous fat leads to adherence of the denuded dermis
directly onto the platysma muscle, producing 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.
Preoperatively, the patient shown in Fig. 52.43 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 dyschromias resulting from CO2 laser resurfacing. Excision
of digastric muscles and submandibular 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 redraping 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 include an upward vector in the face and a
diagonal posterior vector. Excessive posterior traction on the neck
without adequate vectors of elevation anteriorly along the jawline
will lead to a banding or a ´hammock effect,µ whereby the lower
and posterior neck are effectively tightened, but laxity remains in
the submental area, jowls, and neckline.
The patient shown in Fig. 52.44, who had undergone two previ-
ous facelifts, demonstrates the inappropriate vectors and planes of
intervention employed during her previous facelifts. 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
Skin problems following neck lifts are usually related to
failure of adequate redraping 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 facelift with appropriate
management of the facial skin.
Fat problems are related to overexcision or underexcision.
Overexcision is most often 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 pla-
tysma and adjacent to the submental incision itself. These can be
avoided through proper planning and appropriate 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
Fig. 52.42 (a) Preop and (b) postop photos of patient who received a
face- and neck lift, including subplatysmal fat removal and platysma
plication.
Fig. 52.43 (a) Preop view of patient with neck irregularities from
overzealous fat removal during a prior surgery and skin dyschromias
from CO2 laser resurfacing. (b) Postop view following excision of
digastric muscles and submandibular glands demonstrates improved
neck contour. Skin adhesions to the platysma limit the final result.
a
a
b
b

52 Neck Lift
769
are not dealt with primarily or when the plication sutures fail.
Solutions include reoperation to plicate or resect as indicated and
temporary treatment with botulinum toxin injections. Alternative
approaches such as transcutaneous division of platysma bands, as
advocated by Gonzalez, 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 subcutaneous fat was removed.
Correction is relatively straightforward, entailing digastric exci-
sion through a submental incision.
Bulging in the submental triangle results from an enlarged sub-
mandibular gland. Most often this was present preoperatively and
was not dealt with or was unmasked by subcutaneous 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 posterior 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
countertraction in the others will result in banding or a hammock
effect. Correction includes reoperation and remobilization with
more balanced traction.
Fig. 52.44 (a,d) Preop view of a patient with a suboptimal result from two prior facelifts. (b,e) 1-year and (c,f) 2-year postop views following tertiary
face and neck lift with redirection of superficial musculoaponeurotic system and skin vectors and subplatysmal recontouring.
a
d
b
e
c
f

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VIII Surgical Rejuvenation of the Face and Neck
52.7 Concluding Thoughts
The neck does not always have to be opened in order to be
recontoured and rejuvenated, nor is it necessary to operate deep
to the platysma in every patient. A full preoperative 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 3 mm or smaller in diameter should
be used.
• Patients must be evaluated for platysma bands and subpla-
tysmal fat before liposuction.
• Liposuction may unmask preexisting platysma bands.
• Liposuction should be avoided in patients who have fat super-
ficial 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 overresec-
tion of subcutaneous fat.
• The need for digastric or submandibular gland excision should
be evaluated intraoperatively.
• Submandibular gland excision is performed within the cap-
sule 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 (such as a peel with 20% trichloroacetic acid)
should be considered to improve skin quality in the neck.
Suggested Reading
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>10@ Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg 1985;76(6):882–889
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>15@ Feldman --. Corset platysmaplasty. Plast Reconstr Surg 1990;85(3):333–343
>16@ Feldman JJ. Neck Lift. St. Louis, MO: 4uality Medical Publishing; 2006
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Plast Reconstr Surg 1998;102(5):1710–1714, discussion 1715
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>20@ Giampapa VC, Di Bernardo BE. 1eck recontouring with suture suspension and
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myotomy: a simple way to treat deformities of the neck caused by aging. Aesthet
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>22@ Gradinger GP. Anterior cervicoplasty in the male patient. Plast Reconstr Surg
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pushing the (skin) envelope to avoid a face lift for unsuitable candidates. Plast
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>24@ Guerrerosantos -. Surgical correction of the fatty fallen neck. Ann Plast Surg
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>25@ Guerrerosantos -. 1eck lift. Simplified surgical technique, refinements, and
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modified S-lift. Plast Reconstr Surg 2002;109(6):2074–2086

53 Secondary Neck Lift
771
53 Secondary Neck Lift
Timothy Marten and Dino Elyassnia
Abstract
The increased number of patients seeking neck improvement
at a younger age, coupled with the typically disappointing out-
comes of “noninvasive” and “minimally invasive” treatments,
has resulted in a significant increase in requests for secondary
neck lift procedures. In the evaluation and treatment of the
patient presenting for secondary neck lift, one must identify
and treat not only new problems due to age and time but
those that have resulted from prior procedures as well. Often,
these secondary irregularities present the biggest challenge to
the surgeon in terms of creativity, planning, preparation, and
technique.
