Neck Rejuvenation

Surgical and Nonsurgical Techniques

Samuel J. Lin, MD, MBA, FACS

Program Director, BIDMC/HMS Plastic Surgery Residency Training Programs
Co-Director, Harvard Aesthetic and Reconstructive Fellowship at BIDMC
Associate Professor of Surgery, Divisions of Plastic Surgery and Otolaryngology
Beth Israel Deaconess Medical Center, Harvard Medical School
Boston, Massachusetts, USA

Sumner A. Slavin, MD
Plastic Surgeon, Chestnut Hill Plastic Aesthetic Surgery Associates, Chestnut Hill
Co-Director, Harvard Aesthetic and Reconstructive Fellowship at BIDMC
Associate Clinical Professor of Surgery
Beth Israel Deaconess Medical Center, Harvard Medical School
Boston, Massachusetts, USA

Associate Editor

Vickram J. Tandon, MD
Plastic Surgeon
Boston Center for Plastic Surgery
Boston, Massachusetts, USA

289 Illustrations

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Comments

To my past, current, and future patients who have entrusted me to take care of them to the best
of my abilities. To my family for their constant support of my career and endeavors.
Samuel J. Lin

Although mindful of so many whose positive influences have shaped my education and indeed
my entire life, one stands out –Dr. Robert M. Goldwyn. I met him as a surgical intern. Over time,
he would become my mentor, my colleague, my best friend, and always a father figure. To this
moment, he exemplifies for me everything that is right in what we do as plastic surgeons.
Sumner A. Slavin

I dedicate this book to my mentors and my wonderful family.

To my mentors, the giants of plastic surgery, who continue to inspire me.
To my parents, Darci and Vania, who supported me to move to another country to advance my career.
To my husband, Ilton, who always believed in my dreams even when they seemed impossible.
To my children, Lucas and Bella, who fulfill my life with joy, purpose, and love.
Munique Maia
Contents

Videos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

1. Neck Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Jeremie O. Piña and Sumner A. Slavin

1.1 Cervical Triangles . . . . . . . . . . . . . . 1 1.5.2 Lesser Occipital Nerve . . . . . . . . . . . 5

1.5.3 Spinal Accessory Nerve. . . . . . . . . . . 6
1.2 Fasciae of the Neck . . . . . . . . . . . . . 1
1.6 Retaining Ligaments of the Face
1.2.1 Superficial . . . . . . . . . . . . . . . . . . . . . 1 and Neck . . . . . . . . . . . . . . . . . . . . . . 6
1.2.2 Deep . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2.3 Infrahyoid Muscle Fascia . . . . . . . . . 2 1.7 Subplatysmal Fat. . . . . . . . . . . . . . . 7
1.2.4 Visceral Fascia . . . . . . . . . . . . . . . . . . 2
1.2.5 Prevertebral Fascia . . . . . . . . . . . . . . 2 1.8 Anterior Digastric and
1.2.6 Carotid Sheath . . . . . . . . . . . . . . . . . . 2 Mylohyoid Muscles . . . . . . . . . . . . . 7

1.3 Platysma and Lower Lip . . . . . . . . 3 1.9 The Facial Nerve and
Lower Lip . . . . . . . . . . . . . . . . . . . . . . 8
1.4 Critical Structures Surrounding
Neck Muscles . . . . . . . . . . . . . . . . . . 4 1.9.1 Mandibular and Cervical Nerve
Branches . . . . . . . . . . . . . . . . . . . . . . . 8
1.4.1 External Jugular Vein . . . . . . . . . . . . 4
1.4.2 Other Superficial Veins . . . . . . . . . . . 4 1.10 Conclusion . . . . . . . . . . . . . . . . . . . . 9

1.5 Sensory Distribution in the Neck 4 References . . . . . . . . . . . . . . . . . . . . 9

1.5.1 Great Auricular Nerve. . . . . . . . . . . . 4

2. Neck Rejuvenation: Evaluation and Management ...................... 11

Jose Foppiani and Samuel J. Lin

2.1 Introduction . . . . . . . . . . . . . . . . . . . 11 2.2.1 Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.2.2 Adiposity . . . . . . . . . . . . . . . . . . . . . . 13
2.1.1 Demographic of Neck Lift/ 2.2.3 Platysma . . . . . . . . . . . . . . . . . . . . . . . 13
Rejuvenation Procedures . . . . . . . . . 11 2.2.4 Digastric Muscle . . . . . . . . . . . . . . . . 13
2.1.2 Criterion for a Youthful 2.2.5 Submandibular Gland. . . . . . . . . . . . 13
Aesthetically Pleasing Neck . . . . . . . 11 2.2.6 Chin . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1.3 Criteria for an Aging Neck . . . . . . . . 12
2.3 Neck Rejuvenation
2.2 Neck Evaluation . . . . . . . . . . . . . . . . 12 Procedures . . . . . . . . . . . . . . . . . . . . 13

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2.3.1 Nonsurgical Procedures . . . . . . . . . . 14 2.5 Expert Commentary by

2.3.2 Surgical Procedures . . . . . . . . . . . . . 16 Dr. Slavin. . . . . . . . . . . . . . . . . . . . . . 21

2.4 Conclusion . . . . . . . . . . . . . . . . . . . . 21 References . . . . . . . . . . . . . . . . . . . . 21

3. Management of the Aging Neck ......................................... 23

Munique Maia and Alan Matarasso

3.1 Introduction. . . . . . . . . . . . . . . . . . . 23 3.9 Case Examples. . . . . . . . . . . . . . . . . 27

3.2 Patient Analysis . . . . . . . . . . . . . . . 23 3.9.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . 27

3.9.2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.3 Patient Selection and 3.9.3 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . 27
Preoperative Planning . . . . . . . . . 24 3.9.4 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.9.5 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.4 Operative Procedure . . . . . . . . . . . 24
3.10 Expert Commentary by
3.4.1 Surgical Technique . . . . . . . . . . . . . . 24 Dr. Slavin. . . . . . . . . . . . . . . . . . . . . . 27

3.5 Postoperative Care . . . . . . . . . . . . 25 3.11 Expert Commentary by

Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . 27
3.6 Complications . . . . . . . . . . . . . . . . . 26
References . . . . . . . . . . . . . . . . . . . . 32
3.7 Ancillary Procedures and
Nonsurgical Treatments . . . . . . . . 26

3.8 Conclusion . . . . . . . . . . . . . . . . . . . . 27

4. The Use of Platysma Window for Neck Contouring . . . . . . . . . . . . . . . . . . . . 35

Rod J. Rohrich, Justin Bellamy, and Nelson A. Rodriguez-Unda

4.1 Patient Considerations, 4.5 Case Example . . . . . . . . . . . . . . . . . 39

Indications, and
Contraindications . . . . . . . . . . . . . . 35 4.5.1 Goals. . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.5.2 Approach . . . . . . . . . . . . . . . . . . . . . . 39
4.1.1 Who Is a Candidate?. . . . . . . . . . . . . 35
4.1.2 Platysmal Bands . . . . . . . . . . . . . . . . 35 4.6 Expert Commentary by
4.1.3 The Central Neck. . . . . . . . . . . . . . . . 35 Dr. Slavin. . . . . . . . . . . . . . . . . . . . . . 39
4.1.4 Contraindications . . . . . . . . . . . . . . . 36
4.7 Expert Commentary by
4.2 What Technique to Use and Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . 39
Why? . . . . . . . . . . . . . . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . 41
4.3 Technique: A Stepwise Summary 36

4.4 How to Avoid Bad Results/

Common Pitfalls . . . . . . . . . . . . . . . 37

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5. Triple Suture for Neck Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Enzo R. Citarella, Ramil Sinder, Alexandra Condé-Green, Samir Janne Hasbun, and
Esther Barrios

5.1 Introduction . . . . . . . . . . . . . . . . . . . 43 5.4.1 Case 1 ......................... 49

5.4.2 Case 2 ......................... 51
5.2 Indications . . . . . . . . . . . . . . . . . . . . 43 5.4.3 Case 3 ......................... 51
5.4.4 Case 4 ......................... 52
5.3 Technique . . . . . . . . . . . . . . . . . . . . . 43
5.5 Expert Commentary by
5.3.1 Position . . . . . . . . . . . . . . . . . . . . . . . . 44 Dr. Slavin . . . . . . . . . . . . . . . . . . . . . . 52
5.3.2 Infiltration . . . . . . . . . . . . . . . . . . . . . 44
5.3.3 Marking . . . . . . . . . . . . . . . . . . . . . . . 44 5.6 Expert Commentary by
5.3.4 Liposuction. . . . . . . . . . . . . . . . . . . . . 44 Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.3.5 Triple-Suture Technique. . . . . . . . . . 46
5.3.6 Treatment of the Lateral Cervical References . . . . . . . . . . . . . . . . . . . . 54
Region (V5). . . . . . . . . . . . . . . . . . . . . 48

5.4 Case Examples . . . . . . . . . . . . . . . . . 49

6. Surgical Approach to Neck Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Ritwik Grover, Andrew L. Kochuba, Rafael A. Couto, Jacob N. Grow, and James E. Zins

6.1 Surgical Anatomy of the Lower 6.5.1 Classification System . . . . . . . . . . . . 61

Face and Neck . . . . . . . . . . . . . . . . . 55
6.6 Operative Technique . . . . . . . . . . . 65
6.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . 56
6.7 Postoperative Care . . . . . . . . . . . . . 67
6.3 Retaining Ligaments . . . . . . . . . . . 56
6.8 Complications . . . . . . . . . . . . . . . . . 67
6.4 Neck Anatomy . . . . . . . . . . . . . . . . . 57
6.9 Commentary by Dr. Zins . . . . . . . . 68
6.4.1 Fat Compartments. . . . . . . . . . . . . . . 57
6.4.2 Platysma Muscle . . . . . . . . . . . . . . . . 58 6.10 Expert Commentary by
6.4.3 Retaining Ligaments and Filaments 58 Dr. Slavin . . . . . . . . . . . . . . . . . . . . . . 68
6.4.4 Digastric Muscles. . . . . . . . . . . . . . . . 58
6.4.5 Submandibular Glands . . . . . . . . . . . 58 6.11 Expert Commentary by
6.4.6 Great Auricular Nerve. . . . . . . . . . . . 59 Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . . 68

6.5 Clinical Assessment, Patient References . . . . . . . . . . . . . . . . . . . . 69

Selection, and Evaluation of the
Neck Lift Patient . . . . . . . . . . . . . . . 59

7. Deep Plane Neck Lift Concepts and Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Benjamin Talei, Hedyeh Ziai, and Daniel J. Gould

7.1 Patient Considerations, 7.1.1 Patient Considerations . . . . . . . . . . . 71

Indications, and 7.1.2 Indications . . . . . . . . . . . . . . . . . . . . . 72
Contraindications . . . . . . . . . . . . . . 71 7.1.3 Contraindications . . . . . . . . . . . . . . . 72

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7.2 What Technique to Use and 7.5.2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . 82

Why? . . . . . . . . . . . . . . . . . . . . . . . . . 72 7.5.3 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . 82
7.5.4 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . 85
7.3 Technique . . . . . . . . . . . . . . . . . . . . . 73 7.5.5 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . 85

7.3.1 Deep Plane Face and Neck Lift . . . . 73 7.6 Expert Commentary by
7.3.2 Internal Neck Lift . . . . . . . . . . . . . . . 81 Dr. Slavin. . . . . . . . . . . . . . . . . . . . . . 85

7.4 How to Avoid Bad Results/ 7.7 Expert Commentary by

Common Pitfalls . . . . . . . . . . . . . . . 81 Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . 88

