Rejuvenation of the Anterior Neck
The When and Why
Jayson Terres, MD, DDS, FACS, FAACS
KEYWORDS
 Rejuvenation  Anterior neck  Liposculpture  Cervicoplasty
KEY POINTS
 Rejuvenation of the anterior neck region requires a complex artistic interpretation of the patient’s desires and potential
anticipated outcomes.
 Whether it is a minimal invasive liposculpture procedure to a full cervicoplasty with chin augmentation and full facelift, the
outcome will be optimal if the anticipated areas of complaints are fully addressed.
 Understanding the patient’s relative aging process will ultimately lead to the correct proposed treatment.
Introduction
One of the most common complaints of the cosmetic patient is
the neck region. Excessive skin, muscle laxity, and increased
fatty deposition are all factors that lead to an unwanted aging
effect. Nevertheless, the esthetic improvement of the anterior
neck complex remains one of the most challenging aspects
of facial rejuvenation.1e13 This area is often one of the first
places people complain of during the “aging” process: whether
it is an early accumulation of unwanted fatty deposition, an
increased prominence of platysma banding, decreased defini-
tion in the cervicomental angle, or loss of skin-muscle tone.
There are several combinations of these complaints among a
wide variety of ages (Fig. 1). It is important to understand what
the patients’ primary concerns are and which proposed treat-
ment would give a maximum outcome. It is also important to
have an artistic eye and predict the patient’s outcome for their
desired procedures to ensure that the other local facial
structures will not hamper treatment results.
Preoperative understanding of the patient’s desired
outcome is paramount in selecting the appropriate surgery.
Younger patients that still possess good skin elasticity may be
able to have a simple liposculpture procedure, whereas an
older patient having the same procedure may not be as pleased
with the outcome due to unmasked jowling that is now more
apparent or possibly the insufficient intrinsic contractility of
skin. Complete fat removal in neck tissue does not lend itself
to the optimal result (Fig. 2). An understanding of the patient’s
current anatomic state will then most commonly dictate what
type of procedure will be performed. These procedures can
range from simple liposculpture, to direct lipectomy, pla-
tysmaplasty, or complete cervicoplasty encompassing a com-
bined facelift (Box 1).
The author has nothing to disclose.
Maxillofacial Trauma, Mother Frances Health System, Tyler, TX, USA
E-mail address: Jjterres2@hotmail.com
Atlas Oral Maxillofacial Surg Clin N Am 22 (2014) 25–36
1061-3315/14/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2013.10.001
Effects on aging/variability of neck types
The anterior neck region is more of a sweeping topographic
landscape with smooth undulations versus its more flat upper
facial counterparts.1e5 A youthful-appearing facial and neck
region has a smooth textured appearance, well-defined cervi-
comental angle, and appropriate suspended fullness. Ellenb-
ogen1 has long established the visual aspects of a youthful neck
appearance. A youthful neck appearance has been classified as
having a cervicomental angle between 105 and 120 with a
distinct mandibular border and smooth nonbanded overlying
skin draping (Fig. 3).2 However, as our aging process begins, the
initial tone and texture of the more superficial structures is the
first visible structure change. Further substructural changes
within muscle then give way. It is this laxity of suspensory neck
muscles in combination of increased fatty deposits and inferior
gravitational movement of the patient’s jowls that account for
aging of the neck region. Furthermore, the accumulation of
excessive fat deposits is increased with aging, weight gain, and
certain medical conditions. Several classification systems have
been introduced to characterize this process. I have adapted
the Baker classification system,3 as its 4 subtypes seem to
encompass most of my patients’ aging attributes (Box 2,
Fig. 4).
In addition, there other components that this author thinks
can potentiate this aging appearance over time, such as sub-
mandibular gland ptosis and mandibular bony atrophydboth of
which contribute to a poor cervicomental angle and loss of
volume. They can further pose some difficulties to the surgeon,
as the decision needs to be made in regards to which procedure
or procedures should be performed to maximize outcome and
achieve the highest success with the patient’s expectations.
