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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VIII Surgical Rejuvenation of the Face and Neck
neck contour can be created without removing and tightening the
skin, and what happens to the ´excessµ skin if only the deeper-
layer treatment is done and no skin is excised. The answer to this
question is twofold.
First is the simple (but often difficult to accept) concept that in a
properly performed neck lift, contour is created by modification of
deep layers of the neck, not by tightening the skin. Skin is intended
to be a covering layer and serve a covering function, and it was
meant to stretch and give as we move and express ourselves. It
was not intended to be a structural supporting layer or to hold
up sagging muscle and fat or lift hypertrophied structures lying
beneath it.
Fig. 53.5 Neck lifts with a submental incision only. Although submental liposuction alone will rarely produce optimal neck improvement, a neck lift
performed through a submental incision without any removal of skin can create attractive cervical contour in many patients. These patients had their
procedures performed through submental incisions only. No incisions were made in the periauricular areas, no periauricular scars are present, no skin
was removed, and no lateral platysmal suspension was performed. (a) Procedure performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic
of Plastic Surgery. (b) Procedure performed by Dino Elyassnia, MD, FACS. Courtesy of Dino Elyassnia, MD. (c) Procedure performed by Timothy Marten,
MD, FACS. Courtesy of Marten Clinic of Plastic Surgery. (d) Procedure performed by Dino Elyassnia, MD, FACS. Courtesy of Dino Elyassnia, MD.

53 Secondary Neck Lift
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The second part of the answer lies in the increase in neck surface
area that occurs when neck contour is improved using deep-layer
neck maneuvers. Improving neck contour by excising redundant
subplatysmal fat and performing other deep-layer maneuvers as
indicated, followed by reconstituting a lax platysma (but not cre-
ating a tight ´corsetµ) will result in a deeper cervicomental angle, a
longer curvilinear distance from the mentum to the sternal notch,
and a more concave and geometrically larger and longer neck
surface. :hen neck skin is redraped and redistributed over the
deeper, more concave surface, ´excessµ skin is absorbed and none
need be removed (Fig. 53.6a). These simple but not necessarily
intuitive or immediately obvious facts explain why skin excision
need not be performed in patients with good skin quality and mild
to moderate apparent skin excess to obtain a good result in both
primary and secondary neck lift procedures. In female patients,
good results can be obtained from short-scar neck lifts in patients
up to their late 30s. In male patients, satisfactory outcomes can be
achieved in patients up to their late 50s.
Once the fact that increased neck surface area is produced by
deepening the cervicomental angle is acknowledged and accepted,
it becomes clear why it is counterproductive to excise any skin
from the submental incision: this can create a ´bowstringµ effect
and actually blunt the cervicomental angle. Skin removal along
this vector is not helpful in most patients. The submental skin
incision is used only for access to the neck in a properly performed
neck lift, and if skin excision is necessary, it is more practically,
effectively, and logically removed from the postauricular area
(extended neck lift or a facelift procedure) along a more appropri-
ately directed lateral vector (see Fig. 53.6b).
The results that can be obtained with a short-scar neck lift
stand as compelling confirmation of the supremacy of the deep-
layer approach over more traditional procedures that mistakenly
focused on skin excision, subcutaneous fat removal, and platysmal
tightening.
53.2.3 Why Not Perform a Short-Scar
Neck Lift on Everybody?
There is a limit to the amount of neck skin that can be absorbed
and managed in this manner, however, and an isolated neck lift
performed through a submental incision only is typically best as
a primary procedure for male patients and younger women with
mild to moderate skin excess, good skin elasticity, and minimal
or modest aging in the midface, cheek, and jowl. In patients pre-
senting for secondary procedures in which skin was aggressively
excised at the primary procedure, a submental incision only
may be needed to perform needed deep-layer maneuvers and to
achieve the desired improvement in neck contour.
53.2.4 Inappropriate Placement
of Chin Implants
The difference between the presence of poor neck contour and
microgenia is frequently misunderstood, and it is a common
misconception that placement of a chin implant improves neck
contour. A chin implant is a treatment for a small chin, not for
a poor neckline, and the presence or absence of microgenia and
the need for a chin implant is a cephalometric determination
that is independent of the condition of the neck. Placement of a
chin implant when microgenia is not present is a conceptual and
artistic error that will create unnatural appearances, and in some
secondary neck procedures it may be necessary to remove an
overly large chin implant and replace it with a smaller one. Much
depends on the type of implant that was placed at the primary
procedure, however. Silicone implants are soft and flexible, do
Fig. 53.6 (a) Redistribution of “excess” skin in short scar neck lift. In
the preoperative condition (left), subplatysmal fullness (subplatysmal
fat and large submandibular glands) has resulted in an oblique neck,
and the neck skin is distributed over a straight surface between the
chin and the sternum. This straight line spans the shortest distance
between the two points, and to the eye excess skin appears to be
present. Postoperatively (right), subplatysmal fullness has been
eliminated, creating a deeper, more concave, and geometrically larger
and longer neck surface. The skin is redistributed over a curved line
that takes a longer path between the two points. (Surgical procedure
performed by Timothy J Marten, MD, FACS. Illustration courtesy of the
Marten Clinic of Plastic Surgery.) (b) Improper excision of skin from
the submental incision and “bowstring effect.” Once it is recognized
that treatment of subplatysmal neck problems increases neck surface
area and deepens the cervicomental angle, it becomes clear why it is
counterproductive to excise any skin from the submental incision, as
this can create a “bowstring” effect and actually blunt the cervicomen-
tal angle. This maneuver will also result in objectionable “dog ears” at
each end of the incision that spoil cervicosubmental contour. If skin
excision is necessary, it is more practically, effectively, and logically
removed from the postauricular area. (Illustration courtesy of the
Marten Clinic of Plastic Surgery.)

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VIII Surgical Rejuvenation of the Face and Neck
not integrate with adjacent tissue, and are typically surrounded
with a smooth, nonadherent capsule that makes removal and
replacement relatively easy. Porous polyethylene implants, how-
ever, are naturally brittle and typically incite tissue ingrowth
that can make removal and replacement or exchange very
difficult. In many cases, porous polyethylene implants have been
divided into pieces at the primary procedure and reassembled
in situ with multiple screws and miniplates. In these situations,
removal and replacement can be very difficult and time con-
suming and require special instrumentation. If a chin implant
is removed completely and not replaced with a smaller one, the
chin pad must be carefully resuspended to avoid chin pad ptosis.
Fat grafting is also typically helpful in reestablishing a full and
supple appearance in such situations.
:hen true microgenia is present, however, placing a chin
implant in combination with a neck lift will produce a more har-
monious and balanced profile and a more aesthetic and attractive
cervicofacial profile (Fig. 53.7). :hen a well-performed, compre-
hensive neck lift is performed, it is often the case that a slightly
smaller implant than the surgeon’s intuition suggests may be
more appropriate.
53.2.5 Residual Skin Excess and
Inappropriate Skin Shifts Due
to Primary Short-Scar Facelift
Surgery Plans
If a significant amount of redundant skin is present, it must be
excised to obtain the best result, and in such situations it is most
logically and effectively excised in the postauricular areas using
periauricular skin incisions extending across the mastoid and
down along the occipital hairline. Skin excision from the submen-
tal incision is conceptually flawed and will actually degrade neck
contour rather than improve it (see Fig. 53.6b), and skin excision
using large midline =-plasties will result in a poorly concealed,
odd-appearing geometric scar and bizarre changes in beard hair
inclination in men (Fig. 53.8). Skin excision from the neck is not
Fig. 53.7 (a–c) Neck lift with a chin implant. The difference between the presence of poor neck contour and microgenia is commonly misunderstood,
and it is a common misconception that placement of a chin implant improves neck contour. When true microgenia is present, however, placing a
chin implant in combination with a neck lift will produce a more harmonious and balanced profile and a more aesthetic and attractive cervicofacial
contour. (Procedures performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

53 Secondary Neck Lift
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possible using a short-scar facelift incision (Fig. 53.9). A significant
excision of skin from the anterior neck and submental region is not
possible when a short postauricular incision plan and a “vertical”
shift of facial skin are used as is advocated in a minimal-access
cranial suspension (MACS) lift or like procedures (Fig. 53.10).
Skin excision can be combined with treatment of the submental
neck and subplatysmal neck problems as an extended or long-scar
neck lift or as part of a facelift procedure (Fig. 53.11; Fig. 53.12;
Fig. 53.13).
53.2.6 Neck Lift with a Facelift
Practically speaking, most patients in need of a neck lift with skin
excision presenting for primary procedures also need a facelift,
as it is unusual to encounter patients with excess skin in the neck
but not elsewhere on the face. This is particularly true in women,
and it is aesthetically inappropriate to perform an isolated neck
lift in most women who present for facial rejuvenation. Lifting
only the neck but not the cheeks, jowls, and jawline at a primary
procedure can create an unnatural and unfeminine appearance.
Combining a facelift with a neck lift is almost always the best
approach in a primary procedure to obtain a balanced, natural,
and harmonious rejuvenation of the female face, although not
all patients will recognize or accept this (Fig. 53.13). Performing
a facelift in combination with a neck lift at primary procedures
also allows for more complete and comprehensive removal of
neck skin. In addition, whereas many men will be put off by the
idea of a ´facelift,µ they will readily agree to undergo the more
palatable-sounding ´extended neck lift,µ which in essence can be
performed as a low-SMAS procedure.
53.3 Surgical Planning in Neck Lift
53.3.1 Planning the Submental Incision
and Correcting Residual and
Uncorrected “Witch’s’ Chin” and
“Double Chin” Appearances
:hether performing a neck lift alone or in combination with a
facelift, optimal improvement in neck contour generally cannot
be obtained in most patients unless a submental incision is
made, despite the long list of historical but conceptually flawed
and failed attempts to avoid doing so.
Traditionally this incision is placed directly in and along the
submental crease in a well-intended but counterproductive
attempt to conceal the resulting scar (Fig. 53.14). This incision
plan should be avoided if possible, however, as it will surgically
reinforce the crease and accentuate a “double chin” or “witch’s
chinµ deformity. Exposure of the submental region will also be
compromised, and difficulty will be encountered when suturing
or dissecting low in the neck. A more posterior placement of
Fig. 53.8 Unaesthetic scarring from submental and anterior neck skin
excision using a =-plasty. If a significant amount of redundant skin is
present on the anterior neck and submental area, it is most logically,
effectively, and aesthetically excised from the postauricular areas
along the occipital hairline rather than on the anterior neck using a
Z-plasty. (a) A large midline Z-plasty used on this man has resulted in a
poorly concealed, odd-appearing geometric scar and bizarre changes
in beard hair inclination. (b) A different patient has had skin excised
from the anterior neck using a similar Z-plasty technique. The obvious
and objectionable-appearing scar is inconsistent with a well-performed
aesthetic surgery procedure. (Courtesy of Marten Clinic of Plastic
Surgery. Procedures performed by unknown surgeons.)
Fig. 53.9 Incorrect incision plan for skin removal in neck lift. If a significant amount of redundant skin is present on the neck, a short-scar facelift
incision plan does not allow skin to be shifted along an optimal vector and is not helpful in reducing loose skin on the anterior neck and in the submen-
tal area. (a) Preoperative plan for a short-scar facelift (red dotted line) resulting from a well-intended but misguided attempt to shorten the incision in
the postauricular area. When skin is shifted along a proper posterior vector parallel to the mandibular border (blue arrow), a dog-ear is produced in the
postlobular area. (b) In some cases the dog-ear is “modest” as shown, but it typically exists as a telltale sign that surgery has been performed and as a
source of embarrassment to the patient. Little or no skin is eliminated from the anterior neck and submental area when such a plan is used. (c) Often
the dog-ear is far from modest, and objectionable puckering and gathering occurs even though little or no improvement is gained in the anterior neck
and submental regions. Planning the incision along the occipital hairline prevents this problem, allows skin to be excised along an optimal vector, and
provides for a well-tailored scar without objectionable bunching or gathering. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
a
b
c
a
b

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VIII Surgical Rejuvenation of the Face and Neck
this incision will preclude these problems but still result in an
inconspicuous and better-concealed scar (Fig. 53.15, Fig. 53.16,
Fig. 53.17).
The submental incision should be placed well within the man-
dibular shadow and well posterior but parallel to the submental
crease at a point lying roughly one-half the distance between the
mentum and the hyoid. This usually corresponds to a site situated
1 to 1.5 cm posterior to the crease (Fig. 53.18).
Regrettably, in many secondary neck lifts an incision will have
been previously made in the submental crease at the primary
Fig. 53.10 Incorrect incision plan for skin removal in neck lift has
resulted in an inappropriate skin shift. The patient underwent a previ-
ous facelift in which a short postauricular incision plan was used and
a vertical shift of preauricular skin was made to minimize the amount
of puckering and gathering in the postauricular area. The use of this
vertical skin vector has resulted in wrinkled neck skin being overshifted
up onto the lower face, creating an objectionable and unnatural appear-
ance, and little or no skin has been advanced out of the submental area,
where skin reduction is needed most. Neck contour remains oblique
because a submental incision was not made and deep-layer problems
(subplatysmal fat accumulation, submandibular gland enlargement,
and digastric muscle hypertrophy) all remain untreated.
Fig. 53.11 Correct incision plan for a long-scar or “extended” neck
lift. If a significant amount of redundant skin is present on the neck, it
must be excised to obtain the best result, and in such situations it is
most logically and effectively excised in the postauricular areas, using
a periauricular skin incision that extends down the occipital hairline
rather than under the chin. This incision plan avoids a temporal inci-
sion, which is of concern to some patients, but provides for significant
skin removal from the neck and some improvement in the lower face
and along the jawline. (Illustration courtesy of Marten Clinic of Plastic
Surgery.)
Fig. 53.12 (a,b) Extended neck lift. Skin excision can be combined with treatment of the neck through the submental incision as an “extended” or
“long-scar” neck lift or as part of a facelift procedure. Both of these patients had skin excised as part of their procedures, and an incision was made in
the periauricular area. (Procedures performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

53 Secondary Neck Lift
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Fig. 53.13 Comprehensive rejuvenation of the face. Combining a neck lift with a facelift and related procedures is almost always the best approach
to obtain a balanced, natural, and harmonious rejuvenation of the female face, although not all patients will recognize or accept this. (a,b,c,d,e) This
62-year-old woman had previously undergone a facelift, neck lift, and blepharoplasties performed by an unknown surgeon. She is seen before and
12 months after a secondary facelift, secondary necklift, limited incision forehead lift, and panfacial fat transfer. Preoperatively in the lateral view
(d) it can be seen that subcutaneous fat has been overresected, and in the lateral (d) and lateral flexed (e) views it can be seen that the traditional
neck lift consisting of submental liposuction, platysmaplasty, and skin excision has failed to produce an attractive neck contour. The secondary neck
lift consisted of excision of residual subplatysmal fat, reduction of prominent submandibular salivary glands, partial digastric myectomy, and pla-
tysmaplasty. No subcutaneous fat was removed, and only a modest amount of skin was removed as part of correcting earlobe irregularities. A more
youthful, fit, feminine, and attractive neck contour can be seen. Addressing all regions of the face has produced a natural, balanced, and harmonious
result, and a far better outcome than a neck lift alone. (Primary procedure performed by an unknown surgeon. Secondary procedures performed by
Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

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VIII Surgical Rejuvenation of the Face and Neck
procedure, and this will have exacerbated a double chin or witch’s
chin appearance. In such cases the patient and surgeon must con-
sider the advantages and disadvantages of using the same site for
the submental incision or making a new one in a more appropriate
location. If the scar in the submental crease is well healed and the
patient is in an older age group, it may be best to make the incision
for the secondary procedure in a more appropriate posterior posi-
tion to obtain optimal access to the deep neck. If the scar in the
submental crease is poorly healed, or if the patient is in a younger
age group or is concerned about having a second scar in the sub-
mental area, it may be best to excise the existing scar, lengthen it
to the extent possible, and use it as access to the deep neck in the
secondary procedure. Ultimately, it is wise to leave the decision to
the patient after appropriate discussion has been made.
The submental incision, when optimally sited in primary pro-
cedures, should be approximately 3 to 3.5 cm in length, but it may
be made longer as long as neither end will be advanced up onto
a visible portion of the face when skin flaps are shifted. Healing
Fig. 53.14 Traditional but incorrect plan for the submental incision.
The incision should not be placed directly along the submental crease
(arrow), as this will reinforce the submental retaining ligaments and
accentuate the “double chin” appearance. Note that the typical plan
of skin undermining (yellow area) also promotes a double chin appear-
ance because the crease is not undermined, the retaining ligaments
are not released, and the fat of the chin and the neck cannot be readily
blended to create a smooth transition between them. (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.15 Correct location for the submental incision. Placing the
submental incision 1.5 cm posterior to the submental crease prevents
accentuation of the double chin and witch’s chin deformities and
provides for easier dissection and suturing in the anterior neck (com-
pare with Fig. 53.14). Note that this incision plan allows the submental
crease to be undermined and submental retaining ligaments to be
released and the fat of the chin pad and submental neck to be blended
to create a smooth and aesthetically pleasing transition between
them. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.16 Correction of the “double chin” deformity. (a) Patient with double chin seen preoperatively. (b) Same patient seen after face- and neck
lift. The submental incision was made posterior to the submental crease to allow undermining and release on the submental retaining ligaments
and blending of chin and neck fat to create a smooth and aesthetically pleasing transition between them. The subplatysmal neck was treated with
subplatysmal fat excision and by excision of protruding parts of the submandibular gland and digastric muscle. (Procedures performed by Timothy
Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)

53 Secondary Neck Lift
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will be best, and the scar will be best concealed, if it is made as a
straight, not a curved, line (Fig. 53.19).
53.3.2 Planning Treatment of
the Platysma
Fundamental Concepts in Treatment of
Platysma Irregularities
As surgeons have pursued improved outcomes in treating the
neck, our understanding of the origin of platysma muscle irregu-
larities has improved and platysma muscle treatment techniques
have evolved. Experience has shown that the traditional notion
that horizontal platysma tightening (´corsetµ platysmaplasty)
will correct deep-layer neck problems, including accumulations
of subplatysmal fat and the presence of large submandibular
glands and protruding digastric muscles, was misguided and
that proper treatment of these problems will require procedures
that address the actual anatomic problems present. Over time,
thoughtful surgeons have come to understand and accept that
a sustained improvement in neck contour is created not by
Fig. 53.18 Plan for optimal submental Incision placement marked
on a patient. The submental portion of the facelift incision (solid line)
should be placed posterior to the submental crease (dotted line),
approximately one-half the distance between the mentum and hyoid
(black arrows) in primary procedures. Usually this corresponds to a
point about 1.5 cm posterior to the submental crease. In secondary
procedures where an incision has already been made and a scar exists
in the submental crease, a decision must be made as to whether the
surgeon should excise the existing scar and use the same incision,
or make an incision in a more appropriate location that gives better
access and exposure to the deep neck. Dotted lines along jawline
and in inferior neck represent approximate extent of subcutaneous
skin undermining. Parallel solid lines on anteroinferior neck represent
approximate location of cricoid cartilage. (Courtesy of Marten Clinic of
Plastic Surgery.)
Fig. 53.17 (a,c) Correction of the “witch’s chin” appearance. (b,d) Patient who has undergone previous “neck lift” consisting of submental
liposuction and platysmaplasty performed by an unknown surgeon, with “witch’s’ chin” appearance seen preoperatively before secondary neck lift.
Same patient seen after facelift, secondary neck lift, fat grafting, and related procedures. The chin pad has been undermined and fat of the chin has
been blended with remaining fat in the submental area to create a smooth and aesthetically pleasing transition between the two areas. (Procedures
performed by Timothy Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.19 Healed submental incisions. Placement of the submental
incision posterior to the submental crease will still result in an incon-
spicuous, well-concealed scar while simultaneously providing better
access and exposure when working in the deep layers of the neck. (a)
Healed submental scar in a female patient. (b) Healed submental scar
in a male patient. (Procedures performed by Timothy Marten, MD,
FACS. Courtesy of Marten Clinic of Plastic Surgery.)
a
b
a
c
b
d

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VIII Surgical Rejuvenation of the Face and Neck
platysma tightening but rather by the deep-layer maneuvers that
specifically target these problems (subplatysmal fat excision,
submandibular gland reduction, and partial digastric myectomy).
Experience has also confirmed that traditional platysma-
tightening procedures will not universally correct platysma bands
and that our traditional view that all platysma bands are a homoge-
neous problem and simply a product of age-associated horizontal
platysmal laxity was conceptually flawed and the underlying cause
of many decades of failed treatments. In reality, ´platysma bandsµ
comprise a heterogeneous group of distinct problems, and for
many patients platysma bands can be seen to be the product of not
only horizontal laxity but longitudinal platysmal hyperfunction and,
as such, refractory to traditional horizontal lifting and tightening
procedures. Proper treatment of these problems requires horizon-
tal platysma transection or partial platysma excision (or treatment
by other like means) to disrupt longitudinal hyperfunction.
Assessing Platysma Deformity
The cervico-submental region of each patient must be care-
fully examined both at rest and during platysmal activation if
complete assessment of platysmal deformity is to be made, as
secondary neck lift patients almost universally have residual
platysma abnormalities. This is best accomplished by asking
the patient to ´push your jaw forward and tighten your neckµ
or ´show me your bottom teeth and tighten your neck.µ It is
often helpful if the surgeon demonstrates this maneuver first for
the patient to be sure it is correctly performed. Frequently an
insignificant-appearing deformity at rest will be obvious upon
muscle activation (Fig. 53.20). Failure to recognize and appro-
priately correct these “dynamic deformities” is the reason too
many neck lift patients appear improved in repose but unnatural
or bizarre in conversation, animation, and other activities that
result in platysma muscle activation.
Examination of the cervico-submental region with and with-
out platysmal activation allows one to distinguish whether the
residual bands are “hard” dynamic or “soft” adynamic bands.
Soft, adynamic bands change little during platysma activation
and are predominantly a problem of loose skin or horizontal
platysmal laxity (Fig. 53.21a). Hard, dynamic bands become tight
or exaggerated upon platysmal activation and indicate a problem
of longitudinal platysmal hyperfunction (Fig. 53.21b).
Plan for Treatment of Horizontal Platysma
Laxity and “Soft” Bands
If submental support is poor due to horizontal platysmal laxity or
platysmal diastasis and optimal improvement in the anterior neck
is desired, anterior platysmaplasty is planned (Fig. 53.22). Anterior
platysmaplasty is the procedure in which the medial borders of
the platysma muscle are sutured together to help consolidate
the neck, reduce horizontal platysmal laxity, and improve neck
appearance when the patient flexes the neck and looks down (Fig.
53.23). It is not, however, adequate or effective in the treatment of
excess subplatysmal fat, prominent submandibular glands, hyper-
trophy of the anterior bellies of the digastric muscles, or ´hardµ
dynamic platysmal bands. 1ot recognizing and acknowledging
this fact, and well-intended but misguided attempts to treat these
problems by medial or lateral platysmal pulling and tightening,
have led to frustration for many surgeons treating the aging neck.
Treatment of these problems will require that other maneuvers,
discussed elsewhere in this chapter, be performed.
Plan for Treatment of Platysma Hyperfunction
and Dynamic “Hard” Bands
It is important to distinguish between ´soft,µ adynamic pla-
tysmal bands and “hard,” dynamic bands in both primary and
secondary neck lift patients, as treatment will vary depending on
the type present. Patients with soft bands are usually adequately
treated with skin excision or skin excision and platysmaplasty
Fig. 53.20 Dynamic assessment of the cervico-submental region and
platysma muscle. (a) The neck is examined in repose and (b) with the
platysma contracted. In repose a modest platysma problem appears
to be present, and horizontal platysma laxity can be seen to be modest
in the patient shown. Upon platysma activation, however, pronounced
longitudinal platysma hyperfunction and objectionable platysma
bands can be seen. (Courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.21 “Soft” and “hard” platysma bands. Examination of the
cervico-submental region during platysma activation allows one to
distinguish between “hard” dynamic and “soft” adynamic cervical
bands. Treatment will vary fundamentally depending on the type of
band present. (a) A patient’s neck seen during platysma activation.
Soft, adynamic bands change little during platysma activation and are
predominantly a problem of loose skin or horizontal platysmal laxity.
(b) A different patient’s neck seen during platysma activation. Hard,
dynamic bands become tight or exaggerated upon platysma activation
and indicate a problem of longitudinal platysma hyperfunction.
Differentiating between hard and soft platysma bands is important
because treatment varies depending on the type of band present.
(Courtesy of Marten Clinic of Plastic Surgery.)
a
b
a
b

