Platysmaplasty Facelift

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.

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]

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]

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

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.

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.

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

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

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.

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.[2, 6, 7, 8, 9, 10]

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[11]

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.

A study by Ramirez et al indicated that lipolysis in patients undergoing platysmaplasty can be successfully accomplished using a continuous-wave 924/975-nm diode laser. The study, of 78 patients who underwent platysmaplasty facelift and elevated-flap laser-assisted lipolysis, determined that the subjects’ cervicomental angle and general appearance were greatly improved postoperatively.[12]

Platysmaplasty[10, 11]

Platysmal banding can be diminished by plication of the platysma muscle. After identifying the medial platysmal edges, approximation is performed. An 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.[13]

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.[14]  A technique described in 2016, the hyo neck lift, involves subcutaneous neck dissection, with suturing of the platysma to the hyoid. Le Louarn subsequently proposed a modified version of this technique, in which vertical anterior subplatysmal and subplatysmal fat opening and dissection are performed, the anterior platysma is attached to the deep cervical fascia, and the lateral platysma is suspended.[15]

Removal of excess skin[11]

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.

Direct excision of excess skin using a Z-plasty has been described.[16]

In some patients, especially those undergoing fat reduction only, removal of skin is contraindicated.[17]

An image of platysma plication is shown below.

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.

See the list below:

• 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

A cadaver study by Sinno and Thorne suggested that post-platysmaplasty recurrence of platysmal bands is associated with persistent innervation of the medial platysma by the main cervical branch of the facial nerve.[18]