Patient expectations
In evaluating the patient’s anterior neck region, several factors
come into play. First and foremost is the patient’s biggest
concern, their chief complaint. In my presurgical consultations,
oralmaxsurgeryatlas.theclinics.com
26 Terres

Fig. 1 Note the difference in neck structural types. Patient on the left exhibits mild submental lipomatosis, whereas the patient on the
right has redundant tissue, lipomatosis, and banding. Also, note the second patient has much more prominent jowls and mandible
notching.

I always explain to the patient that we both must see their this point, I may recommend staged surgeries or give the pa-
issuedif I cannot, this becomes a flag to me, or if I see some- tient a complete understanding of why the “quicker” proce-
thing that the patient does not complain of, I will point it out, dure would not be most beneficial for her/him (Figs. 5 and 6).
because I can see a potential issue that may become exacer-
bated in the future if the wrong surgery is performed. Indications for neck rejuvenation
In listening to my patients, I often hear that they do not
want anything too invasive or they only want a few days of
Given the complexity and variability of the anterior neck re-
down time or they do not want a facelift, just fix their sagging
gion, most treatment options will be individualized for each
neck. Well, as I like to explain to my patients, there is the
patient. Age, gender, race, social history, habits, and genetics
“right answer” for their problem and then there is the “right
all play major roles in the aging process. Table 1 provides a
procedure” for their problem. What I mean by this is, for
brief description of the problem areas and their respective
example, if a 60-year-old patient comes into my office and
treatments and is a basic guide for what would be necessary to
wants his/her neck “tightened” and his/her eyes “lifted”d
correct the problem. Often it is the combination of 2 or more
what he/she likely needs is a brow lift, upper/lower eyelid lift,
of these procedures that is necessary to maximize outcomes.
full face/neck lift, laser resurfacing, and possibly chin and
An in-depth description of neck subregions is described later in
cheek implants. They need 2 to 3 weeks of downtime to ach-
this article.
ieve this simple complaint. Explaining this to a patient that
liposuction and a blepharoplasty will not provide an optimal
outcome on her/him (like it did on a 40-year-old friend) can be Surgical anatomy concepts
difficult. Therefore, even though the optimal procedure for
this type of patient would be a more classic complete facial The anatomy of the neck is complex and in itself is the subject
rejuvenation, I may tailor the surgery to meet my patient’s of full textbooks. The anatomy of the platysma has been
more specific requests. I am not advocating a “quick-fix extensively studied4,5 and a brief summary will not do it any
procedure,” but think it is very important to keep all of the justice, although a brief overview and some important land-
patient’s expectations in mind to the best of my abilities. At marks to aid with the rejuvenation surgical aspect have been
included.

Box 1. Terms
 Liposculpture: classic liposuction, but in the neck the
artistic ability to “sculpt” fatty areas, removing more in
certain areas and less in others to maximize cosmetic
appearance
 Direct lipectomy: removal of fat under direct vision
(can be with lipocannula, surgical scissors, bovie, etc)
 Platysmaplasty: retightening the platysma muscle in
the anterior neck regions. Various methods are used,
whether it is a single or double layered “corset”
approachdwith or without back cuts
 Complete cervicoplasty: encompasses direct removal
of fat, platysmaplasty, and possibly facelift (short inci-
sion, superficial musculo-aponeurotic system (SMAS), or
Fig. 2 This patient had prior neck liposuction. The result was deep plane)
oversculpture and now a more visualized platysma band (arrow).
Rejuvenation of the Anterior Neck
Fig. 3 Note the youthful, smooth neck contour and acceptable chin neck angle.
