You are in: eMedicine Specialties > Plastic Surgery > RHYTIDECTOMY Facelift, PlatysmaplastyArticle Last Updated: Oct 3, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Consulting Surgeon, Myers Wyse Center for the Eye; Director, Center for Facial Rejuvenation; Founding Partner, HC Consulting, Inc Adam J Cohen is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons Coauthor(s): Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota Editors: David W Furnas, MD, Clinical Professor Emeritus, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California at Irvine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: rhytidectomy, facial rejuvenation, facial plastic surgery, cosmetic surgery, aesthetic surgery, submental ptosis, submentoplasty, cervicofacial rejuvenation, sagging neck, turkey neck, submentoplasty, facelift with platysmaplasty, face lift, face-lift with platysmaplasty, face-lift, aging changes, wrinkles, wrinkling, facial surgery, senescence, submental ptosis, cervicofacial surgery, age-related facial changes INTRODUCTIONSection 2 of 10
  Correction of submental ptosis is necessary to reverse the effects of senescence of the face. Although this procedure is usually undertaken in tandem with facial rhytidectomy, surgeons may find themselves addressing only the cervical region. Therefore, this article addresses correction of the effects of aging in the cervical region and does not address the facial region. History of the ProcedureSkoog first described the modern surgical technique. Millard subsequently advocated a horizontal submental incision for lipectomy, excision of hypertrophic anterior platysmal bands, and a wide subcutaneous cervical dissection plane. Owsley later supported a procedure in which the platysma was elevated in conjunction with the superficial muscular aponeurotic system away from the zygomatic arch and preauricular regions to achieve cervicofacial rejuvenation. EtiologyWeakening of the retaining ligaments of the face is a contributing factor in age-related facial changes. In 1989, Furnas provided a description of these ligaments. These ligamentous structures suspend the more superficial and mobile anatomical structures to the deeper and akinetic facial constituents. Fasciocutaneous and osseocutaneous ligaments have been described, with the former extending from the dermis to the facial fascia and the latter extending from the dermis to the periosteum. Other reported causes of skin sagging and drooping over the facial skeleton include loss of bone, loss of skin elasticity, and atrophy of facial fat. PathophysiologyConstant gravitational forces, senescence, and ultraviolet exposure result in an aged and tired facial appearance. ClinicalPatients usually describe a sagging neck, sometimes called turkey neck. INDICATIONSSection 3 of 10
Platysmaplasty is used to reverse the effects of aging, sun exposure, and smoking on the cervical region. RELEVANT ANATOMYSection 4 of 10
Being knowledgeable about lower facial and neck anatomy is of preeminent importance when embarking on a submentoplasty. Most surgical authorities agree that surgical skill alone is not a substitute for knowledge of anatomy. Fewer pilosebaceous units populate the integument of this region compared with other facial regions. This should not be forgotten if laser resurfacing is considered because the presence of fewer pilosebaceous units can increase the risk of pronounced scarring, increase healing time, and cause pigmentary changes. Adipose tissue is segregated anatomically into subcutaneous and subplatysmal and varies depending on genetic predisposition and morphology. Increasing quantities of subcutaneous fat can be observed with weight gain or aging and with some lipodystrophies. Subplatysmal fat is far more vascular and fibrous than subcutaneous fat and can be visualized following an incision into the platysma muscle. This difference results in reduced efficacy of liposuction of subplatysmal fat; therefore, the authors do not routinely use liposuction for subplatysmal fat. Originating from the pectoralis major muscle fascia, the platysma is a layer of muscle that has multiple insertions. Moving anterior to posterior, the muscle is anchored to the mentum and the inferior mandibular border and meets the orbicularis oris laterally and then the depressor anguli oris. Platysmal meshing with the depressor anguli oris contributes to the superficial muscular aponeurotic system, highlighting the importance of this region when attempting to reverse facial senescence. Ventral rami of cervical nerves II-IV provide the tactile sense of the anterior neck. Tracking along the posterior surface of the sternocleidomastoid muscle, these sensory nerves approach the anterior neck. The lesser occipital nerve moves posteriorly to innervate the posterior upper otic surface and retroauricular scalp, while the greater auricular nerve innervates the auricle and mandibular angle. Importantly, the latter is 6-6.5 