53 Secondary Neck Lift
783
alone. Patients with ´hardµ bands, however, require transverse
platysma myotomy or some other procedure that disrupts longi-
tudinal platysma muscle hyperfunction and prevents the muscle
from contracting upon itself. Much as when a dancer with a
ruptured Achilles’ tendon cannot point the toe, dividing the pla-
tysma transversely prevents it from pulling upon itself and away
from the anterior surface of the neck. The result of platysma
myotomy when properly performed is dramatic, long-lasting,
and superior to any suture, suture suspension, lateral suspen-
sion of the platysmal border, or ´corsetµ platysmal tightening
technique (Fig. 53.24). The length of transection required can
be varied depending on the location and configuration of bands
present and may thus differ from patient to patient. The key to
success in treating hard, dynamic bands is to acknowledge that
they are the product of longitudinal platysma muscle hyper-
function, not one of horizontal platysma laxity, and employing
a plan of treatment that recognizes this fact. Pulling medially or
laterally on the platysma muscle borders as commonly advocated
does not address the origin of dynamic platysma bands and is
QRW D ORJLFDO RU H̵HFWLYH WUHDWPHQW Rf WKHP Likewise, attempts
to excise dynamic platysma bands vertically along the length of
the muscle fibers is not a logical or effective treatment, as the
band is not fixed in location and any such maneuver does not
address overall longitudinal muscle hyperfunction in a complete
and comprehensive way.
Platysmal bands are generally seen to lie in medial and lateral
locations and are often referred to as anterior and lateral platysma
bands (Fig. 53.25). Each band is situated near the medial or lateral
Fig. 53.22 Anterior platysmaplasty. Anterior platysmaplasty reduces
horizontal platysma laxity, improves submental support, consolidates
the neck, and is the primary treatment of “soft” platysma bands.
Despite wishful thinking by some surgeons, it is not adequate or
effective treatment of dynamic “hard” platysma bands, nor of excess
subplatysmal fat, prominent submandibular glands, and protrusion of
the anterior bellies of the digastric muscles. (Illustration courtesy of
Marten Clinic of Plastic Surgery.)
Fig. 53.23 Anterior platysmaplasty. Platysmaplasty improves
submental support and enhances neck appearance when the patient
looks down. (a) Patient seen preoperatively with horizontal platysma
laxity. Simply tightening the skin will not correct this appearance in a
sustained fashion. (b) The same patient after extended neck lift and
ancillary procedures that included anterior platysmaplasty. The skin can
be seen to lie smoothly over the deeper, concave, and geometrically
longer anterior neck surface. The procedure included subplatysmal fat
excision and excision of protruding portions of the submandibular gland
and digastric muscle. Fat grafting has also been performed to enhance
the chin and jawline. (Procedures performed by Timothy J Marten, MD,
FACS. Courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.24 Platysma myotomy. (a) Patient seen with objectionable-
appearing “hard,” dynamic platysma bands before platysma myotomy.
(b) Same patient after platysma myotomy. The result of platysma
myotomy is typically dramatic, long-lasting, and superior to any
suture, suture suspension, lateral suspension of the lateral platysmal
border, or “corset” platysma tightening technique. Note that the goal
of the procedure is a reduction in platysma hyperfunction, however,
and not a complete absence of muscle movement. (Courtesy of Marten
Clinic of Plastic Surgery.)
Fig. 53.25 “Anterior” and “lateral” platysmal bands. Platysma bands
are generally seen to lie in medial and lateral locations and are often
referred to as anterior and lateral platysma bands. Each band is situated
near the medial and lateral platysma muscle borders but does not
usually correlate precisely with them. (Illustration courtesy of Marten
Clinic of Plastic Surgery.)
a
b

784
VIII Surgical Rejuvenation of the Face and Neck
platysma muscle border but does not usually correlate precisely
with it, and they are not specifically fixed in location. Patients
with only anterior platysmal bands can be treated with a partial
transverse platysma myotomy by dividing the muscle medially
and subtotally through and beyond the section of it in which the
band is present low in the neck at the level of the cricoid cartilage
(Fig. 53.26). The platysma muscles arguably need not be com-
pletely transected when only an anterior band is present, just the
region where the platysmal band is located.
If lateral as well as anterior bands are present, the myotomy
is carried more laterally to include them as well (Fig. 53.27). If
poor definition is present over the lateral mandibular border in
addition to anterior and lateral neck bands, or if comprehensive
improvement is desired, platysmal myotomy is planned to con-
tinue “full-width” superolaterally up to the anterior border of
the sternocleidomastoid muscle (Fig. 53.28). A similar full-width
myotomy of this type is also indicated in a firm obtuse neck with
a ´short platysmaµ and poor definition over the mandibular angle
but no bands.
In theory and principle, in many necks, only a subtotal myotomy
is indicated and need be performed. As a practical matter, how-
ever, complete transection of the platysma is typically performed
in most of our patients when any form of myotomy is indicated, to
limit the possibility that bands will recur in areas of muscle that
were not divided, or that residual platysma bands will be present.
Despite assertions to the contrary, full-width platysma myotomy
will not result in an overly thin-appearing neck (´lollipop neckµ)
or in ´reduced supportµ of the submandibular glands when
properly performed. These are merely false assertions put forth
by surgeons who do not perform the procedure and do not want
to go to the time and trouble of learning and performing it.
Medial wedge resections of platysma at the hyoid and vertical
excisions of platysma bands, while shown in many textbooks, are
not typically effective in treating dynamic platysma bands, in that
a large segment of adjacent and more laterally situated muscle
remains untreated. Vertical excision of platysma bands, while still
advocated by some, has proven to be an ineffective treatment that
has been abandoned by experienced surgeons. Trying to isolate
and specifically excise the responsible muscle segment is difficult
at best, since the band is not specifically fixed in its location, and a
partial excision along a vertical axis typically allows or incites new
bands to form in an adjacent untreated area. Similarly, attempts
to place rigid support across the cervicomental angle, in the
form of a mastoid-to-mastoid “noose” of suture or commercially
available synthetic straps to lift platysmal bands, are conceptually
flawed and practically problematic. Experience has shown that
these maneuvers do not work and are the source of many patient
problems.
Treatment of “Radiofrequency Neck”
and “Ultrasound Neck”
Medial wedge resections of platysma at the hyoid can result in
unaesthetic exposure of underlying cervical anatomy, a harsh
transition from the submental region to the neck, and lower lip
dysfunction and asymmetric smile. These procedures are not
recommended in routine treatment of platysma bands, although
they are useful in certain secondary cases and in situations
Fig. 53.26 Plan for treatment of “anterior” dynamic “hard” platysmal
bands. Transverse platysma myotomy is performed in the region of
the platysma muscle where the platysmal band is present. (a) Anterior
neck after platysmaplasty but before anterior platysma myotomy. (b)
After anterior platysma myotomy. (Note: Myotomy is most easily and
effectively performed after platysmaplasty has been completed.) Note
that because uninterrupted muscle is present laterally, the potential
for new band formation in that area is possible when this plan is used.
(Illustration courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.27 Plan for treatment of “anterior” and “lateral” platysmal
bands. If lateral bands are present, the myotomy is carried more later-
ally to include them as well. (a) Anterior neck after platysmaplasty but
before anterolateral platysmal myotomy. (b) After anterolateral myot-
omy. (Note: Myotomy is most easily and effectively performed after
platysmaplasty has been completed.) Note that because uninterrupted
muscle is still present laterally, the potential for new band formation
in that area is possible when this plan is used. (Illustration courtesy of
Marten Clinic of Plastic Surgery.)
Fig. 53.28 Plan for “full-width” platysmal transection. Full-width
myotomy not only corrects anterior and lateral bands but provides
improved definition over the lateral mandibular border. (a) Anterior
neck after platysmaplasty but before full-width platysmal myotomy.
(b) After full-width platysmal myotomy. (Note: Myotomy is most easily
and effectively performed after platysmaplasty has been completed.)
A full-width division of this sort minimizes the chance that new bands
will form at a future date in areas where the muscle was not fully
transected. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
a
b

53 Secondary Neck Lift
785
where there has been fibrosis and scarring of subcutaneous
tissues and the platysma in that area. These problems can result
from ´noninvasiveµ treatment of the neck with radiofrequency,
ultrasound, internal tissue heating, cryolipolysis, chemolipolysis,
laser liposuction (see Fig. 53.3, right), or use of inflammatory fill-
ers in the neck area. :hen these ´noninvasiveµ neck deformities
are present, a ´highµ myotomy (division at the level of the thyroid
cartilage rather than the cricoid), or even a partial myectomy
(excising damaged platysma muscle from the anterior neck at
the level of the thyroid cartilage), may be indicated (Fig. 53.29).
53.3.3 Evaluation and Assessment of
the Submental Region
Traditional neck lift techniques do not adequately address many
aspects of aging in the submental region, and it is not enough
in most situations to limit treatment of the neck to preplatysmal
lipectomy alone or with postauricular skin excision. For many
patients,
subplatysmal
fat
accumulation,
submandibular
salivary gland ´ptosisµ (enlargement), and digastric muscle
hypertrophy will contribute significantly to the neck contour
problems present and will necessitate additional treatment if
optimal improvement is to be obtained (Fig. 53.30). It must be
acknowledged and accepted that simply tightening the platysma
and creating a tight platysma ´corsetµ over these problems will
not correct them and will not produce a sustained improvement
in neck contour if underlying deep-layer problems are not
addressed.
Identifying the Neck with Excess Subplatysmal
Volume
The presence of abnormal fullness in the submental space can be
demonstrated preoperatively by taking and examining a lateral
looking-down view photograph (Connell’s view) of the patient’s
neck (Fig. 53.31). Often a neck that looks reasonably good in the
straight lateral view will be revealed to be unexpectedly full
when the patient looks down, as if looking at items on a desk,
a menu at a restaurant, a program at the theater, or images on a
phone screen. Failure to appreciate subplatysmal fullness preop-
eratively and treat it appropriately intraoperatively will result in
compromised outcomes.
Fullness in the subplatysmal space and the need to explore and
treat the ´deep neckµ is indicated when the neck is full in Connell’s
view, and this picture should be taken and examined by any sur-
geon performing neck surgery. If this view is not taken before and
after surgery, the analysis of the patient’s neck was incomplete
and the documentation that the procedure was well performed
is inadequate.
Understanding the Distribution of Fat in
The Neck
A key element to obtaining good outcomes in the neck lies in
understanding the distribution of fat in the cervico-submental
region and choosing a treatment plan accordingly. Cervical fat is
present in three distinct anatomic layers: (1) preplatysmal (sub-
cutaneous), (2) subplatysmal, and (3) deep cervico-submuscular
(´interdigastricµ). :hile our traditional focus has been the pre-
platysmal layer (which all too often has ended up overresected),
the secret to good outcomes in the neck is aggressively treating
the subplatysmal layer to create contour (typically in conjunc-
tion with prominent submandibular glands and digastric muscle
hypertrophy³the ´deep neck triadµ) and fighting to preserve
subcutaneous fat so as to maintain a youthful, healthy, and soft
appearance. Accordingly, contemporary neck lift requires many
surgeons to rethink what they have been taught and the tech-
niques that they are using. In all cases it should be the aim of the
surgeon to produce a youthful, attractive, and healthy-appearing
neck, not simply one devoid of fat.
Assessing the Location of Fat in the Neck
In all but the unusual or young patient, the majority of cervical
fat accumulation in patients seeking neck lifts and facelifts will
be present in a subplatysmal location, and little if any will need
to be removed from the preplatysmal layer. Indeed, as patients
age, fat stores generally shift from a preplatysmal location to a
subplatysmal one, and the small amount of subcutaneous fat
seen in the typical patient presenting for a facelift or neck lift
is necessary and must be preserved if a soft, youthful, natural,
Fig. 53.29 Plan for partial platysma myectomy for treatment of “non-
invasive,” “radiofrequency” and “ultrasound” neck deformity. When
marked fibrosis of the platysma muscle is present, traditional platysma
myotomy (transverse division of the platysma at the level of the cricoid
cartilage) will typically be inadequate, and effective treatment usually
requires partial platysma myectomy and removal of a major section
of the damaged muscle present on the anterior neck. (a) Preoperative
patient with platysma muscle hyperfunction (“dynamic hard bands”)
but uninjured muscle, showing surface expression of hyoid, thyroid,
and cricoid cartilages. This patient would be effectively treated with
simple platysma myotomy performed at the level of the cricoid
cartilage (see Fig. 53.26, Fig. 53.27, Fig. 53.28). (b) Schematic of the
segment of platysma muscle removed in partial platysma myectomy
(area shaded in red) when fibrotic, scarred platysma is present in cases
of “radiofrequency” and “ultrasound” neck. Typically the procedure is
begun by dividing the platysma transversely full-width at the level of
the midthyroid cartilage with electrocautery, working through both
the submental and postauricular incisions, taking care to avoid dividing
the underlying fascia if possible. The superior and inferior cut edges
of the muscle are then undermined using electrocautery on top of the
underlying fascia for a distance of 5 to 10 mm. The undermined seg-
ments of muscle are then excised and beveled flat using Metzenbaum
scissors or cautery. Note that a 1.5- to 2-cm cuff of platysma muscle
is left in place and undisturbed below the cervicomental angle (below
the level of the hyoid), especially laterally, to protect the cervical
and marginal mandibular branches of the facial nerves. (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
a
b

786
VIII Surgical Rejuvenation of the Face and Neck
non-´surgical,µ and attractive appearance is to be obtained.
Although the necks of patients undergoing liposuction (or like
procedures that target subcutaneous fat) may look good ini-
tially when swelling is present, once it resolves, they typically
display an unnatural and unaesthetic ´overresectedµ or ´guttedµ
appearance. Once one acknowledges these facts, the futility and
undesirability of cervicosubmental liposuction in most patients
becomes obvious.
Fig. 53.30 Recognizing the origin of neck problems in the submental region. For many patients requesting secondary necklift, subplatysmal fat
accumulation, submandibular salivary gland “ptosis” (enlargement), and digastric muscle hypertrophy will contribute significantly to the neck
deformity present and necessitate specific treatment. Simply tightening the platysma over these problems will not correct them. Specific additional
treatment is necessary if these problems are to be improved. Note that the presence of submandibular gland and digastric muscle problems can be
diagnosed simply by looking at this patient. (a) Surface expression of common problems seen in secondary necklift patients. (b) Cadaver view of
corresponding problems show in (a). (Illustration courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.31 Assessing the presence of excess volume in the subplatysmal space. (a) Patient seen following traditional neck lift procedure in the
standard lateral view. The result appears ostensibly good. (Procedure performed by an unknown surgeon.) (b) Same patient seen after traditional
neck lift procedure in lateral flex view (Connell’s view). Inadequate treatment of the subplatysmal space is evident and the resulting objectionable
submental fullness can be seen. (Procedure performed by an unknown surgeon.) (c) Same patient after secondary face- and neck lift that included
treatment of irregularities in the subplatysmal space (subplatysmal fat, large submandibular salivary glands, and protruding anterior belly of the
digastric muscle). Proper treatment of the deep neck has provided an improved outcome. (Procedure performed by Timothy Marten, MD, FACS.
Courtesy of Marten Clinic of Plastic Surgery.)
a
b
a
c
b

53 Secondary Neck Lift
787
Assessing the Amount of Preplatysmal Fat
Present
Often just taking a moment to look carefully at the oblique neck
of a patient presenting for neck lift surgery will reveal that,
despite the oblique contour, a paucity of subcutaneous fat is
actually present. In many circumstances the majority of deeper
anatomy can be easily seen beneath the skin, lending an ´oldµ
appearance to the neck. This is in stark contrast to the plushly
padded necks of young people, where a thick layer of subcuta-
neous fat is present and where little if any deep neck anatomy
can be seen.
The presence or absence of preplatysmal fat can also be assessed
by examining the neck with and without platysma activation. In
necks where little preplatysmal fat is present, the bands will be
clearly visible along their entire course, and a ´skin on muscleµ
appearance will be seen (see Fig. 53.20; Fig. 53.21b; Fig. 53.24a;
and Fig. 53.25). :hen preplatysmal fat is present, however, the
bands will be partially obscured, usually predominantly in the sub-
mental area, and the presence of subcutaneous fat overlying them,
lying between the skin and the platysma, can be seen (Fig. 53.32).
Assessing the Presence of Subplatysmal Fat
Abnormal collections of subplatysmal fat can be identified by
preoperative palpation of the neck ´wattleµ with and without
platysmal activation. Fat lying predominantly in a preplatysmal
position will generally feel ´softµ and remain in the examiner’s
grasp upon platysmal muscle activation. Fat lying in a subpla-
tysmal position, however will have a firmer feel and will tend
to be pulled superiorly out of the examiner’s grasp when the
platysma is contracted (Fig. 53.33). This test can be performed
by the patients on themselves under the surgeon’s supervision
as means of helping them understand why liposuction will not
properly address their problem and why a submental incision
must be made and subplatysmal fat removed.
These problems are in forefront of the treatment of the neck
in secondary procedures, as typically the superficial neck (skin,
subcutaneous fat, and platysma) has been aggressively (over)
treated in primary procedures, whereas the deep-neck problems
have been typically unrecognized and ignored.
Two typical scenarios where subplatysmal fat is likely to be
present are in patients undergoing primary procedures who
have firm, obtuse necks and who have been troubled by lifelong
cervicomental fullness and in patients presenting for secondary
surgery who have poor cervical contour. In these individuals,
subplatysmal lipectomy will predictably be required (Fig. 53.34).
1ot all fat should arbitrarily be removed from the deep neck
however, and deep cervical fat (interdigastric fat) should not be
removed. :hen deep cervical interdigastic fat is erroneously
excised, an objectionable depression in the submental region
will result, often referred to as the ´dug-out neckµ or ´cobra neckµ
deformity (Fig. 53.35). Typically this depression is more evident
when the neck is flexed somewhat or when the patient swallows
and when prominent submandibular glands and anterior belly of
the digastric muscles have not been concomitantly reduced. :hen
a ´dug-out neckµ or ´cobra neckµ deformity is present in a patient
presenting for secondary neck lift, significant improvement can
generally be obtained by properly treating residual fullness situ-
ated laterally due to untreated submandibular gland fullness and
digastric muscle hypertrophy.
53.3.4 Planning Treatment of the
Large Submandibular Gland
Preoperative assessment of the submandibular glands must be
made in patients seeking secondary improvement in neck con-
tour, as prominent glands are commonly overlooked or ignored
Fig. 53.32 (a,b) Recognizing the presence of preplatysmal fat. The
presence of preplatysmal fat can be identified by examining the neck
with the platysma contracted. When preplatysmal fat is present the
platysmal bands will be partially obscured, usually predominantly
in the submental area, and the subcutaneous fat overlying them,
lying between the skin and the platysma, can be seen. In this patient
platysma bands can be seen clearly in the inferior neck, where little
subcutaneous fat is present, but are hidden and lost more superiorly in
the submental region, where preplatysmal fat is present. It should be
noted that it is relatively rare to find excess preplatysmal fat in most
patients in this age group and presenting for facelift or secondary neck
lift surgery, as the majority of it was aggressively stripped out with
liposuction or by other means at the primary procedure. (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.33 Assessing the location of cervicosubmental fat.
(a) Submental “wattle” is grasped with the face and neck in repose and
the platysma muscle relaxed. (b) The patient is then asked to activate
the platysma muscle. In this patient, fat is pulled superiorly from the
examiner’s grasp, indicating a predominantly subplatysmal position.
Fat lying predominantly in a subcutaneous, preplatysmal position
would tend to remain within the examiner’s grasp when the platysma
is activated. (Courtesy of Marten Clinic of Plastic Surgery.)
a
a
b
b

788
VIII Surgical Rejuvenation of the Face and Neck
at the primary procedure and typically contribute to the appear-
ance of a full, ´obtuse,µ and ´lumpyµ neck in the secondary sur-
gery patient. Large submandibular glands are most easily seen in
the upper lateral neck in the secondary facelift patient who has
had prior aggressive cervicosubmental lipectomy (Fig. 53.36).
However, they may be partially hidden by residual submental fat
or lax platysma muscle in the patient who was timidly treated
at the primary procedure, and this emphasizes the importance
of palpating the necks of such patients as part of their evalua-
tion. Failure to diagnose the presence of a large submandibular
gland will lead to disappointing and unexpected bulges in the
lateral submental regions postoperatively no matter what
other maneuvers might be undertaken (skin tightening, lateral
platysmal suspension, corset platysmaplasty, suspension suture
placement, etc.).
Submandibular glands are usually palpable as firm, smooth,
discrete, mobile masses in the lateral submental triangle, lateral
to the anterior belly of the digastric muscle and medial to the
inner aspect of the ipsilateral mandibular border. Submandibular
glands lying superior to the plane tangent to the inferior border
of the mandible and the ipsilateral anterior belly of the digastric
muscle do not disrupt neck contour and will usually not require
treatment. Glands protruding inferior to this plane are likely to
be problematic, however, especially if subplatysmal fat has been
removed or partially removed, even if the platysma muscle is
tightened and redundant skin is excised. These glands demand
treatment if optimal improvement in neck contour is to be
obtained.
Understanding the Etiology of the
Prominent Submandibular Gland
Despite various claims to the contrary, experience has shown
that prominent submandibular glands are actually large, not
ptotic, and that the platysma contributes little to their position or
support. Attempts at tightening the platysma when a prominent
Fig. 53.36 Prominent submandibular glands. Large submandib-
ular glands are usually evident as protruding masses in the lateral
submental triangle, lateral to the anterior belly of the ipsilateral
digastric muscle and medial to the mandibular border. (a) Patient with
residual prominent submandibular gland after facelift and submental
liposuction. His prior procedure has made the prominent glands more
obvious. (b) Patient with residual prominent submandibular gland after
“weekend neck lift.” Aggressive resection of subcutaneous fat has
exposed the prominent gland, which was not treated. (c) Patient with
residual submandibular glands after “platysma placation.” (d) Patient
with residual submandibular glands after “corset platysmaplasty.”
(Procedures performed by unknown surgeons. Courtesy of Marten
Clinic of Plastic Surgery.)
Fig. 53.35 (a,b) The “dug-out neck” or “cobra neck” deformity. “Dug-out
neck” and “cobra neck” are pejorative terms used to describe situations
in which too much deep cervical fat has been erroneously overexcised
or when subplatysmal fat has been aggressively excised but protruding
submandibular salivary glands and anterior bellies of the digastric muscles
have not been concomitantly reduced, resulting in an objectionable
depression in the submental region. (Procedures performed by
unknown surgeons. Courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.34 Patients likely to have subplatysmal fat accumulation.
(a) lifelong cervicomental fullness. These patients typically have large
collections of subplatysmal fat and are suboptimal candidates for
submental liposuction. (b) Patient presenting for secondary surgery
who has poor cervical contour. It can be seen that superficial subcuta-
neous fat has been stripped out of her neck at the primary procedure
and the remaining fat is almost completely in a subplatysmal location.
Note soft, plushly padded face but “skin on muscle” appearance in the
submental region. Note also failure to sculpt and blend the fat of the
inferior chin and the submental region and the resulting mild “witch’s
chin” appearance. (Courtesy of Marten Clinic of Plastic Surgery.)
a
a
a
c
b
b
b
d