7.5 Case Examples. . . . . . . . . . . . . . . . . 82 References . . . . . . . . . . . . . . . . . . . . 88

7.5.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . 82

8. Lateral Skin-Platysma Displacement Technique . . . . . . . . . . . . . . . . . . . . . . . . 89

Mario Pelle-Ceravolo and Matteo A. Angelini

8.1 Patient Consideration, 8.7 Other Options to Avoid

Indications, and Inadequate Results in Difficult
Contraindications . . . . . . . . . . . . . . 89 Necks: Cyanoacrylate Glue and
Platysmectomy . . . . . . . . . . . . . . . . 97
8.2 What Technique to Use
and Why? . . . . . . . . . . . . . . . . . . . . . 89 8.8 Lateral Skin-Platysma
Displacement Limitations . . . . . . 99
8.3 The Rationale of Lateral
Skin-Platysma Displacement . . . 90 8.9 Discussion . . . . . . . . . . . . . . . . . . . . 99

8.4 Technique . . . . . . . . . . . . . . . . . . . . . 90 8.10 Conclusions . . . . . . . . . . . . . . . . . . . 102

8.5 Vectors of Traction . . . . . . . . . . . . 91 8.11 Expert Commentary by

Dr. Slavin. . . . . . . . . . . . . . . . . . . . . . 102
8.6 Lateral Skin-Platysma
Displacement Variations . . . . . . . 94 8.12 Expert Commentary by
Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . 102
8.6.1 Submandibular Gland Resection . . . 96
References . . . . . . . . . . . . . . . . . . . . 103

9. Surgical Techniques for Treatment of the Aging Neck . . . . . . . . . . . . . . . . . 105

Munique Maia and Marcelo Cunha Araujo

9.1 Introduction. . . . . . . . . . . . . . . . . . . 105 9.4.1 Skin. . . . . . . . . . . . . . . . . . . . . . . . . . . 107

9.4.2 Fat Layer . . . . . . . . . . . . . . . . . . . . . . . 107
9.2 Facial Analysis and Applied 9.4.3 Platysma Muscle and Subplatysmal
Anatomy . . . . . . . . . . . . . . . . . . . . . . 105 Structures . . . . . . . . . . . . . . . . . . . . . 107
9.4.4 Submandibular Glands . . . . . . . . . . 112
9.3 Patient Evaluation and Surgical
Goals . . . . . . . . . . . . . . . . . . . . . . . . . 107 9.5 Expert Commentary by
Dr. Slavin. . . . . . . . . . . . . . . . . . . . . . 113
9.4 Surgical Techniques . . . . . . . . . . . . 107

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9.6 Expert Commentary by References . . . . . . . . . . . . . . . . . . . . 114

Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . . 113

10. Neck Lift after Massive Weight Loss ..................................... 115

Dennis J. Hurwitz

10.1 Patient Considerations, 10.2.2 Submental Z-Plasty with

Indications, and Parallel Oblique Elliptical Excisions
Contraindications . . . . . . . . . . . . . . 115 of Skin . . . . . . . . . . . . . . . . . . . . . . . . . 120

10.1.1 Considerations . . . . . . . . . . . . . . . . . . 115 10.3 Role of Facelift for Neck Excess . . . 122
10.1.2 Indications . . . . . . . . . . . . . . . . . . . . . 115
10.4 Expert Commentary by
10.2 Isolated Neck Lift: What Dr. Slavin . . . . . . . . . . . . . . . . . . . . . . 124
Techniques to Use and Why? . . . 116
10.5 Expert Commentary by
10.2.1 FaceTite, AccuTite, and Morpheus8 Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . . 124
to the Face and Neck . . . . . . . . . . . . . 116
References . . . . . . . . . . . . . . . . . . . . 126

11. The Use of Radiofrequency for Facial Rejuvenation . . . . . . . . . . . . . . . . . . . . . 127

Erez Dayan and Christopher T. Chia

11.1 Patient Considerations . . . . . . . . . 127 11.5.2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . 129

11.2 Technique . . . . . . . . . . . . . . . . . . . . . 127 11.6 Conclusion . . . . . . . . . . . . . . . . . . . . 129

11.3 Postoperative Care . . . . . . . . . . . . . 128 11.7 Expert Commentary by

Dr. Slavin . . . . . . . . . . . . . . . . . . . . . . 131
11.4 Common Pitfalls . . . . . . . . . . . . . . . 128
11.8 Expert Commentary by
11.5 Case Examples . . . . . . . . . . . . . . . . . 128 Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . . 131

11.5.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . 128 References . . . . . . . . . . . . . . . . . . . . 131

12. Neck Lift and Fat Grafting to the Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Aris Sterodimas

12.1 Introduction . . . . . . . . . . . . . . . . . . . 133 12.4.2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . 137

12.4.3 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . 137
12.2 Patients and Methods . . . . . . . . . . 134 12.4.4 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . 137

12.3 Surgical Technique and Fat 12.5 Discussion . . . . . . . . . . . . . . . . . . . . . 137

Processing and Grafting . . . . . . . . 134
12.6 Conclusion . . . . . . . . . . . . . . . . . . . . 142
12.4 Problem-Based
Examples/Cases . . . . . . . . . . . . . . . . 137 12.7 Expert Commentary by
Dr. Slavin . . . . . . . . . . . . . . . . . . . . . . 142
12.4.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . 137

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12.8 Expert Commentary by References . . . . . . . . . . . . . . . . . . . . 143

Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . 142

13. Neck Rejuvenation: Noninvasive Techniques ........................... 145

Mathew N. Nicholas, Sara R. Hogan, Michael S. Kaminer, and Jeffrey S. Dover

13.1 Introduction. . . . . . . . . . . . . . . . . . . 145 13.4.3 Platysmal Banding . . . . . . . . . . . . . . 149

13.4.4 Skin Laxity . . . . . . . . . . . . . . . . . . . . . 149
13.2 The Aging Neck . . . . . . . . . . . . . . . . 145 13.4.5 Submental Fat and Fullness. . . . . . . 154

13.3 Patient Considerations, 13.5 Conclusions . . . . . . . . . . . . . . . . . . . 161

Indications, and
Contraindications . . . . . . . . . . . . . . 146 13.6 Expert Commentary by
Dr. Slavin. . . . . . . . . . . . . . . . . . . . . . 162
13.4 Which Technique to Use and
Why? . . . . . . . . . . . . . . . . . . . . . . . . . 146 13.7 Expert Commentary by
Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . 162
13.4.1 Dyschromia . . . . . . . . . . . . . . . . . . . . 146
13.4.2 Horizontal or Transverse References . . . . . . . . . . . . . . . . . . . . 162
Necklines . . . . . . . . . . . . . . . . . . . . . . 147

14. Revisional and Secondary Neck Lifts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Ashley N. Boustany, Vickram J. Tandon, and Sumner A. Slavin

14.1 Revisional versus Secondary 14.3.1 Poor Scar Placement. . . . . . . . . . . . . 171

Rhytidectomy . . . . . . . . . . . . . . . . . 167 14.3.2 Scarred Tissue Planes . . . . . . . . . . . . 173
14.3.3 Platysmal Bands . . . . . . . . . . . . . . . . 173
14.1.1 Revisional Neck Lifts. . . . . . . . . . . . . 167 14.3.4 Midline Ridge Deformity . . . . . . . . . 173
14.1.2 Secondary Neck Lifts . . . . . . . . . . . . 168 14.3.5 Submental Hollowing . . . . . . . . . . . 174
14.3.6 Vertical Band Deformity . . . . . . . . . 174
14.2 Patient Considerations . . . . . . . . . 169 14.3.7 Subauricular Band Deformity . . . . . 174
14.3.8 Ear Deformity . . . . . . . . . . . . . . . . . . 174
14.2.1 Identification of Deformity . . . . . . . 170
14.2.2 Factors Influencing Longevity and 14.4 Expert Commentary by
Outcomes . . . . . . . . . . . . . . . . . . . . . . 170 Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . 174

14.3 Problem-Based Technical References . . . . . . . . . . . . . . . . . . . . 175

Considerations . . . . . . . . . . . . . . . . 171

15. Neck Rejuvenation: Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Trina G. Ebersole, Amer H. Nassar, and Sumner A. Slavin

15.1 Hematoma . . . . . . . . . . . . . . . . . . . . 177 15.4 Nerve Injury . . . . . . . . . . . . . . . . . . . 178

15.2 Skin Necrosis . . . . . . . . . . . . . . . . . . 178 15.5 Recurrent Platysmal Bands . . . . . 178

15.3 Infection . . . . . . . . . . . . . . . . . . . . . . 178 15.6 Dystonia . . . . . . . . . . . . . . . . . . . . . . 178

xii
 Contents

15.7 Scars . . . . . . . . . . . . . . . . . . . . . . . . . . 178 15.9 Expert Commentary by

Dr. Slavin . . . . . . . . . . . . . . . . . . . . . . 179
15.8 Case Example . . . . . . . . . . . . . . . . . . 178
15.10 Expert Commentary by
15.8.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . 178 Dr. Lin . . . . . . . . . . . . . . . . . . . . . . . . . 180

References . . . . . . . . . . . . . . . . . . . . 180

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

xiii
 Videos
Video 3.1: Neck Lift
Video by Munique Maia, Alan Matarasso

Video 4.1: Step-by-Step Sequence to the Lateral Platysmal Window

Video by Rod J. Rohrich

Video 5.1: Triple Suture for Neck Contouring

Video by Enzo R. Citarella, Ramil Sinder, Alexandra Condé-Green, Esther Barrios, Samir Janne Hasbun

Video 6.1: Anterior Approach to the Neck

Video by James E. Zins, Andrew L. Kochuba

Video 7.1: Deep Plane Neck Lift

Video by Benjamin Talei, Daniel J. Gould

Video 8.1: Lateral Skin–Platysma Displacement (LSD): A New and Proven Technique for Neck Rejuvenation
Video by Mario Pelle-Ceravolo, Matteo A. Angelini

Video 9.1: The Aging Neck: Subplatysmal Techniques

Video by Marcelo Cunha Araujo

Video 10.1: AccuTite of the Neck, Face, and Forehead

Video by Dennis J. Hurwitz

Video 11.1: Marking for Bipolar Radiofrequency of Lower Face and Neck
Video by Erez Dayan

Video 11.2: Fractional Radiofrequency Using Morpheus8 (InMode; Lake Forest, CA)
Video by Erez Dayan

Video 12.1: Performing Neck Liposuction Using the Syringe Method

Video by Aris Sterodimas

Video 12.2: The Adipose Tissue Aspirated by Liposuction Is Processed

Video by Aris Sterodimas

Video 12.3: Lipografting of the Malar Area Assisted by Stromal Enriched Lipograft
Video by Aris Sterodimas