Merely performing submental liposuction and tightening the
skin ignores a number of anatomic problems and produces medi-
ocre outcomes and secondary neck irregularities, particularly in
the secondary neck lift patient. Submental liposuction can result
in the inappropriate removal of subcutaneous fat essential to a
natural and youthful appearance.
Subplatysmal fat excision, submandibular gland reduction, and
superficial digastric myectomy can all contribute to creating the
best neck contour possible, and the skilled neck surgeon must
master treatment of all three of these “deep layer” problems and
use them in conjunction with each other as indicated in both
primary and secondary procedures if optimal results are to be
obtained.
´Platysma bandsµ comprise a heterogeneous group of distinct
problems. Platysmaplasty and platysmamyotomy address two
different problems. The key to successful treatment will rest in
understanding the origins of platysma problems, identifying the
type of problem present in a given patient, and employing logical
solutions to address those problems.
Keywords
secondary neck lift, submental liposuction, double chin, witches’
chin, submandibular gland reduction, digastic myectomy,
cervical lipectomy, subplatysmal fat, subplatysmal lipectomy,
interdigastric fat, platysmaplasty, platysmamyotomy, platys-
mapexy, platysma bands, anterior platysma bands, platysma
hyperfunction, full width platysma transection, postauricular
transposition flap
53.1 Introduction
The increased number of patients seeking neck improvement
at a younger age, coupled with the typically disappointing out-
comes obtained with the myriad of “noninvasive” treatments
patients and surgeons must navigate, has resulted in a signif-
icant increase in requests for secondary neck lift procedures.
Although many aspects of planning and performing secondary
surgery are similar to those of a well-conceived and planned
primary procedure, additional considerations must be taken
into account in the evaluation and treatment of the patient pre-
senting for secondary neck lift, as one must identify and treat
not only new problems that are the product of age and time but
those that have resulted from any prior procedure as well. Often
these secondary irregularities present the biggest challenge to
the surgeon in terms of creativity, planning, preparation, and
technique.
Consideration must also be given to possible underlying ana-
tomical damage that may have resulted from previous procedures
but is not evident as a visible deformity. This includes possible
damage to skin, subcutaneous fat, superficial musculoaponeurotic
system (SMAS), platysma, and deeper structures. Injury to these
tissues at the time of the primary procedure can preclude certain
maneuvers and limit the overall amount of improvement possible
at the time secondary surgery is performed. ´Red flagµ procedures
in this regard include ultrasonic liposuction (damage to and
overreduction of subcutaneous fat), radiofrequency and ultra-
sonic ´skin-tighteningµ treatments (damage to and overreduction
of subcutaneous fat, damage to skin microcirculation, and damage
to microlymphatics), chemolipolysis (subcutaneous fibrosis),
cryolipolysis (damage to subcutaneous fat, damage to skin micro-
circulation, and damage to microlymphatics), prior ´suture lifts,µ
and prolonged large-volume use of facial fillers (granulomas and
´filler fibrosisµ).
As in primary procedures, recognizing the problems in the
secondary neck lift patient and appreciating their underlying ana-
tomic abnormalities is fundamental to planning and performance
of any repair. Although not all problems can always be completely
corrected, any surgeon able to recognize their anatomic basis
can, through the application of logic and careful planning, select
techniques that are safe and effective.
It is unlikely there will ever be a consensus on how a neck lift
should be performed, and it is a fact that no one procedure will
be best for all patients. The technique used cannot be arbitrary,
must depend on the problems present, and must necessarily vary
from patient to patient. Success or failure in treating the neck in
both primary and secondary cases, as is the case with the nose,
breast, and body, lies in the diagnosis of underlying problems and
the application of a logical surgical plan. Any surgeon capable of
identifying the anatomic basis of patient problems and forming a
sound plan for their correction can potentially achieve excellent
outcomes.