The anatomic structure of the anterior neck is a complex
laminate, made up of layers of skin and soft tissue (fat, fascia,
muscle) that encompass nerves, vessels, and lymphatics.6
When performing full neck rejuvenation, it is paramount to
stay in the right plane, which will not only give the surgeon an
optimal outcome but also keep you away from any troubled
areas (ie, nerves or great vessels). There are several classic
descriptions of the series of “muscle triangles” described by
their relative locations and particular borders.7 The complexity
of the neck anatomy can be overwhelming and not the basis of
this surgical anatomic discussion. Rather, anatomic esthetic
subunits, what they encompass, and how to correct them are
the focused on.
Feldman7 describes the anatomic face as a set of 5 regional
esthetic subunits, with the neck being one. It can be described
as an undulating trapezoid; the neck extends from below the
mandibular border, down toward the collarbones and post-
eriorly to the occiput region, just anterior to the trapezius
muscles. He then further divides into 8 smaller subunits: (1)
jawline bands, (2) chin subunit, (3) submental zone, (4) ver-
tical midline strip, (5) middle neck lowland, (6) lateral neck
highland, (7) small musclulomandibular triangle, and (8)
Box 2. Patient types
 Type I patients have slight cervical skin laxity with
submental fat and early jowls
 Type II patients have moderate cervical skin laxity,
moderate jowls and submental fat
 Type III patients have moderate cervical laxity, but with
significant jowling and active platysmal banding
 Type IV patients have loose, redundant cervical skin and
folds below the cricoid, significant jowls, and active
bands
27
postauricular hinterland. The analysis of these subunits as
a whole must take into account the varying degrees of the
patient’s skin tone texture and tightness, along with the un-
derlying support structure (muscle) and any laxity it may have
developed, and finally, the varying degrees of fat deposition
(Fig. 7).
The first area, the jawline bands, is a very common
complaint of “ jowling.” The degree of facial jowling and the
prejowl notch will dictate the amount of fatty tissue in the
area that needs to be removed and the degree of subcu-
taneous release of the mandibular ligament, which will also
lead into the chin subunit. Identifying the patient for chin
augmentation can accomplish several esthetic goals. First, an
improvement in the cervicomental angle, and second,
camouflaging a prejowl notch. (Even in patients who do not
need anterior-posterior chin advancement, I use a prejowl
implant with no anterior-posterior projection to aid in a deep
prejowl notch.)
The next 2 areas of concern are the submental zone and
vertical midline strip. These areas are going to give the most
information about the rejuvenation process of the neck,
whether it is a young patient with good skin overtone and
moderate lipomatosis or an elderly patient with skin laxity,
muscle banding, and severe lipomatosis. This region dictates
minimal invasive liposculpture to submentalplasty to complete
cervicomentalplasty with combined facelift. The region con-
tains both supra- and subplatysma fat structure, platysma
muscles, hyoid bone, anterior jugular vein, and its communi-
cating branches. The 2 leading edges of the platysma will have
some decussation in most patients, and a small percentage will
have none, although it is this area where redundant tissue
(both muscle and fat) will be excised and tightened (Fig. 8).
The deeper muscle structures, such as the anterior digastric
muscles, may also need to be trimmed or tighteneddbut I
usually find this is on a prior operated neck where other
overlying structures have been repositioned or removed in
excess.
 Fig. 4 Note neck classification types AeD.

Fig. 5 This younger male patient was able to achieve a very good cosmetic resultdliposculpture with a chin implant with minimal
downtime.

Fig. 6 This older female patient requested “liposuction” to her neck; after careful discussion, it was deemed that a combined facelift
and cervicoplasty would be needed to achieve her expectations along with a 2-week downtime period.