xiv
Foreword
“As to methods, there may be a million and then some,
but principles are few. The surgeon who grasps princi-
ples can successfully select his own methods.”
Harington Emerson
Throughout history and across cultures, a long and
graceful neck has been synonymous with beauty. The
mind recognizes this lovely feature of human beauty
within seconds of visually taking it in. So, it natu-
rally follows that beautiful rejuvenation of the neck
remains at the top of every plastic surgeon’s desired
outcome for every patient who seeks help in this
regard—and when it is not accomplished, a sense of
failure ensues. From early attempts at skin excision
to modern techniques aimed at restoring tissue
quality and tone, achieving perfect neck rejuvena-
tion continues to be the “Holy Grail” of facial rejuve-
nation. Neck Rejuvenation: Surgical and Nonsurgical
Techniques by Samuel J. Lin, MD, and Sumner A.
Slavin, MD is a timely contribution that emphasizes
the importance of principles and consolidates expert
approaches to neck lifting and neck rejuvenation in
one outstanding volume. This comprehensive book
brings us a step closer to unraveling the mysteries
surrounding the pursuit of the Holy Grail of neck
rejuvenation. I have learned so much from Dr. Slavin
over the decades since we were young colleagues
together, and he and Dr. Lin are the perfect editors
for this important and latest contribution to our aes-
thetic surgery library.
The book’s well-organized content makes it an
excellent resource for seasoned plastic surgeons
seeking ideas and technical assistance. It is equally
valuable for early career surgeons aiming to broad-
en their knowledge of neck rejuvenation in general.
Unsurprisingly, the foundation of every surgical or
nonsurgical approach lies in understanding neck
anatomy. Our comprehension of this anatomy con-
tinues to evolve, bearing implications for patient
safety and the avoidance of complications. Operat-
ing in the subplatysmal plane carries the risk of
injuring facial nerve branches, while inadequate
knowledge of feeding vessel locations can lead to
problematic bleeding. Fear and lack of knowledge
regarding the anatomy often keep plastic surgeons
within their comfort zones, reluctant to explore the
depths of the neck. This book will improve the level
of comfort.
The editors take us on a journey through history,
covering essential general principles followed by a
range of individualized approaches, all written by
renowned experts. These approaches can be tailored
to suit the specific aging patterns of individual
patients. Like every facet of plastic surgery, accurate
diagnosis is key, and these well-written chapters
help shorten the learning curve for both novice sur-
geons entering the field of facial rejuvenation and
experienced surgeons seeking to improve their re-
sults. This resource will spare them the disappoint-
ment of subpar outcomes when employing a new
technique for the first time. Whether rejuvenating
the neck solely through lateral or submental ap-
proaches or combining multiple techniques, accurate
diagnosis is crucial. Surgeons must know when to
employ a specific method or opt for a more aggres-
sive intervention to prevent recurrence of aging
changes and the need for secondary surgery. The
book also covers the challenges posed by the popula-
tion of individuals who have undergone significant
weight loss, as well as the treatment of complications
and secondary neck surgery.
Throughout my four decades of grappling with
neck surgery challenges, I have frequently experi-
enced less-than-satisfactory results often arising
from the misconception that a thin platysma muscle
can provide long-term support for heavy neck struc-
tures. Consequently, I have had to revise many of
those patients, achieving uniformly more successful
outcomes by addressing the heavy structures in the
subplatysmal plane more aggressively. By studying
the approaches described in these chapters, sur-
geons can identify patients who resemble those they
encounter and determine the most predictably
effective strategies. Failure to address the neck ad-
equately can lead to disappointment with the entire
facelift procedure!
Recent advancements in nonsurgical approaches
have brought these alternatives into the main-
stream, particularly for younger patients or those
who reject the idea of surgery. We are presented
with an array of options, including fat grafting, ra-
diofrequency, and ultrasound energy tightening of
the neck. Undoubtedly, these technologies will con-
tinue to improve over time. Even now, they repre-
sent reasonable alternatives for refining minor skin
irregularities or addressing loose submental skin
xv
 Foreword
while also providing an option for maintaining good
surgical facelift results over time.
This book is not merely a decorative addition to an
office bookshelf; it is a practical resource that will be
picked up, perused, and studied repeatedly. It stands
xvi
as the most up-to-date reference on neck rejuvenation
available. Its comprehensive nature ensures that it cov-
ers all aspects of the topic without overwhelming the
reader. So, dive into its pages and relish the wealth of
knowledge it offers, just as I have.
James C. Grotting, MD, FACS
Past Chair, The American Board of Plastic Surgery
Former President, The American Society for
Aesthetic Plastic Surgery
Former Chairman, Board of Trustees,
American Society of Plastic Surgeons
Grotting Plastic Surgery
Preface
It is our sincere pleasure to introduce you to this
book, entitled Neck Rejuvenation: Surgical and
Nonsurgical Techniques, which has been the prod-
uct of many colleagues’ efforts and many decades’
worth of patient care experience. Our friend and
colleague Dr. Joel Feldman taught us many innova-
tive techniques in his preeminent work, Necklift,
which inspired us to put together a version that
included additional techniques along with nonsur-
gical techniques that have flourished recently.
The challenge is to produce a result that changes a
patient’s life for the better in a single day. This is no
small feat, but when that goal has been reached, the
gratitude of the cosmetic surgery patient must be ex-
perienced to be believed. They can reach the height,
without exaggeration, of ineffable daily happiness.
Their joy is expressed in many ways but most often
in the currency of smiles and hugs. Many of our most
gratifying moments in medicine have come from
these patients; they vindicate all our efforts as doc-
tors, in general, and plastic surgeons, in particular.
But there is, of course, a flipside to the coin of
patient appreciation—those who are dissatisfied be-
cause of unmet expectations. There is little, if any,
forgiveness in aesthetic plastic surgery. It is there-
fore incumbent on us to work assiduously for a goal
of the best final result, commensurate with our sur-
gical skills. More recently, however, the advances
emanating from nonsurgical techniques are leaping
in front of us; they should be used as enhancers and
not viewed as competitors, and sometimes even
embraced as saviors. We are fortunate that the
nonsurgical advances offer our patients and us the
opportunity of improved surgical results without
repeat operation.
The modern aesthetic plastic surgeon must be
versed in both the surgical and nonsurgical techni-
ques for achieving an optimal cosmetic result when
a patient enters the office and states “I hate my
neck.”
If teaching aesthetic surgery to trainees is one of
the more difficult challenges for those of us in the
mentoring side of the profession, it surely compen-
sates with tremendous satisfaction. We are grateful
to every fellow, resident, and student who has
joined us in this endeavor. What we do in our work
is “right out there,” visible to all. That is the very
special quality of aesthetic surgery—none of us can
escape Judgment Day in the office. Those who prac-
tice aesthetic surgery must, by the nature of this
work, strive to understand each patient’s unique-
ness, and always remember the investment of the
patient, both emotional and financial: They trust us
with their faces!
The ability to deliver a safe and durable neck reju-
venation procedure to a patient is always fulfilling
to the practicing plastic surgeon, and this feeling of
fulfillment to the patient never gets old. The results
before and after improved jowling and neck bands
remain an important marker of a happy patient,
although durability without complications is a deli-
cate balance. Additionally, it may be enlightening to
the readership to know that even the great human-
itarian, plastic surgeon, and editor-in-chief emeritus
of the journal Plastic and Reconstructive Surgery, Dr.
Robert Goldwyn, well into his retirement, at one
point quipped, “Thank goodness I don’t have to
worry about any more recurrent platysmal bands!”
Thank you for spending your precious time read-
ing this book.
Samuel J. Lin, MD, MBA, FACS
Sumner A. Slavin, MD
xvii
 Acknowledgments
Sumner Slavin helped to recruit and give me an
amazing opportunity to begin my career in Boston. I
am forever appreciative of his constant mentorship,
support, guidance, and insights about career and life.
I give a huge thank you to all the authors who made
this book possible. Thank you to Munique Maia and
Vickram Tandon for the journey and helping to carry
the project to the finish line! Judith Tomat and Karen
Edmonson were amazing partners at Thieme who
were truly wonderful to work with to get this book
completed—Thank you all!
Samuel J. Lin, MD, MBA, FACS
xviii
The first acknowledgment must be given to Dr. Sam
Lin—an indefatigable colleague full of good judg-
ment, knowledge, patience, and humor; surely hir-
ing him for over a decade as Chief of the Division of
Plastic Surgery at Beth Israel Deaconess Medical
Center will always stand out as one of the best deci-
sions I ever made.
I also wish to acknowledge Dr. Monique Maia, an
outstanding fellow in our Harvard Plastic and Recon-
structive Fellowship Training Program who served as
our Managing Editor; thanks to Dr. Vickram Tandon,
our most recent Fellowship graduate, who assisted in
the preparation of multiple chapters by bringing his
excellent perspectives on what is important for the
young plastic surgeon entering practice; and, of
course, thanks to the superb colleagues listed on
each chapter who contributed their latest ideas and
innovations.
Judith Tomat’s guidance and persistence was indis-
pensable in helping this book emerge from concept
to reality.
In my office, I wish to thank Karen Hamilton,
always in contact with everyone involved in this pro-
duction, coordinating and communicating with all the
parties involved. Nothing happens without Karen’s
energetic input.
Sumner A. Slavin, MD
Contributors
Matteo A. Angelini, MD Erez Dayan, MD
Plastic Surgeon Plastic and Reconstructive Surgeon;
Private Practice Medical Director
Rome, Italy Avance Plastic Surgery Institute
Reno, Nevada, USA
Marcelo Cunha Araujo, MD
Plastic Surgeon Jeffrey S. Dover, MD, FRCPC
Private Practice Dermatologist
Sao Paulo, Brazil Private Practice
SkinCare Physicians
Esther Barrios, MD Chestnut Hill, Massachusetts, USA;
Aesthetic and Reconstructive Plastic Surgeon Department of Dermatology
Private practice Yale University School of Medicine
Rio de Janeiro, Brazil New Haven, Connecticut, USA

Justin Bellamy, MD Trina G. Ebersole, MD

Plastic Surgeon Assistant Professor of Surgery
Private Practice Plastic & Reconstructive Surgery
Palm Beach Gardens, Florida, USA Washington University in St. Louis School of Medicine
St. Louis, Missouri, USA
Ashley N. Boustany, MD
Instructor in Plastic Surgery Jose A. Foppiani, MD
Division of Plastic Surgery Chairman LF1 Surgical Society
Beth Israel Deaconess Medical Center Plastic & Reconstructive Surgery Research Fellow
Harvard Medical School Beth Israel Deaconess Medical Center / Harvard
Boston, Massachusetts, USA Medical School
Boston, Massachusetts, USA
Christopher T. Chia, MD
Plastic Surgeon Daniel J. Gould, MD, PhD
Private Practice Plastic Surgeon
New York, New York, USA Gould Plastic Surgery, Marina Plastic Surgery, USC
Marina Del Rey, California, USA
Enzo R. Citarella, MD
Plastic Surgeon Ritwik Grover, MD
Department of Plastic Surgery Plastic Surgeon
Pontifical Catholic University and Carlos The Plastic Surgery Center
Chagas Institute Whitehall, Pennsylvania, USA
Rio de Janeiro, Brazil
Jacob N. Grow, MD
Alexandra Condé-Green, MD, FICS Aesthetic Surgery Fellow
Plastic Surgeon Department of Plastic Surgery
ACG Plastic Surgery Cleveland Clinic
Boca Raton–Delray Beach, Florida, USA Cleveland, Ohio, USA

Rafael A. Couto, MD Samir Janne Hasbun, MD

Plastic and Reconstructive Surgeon Private Practice
Couto Plastic Surgery – Private Practice Plastic and Reconstructive Surgeon
San Juan, Puerto Rico, USA Puerto Colombia, Barranquilla, Colombia

xix
 Contributors

Sara R. Hogan, MD, FAAD Amer H. Nassar, MD PGY-9

Health Sciences Clinical Instructor Plastic and Reconstructive Surgery–BIDMC
Division of Dermatology Harvard Medical School
University of California Los Angeles Boston, Massachusetts, USA
Los Angeles, California, USA
Mathew N. Nicholas, MD
Dennis J. Hurwitz, MD Dermatology PGY-4
Plastic Surgeon Division of Dermatology
Clinical Professor of Plastic Surgery University of Toronto
University of Pittsburgh Toronto, Ontario, Canada
Pittsburgh, Pennsylvania, USA
Jeremie O. Piña, MS
Michael S. Kaminer, MD PhD Candidate
Private Practice Department of Biomedical Engineering and
SkinCare Physicians School of Dentistry
Chestnut Hill, Massachusetts, USA; University of Utah
Department of Dermatology Sal Lake City, Utah, USA
Yale University School of Medicine
New Haven, Connecticut, USA Mario Pelle-Ceravolo, MD
Professor and Head of Plastic Surgery
Andrew L. Kochuba, MD University of Padua
Aesthetic Plastic Surgeon Rome, Italy
Private Practice
Reston, Virginia, USA Nelson A. Rodriguez-Unda, MD
Chief Resident in Plastic Surgery
Samuel J. Lin, MD, MBA, FACS Baylor Scott-White, Texas A&M College of Medicine
Program Director Temple, Texas, USA
BIDMC/HMS Plastic Surgery Residency
Training Programs; Rod J. Rohrich, MD
Co-Director Clinical Professor of Plastic Surgery
Harvard Aesthetic and Reconstructive Baylor College of Medicine;
Fellowship at BIDMC Past Chair/Distinguished Teaching Professor of
Associate Professor of Surgery Plastic Surgery
Divisions of Plastic Surgery and Otolaryngology UTSW;
Beth Israel Deaconess Medical Center Founding Partner
Harvard Medical School Dallas Plastic Surgery Institute
Boston, Massachusetts, USA Dallas, Texas, USA