The best treatment of secondary problems is to avoid them
in the primary procedure, and as a result, the question arises
of how one should perform a neck lift and what steps can be
taken to avoid common problems and complications. Perhaps
it is easiest to start by recognizing what not to do. Although it
is a commonly advocated practice, it is not enough to perform
submental liposuction and tighten the skin in most patients,
as such an approach ignores a number of anatomic problems
present in many patients seeking neck improvement including

772
VIII Surgical Rejuvenation of the Face and Neck
platysmal laxity, platysma bands, excess subplatysmal fat, large
submandibular glands, digastric muscle hypertrophy, and
developmental factors such as the size and shape of the bony
jaw and chin. Removing subcutaneous fat and/or tightening skin
over these problems does not correct them, and the presence
or absence of each must be looked for in order to create and
apply an appropriate surgical plan (Fig. 53.1). Once this fact is
acknowledged, it becomes clear that any procedure that targets
subcutaneous fat (cryolipolysis, chemolipolysis, liposuction,
etc.) or the skin (postauricular skin excision, radiofrequency or
ultrasound ´skin-shrinkingµ treatment, etc.) is destined to fail
and result in secondary problems. Any surgeon who regards the
problem present in the neck as consisting solely of excess sub-
cutaneous fat and lose skin that can be treated with procedures
that target only that tissue layer and try to remove or shrink skin
is destined to produce mediocre outcomes at best and, more
likely, secondary neck deformities.
It is also conceptually flawed and ultimately clinically inef-
fective to try to force contour in the neck by suspending tissue
(suture lifts, ´thread lifts,µ suspension sutures, ´barbedµ sutures)
or ´corsetµ tightening of the platysma. A young, attractive neck
is not tight and does not have a tight platysma but rather a
youthful distribution of tissue on it. Tightness is an aberration
created by surgeons employing conceptually flawed techniques,
and once that fact is recognized, it becomes clear that common
neck problems are not appropriately treated by platysma tight-
ening (´corsetµ platysmaplasty, ultrasound radiofrequency ´tissue
tightening,µ tissue heating, etc.) and that our goal in neck lift is to
modify tissues that have changed or hypertrophied with age in
a way to create youthful, attractive neck contour³not to tighten
the neck.
53.2 Strategies for Primary and
Secondary Neck Lifts
Patients seeking secondary neck lift will present with a variety
of irregularities and have a range of options available to them
depending on the problems present, the degree of improvement
they seek, and the time, trouble, and expense they are willing
to undergo to obtain the improvement they desire. :hile it is
essential to discuss these options and the advantages and dis-
advantages of each, patients are also seeking our guidance as to
what is possible, what is practical, and what is really best. It is not
enough to steer patients to procedures we are most comfortable
with performing. :e are professionally bound and ethically
obliged to refer patients for the care they need and desire if we
are not able to provide it ourselves.
53.2.1 Submental Liposuction
Submental liposuction (and arguably other ´noninvasiveµ
treatments, including cryolipolysis, deoxycholic acid injec-
tions, and radiofrequency and ultrasound ´skin shrinkingµ
and ´tissue shrinkingµ treatments that primarily exert their
effect through subcutaneous fat destruction) is the simplest
and likely the most commonly performed surgical procedure
to improve neck contour in the range of options available to
patients. It does not constitute a true neck lift, however, and
only occasionally produces optimal outcomes. Patients and
surgeons are predictably drawn into a sense of denial of this,
however, by the fact that submental liposuction will occasion-
ally produce worthwhile improvement in select cases, and it is
these atypical good outcomes that are displayed in surgeons’
offices, placed in advertisements, shown on TV, published in the
beauty press and on websites, and even included in presenta-
tions at plastic surgery meetings and symposia. Adding to the
deception is that fact that these photographs are usually taken
in the early postoperative period, when swelling is still present
that obscures irregularities and underlying but untreated deep
layer problems.
In reality, submental liposuction (along with the afore-
mentioned noninvasive procedures that target subcutaneous
neck fat) is an incomplete solution to neck problems for most
patients. As a standalone treatment it suffers the significant
drawback that it falsely assumes poor neck contour to be
solely the result of the accumulation of subcutaneous fat, and
it is conceptually flawed in that it does not address platysma
laxity and other deep-layer problems that together typically
play a much larger and more important role in the aging
neck and neck contour deformities. As such, the majority of
patients undergoing this procedure achieve arguably marginal
Fig. 53.1 Patient seen before and after neck lift. It is not enough to perform submental liposuction and tighten the skin in most patients. Such
an approach ignores anatomic problems present in many patients seeking neck improvement. (a,c) A careful evaluation shows patient preopera-
tively to be troubled by platysmal laxity, platysma bands, excess subplatysmal fat, large submandibular glands, and digastric muscle hypertrophy.
Little or no excess subcutaneous fat is present, however. (b,d) Removing subcutaneous fat and tightening skin over these problems would not
correct them or produce the type of improvement shown. (Procedures performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of
Plastic Surgery.)
a
b
c
d