Rejuvenation of the Anterior Neck
Table 1 Problem areas and treatments
Problem Area Treatment
1. Subcutaneous Liposculpture or direct lipectomydage
fat dependent
2. Excessive skin Direct excision with redraping (isolated
neck/or facelift)
3. Subplatysma fat Direct excision with platysma tightening
4. Platysma bands Platysma plication with inferior back cut
5. Retrogenia Alloplastic implant or orthognathic
surgery
6. Poor neck angle Combinations of all the above
The midneck lowland region is an important clinical area
that needs to be thoroughly examined before a final treatment
is proposed. The midneck lowland region is the region where
excessive jowling and submandibular salivary gland distinction
must be made. Not only is this an area of excessive lipomatosis,
but also the submandibular gland can be prominent and easily
camouflaged by excess fat. Palpation of this area from both an
intraoral and an extraoral approach can provide great insight
as to whether the gland will require a partial resection, sus-
pension, or oversew in the supporting muscle.
The lateral neck highland area is the topographic area
overlying the sternocleidomastoid muscle and is the most
difficult area for cutaneous flap elevation. The fascia fibers
overlying the muscle structure are in greatest number here and
make dissection challenging. However, it is of great impor-
tance to dissect enough tissue away to ensure a proper skin
“redraping”; otherwise a gathered tissue appearance will give
a noticeable “operated” neck.
The final 2 described areas are small triangle regions. The
first area is the musculomandibular triangle, just inferior to the
earlobe. This area can be somewhat problematic because
inferior earlobe distortions from improper suspension can be
quite visible. The classic “pixie-ear” deformity from an iso-
lated neck lift or complete face and neck lift is formed from
improper suspension of tissue and excessive skin pull (Fig. 9).
This area can also be affected if there is too much fatty tissue
left behind, causing a blunting of the posterior border of the
mandible. Careful attention is also warranted to ensure that
Fig. 7 The subdivisions of the neck as described by Feldman.
29
there is no excessive parotid tissuedif present, I prefer to
leave the gland structure but will remove excessive fatty tissue
to improve the clinical cervicomental angle. The final area is
the postauricular hinterland; the region is just posterior to the
auricle, where the final resting place of newly suspended tissue
resides. Passive tissue will give the most optimal results.
Excessive removal will lead to wound breakdown and widened
scar bands. Too little removal can leave “tissue rolls” that may
take several months to soften and often patients will complain
of lumpy tissue.
Nonsurgical techniques
There are several nonsurgical modalities for improving the
aging neck. These techniques can include anything from neck
muscle exercises, botulism injections, and skin tightening with
lasers, radiofrequency, or even chemical peeling. In my opinion
these are very patient-specific and yield only temporary
results. Some are discussed, because they remain popular
requests among patients.
Botulinum toxin
Chemodenervation with Botulinum toxin (Botox, Dysport, and
others) will help with static platysma bands. Muscle atrophy
can ensure and a loss of prominence can improve the anterior
neck appearance.8 Dynamic bands can also be treated with
Botox injections. Softening of these “active” muscle bands can
delay the formation of static platysma lines with repeated
injections. Just as Botox reduces dynamic and static line for-
mation in the forehead and glabella regions, it can be helpful
in the anterior neck as well. However, due to differences in the
affected muscle structures, overlying skin tone, textures, and
subunit attachments, the benefits are usually not as great as
those seen in the forehead area.
Laser resurfacing
Laser resurfacing to the anterior neck can improve the tone
and texture of the skin and to some degree collagen tightening
will also occur. However, these treatments must take into
account the skin difference from the upper facial units: the
amount of sebaceous type tissue and the skin epidermal and
30 Terres

Fig. 8 The lines represent the platysma muscle. On the right is the planned surgical corset and inferior back cuts with a “double-layer”
closure.

dermal depth differences. Unfortunately, the neck has an
inconsistent and dramatically less pilosebaceous unit than the
face, and therefore, is less able to recover from the same
depth of treatment as the face.9 There is an increase in scar-
ring, pigmentation changes, as well as delayed healing. Laser
resurfacing the neck must be done with caution not to create
severe skin damage. The other issue that I have with this
treatment (when done alone) is that it does not usually address
the underlying issue, which most commonly is an abundance of
fatty deposition and muscle laxity.