Munique Maia, MD Ramil Sinder, MD

Plastic Surgeon Department of Plastic Surgery
Private Practice Pontifical Catholic University of Rio de Janeiro
Tysons Corner, Virginia, USA Rio de Janeiro, Brazil

Alan Matarasso, MD, FACS Sumner A. Slavin, MD

Plastic Surgeon Associate Clinical Professor of Surgery
New York, New York, USA; Beth Israel Deaconess Medical Center
Clinical Professor of Surgery Harvard Medical School
Hofstra University, Northwell School of Medicine Boston, Massachusetts, USA
New York, New York, USA

xx
 Contributors

Aris Sterodimas, MD, MSc, PhD, ARCS Hedyeh Ziai, MD

Head Facial Cosmetic and Reconstructive Surgery Fellow
Plastic & Reconstructive Department Beverly Hills Center
Department of Plastic Surgery Los Angeles, California, USA
Metropolitan General Hospital
Athens, Greece James E. Zins, MD
Chairman
Benjamin Talei, MD Plastic Surgery
Facial Plastic Surgeon Cleveland Clinic
Beverly Hills Center for Plastic Surgery Cleveland, Ohio, USA
Beverly Hills, California, USA

Vickram J. Tandon, MD
Plastic Surgeon
Boston Center for Plastic Surgery
Boston, Massachusetts, USA

xxi
1 Neck Anatomy
Jeremie O. Piña and Sumner A. Slavin
Abstract
Critically integrated with the facial aging process,
the neck and its supporting structures require tar-
geted evaluation and treatment for successful neck
rejuvenation. A good understanding of the anato-
my of the surgical site enables the operating sur-
geon to approach each individual patient with
confidence and caution. Herein, we present a brief
summary of the major surgically relevant anatomi-
cal structures pertinent to rejuvenation of the neck
and its supporting tissues.
Keywords: anatomy, fascia, platysma, SMAS, facial
nerve, retaining ligaments, lower lip
Key Points
● Knowledge of neck anatomy empowers the
clinician to optimize patient-specific outcomes
in surgical and nonsurgical neck rejuvenation.
● Maintaining the integrity of the key supporting
structures within the neck (e.g., superficial fascial
layer) helps curtail bleeding from cut muscle and
preserves the strength of the musculofascial layer
during neck dissection.
● It is critical to know where to find the neurovas-
cular structures most at risk during neck rejuve-
nation procedures, and to understand how to
effectively treat any related complications.
1.1 Cervical Triangles
Although clinicians typically approach the neck in
terms of aesthetic units, anatomists still refer to
the muscular triangles when describing both the
surfaces and contents of the neck. The sternoclei-
domastoid muscle divides the sides of the neck
into the anterior and posterior triangles.
The anterior triangle is bordered by the midline
and the mandible, further subdividing into the sub-
mandibular, carotid, and muscular triangles. The
carotid and muscular triangles are separated by the
posterior belly of the digastric muscle (accompa-
nied by the stylohyoid muscle), and the region
splitting the anterior bellies of the digastric muscles
from the hyoid bone is referred to as the submental
triangle.1
The posterior triangle is bounded by the trape-
zius, sternocleidomastoid, and middle third of the
clavicle. This triangle can be further subdivided as
well, into the supraclavicular (omoclavicular) and
posterior cervical (occipital) triangles, split by the
inferior belly of the omohyoid muscle.2
1.2 Fasciae of the Neck
1.2.1 Superficial
As a discrete sheet of subcutaneous connective tis-
sue, the superficial fascia encases the platysma
muscle (the only muscle in the head and neck with-
out a direct bony origin or insertion) and fuses into
a single layer along the neck midline, forming a
midline bridge of superficial fascia so thin that in
most patients it is essentially invisible.3 During sub-
cutaneous lipectomy in the neck, maintaining the
integrity of this thin superficial fascial layer helps
curtail bleeding from cut muscle and preserves the
strength of the musculofascial layer.
The superficial fascia arises inferiorly from the
deep thoracic fascia, covering the pectoralis major
and deltoid muscles. At the lateral aspects of the
neck, the superficial fascia fuses with the investing
deep fascia covering the sternomastoid and trape-
zius muscles. Above the mandibular border, the
superficial fascia (then referred to as the superfi-
cial musculoaponeurotic system, or SMAS) and its
platysma component become increasingly fibrous.
While there is always a distinction between the
SMAS and deep fascia (also called the parotideo-
masseteric fascia or parotid capsule) at the lateral
aspect of the cheek, the pretragal region repre-
sents a region of closely attached fibers.4 Lateral to
the parotid, however, the SMAS becomes thinner
and increasingly difficult to visualize (gross and
microscopically). It eventually becomes an invisi-
ble epimysium, enveloping the superficial layer of
the perioral and periorbital muscles (e.g., risorius,
zygomaticus major and minor, orbicularis oculi).
Further toward the facial midline, the SMAS may
continue across the nasolabial crease as the super-
ficial portion of the orbicularis oris muscle.5
Superior to the parotid gland, the SMAS and deep
fascia of the cheek coalesce approximately 1 cm cau-
dal to its insertion into the zygomatic arch, signifying
1
 Neck Anatomy
that the SMAS is likely not contiguous with the
superficial fascia of the lateral orbital and temporal
regions of the scalp (this may be referred to as the
superficial temporalis fascia, the temporoparietal fas-
cia, the galea aponeurotica, or the fronto-occipitalis
layer).6 However, there remains some scrutiny in the
field regarding this anatomical convergence.7
1.2.2 Deep
The deep fasciae of the neck are arranged somewhat
concentrically, running contiguous on the inferior
aspect with the deep thoracic fascia and on the
superior aspect with the cranial fasciae. The most
superficial layer of the deep fascia (and the most im-
portant in regard to neck lift surgery) is the investing
deep fascia (often confused with the real superficial
fascia of the neck, aka the platysma and SMAS).7 This
superficial layer of the deep cervical fascia envelops
the deep neck tissues from anterior to posterior in a
continuous sleeve of connective tissue, similar to the
fasciae seen encompassed in the limbs.
Further division of the deep investing fascia enc-
loses the sternomastoid and trapezius muscles
before reconverging into a single sheet covering the
anterior and posterior triangles of the neck. The
deep investing fascia maintains attachments to all
exposed bony parts and ligaments in its path, from
the occipital protuberance, ligamentum nuchae,
and spine of C7 posteriorly to the superior nuchal
line, mastoid process, and mandible cephalically.8 It
splits above the mandible to encapsulate the paro-
tid gland, and splits below the mandible to envelop
the submandibular salivary gland. A thickening of
this fascia extends from the tip of the styloid process
to the angle of the mandible (aka the stylomandibu-
lar ligament or interglandular septum), creating a
common wall between the capsules surrounding
the parotid and submandibular glands.9
1.2.3 Infrahyoid Muscle Fascia
Classically referred to as the “middle fascia,” the fas-
cia of the infrahyoid muscles actually consists of two
distinct layers: the superficial layer (enclosing the
sternohyoid and omohyoid muscles) and the deep
layer (investing the sternothyroid and thyrohyoid
muscles).10
1.2.4 Visceral Fascia
The visceral fascia is split into two components: the
pretracheal fascia (covering the larynx, trachea, and
2
thyroid gland) and the buccopharyngeal fascia (cov-
ering the buccinator muscle and dorsal esophagus).
1.2.5 Prevertebral Fascia
The prevertebral fascia envelops the vertebral col-
umn and its surrounding muscles as well as cover-
ing the prevertebral musculature, forming the
floor of the posterior triangle of the neck (aka the
“fascial carpet”).
1.2.6 Carotid Sheath
The carotid sheath envelops the internal and com-
mon carotid arteries, as well as the jugular vein
and the vagus nerve. The pretracheal (thyroid) fas-
cia is adherent to it along with the investing deep
fascia under the sternomastoid muscle.11 Along
the lateral aspect of the sternomastoid muscle, the
nerves providing sensory input to the neck (e.g.,
great auricular nerve, lesser occipital nerve, trans-
verse cervical nerve, and supraclavicular nerves)
pierce the investing deep fascia and thereafter be-
come enclosed by the thin layer of superficial neck
fascia.12 Further posterior along the edge of the
sternomastoid muscle, the spinal accessory nerve
emerges within the posterior triangle of the neck,
continuing downward and backward toward the
trapezius muscle under a thin two-layer veil of fas-
cia (investing deep and superficial neck fasciae).
Anterior to the sternomastoid muscles, the in-
vesting deep fascia crosses the midline of the neck,
enveloping and attaching to the entire body and the
greater horn of the hyoid bone, finally inserting
above into the symphysis menti. The fascia of the an-
terior bellies of the digastric muscles and the fascia
of the mylohyoid muscles are also contained within
this investing deep fascia. Of particular importance
in neck lift surgery, the investing deep fascia often
needs to be vertically lengthened by partial trans-
verse incisions or excisions to improve the depth
and definition of the hyoid angle.10
When operating on the subplatysmal midline and
paramedian areas, the investing deep fascia acts as a
visual and mechanical safety barrier, given that there
are no vital midline structures superficial to the in-
vesting deep fascia.4 Inferior to the hyoid bone, along
the midline of the neck between the infrahyoid strap
muscles, exist three layers of fascia: the investing
deep fascia, the fused strap muscle fascia, and the
pretracheal fascia. Clinically, all three of these fascial
layers appear as one blended matrix.13