53 Secondary Neck Lift
789
gland is present usually result in modest, short-lived improve-
ment. The same is true with the various conceptually flawed
suture suspension methods that have been historically tried and
now largely abandoned. Careful preservation and sculpting of
the periglandular fat will sometimes allow ´smallµ prominent
glands to remain relatively disguised, but large, prominent
glands will require that the protruding portion be resected if
optimal improvement is to be obtained (Fig. 53.37).
Discussing Submandibular Gland Reduction
with the Patient
:hile a routine part of a neck lift procedure in many surgeon’s
practices and not something for which most surgeons obtain
specific written consent, the decision to perform submandibular
gland reduction is arguably best made in conjunction with the
patient after appropriate discussion of the advantages and dis-
advantages of the procedure have been made. Often a prominent
submandibular gland and the disturbing appearance of the
resulting lump in the anterior neck is one of the primary con-
cerns of the patient presenting for secondary surgery. Patients’
desire to obtain correction usually outstrips their concerns over
possible problems and complications.
Consideration should be given to informing the patient that
the procedure may prolong submental induration and edema
and carries a small increased risk of temporary submental
discomfort, bleeding, sialoma, salivary fistula, and dry mouth
symptoms, although in our combined 40 years of practice per-
forming submandibular gland reduction, we have seen no major
complications and only the occasional fluid collection requiring
percutaneous aspiration. Patients should be informed when these
problems are discussed that, while uncommon, they can occur. It
is also helpful if they understand that only the protruding portion
of the gland is excised and that the majority of the gland is left in
place and not removed.
53.3.5 Planning Treatment of Prominent
Anterior Belly of the Digastric
Muscle
A subgroup of patients seeking both primary and secondary
surgery will present with large, bulky anterior bellies of their
digastric muscles that are commonly seen in secondary neck lift
patients as linear paramedian submental fullness (Fig. 53.38).
Large anterior bellies of the digastric muscles are most easily
seen in the secondary surgery patient whom has had prior
aggressive cervicosubmental lipectomy. However, in patients
presenting for primary procedures large muscles are frequently
hidden by excess submental fat, large submandibular glands, or
lax platysma muscle, and a surgeon’s failure to identify them in
these patients will predictably result in unexpected and objec-
tionable submental fullness postoperatively regardless of what
other maneuvers might be undertaken (skin tightening, lateral
platysmal suspension, “corset” platysmaplasty, suspension suture
placement, etc.).
:hen large, prominent digastric muscles are present, subtotal
VXSHUfiFLDO GLJDVWULF P\HFWRP\ (excising the protruding portion of
the muscle) is indicated and can provide for significant improve-
ment in neck contour. In unclear cases the final decision as to
whether partial digastric myectomy should be performed is often
best deferred until the day of surgery, after the improvement
produced by other modifications of the deep neck (subplatysmal
fat excision and submandibular gland reduction) can be assessed,
and digastric muscle reduction is usually performed as the third
step in treatment of these three structures (´deep neck triadµ).
Fig. 53.37 Correction of the prominent submandibular salivary gland.
Despite claims to the contrary, experience has shown that prominent
submandibular glands are actually large, not ptotic, and proper treat-
ment will require that the protruding portion be resected if meaningful
improvement in neck contour is to be obtained. (a) Patient with prom-
inent submandibular gland that contributes significantly to poor neck
contour and an elderly, unmasculine appearance. (b) Same patient seen
after neck lift that included submandibular gland reduction. Submental
liposuction and skin tightening would have made the prominent gland
more visible. Platysmal tightening would have produced a short-term
improvement at best, because the prominent gland is large and sits in a
solid fossa of tissue formed by the anterior belly of the digastric muscle,
the inselateral mandibular border, and the mylohyoid muscle. Trying to
“lift” it by tightening the platysma is like trying to put 2 liters of water
in a 1-liter bottle. (Procedures performed by Timothy Marten, MD,
FACS. Courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.38 Prominent anterior belly of the digastric muscle in patient
who has had a prior neck lift. The anterior belly of the digastric
muscle can be seen as objectionable linear paramedian fullness in the
submental region. Prominent digastric muscles often go unnoticed at
the time of the primary procedure, because they are frequently hidden
by cervical fat and lax platysma muscle. Postoperatively they are often
erroneously regarded as a “low hyoid.” (Previous procedure performed
by unknown surgeon. Courtesy of Marten Clinic of Plastic Surgery.)
a
b

790
VIII Surgical Rejuvenation of the Face and Neck
:hile a routine part of a neck lift procedure in many sur-
geon’s practices and not something for which most surgeons
obtain specific written consent, the decision to perform partial
digastric myectomy (muscle reduction) is arguably best made in
conjunction with the patient after appropriate discussion of the
advantages and disadvantages of the procedure have been made.
Typically patients’ desire to obtain optimal improvement in neck
contour outstrips their concerns over possible problems and
complications of the procedure.
Consideration should be given to informing the patient in whom
digastric muscle reduction may be needed that it may prolong
submental discomfort, induration, and edema and carries a small
increased risk of bleeding and a theoretical risk of vocal distur-
bance in voice professionals, although in our combined 40 years of
practice performing digastric muscle reduction, we have seen no
major complications and only one hematoma attributable to the
procedure. Patients should be informed when these problems are
discussed that, while uncommon, they can occur. It is also helpful
if the patient understands that only the protruding portion of the
muscle is excised and that the majority of the muscle is left in
place and not removed.
53.3.6 Preoperative Preparations
and Care
All patients undergo a preoperative physical evaluation, and all
those over 50 years old and any with significant medical prob-
lems must be cleared by their internist or personal physician
before their procedure is performed. Each patient is required to
avoid agents known to cause platelet dysfunction for 2 weeks
prior to surgery, and a list of products that contain aspirin and
other medications and products that have antiplatelet activity
is provided.
Smokers and Former Smokers
All patients who smoke are asked to quit 4 weeks before their
procedure and are required to avoid smoking and all secondhand
smoke for 2 weeks after. Patients who smoke, or who have a sig-
nificant history of smoking but have quit, are advised in writing
that their risk of serious complications, including poor healing,
flap necrosis, skin slough, and thromboembolic phenomena, is
significantly higher than in nonsmokers. It is generally assumed,
however, that most patients will not cease smoking, and extra
care should be taken to be sure informed consent is complete in
this regard.
Fortunately, flap viability is dependent upon a variety of factors
other than smoking that are under the surgeon’s control. These
factors include the amount of tissue trauma during dissection,
the extent of skin undermining, and the amount of tension on
the skin flap. Because deep neck lifting procedures create contour
by modifying deep neck structures and not by placing tension
on cervicofacial skin flaps, a careful surgeon employing proper
technique can operate with acceptable risk on smokers. It is also
often the case that a patient presenting for secondary surgery
has a more robust and durable skin flap with enhanced axial
blood flow (´delayed flapµ) that is less prone to compromise and
slough than a patient presenting for a primary procedure. Smokers
should always be approached with caution, however, and it should
be recognized that these patients are suboptimal candidates for
surgery and are at increased risk for serious local and systemic
complications.
Ultrasonic and Radiofrequency
“Skin-Shrinking” Treatments
Patients should be questioned carefully about previous noninva-
sive radiofrequency and ultrasonic ´skin-shrinkingµ procedures
(Ultherapy, Ulthera, Inc., Mesa, A=; Thermage, Solta Medical,
Bothell, :A; or Thermi, Solta Medical, Bothell, :A), as experience
strongly suggests that these treatments injure subcutaneous
fat, damage skin subdermal microcirculation, and compromise
superficial microlymphatic vessels. Patients who have undergone
these treatments seem to be suboptimal candidates for both
primary and secondary facelift and neck lift procedures.
The patient who has previously undergone facial ultrasonic and
radiofrequency ´skin shrinkingµ treatments is part of a growing
body of patients who seem to sustain clinically significant com-
promise of their skin microcirculation as a result of these and like
procedures, putting them at greater risk of slough and healing-
related problems following facelift and neck lift procedures.
Typically, the neck has been subjected to more aggressive treat-
ment. Unlike laser resurfacing, ´skin-shrinkingµ procedures direct
and dissipate energy under the skin, rather than on its surface, and
energy meant to ´tightenµ the face appears to damage both sub-
dermal microcirculation and adjacent superficial microlymphatic
vessels. The incidence of problems seems to parallel the number
and intensity of treatments the patient has undergone, which
one would expect to parallel the degree of compromise of their
tissues. These patients also seem to experience prolonged edema
and a longer period of recovery following facelift and neck lift
surgery when they have previously undergone these procedures.
Consideration should be given to advising patients who have
undergone previous ultrasonic or radiofrequency “skin-shrinking”
treatments in writing that their risk of serious complications,
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higher than in patients who have not undergone these procedures,
especially if they have undergone multiple previous treatments. From
the surgeon’s standpoint, experience has shown that these patients
should be regarded, approached, and treated as similar to smokers.
Allocating Operating Room Time
It is important that adequate operating room time be allotted
for secondary neck lift procedures, as they are deceptively time-
consuming compared with primary procedures. A secondary neck
lift, when performed in conjunction with facelift revision, forehead
plasty, eyelid surgery, fat injections, skin resurfacing, and other
procedures often needed when secondary neck lift is performed,
will often encompass 6 hours or more, even when performed by
a ´fastµ surgeon working with a well-organized and experienced
OR team. Most surgeons we know who perform these complicated
combined procedures on a regular basis have resigned themselves
to this fact and have made appropriate adjustments in their sur-
gery schedules. Usually this means allotting an entire day for the
procedure. For difficult procedures, or when additional surgery is
requested (e.g., rhinoplasty), it is recommended that the proce-
dures be staged over two separate days.

53 Secondary Neck Lift
791
53.4 Anesthesia Technique
53.4.1 Anesthesia Considerations for
Neck Lift Procedures
:hile it is possible to perform a limited procedure that one can
technically call a ´neck liftµ under local anesthesia, any such
procedure necessarily encompasses significant compromises in
the treatment of the deep neck and platysma that form the foun-
dation of the modern neck lift procedure and will typically not
allow the performance of important related and ancillary pro-
cedures, including comprehensive fat grafting, SMAS facelifting,
and often-needed forehead surgery, due to limits on the amount
of local anesthetic that can be administered and the patient’s
and surgeon’s tolerance for the procedures’ complexity and
length. Adding oral and/or intravenous (IV) sedation (´conscious
sedation”) to procedures performed under local anesthesia can
improve the patient’s experience and facilitate the performance
of more comprehensive operations, but doing so negates many
of the purported advantages of a ´localµ technique. It also places
the surgeon in the role of anesthesiologist and in charge of mon-
itoring the patient and managing and treating intraoperative
problems (hypertension, arrhythmias, etc).
Secondary neck lift procedures are typically time-consuming
and technically demanding and arguably will test the patience
and composure of almost any surgeon. It is highly recommended
that any surgeon new to these techniques consider enlisting the
services of an anesthesiologist as part of a team approach to
patient care. This is particularly important when the procedure
is to be performed upon a patient who is apprehensive or has a
history of anesthetic difficulties, hypertension, sleep apnea, gas-
troesophageal reflex disorder (GERD), or other significant medical
problems. This will avert the frustration and aggravation of trying
to perform a technically demanding procedure while simulta-
neously being shouldered with the responsibility of supervising
the administration of an anesthetic, monitoring the patient, and
managing intraoperative problems.
53.4.2 Our Preferred Neck Lift Anesthesia
Technique
1ot using local anesthesia does not automatically equate to
a need for general anesthesia, however, and formal general
anesthesia, in which patients are paralyzed, endotracheally
intubated, and placed on a ventilator, is not necessary and is
arguably not optimal for the performance of most facelift and
neck lift procedures, including secondary ones.
The majority of our primary and secondary neck lifts are now
performed under deep sedation administered by an anesthesi-
ologist using a laryngeal mask airway (LMA). The use of a LMA
allows the patient to be heavily sedated without compromise of
the airway, but the patient need not receive muscle relaxants and
can be allowed to breathe spontaneously. An LMA is also less likely
to become dislodged during the procedure than an endotracheal
tube, and it will not trigger coughing and bucking when the
patient emerges from the anesthetic.
It is useful to modify the way in which the laryngeal mask is tra-
ditionally used when performing neck lift and related procedures.
Traditionally the cuff of the LMA is inflated to create a seal so that
a ventilator can be used, positive pressure ventilation applied, and
vapor anesthetics administered. This is not necessary, however,
when patients are not paralyzed and only heavily sedated, when
intravenous sedation is used rather than inhalation anesthetics,
or when the patient is allowed to breathe spontaneously. In such
cases the cuff of the LMA can be left uninflated or be minimally
inflated and the LMA left to function as simply a large oral airway.
1ot inflating the cuff limits pressure in the hypopharynx and
reduces the likelihood of related postoperative discomfort in the
throat.
The ÁH[LEOH LMA (LMA device with a flexible shaft) is partic-
ularly useful in neck surgery (Fig. 53.39). :hen this device is
used and the breathing circuit is separately draped, the breathing
circuit can be moved from side to side as required during the
procedure to obtain unobstructed access the cervicosubmental
region as needed.
Most surgeons initially considering using an LMA are under-
standably fearful that the bladder on the device, when inflated,
will distort the cervical region and interfere with neck assess-
ment and treatment. :e have found this not to be the case, and
although a bulge is often evident if the LMA cuff is inflated, the
surgeon can simply ignore it and carry out all neck maneuvers as
usual and as indicated. The bulge created by the inflated cuff will
not affect gauging the extent to which deep-layer neck maneuvers
are carried out (submandibular gland reduction, subplatysmal fat
resection, and digastric muscle reduction) or interfere otherwise
Fig. 53.39 Flexible laryngeal mask airway (LMA). The use of a laryngeal
mask allows the patient to be heavily sedated without compromise of
the airway, but the patient need not receive muscle relaxants and can
be allowed to breathe spontaneously. An LMA with a flexible shaft is
particularly useful in neck surgery, as it allows the breathing circuit to
be easily moved when working in the submental area.

792
VIII Surgical Rejuvenation of the Face and Neck
with the neck lift procedure (platysmaplasty, platysmamyotomy,
lateral platysma suspension using a postauricular transposition
flap, drain placement, etc).
53.4.3 Preop Anesthesia Medications
Most patients receive preoperative medication tailored and
adjusted to their age, weight, height, personality, specific cir-
cumstances, and general health, and this regimen is modified
depending upon the type of anesthetic used. Typical preop
medications currently used for patients in good health without
contraindications and as appropriate for their weight and gen-
eral conditions include clonidine (0.1–0.3 mg orally), atenolol
(12.5–25 mg orally), and midazolam 3 to 5 mg intramuscularly,
typically administered in the deltoid muscle. These medications
should be administered after all preop discussions have been
made, patient questions answered, and preoperative consents
and other related paperwork signed. Oral narcotics should not
be given as part of the premedication, as they commonly result
in nausea and vomiting. Cocaine, anticholinergics, and parasym-
pathomimetics are also avoided in our practices.
Antiemetics are given routinely in a preemptive fashion at the
beginning of each procedure and typically include ondansetron
(10 mg IV) and dexamethasone (3–5 mg IV). It should be noted that
dexamethasone is administered for its antiemetic properties, not
as a means to reduce swelling. Patients with a history of motion
sickness, perioperative nausea and vomiting, or other risk factors
are given medications to block the emetic reflex at multiple levels,
typically including aprepitant (Emend) (40–80 mg orally) and/or a
scopolamine patch (placed on the upper inner thigh).
53.4.4 Patient Monitoring During
Anesthesia
All patients are fully monitored with electrocardiography,
automatic sphygmomanometry, transcutaneous pulse oximetry,
and mainstream capnography. Perioperative blood pressure is
closely monitored and aggressively treated should it become
significantly elevated, especially in patients with existing hyper-
tension or a ´borderlineµ condition. The latter group of patients
should be watched closely and treated preemptively, as they
typically become hypertensive once the surgery and anesthesia
is begun.
53.4.5 Method of Intraoperative
Sedation
The current mainstay of patient sedation during our face- and neck
lift procedures is achieved through the use of propofol. Typically
a bolus (1–2 mg/kg) is administered by the anesthesiologist prior
to LMA insertion, followed by a drip infusion administered via
an infusion pump depending on the patient’s circumstances and
titrated to the patient’s needs (75–200 —g/kg/min).
In most cases the IV anesthetic infusion is titrated to a deeper
level for a brief period once the patient has been prepped and
draped to give the surgeon a few minutes of deep sedation in
which to perform local anesthetic nerve blocks and infiltrate all
proposed sites for incision with local anesthetic solution.
53.5 Surgical Technique
53.5.1 Patient Positioning, Urinary
Catheter Insertion, and Patient
Marking
The patient is placed supine on a warmed and well-padded,
slightly flexed operating table, and a special effort is made to
ensure and document that the elbows, heels, and other potential
pressure points are well protected. The patient’s lower extrem-
ities are then elevated and antiembolic pedal compression
devices applied. If the procedure is anticipated to take longer
than 4 hours, an indwelling balloon-tipped urinary catheter
(Foley catheter) is placed after sedation is begun or general
anesthesia administered. During this time the incision plan
is marked with a fine-tipped surgical marker after skin to be
marked is degreased with isopropyl alcohol. If fat grafting is to
be performed, fat is harvested at this time, before the face is
prepped and draped, which typically entails turning the patient
into right and left lateral decubitus positions. A temperature
probe is then taped in the axilla or groin, and the patient is suf-
ficiently covered or a patient warming device applied to allow
the room to be cooled for the comfort of the scrubbed team
members.
53.5.2 Patient Prepping and Draping
After anesthesia is begun, fat has been harvested, the patient
has been positioned on the table, the urinary catheter placed
(if indicated), and the incision plan marked on the patient, a
sterile prep drape is placed beneath the patient’s head and bland
ophthalmic ointments instilled into each eye. Each patient then
receives a full surgical scrub of the entire scalp, face, ears, nose,
neck, shoulders and upper chest with full strength (1:750) ben-
zalkonium chloride (BA.; e.g., =ephiran, Sanofi, Paris, France)
solution. The patient’s head is then placed through the opening
of a ´split sheet,µ or split adhesive-backed disposable transverse
laparotomy sheet (tails facing the patient’s feet), leaving the
entire head and neck region unobscured from the clavicles up.
1o ´turbanµ or ´head drapeµ is used if facelift, extended neck
lift, or foreheadplasty is to be performed. This allows unim-
paired examination of the cervicofacial profile in its entirety
throughout the procedure and provides complete access to the
periauricular areas when required.
The breathing circuit is subsequently draped separately from
the patient by wrapping it with a sterile paper drape sheet and
securing it with 1-inch (2.5-cm) Steri-Strips (3M, St. Paul, M1)
or by covering it with a sterile stockingette. This allows it to be
moved during the procedure as the patient’s head is turned from
side to side and away from the submental area when working
in the neck through the submental incision. :hen drapes are
applied in this manner, it is not necessary to secure the LMA
with tape or by other means as long as the anesthesiologist
and/or other members of the operating room team present are
watching its position. If an endotracheal tube is used, it can be
conveniently and effectively secured to the upper lip skin with a
TegaDerm (3M, St. Paul, M1) or similar sterile, adhesive-backed
dressing.

53 Secondary Neck Lift
793
53.5.3 Administering Local Anesthesia
Local anesthetic is administered even if deep sedation or general
anesthesia is used. This limits stimulation of the patient and the
overall amount of anesthetic needed and significantly reduces
or often eliminates the need for intraoperative narcotics. A
significant and helpful hemostatic effect is also obtained when
epinephrine/tranexamic acid–containing solutions are used.
Sensory nerve blocks are performed using 0.25 bupivacaine
(Marcaine) with epinephrine 1:200,000 injected with a 25-gauge
needle attached to a 10-mL ring control syringe. This allows the
rest of the neck or face to be injected with a reduced degree of
stimulation. Skin marked for incision is then infiltrated with
the same solution. Areas where subcutaneous dissection will
be made are infiltrated with 0.1 lidocaine (Xylocaine) with
epinephrine (1:1,000,000) and tranexamic acid (1,000 mg per
500 mL of local anesthetic solution), taking care to ensure that
the total dose of lidocaine does not exceed 7 mg per kilogram
per 4 hours (Fig. 53.40). Using this dilute local anesthetic solu-
tion, the subcutaneous neck can be generously infiltrated, and
typically 100 mL or more is infiltrated per side. A generous infil-
tration provides several important advantages, including hydro-
predissection, expansion of the subcutaneous space to be dis-
sected, and improved hemostasis.
Infiltration of the preauricular cheek (if indicated) and postau-
ricular areas is carried out using a 22-gauge spinal needle, as skin
in these areas is typically adherent and resistant to injection with
a blunt cannula, especially if previously dissected at a primary
procedure. Infiltration of the neck and submental regions is
carried out with a 1.6-mm 20-cm-long multihole, blunt-tipped
infiltration cannula. If subcutaneous fat was aggressively resected
at the primary procedure, subcutaneous infiltration can be a dif-
ficult and time-consuming activity that must be undertaken with
care. 1o direct infiltration beneath the platysma is necessary if the
overlying subcutaneous tissues are infiltrated generously at the
beginning of the procedure as just described.
Generous infiltration of dilute local anesthetic solution with a
1.6-mm (or like) infiltration cannula is particularly helpful if tissue
conditions allow it, as the blunt tip tends to keep the infiltration
in the proper plane and the multiple back-and-forth passes
needed to infiltrate the large volume of local anesthetic effectively
predissect and preestablish the plane to be subsequently sharply
dissected with Metzenbaum scissors. In many cases, additional
back-and-forth injection cannula movements above and beyond
what is needed to infiltrate the local anesthetic solution are made
to maximize this predissection effect.
53.6 Operative Sequence for Skin
Flap Elevation
53.6.1 Preservation of Existing
Subcutaneous Fat
Many surgeons begin neck lift surgery by performing submental
liposuction, but in almost all cases in secondary procedures
a conscious and concerted effort must be made to preserve all
subcutaneous fat that is present. Typically subcutaneous fat
has been previously overresected at the primary procedure in
the misguided belief that the poor neck contour present was
the due to excess subcutaneous fat, and additional fat removal
compounds the hard and aged appearance that is usually pres-
ent. A careful examination made by a thoughtful and observant
surgeon of patients presenting for secondary neck lift will often
show them to typically have a relatively soft, plushly padded face
with a skeletonized ´skin on muscleµ appearance in the neck (see
Fig. 53.2; Fig. 53.3). Once this occurrence is acknowledged and
the resulting appearance recognized, it becomes apparent that in
most cases the surgeon must fight to preserve as much subcuta-
neous fat as possible and sacrifice only subcutaneous fat that is
found to be truly redundant after all deep-layer maneuvers have
been performed.
53.6.2 Submental Incision Placement
If a submental incision was not made at the primary procedure, it
should be made in the secondary operation, 1.5 cm or more pos-
terior to the submental crease, approximately halfway between
the mentum and hyoid (Fig. 53.18). Making the incision in this
location helps conceal it in the shadow of the mandible, avoids
Fig. 53.40 (a,b) Local anesthetic solutions. (Courtesy of Timothy
Marten, MD, FACS, and the Marten Clinic of Plastic Surgery. Used with
permission.)

