eMedicine Specialties > Plastic Surgery > Rhytidectomy

Facelift, Platysmaplasty

Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota

Updated: Feb 18, 2009

Introduction

Correction of submental ptosis is sometimes necessary to reverse the effects of senescence. Although this is usually undertaken in tandem with facial rhytidectomy, surgeons may find themselves addressing only the cervical region at times.

History of the Procedure

Skoog first described the modern surgical technique. Millard subsequently advocated a horizontal submental incision for lipectomy, excision of hypertrophic anterior platysmal bands, and wide subcutaneous cervical dissection.^1,2 Owsley later supported a procedure where the platysma was elevated in conjunction with the superficial muscular aponeurotic system (SMAS).³

Etiology

Weakening of the retaining ligaments of the face contributes to age-related changes. In 1989, Furnas provided a description of these ligaments.⁴ These ligaments suspend the more superficial and mobile anatomical structures to the deeper and akinetic facial constituents.

Fasciocutaneous ligaments extend from the dermis to the facial fascia, and osseocutaneous ligaments extend 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.

Indications

Platysmaplasty is used to reverse the effects of aging, sun exposure, and smoking on the cervical region.

Relevant Anatomy

Fewer pilosebaceous units populate the integument of this region compared with other facial regions. If laser resurfacing is considered, the presence of fewer pilosebaceous units can increase the risk of pronounced scarring, increase healing time, and increase pigmentary changes. For information on laser resurfacing techniques, see eMedicine articles Skin Resurfacing, Laser: Carbon Dioxide and Skin Resurfacing, Laser: Erbium YAG.

Adipose tissue is segregated into subcutaneous and subplatysmal. Increased amounts of subcutaneous fat can be observed with weight gain, aging, and lipodystrophies. Subplatysmal fat is far more vascular and fibrous than subcutaneous fat and is visualized after incising the platysma muscle. This difference results in reduced efficacy of liposuction of 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 (SMAS), highlighting its importance when attempting to reverse facial aging.

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; the greater auricular nerve innervates the auricle and mandibular angle. 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 and the anterior jugular veins are deep to the platysma. They provide vascular conduits to the facial, retromandibular, and posterior auricular veins.

The submandibular glands are lateral to the anterior belly of the digastric muscles.

Contraindications

This procedure is contraindicated in patients who are not medically stable or those who cannot tolerate anesthetic agents.

Patients who do not have realistic expectations of surgical outcomes should undergo preoperative counseling or should not undergo the operation.

Workup

Laboratory Studies

Blood cell counts, coagulation profiles, and chemistries are obtained based on age and morbidity.

Imaging Studies

Standard preoperative photos are recommended for documentation, intraoperative reference, and reminding patients of their presurgical appearance when they critique their outcome.

Treatment

Preoperative Details

Patients should not ingest alcohol or use tobacco 2 weeks prior to surgery.

Patients should discontinue use of aspirin, nonsteroidal anti-inflammatory agents, anticoagulants, vitamin E, multivitamins, fish and flax seed oil, homeopathic remedies, and Alka-Seltzer 2 weeks prior to surgery.

Arnica montana is believed to reduce postoperative edema and bruising when used in the perioperative period.

On the morning of surgery, patients should refrain from using cosmetics, perfumes, after-shave lotions, colognes, or moisturizers.

On the day of surgery, instruct patients to wear comfortable clothes with a button-down shirt and to bring a scarf and sunglasses.

Postoperative Details

In 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.

Rest at home, but complete bed rest is not necessary. While in bed, elevate the head and keep it straight. Use pillows to prevent the face or body from turning during sleep.
Use of a compressive chin/neck bra for 3 weeks is needed.
Refrain from physical exertion, bending, heavy lifting, and sexual activity for at least 2 weeks.
Do not use tobacco products, alcohol, aspirin, nonsteroidal anti-inflammatory agents, vitamin E, or nicotine gum or patches for 3 weeks.
Do not drive or fly for 2 weeks. Being a passenger in a motor vehicle is acceptable, but do not operate it.
Showering and hair washing are permitted the day after surgery.
Avoid the sun for 2 months following surgery.
Do not undergo dental procedures for at least 6 weeks, unless emergent dental intervention is needed.
Optimum results from the surgery may not be apparent for 2-3 weeks following the procedure.
Finish all prescribed medications as directed.