1.3 Platysma and Lower Lip
Situated between the subcutaneous fat and the
subplatysmal fat (superficial and deep adipofascial
layers, respectively), the platysma muscle is a
broad elastic dual-sided band whose thickness and
width vary widely. Of important clinical signifi-
cance, the platysma shares a physical and func-
tional connectivity to the corners of the mouth
(aka the modiolus, a dense, flexible fibromuscular
mass palpable just lateral to the oral commissure),
which can lead to lower lip depressor weakness
following neck lift or face lift surgery.14 Namely,
the depressor anguli oris is a muscle that inserts
into the modiolus just outside the corner of the
mouth, with just a few fibers extended directly in-
to the lateral lower lip. Immediately adjacent sits
the labial part of the platysma (aka the pars labialis
platysma) running beneath the depressor anguli
oris and inserting into the lateral lower lip. Along-
side in the same plane to the labial part of the pla-
tysma (and even intermingling fibers along the
way) runs the depressor labii inferioris muscle.15
The orbicularis oris serves as the lower lip tight-
ener, blending with a network of perioral muscles
with its embryologically distinct parts: pars mar-
ginalis (superficial, beneath the vermillion, blends
with the SMAS) and the pars peripheralis (deep,
caudal nonvermillion portion of the lip, derived
from the buccinator muscle).2 The orbicularis oris
receives its innervation from the lower buccal
branches and mandibular branches of the facial
nerve.
An accessory part of the orbicularis oris muscle
is the incisivus labii inferioris, having bony at-
tachment to the floor of the incisive fossa of the
mandible lateral to the mentalis muscle.15 This
muscle’s action is to pull the corner of the mouth
toward the midline, as is done when pursing the
lips for whistling.
Interlacing its fibers with this network of lower
lip muscles, the platysma can be envisioned as
being composed of three parts. The predominant
pars modiolaris platysma sits posterolateral to
the depressor anguli oris, pulling the corner of the
mouth outward and downward. The intermediate
pars labialis platysma runs deep to the depressor
anguli oris, occupying the space between the de-
pressor anguli oris and the depressor labii inferio-
ris. The anterior pars mandibularis platysma finds
its attachment at the center of the mandible and
1.3 Platysma and Lower Lip
crosses the mental protuberance, extending verti-
cally to the lower lip.
The risorius, considered the corner of the
mouth stretcher, pulls the corner laterally via its
transverse orientation toward the cheek, arising
from the parotideomasseteric fascia and inserting
into the modiolus. Innervated by the buccal branch
of the facial nerve, the risorius may share fibers
and functionality with the upper oblique fibers of
the pars modiolaris of the platysma.16 In some pa-
tients, the risorius is absent.
The depressor anguli oris is a prominent and
superficial muscle taking origin from the oblique
line of the mandible. Its fibers pass upward to con-
verge on the modiolus, with some fibers of the
pars modiolaris platysma blending with those of
the depressor anguli oris. This muscle is not a true
depressor of the lower lip; instead, it is a depressor
of the corner of the mouth (modiolus), often work-
ing in concert with the mentalis muscle.17 Buccal
and mandibular branches of the facial nerve pro-
vide its innervation.
The depressor labii inferioris arises from the
mandible above the oblique line medial to the
mental foramen, with fibers directed upward and
medially before inserting into the skin of the lower
lip. Inferolaterally it is continuous with the pars
labialis of the platysma. The depressor labii inferioris
pulls the lower lip downward and in a slightly lateral
direction, potentially exposing the lower teeth down
to the gingiva.18 Its action may also cause the chin to
wrinkle slightly. Its motor nerve is a marginal man-
dibular branch, and it functions primarily during
phonation.
The mentalis is a dual-sided (one on each side
of the midline), small conical muscle arising from
the mandible below the incisors.19 The mentalis
fans out into the skin of the chin just inferior to
the pars marginalis of the orbicularis oris muscle.
Its action pulls the skin of the lower chin upward,
puckering it, and thus assists in protruding the
lower lip.20 It is innervated by one of the marginal
mandibular branches of the facial nerve.
The depressor labii inferioris, likely in tandem
with the pars labialis platysma, contributes to pull-
ing the lower lip downward so the lower teeth are
bared sometimes almost to the gingiva while si-
multaneously pulling the lip slightly outward away
from the teeth, creating a shadowed overhang.21
However, both muscles likely pull the lower lip
downward in the so-called full-denture smile, in
3
 Neck Anatomy
which the lower teeth are unveiled, creating a
square-shaped mouth.
The depressor anguli oris muscle fibers situate
around the chin like a chin strap, but they do not
directly insert into the lower lip.22 The action of
each muscle is to pull the corner of mouth down-
ward, producing a signature row of curved trans-
verse bulges, similar to waves approaching a
shoreline. This muscle also creates a frown that
looks like an upside-down smile. The depressor
anguli oris muscles often act in tandem with the
mentalis muscles to create an expression some-
times called the “facial shrug.”
1.4 Critical Structures
Surrounding Neck Muscles
The region of the neck between the posterior bor-
der of the platysma and the anterior border of the
trapezius muscle is an anatomically congested
neighborhood. Within these boundaries are identi-
fied the main sensory nerves of the upper neck
and periauricular region, the external jugular vein,
and just enough of the spinal accessory nerve to
cause that nerve to be occasionally vulnerable dur-
ing surgery. According to Feldman, during neck lift
surgery, this is an area that very often needs skin
flap undermining to obtain an adequate redistrib-
ution of the lateral neck skin, but it is also the area
that is the most difficult to undermine, given the
network of tight connective tissue binding the skin
to the investing deep fascia covering the sterno-
mastoid and trapezius muscles.10 Thus, it is critical
to know where to find the neurovascular struc-
tures most at risk during neck rejuvenation proce-
dures (▶ Fig. 1.1).
1.4.1 External Jugular Vein
Formed just beneath the superficial fascia, posterior
and inferior to the angle of the mandible, the exter-
nal jugular vein arises from a union of the retro-
mandibular vein and the posterior auricular vein.2
This union can sometimes occur at the caudal edge
of the parotid gland.23 Descending vertically beneath
the superficial fascia of the neck, the external jugu-
lar vein obliquely crosses over the sternomastoid
muscle near the junction of the lower and middle
thirds of the muscle belly, with a trajectory toward
the midclavicle. Just above the clavicle (~2 cm), it
pierces the investing deep fascia, coalescing as
the subclavian vein. As the posterior border of the
4
platysma muscle often runs parallel and anterior
to the external jugular vein, the vein may not be
underneath the muscle along a good portion of its
course; rather, it may instead just be covered by a
thin veil of superficial cervical fascia.
1.4.2 Other Superficial Veins
Right and left anterior jugular veins, unequal in
size and placement, emerge in the submental re-
gion, running just off the midline within the sub-
platysmal fat overlying the investing deep fascia
and sternohyoid muscles to eventually pierce the
deep fascia approximately 1 inch above the manu-
brium to enter the substernal space and unite.24
They also course laterally along the upper border
of the clavicles between the sternomastoid and
infrahyoid strap muscles, ending in the external
jugular vein. Sometimes, a communicating vein,
lying along the anterior border of the sternomas-
toid muscle, connects the common facial vein and
the anterior jugular veins.25
1.5 Sensory Distribution in the
Neck
1.5.1 Great Auricular Nerve
With very little (if any) dispute, the statement
made by Rees and Aston in 1978 remains the con-
sensus: The nerve most frequently injured during
face and neck lift surgery is a sensory nerve, the
great auricular nerve, the largest branch of the
cervical sensory plexus.26,49 It supplies sensory
innervation to the lower half to two-thirds of the
ear as well as the inferior preauricular area and a
variable postauricular area covering the mastoid.
The great auricular nerve emerges approximately
midway along the posterior border of the sterno-
mastoid muscle, looping onto the surface of the
muscle where it heads straight upward approach-
ing the angle of the mandible. The main nerve
body runs vertically upward and can variably be
identified just beneath or just superficial to the
sternomastoid fascia as it courses up to the base
of the ear lobule. Thus, when elevating a skin flap
in the lateral neck, maintaining the integrity of
the sternomastoid fascia will greatly increase the
likelihood of preserving the great auricular nerve.
However, given the variability in the nerve’s
course along the sternomastoid fascia, this is not
always the case.27 Within 1 to 2 cm of the ear

Fig. 1.1 (a., artery; v., vein; n., nerve; m., muscle) Critical anatomical structures in the neck and lower face. Courtesy
Wasila Madhoun, MD.
lobule, the great auricular nerve arborizes within
the deep fibrofatty subcutaneous tissues, spread-
ing anterior fibers into the parotid gland. Span-
ning from an injury to one of the small distal
branches of the nerve near the ear lobule to an in-
jury of the main nerve body overlying the sterno-
mastoid muscle, a spectrum of dysesthesias can
range from mild, temporary, small areas of hypes-
thesia to a longer-lasting, dense, numbness of the
entire lower ear, or even to a painful neuroma at a
site of more proximal partial or complete nerve
transection.28 Given the relatively high incidence
of transient numbness around the ear following
face and neck lift surgery, many surgeons consider
this to be a normal consequence of the operation,
not a complication.10
1.5 Sensory Distribution in the Neck
1.5.2 Lesser Occipital Nerve
Providing sensory innervation for most of the post-
auricular mastoid region, as well as sensation to the
upper ear, the lesser occipital nerve emerges
behind the posterior edge of the sternomastoid
muscle cephalad to the great auricular nerve at a
point approximately 5.3 cm below a transverse line
connecting the lowest points of the external audi-
tory canals and 6.5 cm from the vertical posterior
midline.29 Traveling obliquely upward between the
sternomastoid fascia and the platysma–SMAS layer,
it provides terminal branches to the ear and mastoid
areas. Similar to the great auricular nerve, the lesser
occipital nerve begins deep to the superficial fascia
(platysma–SMAS layer), but often becomes more
5
 Neck Anatomy
superficial (i.e., more proximal and caudal) earlier
than does the great auricular nerve. In order to
maintain adequate blood supply to the postauricular
skin flap during neck lift or face lift surgery, it is
common for surgeons to elevate the mastoid area
skin flap just superficial to the sternomastoid fascia;
however, dissection on the muscle fascia may lead
to injuring of some of the major terminal branches
of the lesser occipital nerve, which run more super-
ficial in the subcutaneous tissue in this region.30
Thus, it is suggested to leave behind a little fatty tis-
sue on the muscle fascia.
1.5.3 Spinal Accessory Nerve
Fortunately, it is uncommon for the spinal acces-
sory nerve to be found in the field of dissection
during the majority of neck lift surgeries. However,
some patients will require a far-lateral neck skin
undermining, which places this nerve close at
hand.10 Similar to the great auricular nerve, the
spinal accessory nerve is often found sandwiched
tightly between the skin and muscle fascia; as
such, when attempting to free up the skin in the
lower lateral neck, it is possible that the spinal
accessory nerve emerges and could be injured. In
such a case, a spectrum of symptoms can arise de-
pending on the extent and severity of nerve injury;
neurapraxia can cause temporary pain in the
shoulder and trapezius muscle dysfunction even
when the nerve is entirely intact, whereas in a se-
vere injury (e.g., partial or complete transection) a
progressive and debilitating dysfunction of the en-
tire girdle could result. Very close attention must be
paid intraoperatively to determine the extent of
possible nerve injury, and if any postoperative clini-
cal signs or symptoms of trapezius dysfunction are
identified, operative repair of the transected nerve
should be performed within 3 months of the origi-
nal surgery for optimal recovery of function.
1.6 Retaining Ligaments of the
Face and Neck
Retaining ligaments are strong, discrete aggrega-
tions of fibrous connective tissue holding hard and
soft tissues to one another at specific attachment
sites.31 There are five general categories of retain-
ing ligaments, namely, aptly according to their
deep to superficial attachments: periosteum to
skin (osteocutaneous), periosteum to deep fascia
6
and or superficial fascia (osteofascial), deep fascia
to superficial fascia (fascio-fascial), and deep fascia
and/or superficial fascia to skin (fasciocutaneous).
Furthermore, retaining filaments are rows of spe-
cialized fasciocutaneous fibers within the subcuta-
neous fat, serving as more densely packed, tighter
anchors to bond the skin and the superficial fascia
at specified areas in the neck.32
Specifically anchoring the neck skin in position,
there are nine identifiable retaining ligaments and
filaments: the mandibular ligaments, the submen-
tal ligaments, the mastoid-cutaneous ligaments, the
platysma-auricular ligaments (including earlobe
ligaments), the lateral sternomastoid-cutaneous lig-
aments, the clavicular-cutaneous ligaments, the
medial platysma-cutaneous filaments, the medial
sternomastoid-cutaneous filaments, and the skin
crease-platysma filaments.10 In addition, there are
three identifiable retaining ligaments anchoring the
platysma muscle to deeper underlying tissues: the
hyoid ligament, the paramedian platysma retaining
ligaments, and the submandibular platysma retain-
ing ligaments.33
Found on either side of the chin, the mandibular
ligaments emerge from their osseous origin be-
tween fibers of the pars labialis of the platysma and
the lateral border of the depressor anguli oris
muscle, approximately 1 cm superior to the mandib-
ular border, running outward to a solid insertion in
the overlying dermis.34 These ligaments outline the
anterior border of the jowl, primarily responsible for
the indentation that is often seen in this region
called the prejowl notch. Surgical division of the
mandibular ligaments just under the skin (superfi-
cial to the SMAS–platysma layer), in addition to a
repositioning or trimming of the ptotic jowl fat, typi-
cally eliminates the prejowl notch.35
A true lift of the soft tissues in the face and/or
neck involves lateral skin excision coupled with se-
vering the mandibular ligaments and releasing
the tissues along the medial jawline so that they
can be stretched back into a smoother contour.36
As the mandibular ligaments are short and strong,
they cannot be divided simply by passing through
open scissor tips; it is necessary to cut sharply by
snipping just beneath the skin. Of importance, the
marginal branches of the facial nerve are deep to
the SMAS–platysma layer, so scissoring superficial
to both the depressor anguli oris and platysma
muscles can be done without risking nerve injury.
The labiomandibular crease, or marionette
crease, runs from the modiolus to the mandible.