794
VIII Surgical Rejuvenation of the Face and Neck
surgical reinforcement of the crease and accentuation of the
double chin and witch’s chin irregularities, and provides better
exposure of and facilitates dissection of the deep neck (see Fig.
53.13; Fig. 53.14; Fig. 53.15; Fig. 53.16; Fig. 53.17).
If an existing scar is present in the submental crease where a
submental incision was made previously at the primary procedure,
one must decide whether this should be excised and reused or a
new incision in the submental region made (and thus a new scar
created) in the more advantageous location just described. Factors
to be considered are the quality of the existing submental scar, the
patient’s age, and the patient’s skin type and quality. If the scar is
inconspicuous and mobile, if the patient is older, and if the patient
is fair-skinned, these factors favor making a new incision in a more
appropriate and advantageous position. In such cases the existing
scar can be undermined and released from the relocated one and
then intradermally fat grafted (if necessary), and the new scar can
be expected to be inconspicuous once healed. Moving the incision
in this way also allows it to be made longer and will provide better
exposure than if it is made a second time in the submental crease.
If the scar is irregular and/or tethered, if the patient is younger,
or if the patient has a darker skin type, it may be preferable to
excise the existing scar and release the adjacent tethered areas,
even though this will make exposure and dissection in the deep
neck more difficult. It is wise in such circumstances to leave the
final decision to the patient after appropriate discussion of the
advantages and disadvantages of relocating the scar.
53.6.3 Skin Flap Elevation
Once the submental incision has been made, the surgeon should
stand at the head of the table during dissection of the submental
region while the assistant retracts the edges of the incision with
a pair of 10-mm double-pronged skin hooks. Having the assistant
retract frees up the surgeon’s nondominant hand to apply coun-
tertraction to the skin being elevated and to assess flap thickness
and provides for optimal teamwork. Skin undermining should be
made using a medium curved Metzenbaum scissors, and the dis-
section should be made subcutaneously, leaving the majority of
the subcutaneous/preplatysmal fat on the platysma surface. This
makes fat excision and sculpting easier later in the procedure if
required, and it precludes the need for more tedious and demand-
ing excision of fat from the undersurface of the cervical skin flap.
Unlike the dissection of the facelift skin flap, in which a con-
scious effort must be made to prevent the flap from becoming too
thick and the SMAS from being compromised, a slightly deeper
dissection should be made in the neck to preserve a slightly
thicker layer of subcutaneous fat. Preservation of a thicker layer
of fat helps avoid a hard or overresected appearance in the cervi-
cosubmental area and objectionable overexposure of underlying
neck anatomy postoperatively. Many necks of secondary facelift
patients will have been previously aggressively stripped of sub-
cutaneous fat, and only subplatysmal fat will need to be or should
be removed. Raising a cervical skin flap in these patients can be
tedious and time-consuming and should be undertaken with care.
Submental dissection is continued inferiorly and laterally. If a
short-scar neck lift is being performed, the dissection is extended
laterally to the anterior border of the sternocleidomastoid muscle
and up into the postlobular area (Fig. 53.41).
If an ´extendedµ (long-scar) neck lift or concomitant facelift is
being performed, this dissection will join the upper lateral neck
dissection made previously through postauricular and perilobular
incisions (Fig. 53.42).
Cervical skin flap elevation can be technically challenging in
the secondary neck lift patient, especially in the submental and
postauricular areas, where subcutaneous fat excision by liposuc-
tion or other means is typically more aggressive. In these areas
one frequently encounters thick patches of fibrotic subcutaneous
tissue and dermomuscular adhesions that must be carefully dis-
sected and released. Careful infiltration of local anesthetic with a
blunt infiltration cannula in the proper plane (hydrodissection) in
combination with repeated back and forth movements of the infil-
tration cannula in that plane (blunt dissection or predissection)
as mentioned previously will greatly facilitate subsequent sharp
dissections in such circumstances.
Upon completion of subcutaneous undermining of the anterior
neck and submental regions, a retrograde dissection should be
made subcutaneously up onto the inferior chin. This will ensure
that the submental restraining ligaments present under and
responsible for the submental crease have been divided and that
the submental crease has been released from its bony attachments,
and this maneuver provides for subsequent blending of chin and
submental fat after other neck maneuvers have been completed to
obtain a visually smooth and optimally seamless, aesthetic tran-
sition from chin to submental region. This has typically not been
done at the primary procedure, and failure to do so contributes
significantly to the presence of a double chin. Some bleeding is
usually encountered from perforating vessels that accompany
ligaments in this region during this maneuver, but this should not
prevent the surgeon from carrying out this important step. Care
should be taken when using cautery in this area to avoid cautery
injury to the overlying skin.
If a facelift or extended neck lift is being performed and the
upper lateral neck is being approached from a postauricular
incision, care must be taken to avoid injury to the great auricular
nerve. This nerve provides sensation to the lower two-thirds of
the ear and travels superficially superiorly in the upper lateral
neck over the sternocleidomastoid muscle fascia. The most
superficial portion of the nerve is anatomically constant and lies
approximately 6.5 cm inferior to the auditory meatus, midway
between the anterior and posterior borders of the sternocleido-
mastoid muscle, and it is helpful to mark this spot preoperatively
on the neck skin surface to guide dissection. If the dissection
is performed in the correct plane, however, the nerve will lie
deep to the plane of skin flap elevation and will be covered by
a thin layer of subcutaneous fat, at least in the primary surgery
patient. It is prudent that all dissection made through the ´great
auricular corridorµ (over the course of the great auricular nerve),
in both secondary and primary cases, be made with great care
under direct vision and not blindly or using a scissors pushing
technique.
Patients with thin faces, or those undergoing secondary facelifts,
will not uncommonly have little subcutaneous fat between the
superficially situated portion of the great auricular nerve and
the skin, however. For this reason, extra caution must be taken
in these patients in elevating the skin flap in this area, and a clear
knowledge of nerve anatomy is required.

53 Secondary Neck Lift
795
53.6.4 Cervical Lipectomy
The key to obtaining good outcomes in the neck in both primary
and secondary cases is in understanding the distribution of fat
in the cervico-submental region and choosing a treatment plan
accordingly. Cervical fat is present in three distinct anatomic
layers: preplatysmal (subcutaneous), subplatysmal, and deep
cervico-submental (interdigastric), and the thoughtful surgeon
must learn how to recognize and treat each layer appropriately
for the conditions present.
:hile our traditional focus has misguidedly and mistakenly
been on the preplatysmal layer (submental liposuction and
related surgical and nonsurgical procedures that reduce subcuta-
neous fat), most patients presenting with poor neck contour will
be troubled instead by fat excess predominantly in the subplatys-
mal layer. This is even more so the case in the patient presenting
for secondary neck lift, as typically the surgeon performing the
primary procedure mistakenly targeted the superficial layer only.
Understanding and accepting this anatomic reality, and learning
to treat subplatysmal fat appropriately, is a key part of obtaining
consistently good outcomes in both primary and secondary neck
lift procedures.
Cervical lipectomy is a technically demanding maneuver that
requires patience, perseverance, and artistic sensitivity, and the aim
of the surgeon should be to produce an attractive neck, not simply one
devoid of fat. Contrary to what is traditionally practiced, if a facelift
is being performed in conjunction with the neck lift, subcutaneous
lipectomy (including liposuction), if indicated, should be performed
after deep-neck maneuvers and shifting and suturing of the SMAS
and platysma, not at the beginning of the procedure. If subcutaneous
submental liposuction and/or lipectomy is performed at the begin-
ning of the procedure, fat will be mistakenly excised from regions
of the neck that will be raised onto the face when SMAS flaps are
advanced and suspended, and this can result in inadvertent creation
of harsh or irregular mandibular contours (Fig. 53.43). In almost all
cases, but especially in secondary procedures where subcutaneous
fat has typically been previously overresected, it is best to leave the
subcutaneous fat layer untouched until all other maneuvers are com-
pleted and improvements obtained with them assessed. Only then
should the surgeon consider removing fat from the subcutaneous
layer. Typically what appeared to be excess fat initially will be seen
not to be so after deep-layer maneuvers have been completed.
Exploration of the subplatysmal space is indicated if pre-
operative assessment suggests that a significant collection of
Fig. 53.41 Extent of skin undermining in short-scar neck lift. Skin
undermining is carried inferiorly below the level of the cricoid cartilage
(double solid lines), laterally to the anterior border of the sternocleido-
mastoid muscle, and superiorly beneath the submental crease (dotted
line) and through the submental and mandibular retaining ligaments.
Undermining and releasing the submental crease and carrying the
dissection retrograde up onto the chin allow the fat of the chin and
submental area to be seamlessly blended. The solid line shown poste-
rior to the submental crease is the site for the submental skin incision.
(Illustration courtesy of the Marten Clinic of Plastic Surgery.)
Fig. 53.42 Subcutaneous skin undermining for an extended neck
lift or when a necklift is performed with a facelift. Orange-lit area
shows subcutaneous skin undermining that is performed through the
periauricular incisions when a neck lift is performed with a facelift (or
during an extended neck lift procedure). Submental skin undermining
(yellow-lit area) is then completed through the submental incision (solid
line in submental area). Double horizontal lines on the inferior anterior
neck show the location of the cricoid cartilage. (Illustration courtesy of
Marten Clinic of Plastic Surgery.)

796
VIII Surgical Rejuvenation of the Face and Neck
subplatysmal fat is present, large submandibular glands are
identified, or large digastric muscles are detected or if uncertainty
exists as to any aspect of the condition of the subplatysmal
space. The presence of excess volume in the submental space
can be demonstrated preoperatively by examining a lateral look-
ing-down view photograph (Connell’s view) of the patient’s neck
(see Fig. 53.31). Significant accumulations of subplatysmal fat,
and the presence of abnormal fullness in the subplatysmal space
can also be demonstrated intraoperatively by Connell’s Test. This
consists of placing gentle superior traction on the cheek flaps (if
face lift) or cheeks (if isolated neck lift) and flexing the neck. If the
neck appears full upon this maneuver, consideration should be
given to exploration of the subplatysmal space and the removal of
redundant subplatysmal fat and/or protruding portions of other
enlarged structures.
Subplatysmal exploration is performed through the submental
skin incision. The subplatysmal space is entered by incising the
superficially situated fascia between the medial platysma muscle
borders using a Metzenbaum scissors or electrocautery. In many
patients, varying degrees of decussation of the right and left pla-
tysma muscles will be present in the submental region, and this
area is divided. A combination of blunt and sharp scissors tech-
niques is used to isolate and elevate the medial muscle edges. This is
greatly facilitated by grasping and retracting the muscle edge near
the chin by the assistant using a 10-mm double-prong skin hook or
an Allys forceps. The surgeon can then place countertraction more
inferiorly on the muscle edge with a DeBakey or similar forceps.
The dissection is subsequently carried laterally, over the anterior
belly of the digastric muscle hugging the underside of the platysma.
Typically the subplatysmal space will be found to have been
untouched or timidly dissected at the primary procedure in
secondary cases, and if this dissection is carefully made, a well-
defined and relatively avascular plane can usually be identified.
Small communicating vessels are not infrequently encountered,
however, especially near the medial muscle borders. These should
be carefully divided and fulgurated as required. Subplatysmal
fat should be left on the deep surface of the neck and not raised
with the platysma flap. This will facilitate subplatysmal fat pad
removal, as it is technically more difficult to resect fat from the
undersurface of the muscle than en bloc from the deep surface of
the neck. As the dissection proceeds laterally, the assistant places
a small Harrington or similar retractor in the subplatysmal space
to retract the platysma and expose the submandibular gland.
The plane tangent to the anterior bellies of the digastric muscles
with the neck in neutral or slightly flexed position should be used
as the landmark for subplatysmal fat removal. Fat deep (superior) to
this plane is deep cervico-submental fat (interdigastric fat), which
should not be removed if a ´dug outµ or ´cobraµ neck deformity is
to be avoided (see Fig. 53.35). All fat present in the subplatysmal
space lying superficial (inferior) to this plane consists of subplatys-
mal fat and should theoretically be removed if optimal contour is
to be obtained. If subplatysmal fat excision is made with the neck
flexed, inadvertent overexcision of intradigastric fat can occur.
As a practical matter, overall neck contour must be considered,
as it is the curvilinear plane across the submental region tangent
to the borders of the mandible and the anterior bellies of the
digastric muscles that ultimately determines attractive neck
contour (Fig. 53.44).
If large submandibular glands or anterior bellies of the
digastric muscles are present and it is elected that they not be
treated, subplatysmal fat removal should be more conservative
if accentuation of these problems is to be avoided. Fibrous fat
in the prehyoid region should also not be arbitrarily removed,
especially in women, as accentuation and masculinization of the
Fig. 53.43 Sequencing excision of preplatysmal fat when simultaneous
facelift and neck lift are performed. If submental liposuction is
performed before the superficial musculoaponeurotic system (SMAS)
is elevated, denuded areas will be subsequently advanced onto the
lower face. This can result in a harsh mandibular contour. To avoid
this problem, preplatysmal fat should be removed, if indicated, after
the SMAS flap has been raised. (a) Incorrect plan for preplatysmal fat
excision (gray shaded area indicated by arrow). Submental liposuction
is performed at the beginning of the procedure before SMAS flap is
raised. (b) After SMAS elevation, areas stripped of fat (gray shaded
area indicated by black arrow) are moved up onto the lower face.
(Illustration courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.44 Anatomy of optimal neck contour. The curvilinear plane
across the submental region tangent to the borders of the mandible (near
black line), to the ipsilateral anterior belly of the digastric muscle (near red
line), to the contralateral digastric (far red line), to the contralateral man-
dibular border (far black line) ultimately defines optimal attractive neck
contour. Between the border of the mandible and the ipsilateral digastric,
poor contour is due to protruding submandibular glands (excised
specimen shown). Between the digastric muscle bellies the problem is the
subplatysmal fat (excised specimen shown). After subplatysmal fat removal
and submandibular salivary gland reduction, additional improvement can
be obtained by reducing the anterior digastric muscle bellies themselves
(area beneath near and far red lines). (Procedure performed by Timothy
Marten, MD, FACS. Courtesy of Marten Clinic of Plastic Surgery.)
a
b

53 Secondary Neck Lift
797
larynx can occur. If prominent submandibular glands and digastric
muscles are appropriately treated, however, more aggressive and
near-complete resection of subplatysmal fat can typically be made.
Subplatysmal fat will be evident as a centrally situated, trian-
gular fat pad with its base lying at the hyoid and its tip near the
mentum (Fig. 53.45). It should be removed as appropriate, and as
determined by the position and size of the digastric muscles and
the size of the submandibular glands. Fat removal should not be
arbitrary, and close attention must be paid to the new contours
created. Subplatysmal fat excision often results in division of
Fig. 53.45 Subplatysmal fat. (a) Illustration showing the position of the triangular subplatysmal fat pad located in the submental part of the subpla-
tysmal space with its tip near the mentum and base at the hyoid bone. (c) Cadaver view of the submental region and subplatysmal fat similar to that
shown in the illustration above but closer up. The arrow is pointing to the subplatysmal fat, which has been outlined with a broken line. The right and
left borders of the platysma have been elevated, showing the contents of the submental space. The subplatysmal fat pad can be seen overlying the
digastric muscles to the upper right and left of the triangle. The hyoid bone is at the base of the triangle. (b) Cadaver demonstration of subplatysmal fat.
The head is slightly turned to the viewer’s right and the chin is at the upper right-hand corner of the photo. The two upper arrows point to the anterior
bellies of the right and left digastric muscles, and the lower arrow to the subplatysmal fat pad. In this photo, the subplatysmal fat pad has been reflected
inferiorly but is still attached at its base just inferior to the hyoid. The hyoid is now visible along with the interdigastric space. There is a small amount of
deep cervical fat (interdigastric fat) visible between the two upper arrows that has been reflected to the viewer’s right. (d) Intraoperative demonstration
of the subplatysmal fat specimen lying over the submental part of the subplatysmal space from which it was removed. The patient’s chin is pointing
superiorly and is in the upper left corner of the photo. The neck is in the lower right corner of the photo. (Courtesy of Marten Clinic of Plastic Surgery.)
a
b
c
d

798
VIII Surgical Rejuvenation of the Face and Neck
tributaries of small pretracheal and submental vessels, and a long
shielded cautery forceps and good suction should be available to
obtain adequate hemostasis when required.
Fat situated deep to the plane tangent to the anterior bellies of
the digastric muscles and beneath the deep cervical fascia (deep
cervical or “interdigastric” fat) should not be removed, and the over-
whelming temptation to “clean out” the deep cervical space must be
resisted. Platysmaplasty, invaginating platysma in a ´corsetµ fash-
ion, suturing the anterior bellies of the digastric muscles together,
and other like maneuvers that have been tried and failed cannot
compensate for overzealous excision of deep fat, and in time, once
submental swelling has subsided, an objectionable ´dug-outµ or
´cobra neckµ submental depression will appear in the necks of
patients so treated (see Fig. 53.35).
Operative Sequence for Subplatysmal Fat
Excision
Once the platysma muscles have been raised and the prominent
submandibular glands identified (see discussion that follows),
the subplatysmal fat pad is most easily isolated by identifying
each anterior belly of the digastric muscle near its insertion
at the chin after making a small incision with scissors in the
overlying fat and fascia. Once the muscle is identified in that
location, the dissection is carried down inferiorly and laterally
on the digastric muscle’s anterior (inferior) surface to its inser-
tion at the lateral hyoid. If the submandibular glands have been
previously mobilized inside their capsules, the dissection along
the surface of each anterior digastric muscle belly can be taken
into the submandibular capsule, and this dissection along the
anterior surface of each digastric defines the lateral border of
the subplatysmal fat pad. Fat overlaying each anterior digastric
muscle belly is then divided with electrocautery because of
the predictable presence of a branch vein in this area. Once the
lateral borders of the fat pad have been dissected, the right and
left inferior corners are dissected up off the underlying muscle
fascia toward the midline. The plane tangent to each digastric
muscle anterior belly is then imagined, and all fat lying inferior
(superficial) to that plane is removed using electrocautery, leav-
ing the interdigastric fat between the anterior digastric muscle
bellies intact and in place. Typically a vein will be encountered
and require cautery in the prehyoid region.
53.6.5 Submandibular Gland Reduction
If large submandibular glands are present, they can usually be
seen and palpated lateral to the ipsilateral belly of the anterior
digastric muscle on each side within its respective subman-
dibular triangle, protruding inferiorly to a plane tangent to the
digastric muscle belly and the mandibular border (Fig. 53.46; see
also Fig. 53.36, Fig. 53.37).
The protruding portion can be resected through the submen-
tal incision before submental platysmaplasty is performed to
improve neck contour, if indicated (Fig. 53.47). :hile excising
subplatysmal fat predominantly improves neck contour under the
chin and in the lateral view, reducing protruding submandibular
salivary glands improves contour under the mandible and in the
oblique view and accentuates the shadow under the jawline. As
such, simply removing subplatysmal fat is incomplete treatment
of the neck and fails to rejuvenate the cervico-submental area
comprehensively.
Prominent submandibular glands will be encountered as
subplatysmal dissection is carried over the anterior belly of the
ipsilateral digastric muscle. The prominent gland will appear as a
smooth pink to tan mass covered by a smooth capsule. Reduction
is begun once the ipsilateral platysma muscle has been elevated
by incising the capsule overlying the gland inferomedially just
lateral to the anterior belly of the digastric muscle. The subman-
dibular gland will be evident once exposed in this manner due
to its distinctive lobulated appearance. Its inferior portion is then
gently grasped and easily separated from its capsule using a gentle
blunt scissors spreading technique. Although all vital structures
are outside the glandular capsule, care should be taken when
mobilizing the gland superolaterally, as both the retromandibular
vein and the marginal mandibular branch of the facial nerve are
in proximity in that area.
Fig. 53.46 (a,b,c) Surface expression of large submandibular salivary gland. Typically large submandibular glands will be seen in the lateral submen-
tal triangle as a round protrusion situated lateral to the more medially situated anterior bellies of the digastric muscles, which appear as a more linear
paramedian fullness, and the difference in appearance of the two problems is a reflection of their differing anatomic origins. In many instances, and
especially in many patients seeking secondary neck surgery, the diagnosis of both problems can be made by simply looking at the patient’s neck, as
in this case. This patient has had a prior face- and neck lift. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
a
b
c

53 Secondary Neck Lift
799
An examination of the gland once mobilized inside its capsule
will show it to be large, not merely ´ptotic,µ and this observation
forms the basis of the recommendation that resection of the
protruding portion be performed. Examination of the exposed
gland will also clearly demonstrate that attempts to reposition it
more superiorly by suture suspension or by tightening overlying
platysma muscle will ultimately be fruitless.
A key step in the safe performance of the procedure is adequate
mobilization of the gland, and a modest overmobilization will
make both gland resection and the control of any intraglandular
bleeding that might be encountered much easier.
Once adequately mobilized inside its capsule, the inferior portion
of the gland is grasped, and pulled gently inferiorly and medially
out of its fossa and away from adjacent structures. The redundant
portion is subsequently gauged and excised under direct vision in a
medial-to-lateral direction along the planned line of resection with
monopolar coagulating current cautery. Excision of the excess part
of the gland should be performed in such a manner that the portion
protruding inferior to a plane tangent to the ipsilateral anterior
belly of the digastric muscle and the ipsilateral mandibular border
will be resected. It is usually best that initial resection be conser-
vative and that the gland be incrementally reduced thereafter as
required. 1ever is it necessary or appropriate to remove an entire
gland (and in fact the majority of the submandibular salivary gland
sits cephalad to the mylohyoid muscle in the floor of the mouth
and cannot be accessed or resected from the superficial submental
approach described herein). This could result in a depression or
other contour abnormality and could precipitate an objectionable
depression or “dry mouth” condition.
Excision of the redundant and protruding portion of the
submandibular gland should be performed using an extended
flat-tipped cautery and a long, high-quality atraumatic (DeBakey
or similar) forceps. A flat-tipped, extended cautery is superior
for controlling bleeding of an intraglandular vessel, should it be
encountered, than is a needlepoint cautery tip, and monopolar
current is superior for this purpose to bipolar cautery. A long,
high-quality, insulated coagulation forceps is also required.
As in all surgery of the neck and submental region, a fiber-optic
headlight or retractor is mandatory, as are a competent assistant
and a second scrubbed team member to pass instruments and
sutures as needed. One person cannot effectively or safely per-
form both these roles. A suction cannula (evacuating retractor should also be placed, and the position of the
cautery tip relative to vital adjacent structures must be known
at all times during the resection. If a smoke-evacuating retractor
is used, a second suction setup for a available in the event that bleeding is encountered during the
resection and suction is needed to obtain hemostasis.
Anatomy of Submandibular Gland Blood Supply
The submandibular artery enters the submandibular gland
superolaterally and will not be directly and specifically encoun-
tered when performing conservative resections typically made
for aesthetic purposes; only its terminal branches, extending into
the gland itself, will be encountered. Dissection should always be
made carefully in this area, however, and as one becomes more
practiced in the procedure and makes more comprehensive
resections as a result, this vessel will often be seen as a discrete
Fig. 53.47 Surgical approach to submandibular gland reduction. (a)
Cadaveric demonstration of submandibular triangle. Chin is in the upper
right corner of the photo. The excessive portion of the submandibular
gland (SMG) is found protruding inferiorly to a plane tangent to the
digastric (lower arrow) and the mandibular border (small upper arrow).
(b) Intraoperative photo demonstrating exposure of the submandibular
gland. The patient’s head is in similar position to the cadaver head shown
in (a) with the chin in the upper right corner. A submental incision has
been made approximately 1.5 cm posterior to the submental crease and
the neck subcutaneously undermined. The right platysma muscle has
been elevated and is retracted with a double-pronged skin hook and a
malleable retractor. The gland will be seen as a distinct bulge just lateral
to the ipsilateral anterior belly of the digastric (scissors tips rest on digas-
tric). The capsule has been incised inferomedially and the submandibular
gland isolated using blunt dissection. (c) Intraoperative photo prior to
resection of the excess portion of the gland with head in similar position
to (a) and (b). The gland has been mobilized and gently pulled inferiorly.
The dotted line represents the level at which the inferior portion of the
gland will be excised. (d) Intraoperative photo just prior to excision of the
protruding part of the gland with head in a similar position to (a) and (c),
but close-up. Gland reduction should be performed incrementally with
electrocautery in such a manner that the portion protruding inferior to
the plane tangent to the ipsilateral anterior belly of the digastric muscle
and the ipsilateral mandibular border will be resected. (e) Patient seen
immediately after necklift that included partial submandibular gland
reduction but no skin resection. The photo shows the excellent contour
created without skin tightening. The excised portions of the subman-
dibular glands are also demonstrated on both the right and left sides
(subplatysmal fat was also excised and the anterior bellies of the digastric
muscles reduced; however, these specimens are not shown).
a
b
c
d
e