mm inferior to the external auditory canal while coursing over the sternocleidomastoid muscle. The anterior triangle of the neck receives the transverse cervical nerve for sensory innervation of the region within the boundaries of the sternum and mandible. This nerve branches out over the anterior surface of the sternocleidomastoid muscle and is found within the deep cervical fascia. The external jugular vein, a rather large tributary, and the anterior jugular vein are at risk during dissection for platysmaplasty. Found deep to the platysma, they provide several vascular conduits, ie, to the facial, retromandibular, and posterior auricular veins. Of course, large arterial structures such as the carotid and its branches must absolutely be avoided. The submandibular glands are usually encountered during submentoplasty. They are lateral to the anterior belly of the digastric muscle. CONTRAINDICATIONSSection 5 of 10
This procedure is contraindicated in patients who are not medically stable or those who cannot tolerate anesthetic agents. Importantly, patients who do not have realistic expectations of surgical outcomes should undergo more counseling or should not undergo the operation. WORKUPSection 6 of 10
Lab Studies
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TREATMENTSection 7 of 10
Preoperative DetailsEnsure that all patients undergo a complete medical examination by the appropriate specialist, including a complete blood cell count, metabolic chemistry analysis, ECG, and, if indicated, a chest radiograph. Instruct patients to abstain from ingesting alcohol or using tobacco 2 weeks prior to surgery. Also instruct patients to discontinue the use of aspirin, nonsteroidal anti-inflammatory agents, anticoagulants, vitamin E, multivitamins, and Alka-Seltzer 2 weeks prior to surgery. Finally, instruct patients to discontinue any homeopathic remedies and begin daily vitamin C supplementation (500-1000 mg) at least 3 weeks prior to facial rejuvenation. The authors usually provide a broad-spectrum antibiotic to be taken the night before surgery, and the antibiotic, along with prednisone, is usually continued for 3 days postoperatively. If the patient uses tobacco products, the antibiotic may be prescribed for 7 days. Instruct patients to wash their face, neck, and external ears the night before and the morning of surgery. Also instruct patients to refrain from using cosmetics, perfumes, after-shave lotions, colognes, or moisturizers the morning of surgery. On the day of surgery, instruct patients to wear comfortable clothes with a button-down shirt and to bring a scarf and sunglasses. Intraoperative DetailsThe authors prefer a customized approach guided by the anatomical irregularity and desired surgical correction for each patient. Several scenarios exist related to (1) the amount of excess adipose tissue, (2) skin excess and inelasticity, and (3) platysmal banding. Each of these may or may not be present, and each of these 3 entities must be addressed in order to achieve a successful outcome. No algorithm will always yield the optimal result. The surgeon must rely on his or her experience to formulate a well-orchestrated surgical plan. For instance, a younger patient may present with excess adipose tissue, elastic skin, and no platysmal banding. Submental liposuction or lipectomy can likely achieve a satisfactory surgical outcome, without platysmal plication or excess skin removal. If excess fat and skin are present in conjunction with platysmal banding, perform submental liposuction or lipectomy, postauricular incisions with subcutaneous dissection, and platysmaplasty. Removal of excess fat, removal of excess skin, and platysmaplasty are described as 3 separate entities below. However, understand that these may be performed in conjunction or modified as the surgeon sees fit. Removal of excess fat If liposuction is the modality of choice, a 4-mm area just beneath the chin in the midline submental region is anesthetized using 0.3 mL of 1% lidocaine with 1:100,000 epinephrine. Temporal, preauricular, and postauricular incision lines are anesthetized with local anesthetic (1% lidocaine with 1:100,000 epinephrine) using a 27-gauge by 1- to 1.5-inch needle. A 27-gauge spinal needle is then used to infiltrate under the flaps to be raised and in the submental area, using the same lidocaine and epinephrine diluted with normal saline to a 50% concentration. The concentration can be reduced to 25%, or other tumescent solutions may be used if desired. Using a No. 15 blade, make a small midline stab incision in the submental crease. Through this incision, the area of the neck adiposity to be addressed is anesthetized and can be hydrodissected using a tumescent technique. Liposuction is performed through the incision used for tumescent anesthesia using a 12-gauge fat harvester on a 12-mL syringe or suction machine, with the lumen of the cannula directed away from the dermis. While staying within