My View
Suture Suspension Technique Offers Predictable,
Long-lasting Neck Rejuvenation
T
he underlying mechanisms involved in the aging
neck include increased laxity in the skin, buildup
of subcutaneous fat in the subdermal, submental,
and preplatysmal planes, and a lack of tone and length-
ening of the platysma muscle.1 Due to these factors, loss
of a well-defined cervicomental angle and a decrease in
the definition of the inferior mandibular border can be
observed.
Traditional surgical techniques focus on the redraping of
the skin through preauricular incisions and the tightening
or plicating of the muscle through a myriad of tech-
niques, all which fail to achieve reliable long-term
results.2-4 Key elements for long-term success with the
suspension technique include proper patient selection and
appropriate attention to the technical details of the pro-
cedure.
Patient Selection
The suture suspension technique is an excellent option
for the patient who would like to avoid a face lift inci-
sion and whose primary signs of aging have occurred in
the neck and mandibular area. It is also an excellent
choice for a patient who has undergone a previous
rhytidectomy with an unsatisfactory result at the level of
the cervicomental angle and mandibular border.
When I examine a patient with neck laxity, the first step
is to check the depth of the natural cervicomental angle.
The suture suspension technique
is an excellent option for the
patient who would like to avoid
a face lift incision and whose
primary signs of aging have
occurred in the neck and
mandibular area.
AESTHETIC
This can be easily accom-
plished with a cotton appli-
cator and gentle pressure.
The deeper the cervicomen-
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tal angle, the better suited
the candidate for this proce-
dure. A deep cervicomental
angle will take up the exces-
sive skin and muscle laxity Vincent C. Giampapa, MD,
and allow for a new neck Montclair, NJ, is a board-
contour with no postopera- certified plastic surgeon.
tive redundancy of either of
these key structures.
A wide and prominent mandibular border is important
when the applied suspension suture is tightened and the
platysma muscle is subsequently tucked beneath the bor-
der of the mandible. With a narrow jaw, the amount of
mandibular definition is less optimal and less observable.
The degree of skin laxity is also important in designing
details of the technique for a specific patient.
Technique
With the patient in the supine position, intravenous seda-
tion and local anesthesia are administered. A submental
incision is made, and the neck area is suctioned with a 3-
mm liposuction spatula cannula to remove a fine layer of
subcutaneous fat, mainly just below the dermis. It is
important to note that oversuctioning of the dermal flaps
will create a skeletonized or overmasculinized look to the
neck and should be avoided.
On completion of the liposuction through the submental
incision, bilateral subcutaneous tunnels are made along
the border of the mandible with a face lift scissors. The
tunnel is suctioned again with a small 3-mm spatula can-
nula, while the fat on the superficial surface of the platys-
ma muscle is removed. This can be observed directly with
fiberoptic illumination. In addition, the area immediately
above the tunnel on the dermal side of the skin flap is suc-
tioned to help enhance skin retraction to the underlying
platysma muscle and create a well-defined submandibular
border. The muscle is then tucked under the border of the
mandible with 4-0 Prolene suspension sutures (ETHICON,
SURGERY JOURNAL ~ MAY/JUNE 2000 253
 My View
A B
Figure 1. Class I deformity. A, Preoperative view of a 52-year-old
patient with no midface laxity, mild platysmal laxity, and mild submen-
tal fat. This type of patient is the absolute ideal candidate for the suture
suspension technique and invariably demonstrates an excellent early
postoperative result. B, Postoperative view 1 year after the suture sus-
pension technique.
Inc., Somerville, NJ). An important step is choosing the
depth of the desired cervicomental angle; this can be
determined by placing the sutures at the exact height of
the superior border of the hyoid. If the hyoid is in an
extremely low position—as is found in the obtuse neck
deformity—the new cervicomental angle depth can be
gauged by placing the suspension sutures approximately 1
to 2 cm below the inferior border of the angle of the
mandible.
At this time, the head of the patient is turned to the right
and a postauricular skin ellipse is removed from behind
the ear. The size of the ellipse is directly determined by the
amount of lax skin present in the lateral aspect of the
neck, especially around the cervicomental angle. The skin
in this area is then undermined, and the postauricular
incision is connected to the submandibular tunnel, as pre-
viously described. The suspension suture is grasped with a
long, curved clamp and extracted through the tunnel. As
the suture is pulled—under direct observation—the platys-
ma muscle can be seen to retract immediately below the
border of the mandible, creating the submandibular defin-
ition required to enhance the mandibular contour. At the
same time, the cervicomental angle is elevated into its new
position. The suspension sutures are then tightened and
sewn to the mastoid fascia in a horizontal mattress fash-
ion. It is often necessary to use a 5-0 chromic suture or
some other form of absorbable suture to gather local tis-
sues and cover the knot that is being used to tighten the
suspension sutures to the mastoid fascia behind the neck.