800
VIII Surgical Rejuvenation of the Face and Neck
branch of the much larger submental artery. In many cases, if
care is exercised, resection of the most superolateral portion
of the protruding portion of the gland can be made without
dividing this vessel, and it can be isolated and grasped with a
hemostatic (Schnidt) forceps and ligated.
Algorithm for Management of Bleeding
Encountered During Submandibular Gland
Reduction
Submandibular gland reduction must not be performed without
good light, proper instruments, requisite exposure, adequate
suction, sufficient personnel, and considered caution, as intra-
glandular vessels may be encountered. These vessels are more
commonly encountered when larger resections are necessary
and are most easily managed by immediate and thorough fulgu-
ration before further dissection is made. Typically, bleeding will
occur from both the gland (patient) side and the specimen side,
and this is usually best controlled by quickly moving the cautery
back and forth between the two ends of the cut vessel. If only the
gland (patient) side is cauterized, bleeding will often continue
from the specimen side, obscuring the surgical field. In most
cases, pulling inferiorly on the specimen side will slow bleeding
from the cut vessel edges and facilitate controlling them.
If bleeding cannot be readily controlled by direct cauterization
of each side of the cut vessel, suction should be applied, an insu-
lated cautery forceps used to grasp the bleeding point directly, and
the point subsequently cauterized by application of coagulating
cautery current to the instrument.
If bleeding is brisk and not easily controlled by the cauterization
methods described above, the gland should be pulled inferiorly
and its entire cut edge compressed proximally with a second
DeBakey or long insulated coagulation forceps. Once bleeding is
controlled in this manner, the wound can be irrigated and suc-
tioned to clear the field and the offending vessel then carefully
identified by gently intermittently releasing the compression
across the cut edge of the gland. Once identified, it can then be
grasped with a second instrument and cautery applied.
In the unlikely event that bleeding cannot be controlled by the
preceding three maneuvers, the submandibular fossa should be
packed with a gauze sponge and digital pressure firmly applied
by the surgeon’s finger for several minutes, pressing the gland
against the inner aspect of the mandible and the floor of the
mouth. In most cases, when the gauze is carefully removed, the
bleeding will be seen to have stopped, the subplatysmal space can
be irrigated and suctioned to clear the operative field of any blood,
and a search for the bleeding point can be made and any suspi-
cious areas cauterized or ligated. In the unlikely circumstance that
direct pressure applied in this manner is not effective (and this
has never been the case in our combined 30 years of performing
the procedure), the surgeon can place a finger or fingers from the
opposite hand inside the patient’s mouth and bimanually com-
press the gland to halt the bleeding.
Treatment of the Cut Submandibular
Gland Edge
Once excision of the protruding portion of the gland is complete,
the submental region is irrigated and a check for hemostasis
along the gland’s cut edge is made. Experience has shown that it
is not necessary or productive to attempt to oversew the cut edge
of the gland or close the glandular capsule. These maneuvers not
only are technically difficult but also could result in injury to
nearby neurovascular structures. It is also not necessary or pro-
ductive to overcauterize the cut edge of the gland in an attempt
to seal or shrink it. This typically results in more postoperative
pain and swelling and prolonged submental induration.
Submandibular Gland Reduction and
Major Complications
Subtotal submandibular gland reduction to date has not resulted
in any cases of hematoma, airway compromise, salivary fistula,
or gustatory sweating in our practices and our combined 30-year
experience.
Limits of the Submandibular Gland
Reduction Procedure
It must be understood and acknowledged that submandibular
gland reduction, although important in the rejuvenation of most
necks, will not in and of itself result in attractive neck contour.
Other problems must be identified and addressed if optimal
results are to be obtained.
Submandibular reduction should be regarded as an advanced
technique. It should be undertaken by surgeons well versed in
cervical anatomy and experienced in more basic maneuvers used
to rejuvenate the neck, and the operating surgeon must at all
times have the specific algorithm for managing bleeding clearly
in mind. It is highly recommended that any surgeon uncertain of
the anatomy of the submental triangle or the exact relationships
of important structures in this area review them carefully before
undertaking this dissection.
53.6.6 Partial Digastric Myectomy
After subplatysmal lipectomy and submandibular gland reduc-
tion have been performed, assessment should be made of the
anterior bellies of the digastric muscles and whether partial
digastric myectomy would produce further improvement in neck
contour. In most cases, additional improvement in neck contour
can be obtained by performing this procedure.
Typically, large digastric muscles will appear as a linear para-
median fullness lying medial to the rounder and more laterally
situated submandibular gland fullness and the difference in
appearance of the two problems is a reflection of their differing
anatomic origins: the anterior belly of the digastric muscles is a
linear paramedian structure and the submandibular gland is a
rounder more laterally situated structure (Fig. 53.48).
Usually digastric muscle excess is most evident after subpla-
tysmal lipectomy and submandibular gland reduction has been
performed, but in some cases it may be evident preoperatively in
patients seeking secondary or, less commonly, primary surgery.
In these situations additional improvement in neck contour may
be obtained by performing superficial, subtotal anterior digastric
myectomy (excising the protruding portion of the muscle).
Superficial, subtotal anterior digastric myectomy is performed
under direct vision, through the submental incision after the

53 Secondary Neck Lift
801
subplatysmal space has been opened, the platysma muscle
mobilized, and subplatysmal fat and protruding portions of the
submandibular gland resected, if indicated. The redundant por-
tion of muscle can be excised either by a tangential strip excision
technique or by a partial division and excision technique. :hile
both are reliable and effective, in most cases tangential strip exci-
sion provides the simplest and most intuitive and straightforward
means of removing the protruding portion of the muscle belly.
Tangential strip excision is performed by visually gauging
the muscle redundancy, grasping the redundant portion with a
DeBakey or similar forceps, and tangentially excising a strip of
muscle longitudinally from the muscle belly with a Metzenbaum
scissors or, more commonly, with monopolar electrocautery using
coagulating current. Typically tangential excision will result in
modest bleeding from the excised area that is easily controlled
with cautery once muscle reduction is complete if Metzenbaum
scissors are used.
Excision is begun near the muscle origin at the mentum and
continuing to the muscle belly insertion at the lateral hyoid.
The muscle is then reassessed and the action repeated until the
protruding portion is fully removed and optimal contour has been
established. Approximately 50 of the muscle is removed in the
typical case, with the most muscle removed near the hyoid and
the least near the chin (Fig. 53.49).
In the partial division and excision technique of digastric muscle
reduction, the excess muscle present is gauged and isolated on a
tonsil forceps by pushing the tips of the instrument through the
midmuscle belly at the level of optimal contour and spreading to
split the muscle along the length of its fibers. The isolated muscle
segment resting on the instrument, consisting of the superficial,
protruding portion of the muscle, is then excised with scissors or
cautery by dividing it near the mandible and the hyoid (Fig. 53.50).
The neck is re-examined and the maneuver repeated again if nec-
essary until an improved contour is obtained. Usually this entails
the excision of the most superficial half or less of each muscle, with
more muscle excised near the hyoid and less near the chin, as is the
case when the tangential excision technique is used.
It should be noted that the myectomy, regardless of how it is
performed, is a partial and subtotal reduction of the protruding
portion of the digastric muscle only, not an arbitrary exentera-
tion of the entire muscle belly. It should also be understood that
optimal contour is achieved when more muscle is resected near
the hyoid and less near the chin. In addition, partial, superficial
digastric myectomy, although an important maneuver in the
rejuvenation of many necks, will not in and of itself result in
attractive neck contour. Other problems must be identified and
treated if optimal results are to be obtained. Finally, although
Fig. 53.48 Surface expression of large digastric muscle. Typically large
digastric muscles will appear as a linear paramedian fullness lying
medial to the rounder and more laterally situated submandibular gland
fullness, and the difference in appearance of the two problems is a
reflection of their differing anatomic origins. In many cases the diag-
nosis of both problems can be made by simply looking at the patient’s
neck, as in this case. This patient has had a prior face- and neck lift (see
also Fig. 53.30 and Fig. 53.46). (Illustration courtesy of Marten Clinic
of Plastic Surgery.)
Fig. 53.49 Digastric muscle reduction strategy. (a) Typical appearance
of a large anterior belly of the digastric muscle. (b) Digastric muscle
fullness is treated in a manner that optimizes submental contour.
Approximately 50% of the muscle is removed in the typical case with
more muscle removed near the hyoid and less near the chin (shaded
gray area). (Illustration courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.50 Partial division and excision technique of digastric muscle
reduction. (a) Excess muscle present is gauged and isolated on a
tonsil forceps by pushing the tips of the instrument through the
midmuscle belly at the level of optimal contour and spreading to split
the muscle along the length of its fibers. (View from patient’s right of
right digastric muscle through submental incision. Patient’s chin is at
the left upper corner of the photo, and the neck is on right.) (b) The
isolated muscle segment resting on the instrument, consisting of the
superficial, protruding portion of it, is then excised with scissors or
cautery by dividing it near the mandible and the hyoid. The neck is
re-examined and the maneuver repeated again if necessary until an
improved contour is obtained. (Illustration courtesy of Marten Clinic
of Plastic Surgery.)
a
a
b
b

802
VIII Surgical Rejuvenation of the Face and Neck
partial, superficial digastric myectomy is conceptually simple and
technically straightforward, it should be regarded as an advanced
technique. It should be undertaken by surgeons familiar with
cervical anatomy and experienced in more basic maneuvers used
to rejuvenate the neck.
53.6.7 Anterior Platysmaplasty
Once subplatysmal fat excision, submandibular gland reduction,
and partial digastric myectomy have been performed as indicated
and treatment of the subplatysmal space is complete, anterior
platysmaplasty is performed. Anterior platysmaplasty (perhaps
more properly referred to as anterior platysmorrhaphy, but
most commonly referred to in our literature as platysmaplasty)
is the procedure in which the medial borders of the platysma
muscle are sutured together to help consolidate the neck, reduce
horizontal platysma laxity, and improve neck appearance when
patients flex their neck and look down (see Fig. 53.22 and Fig.
53.23). It is performed in the majority of patients and provides
an improved result in most necks. It is not, however, adequate or
effective treatment of excess subplatysmal fat, prominent sub-
mandibular glands, protruding anterior bellies of the digastric
muscles, or the treatment of platysma hyperfunction and “hard”
dynamic platysma bands. Treatment of these problems will
require that other deep-layer maneuvers previously discussed
(and subsequently discussed) be performed.
Anterior platysmaplasty is performed by suturing the medial
muscle borders of the platysma muscles together from mentum
to thyroid cartilage (Fig. 53.51). If redundant muscle is present
medially, it is excised and discarded before suturing is performed
so that a smooth, edge-to-edge approximation of the medial
muscle borders can be made without inversion, invagination, or
imbrication (Fig. 53.52). Experience has shown that this produces
a better and more consistent outcome and makes it less likely
that objectionable midline fullness or central neck bands will
result after healing and relaxation of tissues has occurred than
when excess muscle is invaginated and a multilayer ´plicationµ or
“corset” is performed.
Typically, platysmaplasty is performed by suturing the
trimmed medial muscle borders together edge to edge, without
invagination, with interrupted sutures, beginning at the mentum
and proceeding inferiorly to the hyoid and then down to the level
of the midthyroid cartilage. Alternatively, approximation can be
started at the hyoid and then extended superiorly to the mentum
and then from hyoid to midthyroid level. The approach is not as
important as is creating a smooth, well-tailored approximation
and reconstitution of the platysmal layer.
:hen a facelift and a neck lift are performed together, platys-
maplasty should be performed after cheek SMAS flap dissection
and suspension to prevent an accentuation of the effects of
aging and gravity and compromised improvement on the face
(Fig. 53.53). Although raising and suspending cheek SMAS flaps
first makes platysmaplasty suture placement more difficult by
superiorly shifting the skin, it allows optimal repositioning of the
cheek and jowl and provides for the best overall improvement.
,f SODW\VPDSODVW\ LV SHUfRUPHG fiUVW, WKH FKHHNV DQG MRZOV ZLOO EH
SXOOHG LQfHULRUO\ WRZDUG DQG LQWR WKH QHFN, DQG WKH H̵HFWLYHQHVV Rf
WKH 60$6 ÁDS ZLOO EH VLJQLfiFDQWO\ GLPLQLVKHG (Fig. 53.54).
Platysmaplasty is usually performed using multiple simple
interrupted sutures of 3–0 polyglactin (Vicryl), or suture of choice,
on a medium to large (FS-1) needle. Long instruments are needed,
and patience will be required. The platysmaplasty repair should
be snug but should not be tight. A tight ´corsetµ and permanent
sutures are not necessary, and a tight ´corsetµ will not result in
a sustained improvement in cervical contour if deep-layer prob-
lems are not addressed.
Optimal improvement generally cannot be obtained if repair
is performed using a running suture, as some gathering and a
´purse stringµ effect can occur. This will result in shortening along
the line of repair and can cause bowstringing and postoperative
midline band formation. If the initial approximation is made using
interrupted sutures, this problem is averted and the platysma is
distributed over and into the concave surface created by deep-
layer neck maneuvers (removal of subplatysmal fat, subman-
dibular gland reduction, and partial digastic myectomy). If only
partial suturing to the hyoid is performed in the submental area,
irregularities may result at the cervicomental angle.
Once initial approximation has been made with interrupted
sutures, the line of repair can be oversewn and reinforced with a
simple running or running inverting suture without a purse string
and shortening effect, although this is typically not done in our
patients. If a permanent suture is used, care should be taken to
saturate each suture with antibiotic solution prior to placement
and to bury all knots.
Fig. 53.51 Anterior platysmaplasty. Repair of platysmal diastasis from
mentum to thyroid cartilage (arrows) improves submental support and
helps consolidate the neck. It is not adequate or effective treatment for
“hard,” dynamic platysmal bands, however. If dynamic platysma bands
are present, proper treatment will require that platysmamyotomy be
performed (Fig. 53.26, Fig. 53.27, Fig. 53.28). (Illustration courtesy of
Marten Clinic of Plastic Surgery.)

53 Secondary Neck Lift
803
Platysmaplasty should be performed with the neck in a neutral
position. If the closure is made with the neck extended, excessive
tightness may result when the patient looks down after surgery.
This is particularly the case if platysmaplasty is performed in
conjunction with some form of lateral platysmal suspension,
discussed in the following section.
53.6.8 Management of the
Lateral Platysmal Border
If a ´short-scarµ neck lift is performed, there is no access to, or
option for, lateral platysma suspension. If a neck lift is performed
in conjunction with a facelift, or if an extended neck lift is being
performed, lateral platysmapexy (Fig 53–55) can be performed,
or more typically a post-auricular transposition flap is created
and used (Fig 53.56, Fig. 53.57).
:hen mild horizontal platysma muscle redundancy is present
in the neck, lateral platysmapexy is performed (Fig. 53.55). Lateral
platysmapexy ensures that the platysma is draped smoothly and
snugly along the cervicomental angle and helps to consolidate the
neck further, especially when the patient looks down. It is usually
effective only when suturing is performed over the upper one-
fourth of the sternocleidomastoid muscle, where its fascia is less
mobile. In thin necks the cut muscle edges can be overlapped. In
fuller necks, redundant muscle can be trimmed and the muscle
segments sutured edge to edge. Due to the overall mobility of
sternocleidomastoid fascia, however, limited support can be
obtained by these maneuvers.
:hen horizontal platysma muscle redundancy is large, or
optimal improvement is cervicomental contour is desired,
a postauricular transposition flap (PATF) of cheek SMAS is
planned (Fig. 53.56, Fig. 53.57). The PATF is created by splitting
off redundant tissue from the posterior margin of the cheek
SMAS flap, but leaving it attached inferiorly to the cervico-sub-
mental platysma. If properly constructed and secured, this flap
will provide for optimal reduction in horizontal platysma laxity
Fig. 53.52 Anterior platysmaplasty. (a) If redundant muscle is present
medially (dashed red line), it is gauged and excised before suturing is
performed (b) so that a smooth, edge-to-edge approximation of the
medial muscle borders can be made (right). This produces a better
outcome and reduces the likelihood that objectionable midline fullness
or bands will result after healing has occurred, compared with when
excess muscle is invaginated and a multilayer “plication” or “corset” is
performed. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.54 SMAS flaps should be raised before platysmaplasty is
performed. (a) If platysmaplasty is performed before cheek SMAS
suspension (black arrows), (b) elevation of the cheek SMAS flaps and
improvement in the face will be compromised (red arrows). (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
a
a
b
Fig. 53.53 (a,b) SMAS flaps should be raised before platysmaplasty
is performed. If the neck lift is done with a facelift, the cheek SMAS
should be suspended (green arrows) before platysmaplasty is per-
formed. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
a
b
b
Fig. 53.55 Lateral platysmapexy. When mild horizontal platysma
muscle redundancy is present in the neck, lateral platysmapexy may
suffice. (a) Before lateral platysmapexy. (b) After lateral platysmapexy.
The inferior border of the posterior margin of the superficial muscu-
loaponeurotic system (SMAS) flap is advanced laterally and posteriorly
and sutured to the upper sternocleidomastoid fascia in a manner
that tightens the platysma under the mandibular border and along
the cervicomental angle. Lateral platysmapexy should be performed
after anterior platysmaplasty (see Fig. 53.22, Fig. 53.53). (Illustration
courtesy of Marten Clinic of Plastic Surgery.)
a
b

804
VIII Surgical Rejuvenation of the Face and Neck
and dynamic reinforcement of the upper neck and submental
areas when the patient looks down. :hen used in conjunction
with an anterior platysmaplasty, PATFs result in a continuous
mastoid-to-mastoid sling of muscle across the upper neck
along the cervicomental angle and optimal improvement in
neck contour.
If an extended neck lift is performed, a limited periauricular
incision will be present, but a PATF can still be created and a low
SMAS flap can be used to effect improvement in the lower face
and along the jawline that otherwise would not be obtained if pla-
tysmaplasty alone, or platysmaplasty and lateral platysmapexy,
were performed (Fig. 53.56).
Fig. 53.56 Postauricular transposition flap (PATF) when an extended neck lift is performed. If an extended neck lift is performed, a limited preauricular
incision will be present, but a PATF can still be created, and a “low” superficial musculoaponeurotic system (SMAS) flap can be used to effect improve-
ment in the lower face and along the jawline that otherwise would not be obtained. (a) Plan for PATF with low SMAS flap. (b) After flap creation and
transposition to the postauricular area. (c) After elevation and suturing of low SMAS flap and suturing of PATF to the mastoid fascia. In combination
with anterior platysmaplasty (broken line), a mastoid-to-mastoid sling of autologous tissue that defines the cervicomental angle is created. The low
SMAS flap provides improvement in the lower face and along the jawline that would not be otherwise obtained if platysmaplasty alone or platysma-
plasty and lateral platysmapexy were performed. (Illustration courtesy of Marten Clinic of Plastic Surgery.)
Fig. 53.57 Postauricular transposition flap (PATF) when a facelift is performed. If a facelift is performed, a PATF can be created from the posterior
margin of a “high” superficial musculoaponeurotic system (SMAS) flap, and the high SMAS flap can be used to effect improvement in the cheek and
midface region. (a) Plan for PATF with high SMAS flap (superior margin of SMAS flap planned at level of zygomatic arch). (b) After flap creation and
transposition to the postauricular area. (c) After elevation and suturing of high SMAS flap and suturing of PATF to the mastoid fascia (typically some
shortening of the flap is performed). In combination with anterior platysmaplasty (broken line), a mastoid-to-mastoid sling of autologous tissue that
defines the cervicomental angle is created. The high SMAS flap provides improvement in the upper face and midface that would not be otherwise
obtained if platysmaplasty alone, or platysmaplasty and lateral platysmapexy, or platysmaplasty and low SMAS lift, were performed. (d) Partially
completed PATF seen in a facelift patient. High SMAS flap has been elevated and its superior margin anchored over the zygomatic arch. Because
the SMAS flap is properly advanced along a vector parallel to the long axis of the zygomaticus major muscle some redundancy is present along the
posterior margin of the flap. This is excised in a manner such that when the posterior margin of the flap is sutured to the pre-auricular SMAS remnant
it is closed under no tension, but it is left attached to the cervical platysma below the mandibular border. This allows suspension of the lateral
platysma border to the fixed mastoid fascia.