Intraoperative Details^{2,
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The amount of excess adipose tissue, skin excess and elasticity, and platysmal banding varies from patient to patient. Each of these important factors may exist alone or in conjunction, necessitating a customized approach to each patient.

For instance, a younger patient may present with excess adipose tissue, good skin elasticity, and no platysmal banding. Submental liposuction or lipectomy can achieve a satisfactory surgical outcome, without platysmal plication or excess skin removal.

If excess fat and skin are present in conjunction with platysmal banding, submental liposuction or lipectomy, postauricular incisions with subcutaneous dissection, and platysmaplasty are indicated.

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.

Preoperative markings

Patients are marked in a sitting position. A submental crease incision site should be marked. Liposuction requires a small stab incision, while lipectomy necessitates a larger incision. This larger incision should be curvilinear and directed away from the mandible.

The lateral and inferior borders of liposuction and undermining are marked. These markings are located at the anterior edge of the sternocleidomastoid muscle and thyroid notch, respectively.

Active contraction of the platysma can aid in identifying and marking anterior platysmal banding.

Removal of excess fat

Both tumescent and nontumescent liposuction techniques exist. The nontumescent technique is described here.

With liposuction, an area just beneath the chin in the midline submental region is anesthetized with a local anesthetic. With a No. 15 scalpel blade, create a small, midline stab incision in the submental crease.

Following the incision, subcutaneous dissection with a No. 15 scalpel blade or pair of scissors is helpful.

Liposuction is performed using a 3- or 4-mm cannula directed toward the dermal surface. The skin should be tented upward during liposuction. While staying within the premarked boundaries, the cannula is moved in a fan or spoke-wheel pattern. This technique produces adipose reduction from the central to peripheral regions. Progress is evaluated by pinching the skin and feeling a thin layer of fat between the rolled-up skin.

An aggressive liposuction technique may induce prolonged lipolysis and dimpling.

If lipectomy is performed, the submental incision must be enlarged to 3 cm and directed away from the mandible to allow for direct visualization of submental fat. Subcutaneous dissection isolates the dermal fat from the platysma muscle. A 3- to 4-mm layer of dermal fat must remain.

A retractor is used to visualize and excise the fat with long forceps and scissors. If necessary, the submental fat deep to the platysma can be resected. The marginal mandibular nerve and anterior jugular veins can be damaged during subplatysmal dissection.

Hemostasis is best achieved with bipolar cautery to reduce scarring.

Platysmaplasty⁹

Platysmal banding can be diminished by plication of the platysma muscle. After identifying the medial platysmal edges, approximation is performed. A absorbable or nonabsorbable suture is used to create a muscle sling. The plication should extend from the submental incision to the thyroid cartilage. If a running suture is used, the plication should continue in a reverse direction, allowing for the plication of the lateral edges.¹⁰

A wedge excision of the medial border of the platysma at the cervicomental angle provides additional definition.

Other techniques for platysmaplasty include purse-string platysmaplasty.¹¹

Removal of excess skin

With female patients, postauricular sulcus incisions are carried posteriorly over the mastoid. The incision continues into the hairline in a horizontal fashion. This technique minimizes distortion of the hairline.

Male patients should have a postauricular incision within the cephaloauricular border. This prevents hair growth on the posterior otic surface.

Subcutaneous dissection to the midline of the neck is performed. The posterior edge of the platysma may be transected and anchored to the mastoid periosteum, defining the jaw line. Placement of these sutures is critical because this defines the jaw line. Redundant skin is then trimmed. The wound is closed with minimal tension, and a Jackson-Pratt drain may be placed.