Other new nonsurgical or “minimal-risk” neck rejuvenation
procedures often promise great results with minimal or no
downtime. Please do not be misguided by these claims,
because the Fountain of Youth does not exist with “no down
time and no pain.” My recommendation to my patients when
asked if I do any of these types of procedures is that the evi-
dence just is not there. I always tell them to request several
before-and-after photographs of “actual” patients with long-
term follow-up photographs (at least a year)dI am waiting to
see them.
Surgical managementdnoninvasive versus
invasive
There are both invasive and noninvasive surgical treatments
used to correct the anterior neck region. This set of procedures
includes combinations of liposculpture/direct lipectomy, re-
moving or altering neck musculature, and the redraping of
excessive skin and removal as necessary.
Liposculpture (liposuction)
Liposculpture (liposuction) is a common procedure performed
very routinely not only on the face but also on multiple areas of
the body. It can be done very safely and effectively if done
properly. In young patients (Baker type I) this is an excellent
treatment modality. The younger patient often still has very
good intrinsic contractility strength in their skin, which will
allow for good elastic recoil after the unwanted fatty deposits
are removed. Liposculpture (liposuction) can be done with

Fig. 9 This patient was treated by another surgeon and underwent a chin implant and an isolated “neck lift.” She presented with a
complaint of minimal improvement and worsening of problem areas. Note how improper suspension of neck structures leads to ear stress
(long arrow). There was no addressing the midline structures. Also, the chin implant stopped short of the mandibular notch and accen-
tuates this area more (shorter arrow). The patient had minimal improvement with her cervicomental angle and thus was not pleased with
her outcome.
Rejuvenation of the Anterior Neck
minimal anesthesia and a relatively uneventful postoperative
course. However, whereas liposuction does have a role in
cosmetic surgery of the submental area, it is not a compre-
hensive procedure and does not address all of the anatomic
components leading to submental fullness.10
Direct lipectomy
Direct lipectomy is performed in younger patients with more
neck fullness caused by excessive fatty deposition, but still
good skin tone (Baker type I and some IIsdthis is difficult to
judge and clinical experience is the only way to determine if
you can achieve adequate results in these types of patients).
Again, anesthesia is the surgeon’s preference. However, these
are commonly done through a slightly larger incision than
general liposculpture, and both lipocannulas and facelift scis-
sors are used for direct fat removal.
Platysmal plication
Once muscle laxity has occurred, whether the patient dem-
onstrates a single- or double-banded structure in the anterior
neck, the platysma needs to be tightened (Baker type IIeIII).
There are too many ways to list on how this is performed, but
the procedure involves a submental crease exposure, fatty
cutaneous plane, and direct visualization of the platysma
muscle. Excessive muscle tissue is removed in the midline, and
2 leading edges are clearly identified. The subplatysma fat can
be removed here as deemed necessary; then the muscle is
closed overlying this area and is done in 1 or 2 layers. Various
back cuts have been described.2,5,7 The complete surgical
details are presented later in this article. At this point the
options for isolated posterior neck tightening or the addition of
a formal facelift are done. The addition of a chin implant can
be considered as well.
Cervicoplastyddirect lipectomy, platysmal plication,
SMAS elevation
The goal of this procedure is to provide an improvement in the
cervicomental angle, smooth and uniform skin contour, and a
decrease in the amount of unwanted fatty tissue deposits. It is
most important not to overdo any particular portion or un-
wanted asymmetries or uneven skin texture may hamper your
overall results.
My surgical techniques are very similar for all my “com-
plete-neck” or cervicoplasty rejuvenation patients. These pa-
tients usually fit the Baker type IIIeIV classification and I still
perform almost the same surgical procedure with the excep-
tion of an additional suture corsets layer in the last group.