Completion of this maneuver on both sides of the neck
results in the creation of a new cervicomental angle and a
new mandibular border. The subcutaneous tunnels and the
254 AESTHETIC SURGERY JOURNAL ~ MAY/JUNE 2000
A B
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Figure 2. Class II deformity. A, Preoperative view of a 48-year-old
patient with mild midface laxity, mild jowling, moderate platysmal laxi-
ty, and moderate submental fat. B, Postoperative view 1 year after the
suture suspension technique. This type of patient exhibits excellent early
and long-term results and responds extremely well, with excellent skin
contraction and improvement in neck contours and jowling.
area dissected in the anterior portion of the platysma mus-
cle are irrigated with saline solution and epinephrine to
help with hemostasis. In some cases, immediately before
placement of the suspension sutures, the anterior portion
of the platysma muscle is resected in the shape of 2 small
triangles on the left and right sides. The anterior borders of
the platysma muscle are then bilaterally closed with invert-
ed sutures of 4-0 Prolene to reapproximate the muscle
position and muscle tension. The postauricular incisions
are initially closed with a single suture, which is placed
through the skin and conchal cartilage while the ellipse of
skin is advanced superiorly and inferiorly. This maneuver
allows for an improvement in the skin laxity at the
mandibular angle. The initial suture helps to tack the skin
in its appropriate position and acts as an additional sup-
port during the healing process. The postauricular incision
is then closed bilaterally with a continuous running suture
of 4-0 Prolene; the submental incision is closed in 2 layers
with 5-0 chromic sutures in the dermal planes and 6-0
Prolene running sutures for the final skin closure.
More recently, I have been using a surgical stapler to
close the undermined skin in the submental area and
below the mandibular border to the underlying platysma
muscle. This has alleviated most of the postoperative
wrinkling that occurs in some of my patients. Immediately
over the stapled skin and in the suctioned anterior neck
skin, silk tape or paper tape may be applied to help stent
the soft tissues. Reston foam (3M Healthcare, St. Paul,
MN) is then applied to the submental area for compres-
sion, and tension is applied with an Ace bandage or other
appropriate compressive garment to hold the dressing in
place for the next 7 days.
Volume 20, Number 3
 My View
A B
Figure 3. Class III deformity. A, Preoperative view of a 42-year-old
patient with moderate midface laxity, prominent jowling, moderate
platysmal laxity, and moderate submental fat. B, Postoperative view 1
year after the suture suspension technique. This type of patient exhibits
good results and, in general, responds well, with good skin contracture
to the anterior cervical lateral neck as well. Correction of jowling is usu-
ally incomplete with this technique alone, and other ancillary techniques
may be required.
In most patients, a small butterfly drain is placed through
the postauricular incisions in the area immediately adja-
cent to the mandibular angle where seromatous, bloody
fluid is most likely to accumulate.
Common Mistakes
One of the most common mistakes made by surgeons
using this technique is removing the dressing too early in
the postoperative period. The dressing should stay on for
a full 7 days, not counting the day of surgery. Other
errors include overtightening the suspension sutures,
which creates a feeling of tightness or choking in the
patient, and placing the suspension sutures down too low
on the mastoid rather than within the mastoid fascia
immediately below or within the posterior auricular fold.
Finally, excessive undermining of the skin at the anterior
cervical neck angle can frequently create rippling in the
postoperative period.
Conclusion
Choosing the right patient for this procedure can be
greatly aided by using a classification system for the
degree of neck deformity (Figures 1-4). Using the suture
suspension techniques for class I and class II patients will
assure an excellent result in most cases and alleviate the
need for preauricular incisions, especially in male
Suture Suspension Technique Offers Predictable,
Long-lasting Neck Rejuvenation
A B
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Figure 4. Class IV deformity. A, Preoperative view of a 50-year-old
patient with excessive midface laxity, prominent jowling, extensive labi-
al-mandibular deformities, moderately severe platysmal laxity, severe
submental fat, and subcutaneous laxity in the lower portion of the neck.
B, Postoperative view 1 year after the suture suspension technique.
Treatment of this type of patient should include a rhytidectomy with
complete undermining of the cervicomental area along with the anterior
midface skin. Suture suspension can be used for the platysmaplasty por-
tion of the rhytidectomy.
patients5 who would have problems with beard migration
into the anterior ear and postauricular areas.6 Careful
selection of class III patients will also lead to favorable
results in most cases, provided that the submental area
has a deep cervicomental angle and does not have an
excessive amount of skin laxity. This minimally invasive
technique has evolved over the last 9 years into a reliable
method of producing a clean and predictable neck angle
with shorter recovery time, virtually unnoticeable inci-
sions, and excellent long-term results. ■
References
1. Giampapa VC, DiBernardo BE, Park CE. Anti-aging surgery: A step
beyond cosmetic surgery. In: Klatz RM, ed. Advances in Anti-aging
Medicine. Volume I. Larchmont, NY: Mary Ann Liebert, Inc., Publishers;
1996:57-60.
2. Connell BF. Contouring the neck in the rhytidectomy by lipectomy and a
muscle sling. Plast Reconstr Surg 1978;61:376-383.
3. Connell BF, Gaan A. Surgical correction of aesthetic contour problems
of the neck. Clin Plast Surg 1983;10:491-505.
4. Feldman JJ. Corset platysmalplasty. Plast Reconstr Surg 1990;85:333.
5. Smith JW, Nelson R, Weaver K. Rhytidectomy in male patients.
Aesthetic Plast Surg 1983;7:41-45.
6. Giampapa VC, DiBernardo BE. Neck recontouring with suture suspen-
sion and liposuction: an alternative for the early rhytidectomy candidate.
Aesthetic Plast Surg 1995;19:217-223.
Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO
63146-3318; phone (314) 453-4350; reprint no. 70/1/107269
doi:10.1067/maj.2000.107269
AESTHETIC SURGERY JOURNAL ~ MAY/JUNE 2000 255