Bordering on the neck from above, it is formed in
part by the mandibular ligament at its caudal apex.
The labiomandibular fold, comprising skin-wrapped
cheek fat lateral to the crease, commonly requires
consideration when choosing between a cheek lift
(which improves this) or an isolated neck lift (which
does not).37 Just below the chin, the submental liga-
ments provide an anchor to the submental skin
crease, likely a result of direct attachment to the
platysma by fasciocutaneous adhesions, while the
platysma has its own independent attachment to
the underlying bone by separate osteofascial fibers.38
Laterally, the neck is attached behind the ear to
both the periosteum of the mastoid bone and the
investing deep fascia over the origin of the sterno-
mastoid muscle by a patch of dense connective tis-
sue, the osteofasciocutaneous mastoid-cutaneous
ligament.39 The only separation between the skin
from the deep fascia in this region is a thin layer of
yellow and white fibrofatty areolar tissue. Within
this thin layer, the terminal mastoid branches of the
great auricular nerve and the lesser occipital nerve
are found.
Meshing with the above-mentioned mastoid-
cutaneous ligaments are the fasciocutaneous
platysma-auricular ligaments, which radiate out-
ward from the skin around the base of the earlobe
and converge with the superficial fascia (platysma–
SMAS layer) below and in front of the ear as well as
the medial sternomastoid-cutaneous filaments
and the upper lateral sternomastoid-cutaneous
ligaments.40 Typically, at least the most superficial
of these fibers comprising the platysma-auricular
ligament must be cut to free the skin around the
lower ear whenever an earlobe-base incision is
used for a neck lift procedure.10
In patients presenting with an attached earlobe,
or more severely those who have a congenital pix-
ie earlobe that is pulled caudally toward the angle
of the jaw, there is a thick linear stretch of the
platysma-auricular ligament that forms a distinct
white band tethering the earlobe downward. By
way of a simple electrocautery release of this liga-
mentous tether, the earlobe can be corrected to
allow for upward retraction and a more pleasant
contour.15
Lateral (thicker) and medial (thinner)
sternomastoid-cutaneous retaining ligaments in
the neck form the fibrous connection between the
muscle and the skin in the plane of dissection in
neck lift surgery. The relative thickness of these re-
taining ligaments can often determine the level of
1.8 Anterior Digastric and Mylohyoid Muscles
difficulty of neck skin flap elevation, particularly in
the lateral neck. Further medial in the neck are the
medial platysma-cutaneous filaments, the vertical
columns joining the medial edges of the platysma
muscle bellies to the skin.12 These filaments are
likely responsible for static muscle bands in the me-
dial neck.10
Finally, the skin crease retaining filaments are
a set of organized retinacula cutis holding the deep
horizontal anterior and lateral neck skin creases as
well as the lateral neck vertical skin creases rela-
tively tightly adhered to the underlying fascia.41
Typically, severing these retaining filaments while
undermining the neck skin containing the crease
significantly reduces the crease. However, in some
cases the dermis within the crease is thinner and
more compact than it is in the surrounding skin,
making it harder to achieve full eradication of the
crease with skin undermining alone.10
1.7 Subplatysmal Fat
The subplatysmal fat lies subcutaneously beneath
the superficial fascia of the neck, and as such is at-
tached to the underlying investing deep fascia and
periosteum. As such, this layer of fat tends to be
more fibrous, making it more difficult to remove
than supraplatysmal fat. An equivalent example of
this fatty tissue layer in the face would be the sub-
SMAS fat in the cheek.42 At the neck midline, the
fat sitting between the medial edges of the platys-
ma muscle bellies is often referred to as interpla-
tysmal fat or midline subplatysmal fat. Strongly
anchoring this interplatysmal fat to the hyoid
bone, perihyoid fascia, digastric muscles, and in-
vesting deep fascia of the midline neck is the hyoid
ligament. The quantity of subplatysmal fat can be
quite variable depending on the patient.10
1.8 Anterior Digastric and
Mylohyoid Muscles
The submental triangle is comprised of two anterior
bellies of the digastric muscles and the body of the
hyoid bone, with the mylohyoid muscles acting as a
common oral diaphragm between the floor of the
submental triangle and the floor of the mouth.2 The
main actions of the anterior digastric muscles are to
elevate the hyoid bone and provide stabilization
during speech and swallowing, as well as to pull the
jaw downward against resistance. The main action
7
 Neck Anatomy
of the mylohyoids is to also elevate the hyoid bone,
in addition to the floor of the mouth and tongue
during speech and swallowing. In the majority of
patients, the mylohyoid muscles are hidden from
view during neck lift surgery, as the anterior digas-
tric muscles are completely covering them.10 The
anterior belly of the digastric muscle emerges from
the digastric fossae of the mandible, connecting
with the posterior bellies by way of a round inter-
mediate tendon (splitting the stylohyoid muscle)
held in place by a fascial sling attached to the body
and greater horn of the hyoid bone.43
The mylohyoid muscles arise from the mylo-
hyoid line at the inner surface of the mandible, ex-
tending diagonally across the entire length of the
body of the lower jaw (from below the third molar
to between the mental spine and digastric fossa).2
The mylohyoid line creates a separation between
the fossa for the sublingual salivary gland from the
fossa for the submandibular salivary gland, allow-
ing for the fibers of the mylohyoid muscles to run
inferomedially and insert into the body of the
hyoid bone and join its opposite along a median
raphe extending vertically from the hyoid to the
mandible. Posteriorly, the muscle has an oblique
trajectory and is free.
It is not uncommon for gaps between the fibers
of the mylohyoid muscle to lead to herniation of
soft tissues in the floor of the mouth (e.g., the sub-
lingual glands), which can produce a mass bulging
from the submandibular triangle.10
Neurovascular supply to the mylohyoid and an-
terior digastric muscles comes from the mylohyoid
nerve and the submental artery and vein (in addi-
tion to a small mylohyoid artery). This neurovascu-
lar bundle runs together just under the lower bor-
der of the mandible atop the mylohyoid muscle
within the capsule of the submandibular salivary
gland to the lateral edge of the anterior digastric.
1.9 The Facial Nerve and Lower
Lip
Likely of greatest clinical significance to surgeons
performing neck rejuvenation procedures is the
anatomical layout of the facial nerve branches pro-
viding lower lip depressor innervation, as the
iatrogenic injury to these branches can commonly
cause deformities characterized by the absence of
downward motion on the affected side during
smile and/or speech, as well as a slight rise of the
affected hemilip margin.44 These deformities can
8
be temporary or permanent, as discussed earlier in
this chapter, with the vast majority of cases dem-
onstrating signs of injury being mild and transient.
Complete recovery from the neuropraxia (local
conduction blocks) of these nerve branches by
segmental remyelination tends to occur within 6
weeks postoperatively.45 Should the nerve be in-
jured to the point of axonotmesis, the nerve regen-
erates at a rate of 1 to 3 mm per day following sur-
gery, with full recovery typically occurring within
4 months postoperatively.10
1.9.1 Mandibular and Cervical
Nerve Branches
The main trunk of the facial nerve typically bifur-
cates within the parotid gland, just posterior to
the ramus of the mandible approximately one-
third of the way from the angle of the mandible to
the mandibular condyle. This bifurcation typically
provides two main divisions: the temporofacial di-
vision (cephalic) and the cervicofacial (caudal).2
There are rare cases of main trunk division into
more than two subsidiaries. While considerable
variation exists in the exact pattern of subdivision
of these nerve branches within the parotid gland
(even from one side to the other in the same pa-
tient), the iconic branches are termed frontal (tem-
poral), zygomatic, buccal, marginal mandibular,
and cervical, making their way toward the muscles
of facial expression.46
Of particular relevance and anatomical impor-
tance to neck rejuvenation procedures are the
marginal mandibular branch and the cervical
branch of the facial nerve. The first (marginal man-
dibular) innervates the depressor anguli oris (dis-
cussed previously), depressor labii inferioris, and/
or the mentalis muscles, while the latter (cervical)
innervates the platysma—exclusively.2
The marginal mandibular nerve (or nerves) exits
the anteroinferior edge of the parotid gland ap-
proximately 0.5 to 1.5 cm anterior to the posterior
border of the mandible, and from 1.5 cm above the
angle of the mandible to 1 cm below the angle.47 It
emerges in variable numbers: as a single nerve
(40%), two branches (50%), or three to four branches
(10%), with each branch traversing forward above,
along, or below the jawline within a horizontal
bandwidth extending from 2 cm above the inferior
border of the mandible to 3 cm below.48 Those
branches that remain above the jawline are typically
encapsulated by the parotideomasseteric fascia,