53 Secondary Neck Lift
805
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be performed after anterior platysmaplasty has been performed. If
the transposition flaps are suspended first, the platysma muscles
can be shifted laterally and it may be difficult to join them in the
midline (Fig. 53.58).
Suspension to the mastoid is performed with interrupted
sutures of 3–0 polyglactin (Vicryl) on FS-1 needle (or other suture
of choice). A permanent suture is not necessary, and if used, the
knots may be palpable by the patient in the postauricular area.
The more proximal portions of the flap are secured to the under-
lying fascia with a simple running suture of the same material
along its upper border. This consolidates the deep layer repair in
the perilobular area and prevents the flap from bunching up or
rolling up upon itself.
For a PATF to be effective, it must be properly designed and
constructed and its intended purpose kept in mind. A common
error is for the surgeon to construct it too timidly and superiorly
and in such a manner that its pull is placed over and along the
mandibular border (Fig. 53.59a). Such a design pulls on the
lateral face and does not improve the neck and cervicomental
angle. Properly constructed, the flap should exert its pull below
and inferior to the mandible and along the cervicomental angle
(Fig. 53.59b).
53.6.9 Transverse Platysma Myotomy
Although anterior platysmaplasty will often result in an
attractive neck at rest and on the operating table, objection-
able-appearing dynamic platysma bands and muscle striations
will often still be evident in conversation and during animation
after surgery if additional steps are not taken. These problems
can be minimized by performing transverse platysma myotomy
(see Fig. 53.24, Fig. 53.26, Fig. 53.27, and Fig. 53.28). The extent
of platysma transection will arguably depend upon the muscle
irregularities present and thus can be varied from patient to
patient.
Platysma myotomy should be performed after anterior platys-
maplasty and lateral platysmal suspension (lateral platysmapexy
or PATF) have been completed, as the platysma muscle will be
uniformly distributed over the anterior neck and under slight
tension. Myotomy should be performed low in the neck at the
level of the cricoid cartilage when the platysma muscle is in
good condition and has not been compromised in the previous
procedure or by noninvasive treatments, and extended slightly
superiorly as it is extended laterally (Fig. 53.60, Fig. 53.61). At
this level the muscle is thin and will bleed less, and the cut edges
are less likely to be visible postoperatively, but muscle action
will nonetheless be interrupted. In addition, a smooth transition
across the cervicomental angle is maintained and the risk of
lower lip dysfunction is minimized. If transection is made higher,
these benefits can be lost (Fig. 53.60b). This is particularly true
when myotomy is performed at the level of the hyoid along the
cervicomental angle or when wedges of platysma muscle are
removed at that location as is shown in many plastic surgery
textbooks. The platysma muscle is much thicker at that level, and
the cut edges are more likely to bleed and/or be visible after sur-
gery. In addition, a high transection or resection of this sort can
result in a severe and unaesthetic transition for the submental
region to the neck and adversely affect platysma action, resulting
in asymmetric movement of the lower lip during speaking and
expression or a change in lower lip posture. Transecting the
platysma high along the cervicomental angle laterally also puts
both the cervical and marginal mandibular branches of the facial
nerve at risk.
Anterior platysma myotomy is best begun working through
the submental incision just inferior to the most inferior platys-
maplasty suture (Fig. 53.26a). The medial platysmal border is
identified over the cricothyroid area and grasped and lifted away
from the deep cervical fascia with a long DeBakey-type forceps.
Myotomy is then made by nibbling through the muscle in small
increments with a Metzenbaum scissors or with electrocautery.
As the muscle is divided, it usually separates a centimeter or
more, exposing the fascia beneath it.
Fig. 53.58 (a) If suspension of the lateral platysmal borders (lateral
platysmapexy or postauricular transposition flap) is performed before
anterior platysmaplasty (black arrows), (b) the plastysma muscles
may be laterally displaced and approximation of the medial plastysmal
borders (platysmaplasty) may not be possible (red arrows).
Fig. 53.59 Improper and proper construction of the postauricular
transposition flap (PATF). (a) Improper design and construction of
the PATF. The flap has been designed and constructed too superiorly
and pulls along the lower face and lateral mandibular border. Such a
construction does little to improve the neck. (b) Correct design and
construction of the PATF. The flap has been designed and constructed
more inferiorly so that its resultant pull is below the mandible and
along the cervicomental angle. Such a design optimizes cervico-
submental contour.
a
b
a
b

806
VIII Surgical Rejuvenation of the Face and Neck
Serrated or ´supersharpµ scissors should not be used, as they
tend to pick up and cut adjacent tissue and posterior fascia and can
result in injury to the anterior jugular vein. Unintended injury to
the anterior jugular vein will result in annoying bleeding that can
be difficult to control. Gentle spreading with scissors tips before
each cut is made helps separate the platysma from underlying
cervical fascia and facilitates dissection when scissors are used. In
most cases, however, cautery is used.
Myotomy is continued laterally and slightly superiorly accord-
ing to the preoperative plan depending on whether anterior
or both anterior and lateral bands are present. If a ´full-widthµ
division of the platysma is planned, the most lateral portion of
the transection (most lateral portion of the muscle) is completed
through the postauricular incisions by identifying the lateral
muscle border, incising it, and incrementally extending the inci-
sion until it is brought into continuity with the incision made in
the muscle anteriorly through the submental incision, using one
of the methods (Metzenbaum scissors or electrocautery) previ-
ously described (Fig. 53.61b).
Patients should be counseled that the goal of platysma myot-
omy is a reduction in platysma hyperfunction and decrease in
the prominence of hard, dynamic platysma bands. It should not
be their expectation that the procedure will result in a complete
absence of platysmal movement or a complete elimination of
hard dynamic bands. Patients desiring and expecting a complete
absence of platysmal movement are not good candidates for the
procedure and are likely to be disappointed with the outcome.
They should instead be steered toward neuromodulators or some
other form of treatment. Patients desiring a reduction in platysma
hyperfunction and decrease in the prominence of hard, dynamic
platysma bands will, however, almost always be pleased with the
outcome of the procedure.
53.6.10 Partial Platysma Myectomy
Despite the historic effectiveness of platysma myotomy in
treating dynamic platysma bands, a growing number of
patients are now being encountered who have been over-
treated with radiofrequency or ultrasound ´skin-shrinkingµ
treatments and are as a result troubled by dense subcutaneous
fibrosis and thermal damage to their platysma, manifested
as objectionable muscle fibrosis, evident as both resting
and dynamic dense platysma thickenings that are largely
refractory to traditional platysma muscle transection³an
occurrence that some surgeons refer to as ´noninvasive neck
deformityµ (Fig. 53.62). In these patients a more aggressive
strategy must be undertaken if meaningful improvement is to
be obtained.
Patients with thermal damage to their platysma as a result
of radiofrequency or ultrasound ´skin-shrinkingµ treatments
(or application of other forms of energy to the subcutane-
ous neck and face) can be significantly improved by partial
platysma myectomy (excising part of the platysma muscle).
Partial platysma myectomy is performed by making a high
myotomy full-width at the level of the midthyroid (instead of
the cricoid) cartilage. The superior cut edge and the inferior
cut edge of the divided muscle are then undermined modestly
and as appropriate for the problem present on the deep fascia,
and each elevated muscle edge is then resected by beveling it
with Metzenbaum scissors or electrocautery. Typically, this will
result in the equivalent of resecting the platysma present on the
majority of the interior neck from the superior border of the
thyroid cartilage to the cricoid cartilage or occasionally lower.
:hen performed correctly, a significant improvement in neck
contour and a marked reduction in neck irregularities can be
obtained.
Fig. 53.61 Sequence for performing platysma myotomy. (a) Anterior
platysma myotomy is begun working through the submental incision
just inferior to the most inferior suture placed when platysmaplasty
was performed. The medial platysma border is identified over the
cricothyroid area and grasped and lifted away from the deep cervical
fascia. Myotomy is then made by nibbling through the muscle in small
increments with a Metzenbaum scissors or using electrocautery. (b) If
a “full-width” division of the platysma is planned, the most lateral
portion of the transection is completed through the postauricular
incisions by identifying the midlateral muscle border, incising it, and
incrementally extending the incision until it is brought into continuity
with the incision made in the muscle anteriorly through the submental
incision.
Fig. 53.60 Correct and incorrect level for platysma myotomy.
(a) Correct level (level of cricoid cartilage) for platysma myotomy.
Myotomy should be performed low in the neck at the level of the
cricoid cartilage and extended slightly superiorly as it is extended
laterally. At this level the muscle is thin and will bleed less, and the cut
edges are less likely to be visible postoperatively. In addition, a smooth
transition across the cervicomental angle is maintained, and lower
lip dysfunction is avoided. (b) Incorrect level (level of hyoid bone) for
platysma myotomy. The platysma muscle is much thicker, and the cut
edges are more likely to bleed and be visible after surgery. In addition,
a high transection or resection can result in an unaesthetic transition
from the submental region to the neck and result in asymmetrical
movement of the lower lip. (An exception is “noninvasive neck defor-
mity,” in which patients will need partial myectomy.) (See Fig. 53.29.)
a
b
a
b

53 Secondary Neck Lift
807
It should be noted that platysma myectomy must maintain a
cuff of muscle along the cervicomental angle posteriorly if the
marginal mandibular and cervical branches are to remain unin-
jured, and that submental platysma must be left intact and simply
contoured if lower lip dysfunction is to be avoided. In some but
not all cases, platysma myectomy will result in a (typically posi-
tive) change in the posture of the lower lip and less lower dental
show during speaking and smiling.
53.6.11 Final Contouring of
Cervicofacial Fat
Once correction of deep layer neck problems has been made and
platysmaplasty, platysma myotomy, and suspension of PATFs
have been performed as indicated, final contouring of subcu-
taneous superficial cervicofacial fat should be performed. This
is typically performed under direct vision using Metzenbaum
scissors. Final fat sculpting should be continued until all con-
tours are smooth and regular, but it is essential that not all fat
be removed if an attractive appearance is to be obtained. In the
secondary neck lift, typically only high spots should be lowered
and as much subcutaneous fat as possible should be preserved, as
the subcutaneous layer was already overtreated at the primary
procedure(s).
If a double chin or witch’s chin is present, an extended dissec-
tion of the perimental area and chin pad should be made, if it was
not already performed (Fig. 53.15, Fig. 53.16); fat contributing to
these problems sculpted and excised; and the two regions seam-
lessly sculpted and blended to ensure a smooth transition from
the chin to the submental area.
In full necks where a true excess of preplatysmal fat is present
(Fig. 53.32, Fig. 53.33), preplatysmal lipectomy can be performed
with scissors or with a suction cannula using an ´openµ liposuc-
tion technique by placing the cannula hole facing down under the
skin flap and holding the skin flap down as resection is made. In
thin necks, and in most of our cases where some excess prepla-
tysmal fat is present, excision is typically made using the scissors
technique.
53.6.12 Drain Placement
Drains are used routinely in both primary and secondary necklift
procedures, and our experience has shown that they reduce
postoperative ecchymosis and seromas, limit tissue firmness and
induration, and enable patients to return to their work and social
lives sooner. As a practical matter, drains are generally necessary
when deep-neck maneuvers (subplatysmal fat excision and sub-
mandibular gland reduction) are performed, and ´tissue glues,µ
advocated by some surgeons to consolidate the subcutaneous
plane, cannot be expected to prevent collections in the subpla-
tysmal area. It should be acknowledged, however, that drains
will not compensate for poor hemostasis in either plane and will
not prevent hematoma formation.
Experience has shown that when subplatysmal fat excision
and submandibular gland reduction are performed, it is prudent
to place a drain in both the subcutaneous and the subplatysmal
space for at least several days after the procedure to reduce edema
and induration in the submental area to reduce the chance of a
fluid collection (lymphatic fluid leakage from the division of
lymphatic vessels during subplatysmal fat excision and/or saliva
leakage from the cut edge of the submandibular gland) and to
speed the patient’s overall recovery. A 10 French round, multiper-
forated -ackson-Pratt (or similar) type drain is routinely placed
in both the subcutaneous and subplatysmal spaces. It is safest to
perform the platysmaplasty (suturing of the medial platysmal
borders together) before subplatysmal drain placement and then
to thread the subplatysmal drain into position afterward. If the
subplatysmal drain is placed before platysmaplasty is performed,
there is a chance that the drain could be caught in one of the
platysmaplasty sutures, making its removal problematic.
The vacuum force applied by the subplatysmal drain will capture
and remove lymphatic fluid and saliva, close down the subplatys-
mal space, and pull the underside of the platysmal muscle against
the cut edge of each submandibular gland. It is convenient to place
the exit site of the subcutaneous drain on the opposite side of the
neck (opposite the exit site of the subplatysmal drain) so that it
is clear which drain is which and so that output from each can
readily be monitored. In a male face or in a large female face, two
subcutaneous drains may be required to drain the subcutaneous
space adequately. The vacuum force applied by the subcutaneous
drain captures and removes fluid from the subcutaneous space of
Fig. 53.62 Noninvasive neck deformity. This patient has undergone
multiple previous noninvasive neck “skin-tightening” procedures,
performed by unknown surgeons, that have degraded the appearance
of her neck and have resulted in difficult-to-treat secondary irregu-
larities. Note the contrast between the plushly padded lower face
and supraclavicular area with marked destruction of subcutaneous
fat in the submental and anterior neck areas where treatments were
administered. Almost no subcutaneous fat remains in the treated
areas, and the patient has an elderly “skin-on-muscle” appearance.
Note also fibrosis and objectionable thickening and banding of pla-
tysma muscle, even though the patient’s face is in repose, as a result of
energy application beneath the skin. Simple platysmaplasty and even
platysma myotomy are ineffective in treating these patients. These
patients typically require partial platysma myectomy (see Fig. 53.29)
and may be candidates for second-stage fat grafting.

808
VIII Surgical Rejuvenation of the Face and Neck
both the face and neck if a facelift is concomitantly performed,
and no drains are needed in the face itself.
Subplatysmal drain placement during deep neck lift should
be performed after platysmaplasty is completed as follows: once
platysmaplasty is complete, a stab incision should be made 1 to
2 cm posterior to the occipital incision on the occipital scalp on
the right side and the proximal (reservoir) side of the drain pulled
retrograde through the incision into position and anchored at its
site of exit from the scalp with a 4–0 nylon suture. The part of the
drain distal to its point of anchoring is then placed in the subcu-
taneous space and the tip brought out the submental incision. If
a short-scar neck lift is being performed and a postauricular inci-
sion is not present, a stab incision is made in the right postlobular
skin or scalp and a 2.4- or 3.0-mm liposuction cannula is used
to tunnel under the lateral neck skin and into the subcutaneous
space that has been dissected more anteriorly. The tip of the
cannula is brought out the submental incision, the proximal (res-
ervoir) side of the drain placed firmly over the tip of the cannula,
and the cannula used to drag the drain into position. The drain is
then anchored as previously described.
:orking thorough the submental incision, the surgeon then
locates the most inferior platysmaplasty suture, and the platysma
muscle on the right side just inferior to the most inferior suture
is grasped and the tip of a long right-angle (Mixter-type) hemo-
static forceps is placed under the muscle edge; then the forceps is
advanced under the platysma muscle in the subplatysmal space
superiorly and laterally up to the approximate location of the right
submandibular gland. The tip of the instrument is then pushed
through the muscle into the subcutaneous space, and the tip of
the drain is grasped and placed over one jaw of the forceps. The
forceps is then closed and the drain pulled into the subplatysmal
space and back out below the most inferior platysmaplasty suture
and out into the subcutaneous space at the midline. The tip of the
right-angle forceps is then placed under the medial edge of the left
platysma muscle just inferior to the most inferior platysmaplasty
suture, and the forceps is used to retract the muscle outward to
hold open the subplatysmal space on the left. The tip of the drain,
now situated subcutaneously in the midline, is then grasped and
stuffed into the subplatysmal space on the left side and up to the
approximate location of the left submandibular gland. Upon com-
pletion of these maneuvers, the majority of the drain will be in
the subplatysmal space, with a smaller section in the upper lateral
right neck in the subcutaneous space.
53.6.13 Incision Closure
If the secondary procedure is such that a ´short-scarµ neck lift
has been performed, only a submental incision will be present,
and this can be conveniently closed in two layers. Prior to closure
it is important to confirm that the wound edge thickness and
amount of subcutaneous fat present are similar on each side of
the incision. Typically the wound edge of the cervical side will
have a thinner edge and have less subcutaneous fat due to con-
tact with instruments and retractors during preceding steps in
the procedure, and the mental, superior side will be thicker and
have more fat. If a discrepancy is present, as it often will be, fat is
carefully removed from the thicker superior side. The first layer
of closure consists of several subcutaneous sutures of 5–0 poli-
glecaprone (Monocryl) or other suture of choice to ensure that
equal amounts of fat are present behind the closed wound and so
that a depressed or irregular scar is avoided. Final approximation
is then made with simple interrupted sutures of 6–0 nylon (or
other suture of choice).
If an ´extendedµ neck lift or a facelift is performed in conjunc-
tion with a secondary neck lift procedure, skin will be excised
from the postauricular area. The postauricular flap is shifted
posteriorly and somewhat superiorly, roughly parallel to trans-
verse neck creases and the mandibular border, in such a manner
that skin is suspended under minimal or no tension and that little
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border. Excessive trimming of skin from the anterior border of the
postauricular skin flap will require the flap to be shifted along
an incorrect superiorly directed vector, and this will produce
a compromised result. The first point of suspension is located
in the postauricular area at the anteriosuperior aspect of the
occipitomastoid incision. The flap is secured at this point with a
simple interrupted suture of 4–0 nylon. 1o incision into the flap is
necessary, and no deep suture is used.
Once this suspension suture has been placed, the flap overlying
the inferior portion of the ear should be carefully divided and the
lobule exteriorized. This is a key step in the procedure, which must
be performed incrementally and with great care if a visible scar, lob-
ular malposition, and objectionable “pixie earlobe” (often present in
the patient presenting for secondary neck lift) is to be avoided. If the
incision to exteriorize the lobule is properly made, the apex of the
incision should rest snugly against the most inferior portion of the
conchal cartilage. If the incision into the cheek flap is made too far
anteriorly or inferiorly, however, artistically appropriate resetting
of the lobule will not be possible, and the outcome of the overall
procedure will be significantly compromised.
Postauricular closure along the auriculomastoid sulcus is
performed next and should be completed before trimming and
closure of the occipital portion of the incision and resetting of the
lobule. It is begun by conservatively trimming the anterior border
of the postauricular skin flap into a soft curve to match the curve
of the incision made in the auriculomastoid sulcus. The incision
is then closed with several interrupted sutures of 4–0 nylon. 1o
deep suture is necessary or used.
It is a VLJQLfiFDQW HUURU and ÁDZHG FRQFHSW to excise any skin over
(superior to) the apex of the occipitomastoid incision or to shorten
the postauricular flap along the long axis of the sternocleidomas-
toid muscle, as commonly practiced and shown in many plastic
surgery textbooks. Despite an apparent redundancy in this area
when the patient is supine on the operating table, there is never
any true skin excess at this location. This pseudoexcess of skin is
present only because of the patient’s high shoulder position in the
supine position. It will vanish when the patient sits up and the
shoulders drop to a normal position. Skin along the axis of the ster-
nocleidomastoid muscle is also needed for side-to-side head tilt.
Inappropriate excision of skin over the apex of the occipitomastoid
defect is the ultimate underlying cause of hypertrophic healing in
the postauricular region and of a wide postauricular scar.
Trimming and closure of the occipital portion of the incision
should be performed after closure of the postauricular area and
suspension without trimming along the transmastoid portion
of the postauricular incision. A facelift marker should be used to
gauge skin flap redundancy along the occipital incision, and all
points along the flap should be intentionally trimmed with 2 to

53 Secondary Neck Lift
809
3 mm of redundancy. It must be remembered that the goal of
skin excision is to remove redundancy, not to tighten the cervical
skin flap, a point that was not always appreciated at the primary
procedure. If trimming is performed correctly, wound edges
should abut one another, and no gaps should be present, before
sutures are placed. The incision is then closed in one layer with
multiple half-buried vertical mattress sutures of 4–0 nylon, with
the knots tied on the scalp side, and simple interrupted sutures
of 6–0 nylon. 1o deep sutures are required, and staples should
not be used. This plan will provide precise wound edge alignment
and prevent cross-hatched scars (suture marks). In addition, if the
incision is closed under no tension as described, an inconspicuous
scar will be obtained.
If the postauricular skin flap has been shifted along a proper
vector and tissue distributed appropriately under no tension
over the occipital area, a precise fit should be obtained. If neck
skin redundancy is large, or if the postauricular flap has been
suspended under tension, a ´dog-earµ will often be present at the
most inferior portion of the occipital incision. This should not be
chased down the occipital hairline, as an obvious scar will result
in the fine hair on the nape of the neck. A better result is obtained
under these circumstances if the dog-ear is inset posteriorly into
the occipital scalp, above the junction of thick and fine hair,
and secured with simple interrupted sutures of 4–0 nylon. This
requires that a small ellipse of scalp be excised from the scalp side
of the incision, but it moves the end of the incision into dense hair,
where it will be well concealed.
53.6.14 Dressings
After all planned procedures have been completed and all
incisions have been closed, the patient’s hair is washed with
shampoo and conditioner, and if long, it is placed in a soft braid.
The hair is then allowed to dry or is blown dry in the recovery
room. A final inspection of sutured incisions is made. If poor
alignment is found in any area, it is locally reprepped and sutures
are removed and replaced as required.
No dressing is required or applied. Patients are typically dis-
charged with a hat, scarf, and sunglasses following the procedure.
The traditional facelift and neck lift dressings consisting of tightly
applied, mineral oil–soaked cotton, and rolled gauze are unnec-
essary if closed suction drains are used, and a strong argument
can be made that they are contraproductive and of potential harm
to the patient. These dressings place unnecessary and potentially
harmful pressure on thin skin flaps in a critical stage of their
healing and can compromise already tenuous circulation in them.
In addition, they preclude inspection and monitoring of the
operative site and can disguise and delay the diagnosis of serious
problems such as hematoma, flap ischemia, and pressure necrosis.
Finally, patients typically find the traditional face- and neck lift
dressings cumbersome, confining, unhygienic, and claustropho-
bic, and their family members are often frightened by them.
Postoperative facial garments are also not routinely used.
Like traditional facelift dressings, these place unnecessary and
potentially harmful pressure on thin skin flaps and can compro-
mise already tenuous circulation in them. They also can generate
significant shear force on cheek skin flaps and periauricular inci-
sions if an extended neck lift or a facelift and neck lift have been
performed, which can disrupt healing incisions and cause wound
separation. If an elastic neck band is to be used, it is prudent to
wait 10 to 14 days before using it, and patients should be given
specific instructions not to apply it too tightly and not flex their
necks or turn their heads side to side while wearing them. If the
patient has undergone only a short-scar neck lift, elastic neck
bands can be used sooner³typically after the drains have been
removed.
53.7 Postoperative Care
Performance of the secondary neck lift procedure, and all aes-
thetic procedures we perform, fulfills only part of our obligation
to the patient, and the care the patient receives postoperatively
is arguably as important as the surgery itself. Diligent postoper-
ative care will also ensure the best result and limit the likelihood
that problems and complications will occur.
Patients are discharged with specific written instructions as
to how they are to care for themselves, and the surgeon should
always be available to answer questions and see any patient, if
needed.
53.7.1 Sleeping and Head Position
All patients are instructed to sleep flat on their backs without a
pillow. A small cylindrical neck roll is permitted if the patient
requests or requires it. This posture assures a ´chin upµ open
cervicomental angle and averts dangerous folding of the neck
skin flap and obstruction of regional cervical lymphatics, which
inevitably occur if the patient is allowed to “elevate their head
on pillowsµ as is commonly recommended after head and neck
surgery. If patients are allowed to elevate their heads on pillows,
their necks will inevitably end up flexed and their skin bunched
and folded. In addition, a flat-in-bed position encourages swelling
to drain not inferiorly to the anterior neck but rather posteriorly
to the back of the head, where it is not harmful, less noticeable,
and more rapidly transmitted away from the head and neck area
when the patient sits upright. This is particularly helpful if a
facelift has been performed as part of the procedure.
Patients are shown an ´elbows-on-kneesµ position for sitting
that ensures an open cervicomental angle. This posture places
the patient’s book, magazine, paperwork, notebook computer,
or meal in a position that allows reading, writing, eating, and TV
watching to be performed comfortably and safely with the chin
up and the neck skin smoothly and uniformly distributed over the
neck. If patients are allowed to sit upright during these activities,
their neck will inevitably end up flexed and their skin bunched
and folded.
53.7.2 Cool Compresses
Patients are asked to rest quietly and apply cold compresses to
their face and neck for 15 to 20 minutes of every hour they are
awake for the first 3 days after surgery. For most patients, edema
peaks at about this time. It is not necessary or productive to apply
cool compresses continually throughout the day or at night. Ice
and ´ice packsµ should never be applied directly to the skin.