In some patients, especially those undergoing fat reduction only, removal of skin is contraindicated.¹²

Complications

Hematoma or seroma
Transient anterior neck hypothesia
Prominence of platysmal bands
Prominent jowls
Cobra neck deformity
Skin dimpling and scar contracture
Skin wrinkling or laxity

Multimedia

Media file 1: Platysma plication in female and male patient.

References

Millard DR, Pigott RW, Hedo A. Submandibular lipectomy. Plast Reconstr Surg. Jun 1968;41(6):513-22. [Medline].
Millard DR Jr, Garst WP, Beck RL, Thompson ID. Submennta and submancibular lipectomy in conjunction with a face lift, in the male or female. Plast Reconstr Surg. Apr 1972;49(4):385-91. [Medline].
Owsley JQ Jr. SMAS-platysma facelift. A bidirectional cervicofacial rhytidectomy. Clin Plast Surg. Jul 1983;10(3):429-40. [Medline].
Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. Jan 1989;83(1):11-6. [Medline].
Toft K, Keller GS, Blackwell KE. Submentoplasty. An anatomical approach. Facial Plast Surg Clin N America. May 2000;8(2):183-92. [Medline].
Brissett AE, Hilger PA. Male face-lift. Facial Plast Surg Clin North Am. Aug 2005;13(3):451-8. [Medline].
Watson D. Submentoplasty. Facial Plast Surg Clin N Am. 2005;13:459-467.
Bitner JB, Friedman O, Farrior RT, Cook TA. Direct submentoplasty for neck rejuvenation. Arch Facial Plast Surg. May-Jun 2007;9(3):194-200. [Medline].
Labbe D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg. May 2006;117(6):2001-7; discussion 2008-10. [Medline].
Fuente del Campo A. Midline platysma muscular overlap for neck restoration. Plast Reconstr Surg. Oct 1998;102(5):1710-4; discussion 1715. [Medline].
Gentile RD. Purse-string platysmaplasty: the third dimension for neck contouring. Facial Plast Surg. Nov 2005;21(4):296-303. [Medline].
Gryskiewicz JM. Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates. Plast Reconstr Surg. Oct 2003;112(5):1393-405; discussion 1406-7. [Medline].
Cohen AJ, Mercandetti M, Chang EW. Rhytidectomy, Subperiosteal Facelift. eMedicine from WebMD [serial online]. Updated October 13, 2008;Available at http://emedicine.medscape.com/article/841787-overview.
Giampapa V, Bitzos I, Ramirez O, Granick M. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fine points for improving outcomes. Aesthetic Plast Surg. Sep-Oct 2005;29(5):341-50; discussion 351-2. [Medline].
Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg. Apr 1 2004;113(4):1275-8. [Medline].
Mercandetti M, Cohen AJ. Facelift, SMAS Plication. eMedicine from WebMD [serial online]. Updated April 30, 2008;Available at http://emedicine.medscape.com/article/1294486-overview.
Mercandetti M, Mirante JP. Aesthetic facial surgery. In: Krause JH, Mirante JP, Christmas DA, Donley S, eds. Office-Based Surgery in Otolaryngology. Philadelphia, Pa: WB Saunders; 1999:143-55.
Noone RB. Suture suspension malarplasty with SMAS plication and modified SMASectomy: a simplified approach to midface lifting. Plast Reconstr Surg. Mar 2006;117(3):792-803. [Medline].
Owsley JQ Jr. Platysma-facial rhytidectomy: a preliminary report. Plast Reconstr Surg. Dec 1977;60(6):843-50. [Medline].
Ruiz-Esparza J. Near [corrected] painless, nonablative, immediate skin contraction induced by low-fluence irradiation with new infrared device: a report of 25 patients. Dermatol Surg. May 2006;32(5):601-10. [Medline].
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Keywords

facelift, platysmaplasty, 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

Contributor Information and Disclosures

Author

Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society
Disclosure: Nothing to disclose.

Medical Editor

David W Furnas, MD, Clinical Professor Emeritus, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California at Irvine
David W Furnas, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Head and Neck Society, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society of Transplantation, California Medical Association, Phi Beta Kappa, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Further Reading