the premarked foundries, the cannula is moved in a fanlike or spoked-wheellike pattern back and forth to form liposuction conduits. Ensure that these conduits intersect. This may be followed by liposuction using a spatula cannula, which also serves to undermine and create a flap, if indicated. If lipectomy is used, then the submental incision must be enlarged to 3 cm to allow for direct visualization of submental fat. The wound is closed carefully after assuring that meticulous hemostasis has been achieved. Removal of excess skin If inelastic or excess skin must be excised, then make postauricular incisions. This is followed by subcutaneous dissection to the midline of the neck under direct visualization. The posterior edge of the platysma may be transected and anchored to the mastoid periosteum with a nonabsorbable suture such as 4-0 Prolene. Careful attention to placement of these sutures is critical because this will define the jaw line. Redundant skin is then trimmed, and a drain may be placed. Platysmaplasty Platysmal banding can be diminished by plication of the platysma muscle. A submental stab incision may need to be created or extended to 2-3 cm. Nonabsorbable suture material (eg, 5-0 Prolene) is used to plicate the medial edges of the platysma in the submental region to the thyroid cartilage. Some authors describe a plication technique using a subcutaneous approach and a noncurved or Keith needle. Postoperative DetailsIn the recovery room, evaluate the patient for pain, nausea, or vomiting. If these are present, administer pain medication and antiemetics as appropriate. Prior to surgery, give the patient instructions for the postoperative period. The following guidelines are adapted from the printed handout distributed by the authors to their patients.
COMPLICATIONSSection 8 of 10
When complications arise, the physician must address them expeditiously and appropriately to minimize poor outcomes and to avoid litigious actions by the patient. A meticulous review of the patient's medical history and use of medications is essential, as is an assessment of his or her psychosocial state and expectations. If the patient has a history of dissatisfaction with other surgeons, unrealistic expectations, or a high level of psychosocial stressors, foregoing the operation may be prudent. Before proceeding, the physician should document the patient's clear understanding of the risks and possible complications. Reducing intraoperative and preventing postoperative hematomas is essential. All patients should be instructed to discontinue aspirin, nonsteroidal anti-inflammatory agents, vitamin E, and other anticoagulative agents 2 weeks prior to surgery. Also, any homeopathic or herbal remedies and alcohol consumption should be stopped 2 weeks prior to surgery. Poor preoperative decision making with respect to incision placement can lead to obvious and pronounced scarring. Intraoperative hemostasis is best achieved with bipolar cautery and ligation of larger vessels. Tumescent anesthetic infiltration and an allowance of 10-15 minutes before proceeding with surgery can aid in hemostasis. Before reapproximating any flaps that have been fashioned, the field should be meticulously inspected for any bleeding and must be dry. If bleeding persists, saline irrigation may aid in identifying the source of bleeding. After skin flaps are closed, hematomas may form immediately or later in the postoperative period. Hematomas arising immediately following platysmaplasty are addressed by removing skin closure materials to open the area of hematoma formation. Pressure should be applied after the clot is evacuated, and, if bleeding persists, the wound should be explored in a sterile fashion with the patient under anesthesia. The bleeder should be remedied, and the skin should be reapproximated. Clot formation that occurs at a later time can be evacuated using open or closed techniques. If small enough, a large-bore needle can be used to evacuate the unwanted serosanguineous fluid pool. All hematomas should be addressed in order to prevent overlying skin necrosis. Although drains are used by some, this is certainly not an adequate substitute for attention to scrupulous hemostasis. Labile blood pressure should be controlled, and postoperative pain should be addressed. The patient should minimize coughing, exertion, and Valsalva maneuvers to reduce hemorrhaging. Overly aggressive fat excision from the central preplatysmal adipose tissue can allow for platysma muscle and skin adhesions, with the resultant platysmal resections becoming visible through the skin (cobra-neck deformity). Excess debulking of fat in the submandibular gland region may allow for increased visibility and ptosis of these glands. Conversely, a poor effort to excise fat can result in asymmetry and suboptimal outcomes. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Facelift, Platysmaplasty excerpt Article Last Updated: Oct 3, 2006 | ||||||||||||