810
VIII Surgical Rejuvenation of the Face and Neck
53.7.3 Medications
All patients are provided oral (usually nonnarcotic) analgesics,
sleeping pills, oral dissolving antiemetic tablets, and related and
other needed supplies with instructions for their use.
53.7.4 Diet after Surgery
Patients undergoing neck lift are placed on a ´salivary restµ diet
consisting of soft, wet, easy-to-swallow foods and are encour-
aged to avoid sweet, salty, sour, dry, and difficult-to-chew foods
and citrus for several weeks. It is particularly important to avoid
these sorts of foods, which stimulate salivation, for 7 to 10 days if
submandibular gland reduction has been performed if fluid col-
lections and neck induration is to be avoided. Patients are asked
to abstain from the intake of alcohol for 2 weeks after surgery.
53.7.5 Wound Care
Patients are instructed to begin a daily routine of showering
and shampooing no later than 3 days after surgery. Patients are
allowed to shower even if their drains are still in place. This helps
remove crusting about the suture lines, keeps incisions clean,
and usually improves the patient’s general outlook and well-
being. Patients are also informed that they need not be as thor-
ough as usual when washing their hair and assured that shower
water, shampoo, and conditioners are not harmful and will not
interfere with healing or cause infection.
53.7.6 Drain Removal
Drains are usually left in the neck until the patient’s first clinic
visit for suture removal 5 days following their surgery. This is
because drain output often quickly falls on the first or second day
after surgery, during the time the patient is mostly supine and
resting, but then typically picks up again when the patient begins
to spend more time upright, starts to move their head about
more, and begins to eat more. Leaving the neck drains in longer,
for 5 to 7 days, will reduce the likelihood that small collections
will form and it will speed the overall resolution of edema, ecchy-
mosis, and induration in the neck area. At the patient’s first suture
removal visit, 5 days after surgery, the progress and drain output
are assessed. If healing is progressing well, drain output is min-
imal, and no fluid collections are present, and if it appears that
the patient is following dietary and other instructions, drains are
removed at that time. It is prudent to release suction before drain
removal and to have patients on an assistant hold pressure over
their anterior neck as the drain is removed for several minutes, to
avoid inducing the formation of a hematoma.
If a patient’s neck appears congested at the fifth postoperative
day, if drain output is still significant, or if the patient appears
not to be following dietary and other instructions, drains are not
removed and are left in place until the patient’s second suture
removal visit 7 days after surgery. In almost all cases, drains, if
still present, are removed at that time.
It is important to monitor the patient’s neck carefully for blood
and fluid collections at each visit, and if found, they should be
addressed. Often small collections resulting from poor drain func-
tion can be removed by ´milkingµ the exteriorized portion of the
drain tube to restart drain flow. Loculated collections that have
accumulated subcutaneously in an area away from the drain can
often be stroked and massaged toward and to it. Collections that
cannot be evacuated in these ways should be transcutaneously
aspirated. Collections of these sorts may require several serial
aspirations performed over a period of several days. It is prudent
to see the patient and continue aspiration until the collection no
longer reforms. Collections allowed to congeal and consolidate
will result in firm, irregular areas that can take many months to
resorb and can result in permanent contour irregularities.
53.7.7 Suture Removal
:hen sutures are removed will vary depending on the type of
procedure performed. If a ´short-scarµ neck lift has been per-
formed, only a submental incision will be present, and sutures
are removed on the fourth or fifth day. If an ´extendedµ neck
lift or facelift and neck lift have been performed, 6–0 sutures
are removed on the fourth or fifth day and half-buried vertical
mattress sutures of 4–0 nylon with the knots tied on the scalp
side are removed on the seventh to ninth day. If sutures are left
in longer, telltale and objectionable ´suture marksµ are likely to
occur.
53.7.8 Return to Work after Surgery
:hen patients return to work and their social lives will depend
upon their tolerance for surgery, their capacity for healing, the
type of work they do, the activities they enjoy, and how they feel
overall about their appearance. Patients are asked to set aside 7
to 10 days to recover, depending on the extent of their surgery,
and additional time off is recommended if a facelift and related
procedures are simultaneously performed. Patients who are
doing well and not experiencing problems are allowed to return
to light office work and casual social activities at that time. It is
often wise that they begin with a limited workday at first and
adjust their schedules thereafter. If a patient’s job entails more
strenuous activity or physical labor, a longer period of convales-
cence may be required. Patients are advised not to drive for the
first 10 days after surgery and until they are feeling well, their
vision is clear, and they are off pain medications.
53.7.9 After-Surgery Activity
Patients are advised to avoid all strenuous activity during the
first two weeks after surgery. Two weeks after surgery, patients
are allowed to begin light exercise and gradually work up to their
presurgical level of activity. Four to six weeks after surgery they
are allowed to engage in more vigorous activities, including most
sports, as tolerated.

53 Secondary Neck Lift
811
53.8 Case Examples
53.8.1 Case Example 1
The 51-year-old woman in Fig. 53.63 had undergone a previous
facelift, neck lift, and related procedures performed by an
unknown surgeon (left images). Mild atrophy in much of the face
is evident. Loss of attractive facial contour due to deep-tissue
ptosis can be seen in the cheek, perioral region, and jowl. 1ote
that loss of jawline contour is evident and some submental
fullness can be seen on anterior view (Fig. 53.63a). An untreated
large submandibular salivary gland can be seen on oblique (Fig.
53.63c) and lateral (Fig. 53.63d, Fig. 53.63e) views. The lateral
view also reveals residual prominent anterior belly of the digas-
tric muscles; it is clearly evident in this view that the neck and
submental area have been incompletely rejuvenated.
She underwent a secondary face- and neck lift, including sub-
platysmal fat excision, submandibular salivary gland and digastric
muscle reduction, that included a PATF created from the posterior
margin of the facelift SMAS flap. Closed forehead plasty; upper and
lower blepharoplasty; fat grafts to the forehead, radix, infraorbital
area, piriform, lips, chin, labiomental sulcus, geniomandibular
grooves, and jawline; earlobe reconfiguration; and perioral
laser resurfacing were also performed. 1o subcutaneous fat was
removed, and no facial implants or suspension sutures were placed.
One year and 7 months postoperatively (Fig. 53.63, right
images), much more youthful, fit, and attractive neck and jawlines
are seen. The PATF has provided soft autologous support along the
cervicomental angle and a reduction in horizontal platysma laxity.
53.8.2 Case Example 2
The man in Fig. 53.64, aged 60, had undergone a previous facelift
and neck lift and related procedures performed by an unknown
surgeon. In preoperative views (left images), atrophy over much of
his face is evident. Loss of facial contour and sagging of tissue in the
submental area can be seen. A large submandibular salivary gland
is partially visible in oblique (Fig. 53.64c) and especially lateral (Fig.
53.64d, Fig. 53.64e) views. In the lateral flexed view (Fig. 53.64e)
the true extent of sagging of redundant tissue in submental area
can be seen and emphasizes the importance of showing facelift
patients in this view. :hile modest recurrent aging is present on
other areas of the face, it can be seen that the patient’s poor neck
contour is what degrades his appearance the most.
He underwent a secondary face- and neck lift, including sub-
mandibular salivary gland and digastric muscle reduction that
included a PATF created from the posterior margin of the SMAS flap.
Supraciliary eyebrow lift; lower blepharoplasty; fat injections to the
forehead, radix, temples, midface, cheeks, and perioral areas; minor
otoplasty; earlobe reduction; and upper lip lift were also performed.
No subcutaneous fat was removed, and no facial implants or suspen-
sion sutures were placed.
He is shown 11 months postoperative (Fig. 53.64, right images).
1ote that fat grafting has created a bolder and more masculine
chin and jawline, and submandibular salivary gland and digastric
muscle reduction has created a deeper submandibular contour, a
more aesthetic shadow under the mandible, and a more youthful
and natural-appearing neck. The PATF provides autologous sup-
port along the cervicomental angle.
53.8.3 Case Example 3
The 72-year-old woman shown in Fig. 53.65 had undergone a
previous facelift and neck lift and related procedures that were
performed by an unknown surgeon. In preoperative views (left
images), atrophy over much of her face is evident. Loss of facial
contour can also be seen. Some fullness and sagging of tissue
in submental area can be seen in anterior view (Fig. 53.65a). A
large submandibular salivary gland is partially visible in oblique
view (Fig. 53.65c). Incomplete rejuvenation of her neck can be
seen, and submental irregularities create an unnatural ´surgi-
calµ appearance, with a double chin in flexed lateral view (Fig.
53.65e), indicative of excess volume in the subplatysmal space
and the need to explore it and make appropriate reduction of
excess subplatysmal fat, submandibular salivary gland, and
digastric muscle.
She underwent a secondary face- and neck lift that included
a PATF created from the posterior margin of the SMAS flap.
Secondary forehead lift; upper blepharoplasty; lower eyelid laser
resurfacing; fat injections to the forehead, radix, nasal dorsum,
periorbital, piriform, lips, chin, labiomental sulcus, geniomandib-
ular grooves, and jawline areas; and earlobe reconfiguration were
also performed. No subcutaneous fat was removed and no facial
implants or suspension sutures were placed.
Twelve months postoperatively (Fig. 53.65, right images), neck
contour can be seen to be improved even in anterior view, but
the majority of the visible change is seen elsewhere on the face.
Fat grafting has created an aesthetic confluence of the chin and
the jawline. More fit and attractive jaw- and neck lines are seen.
Submandibular salivary gland and digastric muscle reduction has
enabled the creation of a deeper contour and a more aesthetic
shadow under the mandible. The PATF has provided soft added
support along the cervicomental angle.
53.9 Summary
A well-contoured neckline is essential to a youthful, fit, and
attractive appearance. 1eck improvement is of high priority to
almost every patient who presents for facial rejuvenation, and
the results of a ´face liftµ are often judged on the outcome in the
neck. If the neck is not sufficiently improved, our patients will
feel we have failed them.
Submental liposuction is an incomplete solution to most
patients’ neck problems and can result in the inappropriate
removal of subcutaneous fat essential to a natural and youthful
appearance. Submental liposuction can be particularly prob-
lematic when aggressive techniques are used. Overexcision of
subcutaneous fat may not be evident at the time of surgery or in
the early postoperative period, when cervico-submental tissues
are swollen, but it can result in problems that appear later and are
very difficult to correct once present. Proper treatment of many
necks requires modification of deep-layer structures and cannot
be limited to submental liposuction and the tightening of skin.
A prominent submandibular gland is large, not ptotic, and
aggressive submental liposuction and subplatysmal fat resection
can make a large submandibular gland more obvious and objec-
tionable appearing. Experience has shown that submandibular
gland reduction is safe and more effective than suture suspension
or platysma-tightening techniques.

812
VIII Surgical Rejuvenation of the Face and Neck
A subset of patients will be encountered who have objection-
ably large anterior bellies of their digastric muscles. Typically,
large digastric muscles will appear as a linear para-median
fullness lying medial to the rounder and more laterally situated
submandibular gland fullness, and the difference in appearance
of the two problems is a reflection of their differing anatomic
origins. :hen large digastric muscles can be identified, additional
improvement in neck contour can be obtained by performing
Fig. 53.63 Case Example 1. Preoperative views (left) and 1 year and 7 months after secondary face- and neck lift including subplatysmal fat excision,
submandibular salivary gland and digastric muscle reduction, and postauricular transposition flap, along with closed forehead plasty, upper and
lower blepharoplasty, partial facial fat injections, earlobe reconfiguration, and perioral laser resurfacing, with no subcutaneous fat removed and no
suspension sutures placed (right). (All procedures performed by Timothy Marten, MD, FACS. Courtesy of the Marten Clinic of Plastic Surgery.) (a)
Anterior views. (b) Anterior smiling views. (c) Oblique views. (d) Lateral views. (e) Lateral flexed views.
a
c
e
b
d

53 Secondary Neck Lift
813
superficial, subtotal anterior digastric myectomy. Failure to iden-
tify and treat large digastric muscles will result in objectionable
fullness and cervical obliquity in the submental region postopera-
tively. Digastric muscle reduction is performed after subplatysmal
fat and protruding portions of the submandibular gland have been
removed.
Subplatysmal fat excision, submandibular gland reduction, and
superficial digastric myectomy, performed in concert as indicated,
provide for the creation of 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 if optimal results are to be obtained.
Fig. 53.64 Case Example 2. Preoperative views (left images) and views 11 months after secondary face and neck lift along with supraciliary eyebrow
lift, lower blepharoplasty, facial fat injections, minor otoplasty, ear lobe reduction, and upper lip lift (right images). (All procedures performed by
Timothy Marten, MD, FACS. Courtesy of the Marten Clinic of Plastic Surgery.) (a) Anterior views. (b) Anterior smiling views. (c) Oblique views. (d)
Lateral views. (e) Lateral flexed views.
a
c
e
b
d

814
VIII Surgical Rejuvenation of the Face and Neck
53.10 Retention of Rights
Publishing Notice
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 permis-
sion. 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.
Fig. 53.65 Case Example 3. Preoperative views (left images) and views 12 months after secondary face- and neck lift along with secondary forehead
lift, upper blepharoplasty, lower eyelid laser resurfacing, facial fat injections, and earlobe reconfiguration (right images). (All procedures performed
by Timothy Marten, MD, FACS. Courtesy of the Marten Clinic of Plastic Surgery.) (a) Anterior views. (b) Anterior smiling view. (c) Oblique views. (d)
Lateral views. (e) Lateral flexed views.
a
c
e
b
d

53 Secondary Neck Lift
815
Clinical Caveats
• As in primary procedures, recognizing the problems in the
secondary neck lift patient and appreciating their underlying
anatomic abnormalities is fundamental to planning and per-
formance of a logical and effective surgical repair.
• It is not enough to perform submental liposuction and tighten
the skin in most patients presenting for secondary neck lift,
as such an approach ignores a number of anatomic problems
typically present in many patients seeking secondary neck
surgery including platysmal laxity, platysma bands, excess
subplatysmal fat, large submandibular glands, and digastric
muscle hypertrophy. These problems will require additional
treatment if optimal improvement is to be obtained.
• Submental liposuction is usually of minimal benefit to the
secondary neck lift patient and can actually degrade neck
appearance in that it was typically performed aggressively
at the primary procedure at which time an over-resection of
subcutaneous fat was made. A thick and substantial layer of
subcutaneous fat must be present in the neck if it is to have
a youthful, healthy, soft, attractive and feminine appearance.
Additional targeting of subcutaneous fat is rarely of any ben-
efit to the patient seeking secondary procedures.
• Submental liposuction is a frequent cause of many vexing
patient problems and complications, as it often leads to unin-
tended but inappropriate removal of subcutaneous fat essential
to a natural and youthful appearance. These problems are typ-
ically not evident in the operating room or in the early postop
period, when cervicosubmental tissues are swollen; however,
they appear later and once present, are very difficult to correct.
• It is conceptually flawed and ultimately clinically ineffective
to try to force contour in the neck by “corset” tightening of
the platysma muscles. A young, attractive neck is not tight
and does not have a tight platysma but rather a youthful
distribution of tissue on it, and the surgeon’s goal must be
one of modifying the aging neck in a way that replicates the
distribution of tissue on it in youth, and in a way that produces
a sustained improvement in neck appearance.
• The difference between the presence of poor neck contour
and microgenia is frequently misunderstood, and it is a
common misconception that placement of a chin implant
improves neck contour. A chin implant is a treatment for
a small chin, not for a poor neckline, and the presence or
absence of microgenia and the need for a chin implant is a
cephalometric determination that is independent of the
condition of the neck. Placement of a chin implant when
microgenia is not present is a conceptual and artistic error
that will create unnatural appearances,
• Traditionally the submental incision used in neck lifts is placed
directly in and along the submental crease in a well-intended
but counterproductive attempt to conceal the resulting scar.
This incision plan should be avoided if possible, however,
as it will surgically reinforce the crease and accentuate a
“double chin” or “witch’s chin” appearance. Exposure of the
submental region will also be compromised, difficulty will be
encountered when suturing or dissecting low in the neck, and
the opportunity to sculpt and blend the fat of the chin and
submental region will be lost.
• Cervical fat is present in three distinct anatomic layers: prepla-
tysmal (subcutaneous), subplatysmal, and deep cervico-sub-
muscular (interdigastric), and one must learn how to recognize
and treat each layer appropriately for the conditions present.
• While our traditional focus has mistakenly been on aggres-
sively resecting the preplatysmal layer, most patients present-
ing with poor neck contour will be primarily troubled instead
by fat excess in the subplatysmal layer. This is even more so
in the patient presenting for secondary neck lift, as typically
the surgeon performing the primary procedure mistakenly
targeted the superficial layer only. Understanding and accept-
ing this anatomic reality, and learning to treat subplatysmal
fat appropriately, is a key part of obtaining consistently good
outcomes in both primary and secondary neck lift procedures.
• Fat situated deep to the plane tangent to the anterior bellies
of the digastric muscles and beneath the deep cervical fascia
(deep cervical or “interdigastric” fat) should not be removed,
and the over whelming temptation to “clean out” the deep
cervical space must be resisted in both primary and second-
ary neck lift procedures.
• Preoperative assessment of the submandibular glands must
be made in patients seeking secondary improvement in neck
contour, as prominent glands are commonly overlooked or
ignored at the primary procedure and typically contribute to
the appearance of a full, “obtuse,” and “lumpy” neck in the
secondary surgery patient.
• Despite various claims to the contrary, prominent subman-
dibular glands are large, not ptotic, and the platysma muscles
contribute little to their position or support. Attempts at
tightening the platysma muscles to treat a prominent gland
usually results in modest improvement that is short-lived.
Large, prominent glands will require that the protruding por-
tion be resected if optimal improvement is to be obtained.
• A subgroup of patients seeking both primary and secondary
neck surgery will present with large, bulky anterior bellies of
their digastric muscles that are visible as linear paramedian
submental fullness When large, digastric muscles are present
excising the protruding portion of the muscle is indicated and
can provide for significant improvement in neck contour.
• When subplatysmal fat excision and submandibular gland
reduction are performed, it is prudent to place a drain in
both the subcutaneous and the subplatysmal space for at
least several days after the procedure to reduce edema and
induration in the submental area to reduce the chance of a
fluid collection and to speed the patient’s overall recovery.
• Anterior platysmaplasty is the procedure in which the medial
borders of the platysma muscle are sutured together to help
consolidate the neck, reduce horizontal platysma laxity, and
improve neck appearance when patients flex their neck and
look down. It is not, however, adequate or effective treat-
ment of excess subplatysmal fat, prominent submandibular
glands, protruding anterior bellies of the digastric muscles,
or the treatment of platysma hyperfunction and “hard”
dynamic platysma bands. Treatment of these problems will
require that other procedures be performed.
• When a facelift and a neck lift are performed together, platys-
maplasty should be performed after cheek SMAS flap dissec-
tion and suspension to prevent an accentuation of the effects

816
VIII Surgical Rejuvenation of the Face and Neck
of aging and gravity and compromised improvement on the
face. Although raising and suspending cheek SMAS flaps first
makes platysmaplasty suture placement more difficult by
superiorly shifting the skin, it allows optimal repositioning of
the cheek and jowl and provides for the best overall improve-
ment. If platysmaplasty is performed first, the cheeks and
jowls will be pulled inferiorly toward and into the neck, and the
effectiveness of the SMAS flap will be significantly diminished
• The cervico-submental region of each patient must be care-
fully examined both at rest and during platysma activation if
complete assessment of platysma irregularities is to be made,
as secondary neck lift patients commonly have residual or
untreated platysma problems.
• Examination of the cervico-submental region with and with-
out platysmal activation allows one to distinguish whether
platysma bands are “hard” dynamic or “soft” adynamic
bands. Soft, adynamic bands change little during platysma
activation and are predominantly a problem of loose skin or
horizontal platysmal laxity. Hard, dynamic bands become
tight or exaggerated upon platysma activation and indicate
a problem of longitudinal platysmal hyperfunction
• It is important to distinguish between “soft,” adynamic plays-
mal bands and “hard,” dynamic bands in both primary and
secondary neck lift patients, as treatment will vary depending
on the type present. Patients with soft bands are usually ade-
quately treated with skin excision and platysmaplasty alone.
Patients with “hard” bands, however, require transverse
platysma myotomy or some other procedure that disrupts
longitudinal platysma muscle hyperfunction and prevents
the muscle from contracting upon itself
• The key to success in treating hard, dynamic bands is to
acknowledge that they are the product of longitudinal pla-
tysma muscle hyperfunction, not one of horizontal platysma
laxity. Pulling medially or laterally on the platysma muscle
borders as commonly advocated does not address the origin
of dynamic platysma bands, and is not a logical or effective
treatment of them
• Patients with prior thermal damage to their platysma as
a result of radiofrequency or ultrasound “skin-shrinking”
treatments (or application of other forms of energy to the
subcutaneous neck and face) are often refractory to standard
treatment by platysmaplasty and platysmamyotomy but
can be significantly improved by partial platysma myectomy
(excising part of the platysma muscle).
Suggested Reading
[1] Marten T-, Elyassnia D. Male facelift. In: Rubin -P, 1eligan P, eds. Plastic Surgery,
4th ed. 1ew >2@ Marten T-, Elyassnia D. Facelift: Secondary deformities and the secondary facelift.
In: Rubin -P, 1eligan P, eds. Plastic Surgery, 4th ed. 1ew 2017:240–272
>3@ Marten T-, Elyassnia D. 1eck lift. In: Farhadieh RD, Bulstrode 1:, Cugno S, eds.
Plastic and Reconstructive Surgery: Approaches and Techniques. 1ew :iley; 2015:1004–1031
>4@ Marten T, Elyassnia D. 1ecklift. In: Scuderi 1, Toth BA, eds. International Textbook
of Aesthetic Surgery. 1ew >5@ Marten T. Lamellar high SMAS face and mid-lift: Improved design of the SMAS
facelift for better results in the mid-face and infra-orbital region. In: 1ahai F, ed.
Aesthetic Plastic Surgery, 2nd ed. 1ew >6@ Marten T-. Facelift with SMAS flaps. In: Guyuron B, ed. Plastic Surgery: Indica-
tions and Practice, 1st ed. Saunders; 2008:1445–1472
[7] Marten T-. High SMAS facelift: combined single flap lifting of the jawline, cheek,
and midface. Clin Plast Surg 2008;35(4):569–603, vi–vii
[8] Secondary facelift. In: Mathes S, ed. Plastic Surgery. Saunders; 2005
[9] Marten T-. Facelift. Planning and technique. Clin Plast Surg 1997;24(2):269–308