running forward over the masseter into the buccal
fat pad, which is also protected by the same deep
fascial membrane.50 Those branches that exit the
parotid gland below the jawline tend to remain be-
neath the investing deep fascia before perforating
the deep fascia just below the anterior tip of the pa-
rotid to enter the subplatysmal plane, then continu-
ing forward just superficial to the capsule of the
submandibular salivary gland. Interestingly, most if
not all marginal mandibular nerve branches that
run below the jawline end up taking turns in their
trajectory to end up above the jawline before enter-
ing their target muscles of innervation in the lower
lip.2
As the marginal mandibular branch of the fa-
cial nerve traverses the path of the facial vein
and facial artery along the jawline, the nerve
branch is found superficial to the facial vein over
the lower masseter muscle edge in 95% of cases,
while the nerve branch traverses superficial to
the more anteriorly situated facial artery in (the-
oretically) 100% of cases—although there may be
some occasional rami that do pass deep to the
facial artery.10
The main branch of the cervical nerve typically
descends within the parotid gland posterior to the
ramus of the mandible, then splitting off from the
marginal mandibular branch prior to emerging at
the caudal tip of the gland accompanied by the
retromandibular vein (eventually becoming the
external jugular vein, discussed previously). The
main cervical branch gives off either a single or
multiple superior cervical branches, which pierce
the investing deep fascia at or just inferior to the
jawline. These branches then turn forward and
travel parallel to the jawline on the deep surface
of the platysma before splitting into several
smaller branches entering the platysma 2 to 3 cm
medial to the medial edge of the sternomastoid
muscle to innervate the superior two-thirds of
the platysma muscle.51
The somewhat more predictable inferior cervi-
cal branch runs downward for 3 to 4 cm beneath
the investing deep fascia along or just below the
anterior edge of the sternomastoid muscle, then
penetrating the investing deep fascia before con-
tinuing forward parallel to the mandible just be-
neath the platysma. The rami also emerge at this
point to innervate the remaining inferior one-third
of the platysma muscle, commonly anastomosing
with the sensory transverse cutaneous nerves of
the neck.
References
1.10 Conclusion
The importance of precision in one’s knowledge of
facial and neck anatomy cannot be overstated. The
techniques forthcoming in this textbook, both sur-
gical and nonsurgical, to rejuvenate the neck are
bound by the limits of the aforementioned ana-
tomical structures. We hope this can serve as an
accurate and clinically relevant reference to the
important anatomy as these techniques are dis-
cussed herein.
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[10] Feldman JJ. Neck Lift. Stuttgart: Thieme Medical Publishers,
Inc.; 2006
[11] Truswell WH, IV, Putman HC, III, Perkins SW, Johnson N. The
superficial musculoaponeurotic system and other considera-
tions in rejuvenation of the lower face and neck. Facial Plast
Surg Clin North Am. 2018; 26(2):135–161
[12] Sandulescu T, Stoltenberg F, Buechner H, et al. Platysma and the
cervical superficial musculoaponeurotic system: comparative
analysis of facial crease and platysmal band development. Ann
Anat. 2020; 227:151414
[13] Becker FF. Superficial musculoaponeurotic system vs deep-
plane face-lift. Arch Facial Plast Surg. 2006; 8(3):191–192
[14] Labbé D, Franco RG, Nicolas J. Platysma suspension and pla-
tysmaplasty during neck lift: anatomical study and analysis
of 30 cases. Plast Reconstr Surg. 2006; 117(6):2001–2007,
discussion 2008–2010
[15] Cruz RS, O’Reilly EB, Rohrich RJ. The platysma window: an
anatomically safe, efficient, and easily reproducible approach
9
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to neck contour in the face lift. Plast Reconstr Surg. 2012; 129
(5):1169–1172
[16] Pezeshk RA, Sieber DA, Rohrich RJ. Neck rejuvenation
through the lateral platysma window: a key component of
face-lift surgery. Plast Reconstr Surg. 2017; 139(4):865–866
[17] Marten T, Elyassnia D. Management of the platysma in neck
lift. Clin Plast Surg. 2018; 45(4):555–570
[18] Kushima H, Iwasawa M, Kiyono M, Ohtsuka Y, Hataya Y.
Functional reconstruction of total lower lip defects with a ra-
dial forearm free flap combined with a depressor anguli oris
muscle transfer. Ann Plast Surg. 1997; 39(2):182–185
[19] Zide BM, McCarthy J. The mentalis muscle: an essential com-
ponent of chin and lower lip position. Plast Reconstr Surg.
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[20] Shannon JL. The mentalis muscle in relation to edentulous
mandibles. J Prosthet Dent. 1972; 27(5):477–484
[21] Hur MS, Kim HJ, Lee KS. An anatomic study of the medial fibers
of depressor anguli oris muscle passing deep to the depressor
labii inferioris muscle. J Craniofac Surg. 2014; 25(2):614–616
[22] Tadokoro T, Kurata S, Terashi H, Sato H, Hosokawa K. Unilat-
erally ruptured depressor labii inferioris muscle. Ann Plast
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[23] Matsumoto F, Ohba S, Fujimaki M, et al. Efficacy of modified
face lift incision for the resection of benign parotid gland tu-
mor located anteriorly or superiorly. Auris Nasus Larynx.
2021; 48(5):978–982
[24] Swiergosz AM, Gunn JS, Schulz SA, et al. The danger zone in
the anterior neck: anatomical landmarks to avoid injury to
anterior jugular vein during face-lift and neck-lift. Eplasty.
2018; 18:e3
[25] van Tonder DJ, Keough N, van Niekerk ML, van Schoor AN.
The position of the common facial vein in neonates: an alter-
nate route for central venous catheter placement. Clin Anat.
2021; 34(4):644–650
[26] Rohrich RJ, Taylor NS, Ahmad J, Lu A, Pessa JE. Great auricular
nerve injury, the “subauricular band” phenomenon, and the
periauricular adipose compartments. Plast Reconstr Surg.
2011; 127(2):835–843
[27] Aboudib Júnior JH, de Castro CC. Anatomical variations analy-
sis of the external jugular vein, great auricular nerve, and
posterosuperior border of the platysma muscle. Aesthetic
Plast Surg. 1997; 21(2):75–78
[28] Christensen NR, Jacobsen SD. Parotidectomy. Preserving the
posterior branch of the great auricular nerve. J Laryngol Otol.
1997; 111(6):556–559
[29] Amirlak B, Lu KB, Erickson CR, et al. In-depth look at the ana-
tomical relationship of the lesser occipital nerve, great auric-
ular nerve, and spinal accessory nerve and their implication
in safety of operations in the posterior triangle of the neck.
Plast Reconstr Surg. 2020; 146(3):509–514
[30] Pantaloni M, Sullivan P. Relevance of the lesser occipital
nerve in facial rejuvenation surgery. Plast Reconstr Surg.
2000; 105(7):2594–2599, discussion 2600–2603
[31] Rossell-Perry P, Paredes-Leandro P. Anatomic study of the re-
taining ligaments of the face and applications for facial reju-
venation. Aesthetic Plast Surg. 2013; 37(3):504–512
[32] Ozdemir R, Kilinç H, Unlü RE, Uysal AC, Sensöz O, Baran CN.
Anatomicohistologic study of the retaining ligaments of the
face and use in face lift: retaining ligament correction and
SMAS plication. Plast Reconstr Surg. 2002; 110(4):1134–
1147, discussion 1148–1149
10
[33] Lemmon ML. Superficial fascia rhytidectomy. A restoration of
the SMAS with control of the cervicomental angle. Clin Plast
Surg. 1983; 10(3):449–478
[34] Lefkowitz T, Hazani R, Chowdhry S, Elston J, Yaremchuk MJ,
Wilhelmi BJ. Anatomical landmarks to avoid injury to the
great auricular nerve during rhytidectomy. Aesthet Surg J.
2013; 33(1):19–23
[35] Owsley JQ, Jr. SMAS-platysma facelift. A bidirectional cervi-
cofacial rhytidectomy. Clin Plast Surg. 1983; 10(3):429–440
[36] Massiha H. Short-scar face lift with extended SMAS platysma
dissection and lifting and limited skin undermining. Plast Re-
constr Surg. 2003; 112(2):663–669
[37] Morales P. Repeating rhytidoplasty with SMAS, malar fat pad,
and labiomandibular fold treatment: the NO primary proce-
dure. Aesthetic Plast Surg. 2000; 24(5):364–374
[38] Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical
anatomy of the lower face: the premasseter space, the jowl,
and the labiomandibular fold. Aesthetic Plast Surg. 2008; 32
(2):185–195
[39] de Almeida ART, Romiti A, Carruthers JDA. The facial platys-
ma and its underappreciated role in lower face dynamics and
contour. Dermatol Surg. 2017; 43(8):1042–1049
[40] O’Brien JX, Rozen WM, Whitaker IS, Ashton MW. Lore’s fascia
and the platysma-auricular ligament are distinct structures. J
Plast Reconstr Aesthet Surg. 2012; 65(9):e241–e245
[41] Zdilla MJ, Swearingen JV, Miller KD, Bender-Heine A, Lambert
HW. The retaining ligament of the anterior digastric muscle. J
Craniofac Surg. 2017; 28(2):534–538
[42] Mendelson BC, Wong CH. Surgical anatomy of the middle
premasseter space and its application in sub-SMAS face lift
surgery. Plast Reconstr Surg. 2013; 132(1):57–64
[43] Perkins SW, Patel AB. Extended superficial muscular apo-
neurotic system rhytidectomy: a graded approach. Facial
Plast Surg Clin North Am. 2009; 17(4):575–587, vi
[44] Harrison DH. Treatment of weakness of the lower lip depres-
sor. Clin Plast Surg. 2002; 29(4):533–538, vi
[45] Barbour JR, Iorio ML, Halpern DE. Surgical decompression of
the great auricular nerve: a therapeutic option for neurap-
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(2):255–260
[46] Lee JY, Kim JN, Yoo JY, et al. Topographic relationships be-
tween the transverse facial artery, branches of the facial
nerve, and the parotid duct in the lateral midface in a Korean
population. Ann Plast Surg. 2014; 73(3):321–324
[47] Jose A, Yadav P, Roychoudhury A, Bhutia O, Millo T, Pandey
RM. Cadaveric study of topographic anatomy of temporal and
marginal mandibular branches of the facial nerve in relation
to temporomandibular joint surgery. J Oral Maxillofac Surg.
2021; 79(2):343.e1–343.e11
[48] Nelson DW, Gingrass RP. Anatomy of the mandibular
branches of the facial nerve. Plast Reconstr Surg. 1979; 64(4):
479–482
[49] Rees TD, Aston SJ. Complications of rhytidectomy. Clin Plast
Surg. 1978;5(1):109–119.
[50] Raslan A, Volk GF, Möller M, Stark V, Eckhardt N, Guntinas-
Lichius O. High variability of facial muscle innervation by fa-
cial nerve branches: a prospective electrostimulation study.
Laryngoscope. 2017; 127(6):1288–1295
[51] Mendelson BC. Extended sub-SMAS dissection and cheek ele-
vation. Clin Plast Surg. 1995; 22(2):325–339
2 Neck Rejuvenation: Evaluation and Management
Jose Foppiani and Samuel J. Lin
Abstract
This chapter thoroughly discusses surgical and
nonsurgical modalities of treatment of neck reju-
venation. It highlights the aesthetics of the neck as
well as its evaluation and how that evaluation can
guide the choice of therapy for the patient. There
is a vast array of old and new treatment options in
this growing realm of cosmetic surgery, and an
attempt to present them holistically is provided in
this chapter. These include various minimally inva-
sive procedures such as the use of injectables and
lasers, as well as surgical procedures such as suction
lipectomy and neck lifts. Granularities exist between
and within procedures, and this chapter explores
these in detail to highlight the indications, techni-
ques, complications, and excepted results of each
technique. Ultimately, patients with minimal excess
skin but an excess of preplatysmal submental fat are
indicated to undergo nonsurgical procedures. In
contrast, patients with excess skin or significant
platysmal banding should undergo a surgical ap-
proach tailored to their characteristics. As neck re-
juvenation grows in popularity, aesthetic surgeons
have the chance to personalize treatment for their
patients to ensure exceptional results with minor
complications.
Keywords: aesthetics of the neck, neck rejuvena-
tion, surgical and nonsurgical intervention, com-
plications, postoperative care
Key Points
● The Ellenbogen Brooks criteria provide a compre-
hensive guideline for an aesthetically pleasing
neck.
● The evaluation of the neck’s anatomical fea-
tures guides the choice of procedures and sig-
nificantly influences the outcomes of given
procedures.
● Patients with minimal skin excess and mostly
preplatysmal fat should undergo minimally
invasive procedures such as lasers, injectables,
and other techniques described in this chapter.
● Patients with excess skin, subplatysmal fat, and
other deeper neck defect should undergo surgical
procedures.
● The choice of technique and the approach
should be guided by the specific characteristics
of each patient.
● Poor outcomes tend to be the result of inappro-
priate patient evaluation leading to suboptimal
choice of surgical procedures.
● Well-planned postoperative care improves the
outcomes and significantly decreases the rate of
complications.
2.1 Introduction
2.1.1 Demographic of Neck Lift/
Rejuvenation Procedures
Neck rejuvenation is one of the most commonly
performed aesthetic surgical procedures in the
world.1 It represented over 260,000 of all aesthetic
procedures in 2016.2 Furthermore, the United
States alone encompassed over 181,000 procedures
in 2019 and over 160,000 procedures in 2020.1 This
popularity thus requires the aesthetic surgeon to
possess an in-depth knowledge of surgical and non-
surgical neck rejuvenation procedures. This knowl-
edge must include a solid comprehension of the
aesthetic principles of the neck area, the anatomy
of the neck, surgical techniques, and potential com-
plications. This knowledge then enables the aes-
thetic surgeon to discuss with their patients the
most appropriate procedures to achieve their goals.
2.1.2 Criterion for a Youthful
Aesthetically Pleasing Neck
The concept of beauty has been explored from the
very inception of mankind. As far back as antiq-
uity, artists and philosophers pondered on the char-
acteristics of beauty. Most notably, Plato explored it
in great depth in his time.3,4 However, as socioeco-
nomic changes arose in history, what and how to
determine if a feature is aesthetically pleasing has
proven a challenge.3,4 Many theories and points of
view exist on the matter. Yet, commonality may
be found within them. Some culture favor lean
body and faces, while others prefer curves. More-
over, symmetry is usually the unifying ground.5,6
Mathematicians have long tried to establish a
11
 Neck Rejuvenation: Evaluation and Management
Fig. 2.1 Characteristic of the youthful neck in (a) male and (b) female patients. NLCP, nose–lip–chin plane; SCM,
sternocleidomastoid muscle. (These images are provided courtesy of MUDr. Roman Kufa and MUDr. Lukáš Frajer.)
clear definition of beauty, but despite the existing
controversy, the golden ratio and Fibonacci sequence
have proven crucially insightful. They stress again
the importance of symmetry and proportions.7,8,9,10
As of today, the Ellenbogen Brooks criteria have pro-
vided a fairly universal set of guidelines in defining a
youthfully aesthetic neck and thus what surgeons
should strive toward (▶ Fig. 2.1).11,12 These criteria
include the following:
● A distinct inferior mandibular border.
● A visible subhyoid depression.
● A visible thyroid cartilage bulge.
● A visible anterior border of the sternocleido-
mastoid muscle.
● A cervicomental angle of 105 to 120 degrees.11
2.1.3 Criteria for an Aging Neck
Similarly to the face, the neck is subject to the aging
process. This aging process induces transformations
that are usually classified as either chronological or
photo induced.13,14 This results in the metamorpho-
sis of the shape, texture, and color of the neck
region.13,14 This change is caused by the degradation
of the quality and quantity of soft tissues. A lifetime
of facial expression, elastosis, gravitational forces,
and tissue atrophy have a significant impact on the
appearance of the neck. This appearance is unique to
each patient, but trends may be found within popu-
lations.13,14,15 Based on their lifestyle (especially skin
exposure to the sun), specific populations and ethnic
12
groups may have very different neck morphology
requiring distinctive interventions. Individuals with
a Fitzpatrick phototype of V or VI, for example, have
a higher amount of melanin protecting them from
the effects of photoaging more so than individuals
with Fitzpatrick phototype I or II.15 This relative low-
er loss of collagen and elastin usually translate into a
younger appearance.15 This may imply that for indi-
viduals of the same age, an aesthetic surgeon may
prefer to choose an invasive versus a noninvasive
method because of the patient’s characteristics. Ad-
ditionally, the characteristic histological differences
and wound healing of individuals of different ethnic
origin may warrant different approaches. Fibroplasia
in these groups may be more significant than in
others, and thus careful consideration of tensions on
incision sites is necessary.15,16 Despite the inherent
differences between ethnic groups, the following
criteria represent a unified definition of an aging
neck region:
● An obtuse cervicomental angle, caused by loose/
excess skin with an excess of subplatysmal fat and
a low position of the hyoid bone.12,17
● Aging chin and lower face with the effacement
of sharp mandibular border.12,17
2.2 Neck Evaluation
An evaluation of the neck depicting the anatomical
relationship between the platysma and preplatysmal
fat is shown in ▶ Fig. 2.2.