A rhytidectomy in conjunction with a neck rejuvenation
procedure is my preferred operation for almost all my pa-
tients. The addition of the SMAS elevation with neck rejuve-
nation allows for a smoother and controlled elevation and
repositioning of the soft tissues, especially aiding in the
lateral neck area. Performing anterior neck surgery alone can
sometimes accentuate jowling and lateral neck fullness as
well as place more of an unwanted visual focus on the pa-
tient’s other aging facial features.7 There are surgeons who
claim that the posterior neck pull after an anterior plication
does not make sense, and the increased in posterior tension
will have an increased likelihood of midline failure but this is
not what I usually see. I think the posterior resuspension
31
needs to be done carefully and not “overly” tightened to give
a good harmonious neck contour. I do not always do a sub-
mentalplasty corset. There are some patients who present
with such severe jowling that requires a large “pull-up” of
SMAS tissue and in these cases if I can just perform anterior
midline resection of excessive laxed muscle tissue and
remove excessive fat, I can maximize their lift and fix the
jowling without being held back by an excessive midline
platysma tightening.
Operative techniques
All of my surgical patients are seen in my accredited ambula-
tory surgery center. I use varying depths of anesthesia, but my
usual routine is done with an laryngeal mask airway and
general anesthetic gas (sevoflurane). Of course, all of the
following procedures can be done with IV sedation, or a gen-
eral anesthetic, and some people will do with PO sedation and
local anestheticdbut this is not my preferred method.
Operative steps: noninvasive and invasive
Noninvasive liposculture
In the preoperative setting, I mark the desired area for lip-
osculpture with the patient in an upright position; using a
mirror, I have the patient directly visualize the anticipated
areas while I mark them. I then outline key anatomic areasd
mandible border, hyoid, muscle structures, and nerve course. I
use 3 small incisions, one submental, and the other 2 just
behind the earlobes. After I complete these markings, I recline
the patient into the anticipated surgical position and reinspect
my markings.
Once in the operating room, a standard sterile drape and
preparation (hibiclens prep is my preferred choice) is
completed. The surgical sites are infiltrated with a small
amount of 1% lidocaine and then the anterior neck is infiltrated
with tumescent solution (my mixture is 0.01% lidocaine with
1 part per million epinephrine) (Fig. 10).
I use 3 small stab incisions when doing liposculpture alone,
but if I plan for a direct lipectomy, the submental incision is
extended to 3 cm in the shadow just posterior to the submental
skin crease.
Starting from the submental incision, bluntly dissect in a
subcutaneous plane, overlying the platsyma with one hand and
hold the neck skin with the other using the cannula in a star-
burst pattern. It is very important to maintain the same plane;
this dissection is relatively easy, so do not overforce it! After
fanning the anterior region of the neck, do the same procedure
from each of the lateral areasdkeeping in mind relative
anatomic structures, nerve courses, and vascular position.
After the dissection is completed, a lipocannula is used to
“sculpt the neck,” with continual sweeping motion with direct
visualization of the cannula underlying the skin. (There are
several types of cannulas for this procedure. I tend to use both
flat spatulas and round cannulas or varying sizes. I also use
cannulas attached to wall suction or with a syringe and Johnny-
lock device [Fig. 11].) You can turn the suction opening “to-
ward” the skin surface, but it is only recommended doing this
in certain areas where the fatty deposits are thicker or more
irregular. The goal is NOT to remove all the fat, just unnec-
essary fat, and provide a smooth plane of dissection above the
platysma muscle to allow an even redraping of skin tissue. I do
occasionally have to do subplatysma fat liposculpture in the
32
Fig. 10 Tumescence solution being infiltrated into subcutaneous tissue. After 12 minutes, tissue blanching in the picture on the right can
be noted.
anterior region as well in more full-neck patients, remem-
bering not to overreduce or you could make the underlying
structures (thyroid cartilage, digastric muscles, hyoid bone)
more apparent.