54 Reoperative Rhytidectomy
817
54 Reoperative Rhytidectomy
James C. Grotting, Nirav B. Patel, and William J. Vinyard
Abstract
Reoperative or ´secondaryµ rhytidectomy presents unique
challenges to the plastic surgeon. A request for it may be moti-
vated by continued facial aging, a desire for further refinements,
unhappiness with results, or past complications.
Systematic facial analysis is critical in prioritizing goals,
enabling a more manageable operative plan, and maximizing
postoperative satisfaction. Important factors to note during physi-
cal examination include skin quality, laxity, and extent of rhytids;
deflation and descent of soft tissues; change in bony morphology
and dentition; and hypertrophy or ptosis of deep structures of the
neck. Surgeons must be aware of potential anatomic differences
between reoperative and primary facelift surgery. Skin quality,
facial volume and shape, and neck contour may all be improved.
Reoperation may be indicated to correct poor results from early
primary facelift, including conspicuous scars, hairline distortions,
and earlobe malposition. More serious complications such as
hematoma, skin necrosis, and nerve injury can result in emotional
disturbances and can be addressed during reoperative rhytidec-
tomy. One must be judicious with any approach and know when
to decline a patient to avoid an overoperated appearance. As with
any reoperative patient, one should not neglect body dysmorphic
disorder.
Secondary facelift options broadly include ´liposculpturing,µ
superficial musculoaponeurotic system (SMAS) manipulation, and
neck contour correction with deep cervicoplasty. Adjuncts that
help maintain a primary rhytidectomy result without resorting to
reoperation can similarly supplement a secondary rhytidectomy.
Staging interventions can be considered to help manage expecta-
tions while minimizing variables one is attempting to control in a
single operation.
Keywords
secondary facelift, rhytidectomy, SMAS elevation, facial rejuve-
nation, facelift complications
54.1 Introduction
Plastic surgeons today are seeing ever-increasing numbers of
patients returning to the practice, or presenting initially, with
requests for facial rejuvenation after previous facial procedures.
Primary facelift patients’ concerns are typically generalized,
whereas concerns of reoperative aesthetic patients vary but tend
to be very specific. A secondary facelift patient will often return
and have common complaints such as ´My creases >nasolabial
folds@ are back,µ ´My neck is loose again,µ or ´My kids ask me what
I’m mad about when I’m not mad at all.µ Reoperative aesthetic
patients are unique in that they can already anticipate what to
expect. They would not have returned to a surgeon if they were
not prepared to have a correction. Generally, they will not be
dissuaded by financial issues or by anxiety over postoperative
pain or general anesthesia.
Every facial rejuvenation patient inquires about the longevity
of the surgical results. Although it is impossible to answer this
question with precise accuracy, plastic surgeons know that facelift
results do not last forever. Patients must understand that surgery
will turn back the clock, but also that the inexorable march of time
will continue. :ith a well-done facelift, patients will always look
better than if they had not undergone the operation. Having a
facelift is a monumental decision for most patients. Nevertheless,
having a second or third procedure is becoming much more
common, especially as cultural norms and stigmas against facial
plastic surgery have softened.
Anticipatory guidance is key. Educating patients about the
possible need to ´shore things upµ at a future time helps to keep
patients within a practice and helps to grow one’s experience
with secondary procedures. If the patient’s tissues have lost all
elasticity and the subcutaneous fatty layer is full, the chances of
requiring an early secondary correction are high.
Generally, there are five categories of patients who require reop-
eration. The first category includes patients seeking adjunctive
procedures to improve or enhance previous results. These adjunc-
tive procedures may not require traditional lifting procedures; the
patient may only require less invasive procedures to rejuvenate
the face. The second category consists of those requesting reop-
eration for continued facial aging. :ithin this group of patients,
only a ´tuck-upµ procedure may be required. The third category
includes patients for whom the surgeon had already planned a
staged approach. There are two subsets to this category: the first
consists of younger patients who require only minimal proce-
dures, such as lipocontouring of the jowls or submental areas, and
who subsequently undergo more traditional lifting procedures as
they age. The other group comprises some of the most difficult
patients to provide satisfactory results for in one procedure. These
patients tend to be older, with doughy, inelastic skin, fatty facial
tissue, and severe neck laxity that extends below the thyroid
cartilage and into the sternal notch. They usually require early
postoperative tightening procedures in the neck, even as early
as 1 year. :e find it best to counsel these patients preoperatively
about their risk of early recurrence. The fourth category includes
patients with complications following primary facelifting. The
fifth category includes those who have not had any complications
but who are dissatisfied with the results they obtained from their
primary facial rejuvenation procedure. Often these patients have
undergone a minimal-scar approach to elevate the skin, but the
consequence is inadequate longevity of their rejuvenation. Some
of these approaches have been heavily promoted and marketed as
´low downtimeµ or as a ´mini-liftµ through extensive commercial
business enterprises, but as unsatisfactory long-term results have
become apparent, they have since begun to fall out of favor.
How is reoperative facial surgery different" Frequently, there
are asymmetries created by the previous operation that need

818
VIII Surgical Rejuvenation of the Face and Neck
to be addressed. The anatomy is different, in part, due to scar
tissue formation and fibrotic adhesions from previously dissected
planes. It is very easy to get into the wrong plane and damage the
facial nerve, which itself can take an unexpected course. This is
especially true in a thin patient who has had multiple previous
procedures. In addition, changes in blood supply may dictate a
novel approach. In one way, the previously undermined skin flap
can be considered a delayed flap, which is safe to re-elevate, but
in other situations it can be quite tenuous, especially in smokers.
In this chapter, we will discuss how to maintain results of suc-
cessful facial rejuvenation, reasons patients request reoperative
facial rejuvenation, aesthetic evaluation for and anatomic differ-
ences that must be considered in secondary rhytidectomy, sec-
ondary facelift options and ancillary treatment of facial subunits,
and management of complications seen in primary rhytidectomy.
54.2 How to Maintain Results
54.2.1 “How Long Will My Facelift Last,
Doctor?”
Most patients want to know the answer to this question during
their initial consultation. Patients who have already undergone
a primary rhytidectomy have a better understanding of what to
expect. It is impossible to accurately predict the longevity of this
procedure for any given patient because of individual differences
in age, skin laxity, actinic damage, genetics, previous procedures,
and many other factors. However, a survey of our postoperative
facelift patients using the FACE-4 demonstrated that they reported
looking an average of 8.4 years younger than their actual age.
:ith experience, we have learned that the final result and
longevity are influenced by the types of procedures performed as
well as the quality of the tissues. Facial rejuvenation has evolved
from merely a skin excision procedure to include manipulation
of deep structures, treatment of facial aesthetic subunits, and
adjuvant procedures, such as chemical peels, laser resurfacing,
dermabrasion, muscle modulation with neurotoxin, and volume
restoration with soft tissue fillers, implant augmentation, and/or
autologous fat injections. :ith these various combinations, the
procedures can be tailored to the individual’s desires and goals so
as to obtain the best results and to improve longevity.
54.2.2 Volume Manipulation
/iSRÀOOing/iSRFRnWRuring
As facial rejuvenation has evolved, we have learned that the
face should be analyzed and treated as a three-dimensional (3D)
structure. :e must correct not only the skin and deep tissue
laxity but also the volumetric changes seen with aging. :ith
aging, facial fat begins to descend and involute, deepening
nasolabial folds, labiomental folds, tear troughs, and lid–cheek
junctions. Fat atrophy creates the supraorbital and temporal hol-
lows, tear trough deformities, skeletonization of the zygomatic
arches, and submalar depressions. Fat can also accumulate,
creating stigmata of facial aging such as jowling. After rhytidec-
tomy alone, these areas either are unimproved or develop early
recurrence of the deformities. These volumetric facial changes
create shadows at these anatomic transitions, like that created in
a valley between two mountains. To minimize this shadowing,
one needs to fill the troughs or decrease the size of the promi-
nences, or some combination thereof.
The combination of facial rejuvenation lifting techniques with
autologous fat injection and liposuction has significantly advanced
the field of facial rejuvenation by facilitating correction of the
volumetric changes seen with aging. Liposuction can remove the
fat in areas of excess, while fat injection can add the fat needed in
areas of deficiency.
:e prefer the use of ultrasound-assisted liposuction (UAL) to
remove jowl fat slowly and precisely in patients with lipodystro-
phy in this area when the excess of fat continues throughout the
whole neck. The key to making this work is to have an aesthetic
eye and not reduce too much fat nor remove fat that will be used to
fill the cheek area. In the neck and submental area, one must also
be cognizant of the expected superior repositioning of soft tissues
with superficial musculoaponeurotic system (SMAS) manipula-
tion techniques and avoid any jawline contour distortions.
Despite limited quantitative evidence of fat survivability, its
benefits have been demonstrated in clinical experience. Fat graft-
ing has influenced longevity of facelifting by creating softness and
aesthetic contours, particularly in the periorbital and perioral
areas. Before repositioning of the malar fat pad and SMAS in a
rhytidectomy, we carefully harvest fat and lipo-fill the areas of
facial fat atrophy. The donor site chosen for fat harvest depends
on the patient’s preference and on adequate adipose stores. :e
most commonly use the lower abdomen and, to a lesser extent,
the medial thighs or anterior hip rolls. The combination of reposi-
tioning the malar fat pad with deep tissue support and replacing
lost fat and/or removal of excess fat has significantly improved the
lasting results of facial rejuvenation. These techniques can be used
in a secondary rhytidectomy to help improve contour irregulari-
ties caused by previous facial procedures.
Soft Tissue Fillers
Soft tissue fillers can also be employed to restore facial volume
for temporary nonsurgical treatment of facial aging. Many
products have been used for soft tissue filling, but hyaluronic
acid (HA) products are among the most commonly used. HA
fillers differ based on the degree of cross-linking present and
their particle sizes. In general, the larger the particle size and
the more cross-linking present, the longer the results tend to
last. The soft tissue fillers differ in the material that is injected
and their longevity. They can be used for facial sculpting and are
most frequently used for temporary improvement of prominent
nasolabial and labiomental folds, lip augmentation, and tear
trough deformities to maintain or augment results after primary
or reoperative rhytidectomy.
54.2.3 Improvement of Skin Texture
and Rhytids
Dermabrasion
In dermabrasion, with the use of a small handheld electrically
powered instrument and an abrasive substance, such as a wire
brush or diamond fraise, the epidermis and a portion of the

54 Reoperative Rhytidectomy
819
superficial dermis are removed. The dermal appendages allow
reepithelialization to occur over approximately 7 days, thus
improving the skin’s surface texture. Dermabrasion can be used
to improve acne scars and deep, coarse perioral rhytides (Fig.
54.1). For reepithelialization to occur, the facial pilosebaceous
glands must be present. This technique should not be used on
areas with a paucity of pilosebaceous glands, due to the risk of
abnormal scar formation, and never around the eyelids.
Laser Resurfacing
:hen used judiciously, laser skin resurfacing can be performed
simultaneously with rhytidectomy to provide safe and effica-
cious results. Deep tissue penetration, however, should not be
used over the undermined skin of the lateral cheeks, since these
areas are most at risk for healing problems due to decreased
blood supply of the skin flap. It is our preference to use an
erbium:yttrium-aluminum-garnet (Er:´peelµ (MicroLaserPeel, Sciton, Palo Alto, CA) on the central
portion of the face to ablate up to 20 to 30 micrometers of
epidermis to treat superficial skin irregularities, mild rhytids,
and dyschromias. A fractional laser technique (ProFractional,
Sciton, Palo Alto, CA) is then used to create microholes at varying
depths up to 500 micrometers, customized to the patient’s skin
thickness and texture. Reaching the reticular dermis with this
technique, collagen remodeling is stimulated in the basal layer of
the dermis to treat moderate to severe rhytids, enlarged pores,
acne scars, and significantly sun-damaged skin. Deep traditional
resurfacing with ablative with or without coagulation can be
used to improve vertical “barcode” rhytides around the lips that
are not corrected with a rhytidectomy (Fig. 54.2). Similarly,
periorbital laser resurfacing can be used to tighten loose skin
around the eyes in patients who have previously undergone a
blepharoplasty or in those with minimal skin redundancy. In
order to ensure adequate re-epithelialization, fractional laser
technique may be combined with a superficial laser peel but not
with deep resurfacing.
Chemical Peels
A chemical peel can help improve actinic skin changes, either
simultaneously with secondary facelift or 3 to 6 months later
once the patient has healed from surgery. The epidermis and
varying degrees of dermis are removed through chemically
induced injury. A neocollagen-rich layer replaces the dermis and
reepithelialization occurs. As discussed in more detail elsewhere
in this book, different peels are available, including croton oil
peels, trichloroacetic acid (TCA) peels, and glycolic acid peels. The
depth of the peel is determined by the type and concentration of
the chemicals used. :e prefer to use croton oil for patients who
have very deep perioral rhytids (Fig. 54.3).
(muOViÀed ,nWrDdermDO )DW GrDIWing
Fat grafting has become an essential tool in restoring facial
volume to achieve a rejuvenated youthful facial contour and
appearance. Autologous macro and micro fat grafting involve
fat harvest and processing to preserve adipocyte integrity so
as to restore volume when injected in deep and subcutaneous
planes and specific fat compartments. Recent advances in autol-
ogous tissue transfer have resulted in the advent of ´nanofatµ
or ´fractionated fat,µ whereby harvested fat is passed through
filters until emulsified, resulting in a dilute consistency that
can be injected in the intradermal plane. Adipocyte integrity is
nearly fully disrupted during the filtration process; therefore,
volume augmentation is not achieved with injection of nanofat.
Emulsified fat, however, has been shown to contain a large
quantity of adipocyte stem cells in the stromal vascular fraction.
:hile the technique is new and data are sparse, clinical reports
demonstrate improvements in skin quality, texture, and pigmen-
tation with intradermal injection of emulsified fat. In reoperative
facelifting, nanofat grafts can be precisely injected into rhytids
and traumatic or acne scars to diminish their appearance and
are particularly effective in the perioral region. Given the liquid
consistency of the fat, nanofat grafts can also be placed in the
delicate plane between the thin eyelid skin and underlying
orbicularis oculi muscle to help with dark pigmentation as well
as to blend the lid-cheek junction. 1anofat grafting can be com-
bined with other methods of skin rejuvenation and remodeling,
including ablative and nonablative lasers and chemical peels for
enhanced skin remodeling and rejuvenative effects.
Radiofrequency Energy–Based Skin Tightening
Radiofrequency (RF) energy devices have emerged as a way
of achieving thermal-induced collagen remodeling and skin
tightening without injuring the epidermal–dermal barrier.
1oninvasive RF devices (e.g., Morpheus8, InMode, Lake Forest,
CA) transmit thermal energy through the epidermis to the
dermis or subcutaneous space without skin ablation. The resul-
tant thermal-induced microinflammatory processes promote
Fig. 54.1 (a) This case illustrates the power of dermabrasion in
correcting deep perioral rhytides when used in conjunction with
reoperative rhytidectomy, (b) with substantial improvement shown at
long-term follow-up.
Fig. 54.2 (a) This patient benefited from erbium:yttrium-aluminum-
garnet (Er:improvement in skin texturing and barcode lines to supplement facial
rejuvenation results obtained from fat grafting and rhytidectomy.

820
VIII Surgical Rejuvenation of the Face and Neck
neocollagenesis and production of elastin and ground substance
production. As a result, progressive signifi cant skin tightening
eff ects occur over the ensuing 6 to 12 months. Even greater skin
tightening and subcutaneous adipose contouring can be achieved
with minimally invasive RF devices (e.g., FaceTite or BodyTite,
InMode, Lake Forest, CA), which deliver energy through an
internal probe electrode. The internal probe electrode delivers
directed intense thermal energy to the surrounding subdermal or
Fig. 54.3 This patient represents a comprehensive facial rejuvenation and maintenance over a span of more than 10 years. (a) Preoperative appear-
ance (b) One year after primary short scar facelift, closed neck treatment, fat grafting, and Erbium Laser resurfacing. (c) Preop secondary facelift
having had a second erbium laser, additional fat grafting, and a croton oil peel at various intervals in the interim. Her complaint at this time is her
neck. (d) One year after secondary facelift, deep cervicoplasty, and additional fat grafting.
a
b
c
d

54 Reoperative Rhytidectomy
821
subcutaneous space. In addition to dermal changes, the internal
energy delivery achieves coagulative tightening of septofascial
cutaneous fibers. 1oninvasive and minimally invasive RF devices
can be used in combination for even greater tissue tightening as
well as with traditional liposuction techniques for simultaneous
tissue debulking.
RF skin tightening can be used everywhere on the body. In
the patient who has previously undergone rhytidectomy, the
technology can be used for ´upkeepµ of the results and/or to offer
additional skin tightening to patients who are unwilling or unable
to undergo additional face- or neck lift surgery.
Neurotoxin
Often, patients who have previously undergone facial rejuvena-
tion have persistence or recurrence of lines and furrows that will
not be responsive to additional surgery. Botulinum neurotoxin is
produced by Clostridium botulinum bacteria and causes muscle
paralysis by inhibiting release of acetylcholine at the presynaptic
cholinergic neuromuscular end plates. 1eurotoxin injections are
versatile and treat the following: glabellar furrows, formed by
the contraction of the corrugator supercilii and procerus mus-
cles; horizontal forehead rhytides, formed by the contraction of
the frontalis muscles; periocular crow’s-feet rhytides, formed
by the contraction of the orbicularis oculi muscles; marionette
lines, accentuated by the contraction of the depressor anguli
oris (DAO) muscles; and vertical lip rhytides, created by the
orbicularis oris muscles. In addition, with appropriate neuro-
toxin placement, eyebrow shape and position can be changed
to improve aesthetics, particularly for women striving for a
feminine arch to their eyebrows. It is also effective for patients
who complain of dimpling and irregularity of the chin.
Skin Care
Maintaining good skin health helps improve the appearance and
longevity of the surgical results. There is a plethora of available
skin care products today, but the first step to good skin care is
minimizing sun exposure. Genetic factors that contribute to skin
aging cannot be altered through behavioral changes, but effects
of sun exposure can. :e recommend that all patients be consis-
tent with sunscreen use and sun exposure protection.
54.3 Indications for Reoperative
Rhytidectomy
It is a hasty mistake to conclude that every patient must have
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be lacking your skill. Patients may have sought you because
your reputation is that of a judicious surgeon who does not
immediately want to do another facelift on everyone. have multiple approaches available, so the first rule is: Listen to
your patient! Ask: ´:hat is it about your face that is beginning
to bother you"µ and ´:ere these features improved after your
first facelift"µ Starting with questions such as these will assist
you in tailoring valuable consultation time toward the patient’s
primary concerns rather than discussing distracting options to
which the patient will simply not be amenable. The consultation
also provides the surgeon with an opportunity to help educate
the patient about procedures or treatments that will give lasting
improvement, rather than treatment options about which the
patient may have incomplete knowledge but for which he or she
is not a suitable candidate. For instance, botulinum toxin and
soft tissue fillers are simply not going to produce a facelift result,
but patients can often be confused about this issue. In some
situations, injectables are the only interventions certain patients
will consider, especially if they had a difficult recovery from their
first facelift.
In recent years, much more attention has been paid to com-
plementing facial rejuvenation procedures with volumetric facial
shaping, midface repositioning, and rejuvenation of facial aes-
thetic subunits (eyes, nose, mouth, and ears)³issues that might
not have been addressed during the patient’s primary facelift.
Volume preservation or enhancement, using fillers or autologous
fat grafting, are now more commonly accepted approaches to
restoring a youthful contour to the face. Continued radial expan-
sion of the midface and aging of aesthetic subunits, particularly
in the central face, are common complaints that bring reoperative
patients back to the office. Ancillary treatments to rejuvenate
the aesthetic subunits can add to the longevity of the secondary
rejuvenation procedure. If assessment reveals an aged midface
appearance, this finding will need to be addressed during surgery.
If the initial surgery was done by someone else, it may be impos-
sible to determine the exact technique and what maneuvers were
performed. Of course, if the patient returns to the surgeon who
performed the initial procedure, access to the original records will
be readily available.
54.3.1 Continued Signs of Aging
The inevitable signs of aging can be mitigated but not halted.
Continued aging is the primary reason for secondary (or tertiary,
quaternary, and beyond) facelifts. A patient may have been
previously happy with the results of a primary rhytidectomy,
but as years pass, facial aging continues. The patient’s genetics
and sun exposure influence the aging process. Frequently, skin
quality has either further deteriorated or had never been treated
in a secondary rhytidectomy patient. Skin quality may be the
primary source of concern for the patient, and therefore less
invasive options, including skin resurfacing, soft tissue filling, or
appropriate skin care can be utilized.
As we later discuss, the appearance of the face as it ages is
different in patients who have already had facial rejuvenation
surgery. Therefore, one’s approach to correcting facial aging is
different in primary than in secondary rhytidectomy patients. It
is helpful if the surgeon knows exactly what was done initially.
In the case shown in Fig. 54.4, the patient’s facelift had been
performed in the subperiosteal plane; therefore, in the secondary
facelift, a formal SMAS elevation was used to achieve the desired
result while remaining in a scar-free surgical plane.
54.3.2 Adjunctive Procedures to Enhance
Previous Results
During the consultation for repeat rhytidectomy, the patient
must be carefully assessed to determine features of aging that
were either purposely or neglectfully not addressed during
the initial procedure. A patient’s previous rhytidectomy may

822
VIII Surgical Rejuvenation of the Face and Neck
not have included treatment of midface descent, which has
influenced that patient’s decision for a secondary rhytidectomy.
Patients may want to add skin treatments with laser resurfacing,
lipocontouring, autologous fat injections, and periocular or peri-
oral procedures to enhance previous results (Fig. 54.5). The neck
may have been treated with liposuction and skin redraping pre-
viously, but the platysma and deeper structures of the neck may
not have been addressed. Failure to contour jowl fat adequately
initially may lead to the need for secondary lipocontouring and
SMAS re-elevation.
54.3.3 Planned Staged Intervention
As aesthetic procedures become more socially acceptable,
patients are beginning to have facial rejuvenation procedures
at earlier ages. Many start with less invasive procedures, such
as neurotoxin injections for improvement of dynamic rhytides,
soft tissue fillers for static rhytides, and laser resurfacing for fine
rhytides. At the early stage in facial aging, less aggressive surgical
procedures, such as lipocontouring or lipofilling, are required to
satisfy patient expectations. These patients are typically coun-
seled about the continued aging process and will likely request
additional procedures years later.
One should also anticipate employing a staged approach for
patients who are typically difficult to achieve excellent results in
a single stage, or in those with tissues prone to early recurrent
laxity. These patients can be identified by poor skin quality and/
or heaviness of their tissues. They should be counseled regarding
the staged procedure so that the surgeon can achieve results that
both parties can reasonably anticipate. :e commonly counsel
patients with severe neck laxity that a revision neck lift may be
needed as early as 1 year postoperatively (Fig. 54.6). However, our
understanding of effects of aging on superficial and deep struc-
tures of the neck continues to evolve, and newer techniques have
been developed to give more reliable and longer-lasting results.
Deeper structures of the neck, including hypertrophic subplatys-
mal fat, enlarged and ptotic submandibular glands (SMGs), and
divergent digastric muscles, must be recognized and corrected to
yield desirable and long-lasting results. Adjunctive measures to
eliminate dead space in the neck and redrape and stabilize the
cervical skin are useful in decreasing complications and enhanc-
ing longevity of results (Fig. 54.7).
54.3.4 Dissatisfaction with
Previous Results
Even without any surgical complications, some patients are still
dissatisfied with the results from their previous rhytidectomy. It
is very important for the reoperative surgeon to spend adequate
time with these patients, both to understand clearly what their
expectations are and to have a detailed discussion with them
about what results can be reasonably achieved. Patients may not
have discussed their dissatisfaction with their previous surgeon
when they seek correction. In these situations, it is important to
obtain the patients’ records from their previous surgeons if at
all possible. :e favor a courtesy telephone call to the previous
surgeon. your decision making for the current operative plan.
54.4 Aesthetic Evaluation for
Reoperative Rhytidectomy
Patients typically present for secondary rhytidectomy, on average,
8 to 12 years following primary rhytidectomy. During this long
interval, morphologic and histologic changes associated with
aging continue to affect the facial skin, soft tissue, and underlying
skeletal framework. Patient evaluation, therefore, must begin
with systematic analysis of the stigmata of facial aging. Repeated
tension on the skin, especially in a disadvantageous vector, will not
restore a youthful appearance. Instead, these types of maneuvers
will yield an appearance that betrays repeated surgery and may be
exceedingly difficult to correct. A laterally swept cheek and jaw-
line, but uncorrected midface, is a classic example of this problem.
The aesthetic evaluation for a secondary rhytidectomy is
similar in many ways to that for primary rhytidectomy, but there
are certain physical examination characteristics that can differ.
Following a rhytidectomy, some areas of the face retain tightened
support, especially laterally, whereas other areas, such as the
midface, continue to descend. Telltale stigmata of a prior rhyt-
idectomy may be present and may include facial asymmetries,
cross-cheek depressions, earlobe and tragal deformities, hairline
Fig. 54.4 (a,b) This 58-year-old woman had undergone a subperiosteal
facelift and open brow lift 14 years earlier. She similarly presented for
secondary facial rejuvenation. (c,d) She is shown 1 year after undergo-
ing a secondary facelift with extended superficial musculoaponeurotic
system (SMAS) dissection and endoscopic browlift.