Background
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.
However, a prospective study by Trévidic and Criollo-Lamilla suggested that relaxation of the platysma and skin laxity are not the source of platysmal banding, with the phenomenon instead being related to platysma muscle activity. The study was conducted on 25 patients with unilateral facial palsy, with platysmal bands tending to occur only on the nonparalyzed facial side in these individuals. According to the investigators, the report indicates that denervation of the platysmal muscle, rather than skin tightening, may be the best surgical treatment for aging necks. [5]
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 Medscape Reference 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.
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Platysma plication in female and male patient.