My surgical approach is exactly the same for direct lipec-
tomy, except following the initial liposculpture, I open the
submental incision to 2.5 to 3 cm and use a lighted retractor to
remove any excessive fatty deposits with direct vision. One
small 6-0 nylon suture is used to close each of the access in-
cisions (more for direct lipectomy) and soft gauze pads are
opened and placed in the anterior neck and an elastic head
wrap is placed. My typical protocol is for the patient to wear
the head wrap for 1 week for 24 hours except when showering
and then an additional week only at night (Box 3).
Invasive cervicoplasty
As discussed earlier, there is great variability between indi-
vidual neck types. The proposed surgical technique is a com-
mon standard procedure that will encompass the rejuvenation
process for most of these types. Certain steps may be omitted
or overly emphasized pending the individual patient.
As previously described, the anterior neck is a harmonious
topographic architecture that needs to be smooth. I like to
think of it as a lump of clay on a potter’s wheel; the clay is spun
and the potter smooths it centrally and brings its up. This
technique is our goal for neck surgical rejuvenation; smooth
out the tissues and “bring them up.” Platysma laxity, sub-
mental lipomatosis, and cervical lipomatosis cannot be ade-
quately addressed solely through a preauricular incision. The
goal of achieving an improved and cosmetically enhanced
Fig. 11 Standard liposuction cannulas, one with a lock-syringe
device and the other for wall suction.
Terres
cervicomental angle is done by the anterior midline platysma
plication, inferior muscle release, and its facial component
that allows for a superior lateral anchor that minimizes tension
of the anterior corset (Fig. 12).11
The initial portion of this is the same as mentioned above
for liposculpture, using the extended 3-cm incision just pos-
terior to the submental crease. The anterior neck is completely
exposed using facelift scissors with both a vertical and a hor-
izontal motion.
The surgical plane established will vary on neck and patient
type but usually extends to below the cricoid (again, inferior
extension varies in each patient), carried out laterally to the
posterior angle of the mandible (Fig. 13). Using lighted re-
tractors, any bulbous fatty deposits are directly removed, and
hemostasis is achieved. This exposure will allow for an
adequate platysmaplasty. Under direct vision the medial
leading edges of the platysma are freed from the underlying
subplatsyma fat and digastric muscles and grasped and brought
to the midline. Excessive muscle and fat are excised and the
leading edges are imbricated together with 1 to 2 layers of
running suture. A release is performed low in the neck to allow
for adequate muscle redrape. This technique will tighten the
platysma and improve the cervicomental angle. I directly
visualize the areas where the submandibular glands are and
pending any herniation or enlarged gland tissue I will either
place a row of support sutures, or if the gland is easily visu-
alized, I will just remove a portion of it. Some authors do
describe an intraoral resuspension,2,5,12 but rarely have I had
to do this.
Although this procedure can be very beneficial in younger
patients, I find that most patients will require lateral neck
Box 3. Quick summary
1. Mark patient
2. Tumescence through 3 small incisionsdwait 15 min
3. Dissect with flat cannula
4. Liposculpt with 4e5 mm flat/round cannula
5. Closure
6. Wrap with head dressing for 1 wk
Rejuvenation of the Anterior Neck 33

Fig. 12 Preoperative markings for combined neck rejuvenation with SMAS lift.

approaches to maximize their expected outcome. I almost al-
ways combine complex neck rejuvenation with a facelift pro-
cedure and by doing so it will allow the surgeon to address the
neck as well as any unwanted jowling or other aging issues. My
preferred adjunctive facelift procedure is an SMAS elevation
whereby a portion of the SMAS flap is elevated superior and
another is transposed posterior to the ear to affect lateral neck
contour (Fig. 14). This portion of the SMAS is secured to the
mastoid fascia with permanent suture. One technical point is
clear: cervical rhytidectomy suspension with a predominantly
superior vector will serve to sharpen the jawline and crisply
define the face-to-neck transition (Fig. 15).11
Chin implant
Patients who are retrognathic and/or retrogenic are good
candidates for chin augmentation. Whether the surgery
relies on an artistic appreciation of facial harmony or a formal

Fig. 13 (A) Surgical access for anterior neck. (B) Exposure opening for direct lipectomy and anterior platysma plication. (C) Surgical
access for SMAS lift component. (D) Connection of face and neck flaps.
