Platysmaplasty Facelift Treatment & Management

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]