34
Fig. 14 Sequential operative technique for anterior neck rejuvenation (direct lipectomy, platysma plication with back cut, and SMAS
elevation). (A) Note extensive cutaneous elevation. (B) SMAS with direct platysma pull. (C) Marking SMAS for partial resection and posterior
plication. (D) SMAS resection.
soft/hard tissue cephalometric analysis is completed, chin
augmentation can have a profound effect on cervicomental
enhancement. Whether a formal horizontal mandibular
osteotomy is carried out or an alloplastic implant is placedd
both can dramatically improve a poor cervicomental angle and
provide an optimal esthetic and functional outcome.14,15
Submandibular gland
The submandibular gland is the one area that that I admit-
tedly overlooked when I first began doing full face and neck
rejuvenation procedures over 10 years ago. Basically, it just
was not an issue in most of my early procedures. Now,
though, this is one of the key areas that I make certain to
address before any procedure is done, from basic lip-
osculpture to full facial rejuvenation. The reason for doing so
is that after a very well-orchestrated surgery, if the gland
becomes a visualized problem, it becomes the only thing the
patient focuses on. That being said, there are a few ways to
ensure that the gland does not become as issue. I routine will
place overlying mattress suspension sutures in the platysma
to create a substructural support if the gland is not overly
large. I also perform a partial gland resection if the superior
head of the gland is excessively prominent or noticeably
herniating through the underlying muscle. Finally, gland
suspension with suspension sutures with a combined intraoral
approach can be done if the gland itself is thought to be
excessively large or not amenable to the other listed
procedures.12
Terres
Fat grafting
Patients who have already had a prior facelift with neck
combination and have a noted middling “trough” appearance
are candidates for fat grafting. Esthetic surgeons have been
performing facial rejuvenation that usually involves excision
and resuspension, but there are many times that restoring
facial volume (lost with aging) with provide similar or better
results.13 In the anterior neck region, the usual patient is
someone that had an overaggressive resection of the supra-/
subplatysma fat, now with lax platysma or a howled out area
with a tethered skin appearance. I perform my routine open
neck from a submental incision and identify and free up the
anterior leading edges of the platysma; if they are connected
in the midline, I separate them and do a direct fat graft into
the subplatsyma area and then perform a double-layered
closure of the muscle. Grafting between the platysma and
cutaneous layer is then a clinical decision. It has been my
experience that the more uniform the grafted fat, the better
the outcome. I routinely overfill by about 15% to 20%.
Pitfallsdareas that are often overlooked
 Low hyoid
 Subplatysma fat content
 The chindchin augmentation can improve cervicomental
angle, soften or decrease to mandible prejowl notch
 Submandibular gland
 Elderly patients almost always require full cervicoplasty
to achieve optimal results
Rejuvenation of the Anterior Neck 35

Fig. 15 All patients (AeC) shown underwent a full anterior neck rejuvenation with SMAS facelift. All result photographs are 1-year
postoperative.
36
Summary
Rejuvenation of the anterior neck region requires a complex
artistic interpretation of the patient’s desires and potential
anticipated outcomes. Whether it is a minimally invasive
liposculpture procedure or a full cervicoplasty with chin
augmentation and full facelift, the outcome will be optimal if
the anticipated areas of complaints are fully addressed. Un-
derstanding the patient’s relative aging process will ultimately
lead to the correct proposed treatment.
References
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4. Vistnes LM, Souther SG. The platysma muscle. Anatomic consid-
erations for aesthetic surgery of the anterior neck. Clin Plast Surg
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Terres
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