Fig. 2.2 Anatomical relationship between platysma and
preplatysmal fat.
2.2.1 Skin
The evaluation of the patient’s skin is paramount
to present to the plastic surgeon initial informa-
tion he or she needs to devise the optimal treat-
ment strategies. The quality of the skin, notably
its elasticity, as well as the quantity of the skin,
notably any absolute/relative excess, should be
investigated.12,18,19 Additionally, rhytids forming
both passively and actively should all be thor-
oughly evaluated.12,18,19 Skin in relative excess
will typically solely require redraping followed by
recontouring. On the other hand, skin with poor
elasticity will require skin excision as well.12,18,19
One should note that worse skin quality will ne-
cessitate a potentially longer skin incision.12,18,19
A recent framework proposed suggests evaluating
the quality of the skin in three categories: visible,
mechanical, and topographical.20 This would uni-
formly codify the approach to skin evaluation
among aesthetic surgeons.
2.2.2 Adiposity
The next step is the evaluation of the adipose tis-
sue distribution, which is key in defining the ap-
proach that the aesthetic surgeons should follow.
The adipose tissue accumulates in either the pre-
platysmal or subplatysmal plane.21 A midline sub-
mental pinching maneuver is used in order to
identify the total amount of fat.12,21 Afterward,
while still pinching the same location, the patient
is instructed to contract their platysma. The re-
maining fat felt during this contraction reflects the
fat present in the preplatysmal layer (▶ Fig. 2.3).21
2.3 Neck Rejuvenation Procedures
2.2.3 Platysma
The key in platysma evaluation is to define the
degree, direction, and location of banding both
passively and dynamically.21,22
2.2.4 Digastric Muscle
The preeminence of the digastric muscle is imper-
ative to evaluate. It can form a subtle but neverthe-
less visible distortion of the contour of the inferior
border of the mandible.12,21 Additionally, a protub-
erance may be created by the digastric muscle fol-
lowing submental fat removal. This leads to poor
aesthetic results for the patient. While preopera-
tive assessment is possible in an emaciated neck, a
surgeon should evaluate/reevaluate the digastric
muscle intraoperatively.12,21,22
2.2.5 Submandibular Gland
As part of the intraoperative evaluation, the extent
of the submandibular protrusion/bulging should
also be assessed.12,21,22 The surgeon will need to ad-
dress the submandibular gland that is ptotic, either
surgically or with the patient preoperatively.
2.2.6 Chin
The chin plays a crucial role in relation to facial
proportion and should thus be evaluated accordingly
including its angle classification. Any abnormalities
of the chin can result in suboptimal contouring of
the neck.12,21,22
2.3 Neck Rejuvenation
Procedures
The treatment algorithm for patient’s neck rejuve-
nation procedures is complex. The most consistent
approach following the aforementioned evaluation
of the patient is to take a targeted layer approach
to the patients12,21,22:
● Superficial:
○ Skin.
○ Subcutaneous fat.
● Intermediate:
○ Platysma (muscle banding target).
● Deep:
○ Digastric muscle.
○ Submandibular gland.
○ Suprahyoid fascia.
○ Subplatysmal fat pad.12,21,22
13
 Neck Rejuvenation: Evaluation and Management

Fig. 2.3 Evaluation of submental fat in a (a) male and (b) a female patient. (These images are provided courtesy of
MUDr. Roman Kufa and MUDr. Lukáš Frajer.)

2.3.1 Nonsurgical Procedures

important role in the head and neck region. Young
Botulinum Toxin patients with minimal/moderate active banding,
Botulinum toxin has long been used in the field of minimal rhytids/jowls, and with minimal skin laxity
aesthetic surgery.23,24,25,26,27,28 It has an especially requiring minor cervicomental angle contouring are

14

all good candidates for botulinum toxin use.25 On the
other hand, patients with excess skin or passive
platysma banding would not be indicated for sole
botulinum toxin therapy. As a rule of thumb, the
preliminary dosage in patients is 5 to 20 injections
per platysmal band.24 A grand total of 40 to 100
units are thus used in most patients per treatment.24
Overall, good results are achieved in young people
where minimal/moderate active banding is present.
Botulinum toxin can successfully be used to tighten
neck jowls, reduce horizontal neck rhytids, and im-
prove skin laxity.23 It is important to note that botu-
linum toxin also has good results in correcting minor
defects as an adjunct in other procedures.26 Its use
delays the need for surgical procedures, but one
should note that another procedure will most often
be needed down the line. Common complications in-
clude muscle paralysis, dysphagia, erythema, edema,
ecchymosis, and hyperpigmentation.24 Due to its
versatile nature, botulinum toxin injections remain
one of the leading nonsurgical aesthetic procedures
worldwide, with an excellent rate of efficacy and pa-
tient satisfaction. The accumulation of clinical evi-
dence with botulinum toxin has led to refinements
in treatment planning and implementation over the
years. Internationally, the Global Aesthetics Consen-
sus Group has repeatedly advocated an ontology-
driven, patient-tailored approach to enable optimal
efficacy and safety in patient populations that are
rapidly diversifying with respect to ethnicity, gender,
and age.28
Microfocused Ultrasound System
The Ulthera microfocused ultrasound system has
received an increasing level of attention over the
last decade.29,30 It underwent multiple studies over
the years including a 103-patient study in 2014 in
the United States.29 This study showed that via its
microcoagulative zones and collagen neosynthesis
effect, the Ulthera system achieved promising re-
sults in skin tightening. Indeed, up to 60% decrease
in skin laxity was reported using this system.29
Since then, another study in 2019 was conducted,
which included 50 adult patients.30 The subjects
were treated with the Ulthera 3.0-mm probes to
target the deep dermis and the 4.5-mm Ulthera
probe to target the superficial muscular aponeur-
otic system.30 It showed up to 93% improvement in
skin laxity in this patient population.30 Overall, the
Ulthera system may be a tool for the aesthetic sur-
geon for targeting skin laxity in neck rejuvenation.
This system may be advantageous in populations
2.3 Neck Rejuvenation Procedures
with darker Fitzpatrick skin types where unlike
laser devices or ultrasound therapy, it does not
target melanin.30 This makes it a safer choice over
lasers for these populations.30 Patients with a body
mass index (BMI) over 30 tend to have a high degree
of subplatysmal fat, making the Ulthera system sub-
optimal to use in that population.29 Some complica-
tions to keep in mind with this system include
immediate posttreatment pain, erythema, edema,
and bruising.30
Lasers/Radiofrequency Devices
Lasers and other radiofrequency devices are an-
other emerging toolbox for the aesthetic surgeon
when targeting skin laxity and fat debulking.30
Similarly to the Ulthera system, treatments with
these devices cause adipocytes to coagulate as well
as stimulating dermal neocollagenesis. Multiple
devices currently exist within this category:
● The PrecisionTx introduced in 2012 is a bidirec-
tional dual-wavelength laser at 1,320 and
1440 nm that leads to fat cavitation. This laser
fires forward in the direction of the cannula at a
90-degree angle, enabling the clinician to rotate
his or her wrist and thus treat both deep and
superficial dermis.30
● The ThermiTight system introduced in 2013 is a
percutaneous monopolar electrode causing the
dermis to reach 50 to 70 °C while keeping the
epidermis at a temperature of 45 °C. The whole
preplatysmal fat area may be targeted in this
way, one of the most advantageous features of
this system.30
● The NeckTite system introduced in 2016 is a
percutaneous bipolar electrode that may be
used with radiofrequency lipolysis devices to
improve neck contouring.30
Other topics will be covered in detail in later chap-
ters of this book. As a group, the percutaneous
thermal devices have multiple advantages. These
include single-treatment modality, the capability to
contour and adjust the location of adipose tissue re-
moval, and its effectiveness in achieving excellent
skin tightening.30,31 Common complications include
swelling, bruises, pain, and a risk of skin burn.
Cryolipolysis
Cryolipolysis is a technique implemented using
Zeltiq’s CoolSculpting and its CoolMini applicator
handpiece available since 2015 following the
15
 Neck Rejuvenation: Evaluation and Management
approval of the device by the Food and Drug
Administration (FDA).31 This system utilizes the
cold sensitivity of adipocytes to selectively induce
their apoptosis. Indeed, the target preplatysmal
fat is kept at a temperature of –10 °C for 45 minutes.
Patients usually have to undergo one to two treat-
ments in order to see noticeable changes.31 Overall,
this technique has been shown to decrease superfi-
cial fat thickness by 2 mm and up to 77% of patients
report improvements in submental appearance.31
However, it is important to note that similarly to
other devices covered in this chapter, the final
reduction in the cervicomental angles occurs over
the course of 3 or 4 months posttherapy. The
advantages of this modality include the ability to
debulk large areas of submental fat and a low risk
of complications in addition to the noninvasive na-
ture of the procedure. Like all other devices, some
disadvantages do exist. These include the inability
to treat skin laxity and platysmal band, the need for
multiple costly sessions, and lack of precise target-
ing of fat debulking. There is a rare risk of paroxys-
mal adipose hypertrophy (PAH), which results in
the hypertrophy of adipose cells following treat-
ment. However, it is important to note that the per-
sistence or “growth” of fat may also be due to
weight gain and not PAH. It is also important to
note that a “butter stick” appearance of the sub-
mental may occur for a few minutes posttherapy.31
Deoxycholic Acid
Deoxycholic acid is a chemical substance that can be
used to target excessive submental adiposity.12,31,32
It usually requires four to six treatment sessions
with 4 to 6 mL of the chemical per treatment.12,31 A
30-gauge needle is used, and 20 to 30 injections of
0.2 mL are given in a 1-cm grid pattern over the
submental area.12,31 Overall, the treatment may
decrease the submental fullness/adipose content
as exhibited by two phase 3, randomized, double-
blind, placebo-controlled clinical studies con-
ducted in 57 centers in Germany, France, Spain,
Italy, Belgium, and the United Kingdom.32 Deoxy-
cholic acid is a treatment with good control over
area and amount of adipose fat reduction and
moderate skin tightening effect. Complications
include pain with administration, lack of clinical
improvement, or hematoma formation in up to
72% of the patient; swelling; and the possibility of
exposing the platysmal bands if the adipose layer
is skeletonized. Patients with bleeding disorders
are usually contraindicated for this treatment.
16
Stromal Vascular Gel
Stromal vascular fraction (SVF) gel is another in-
jectable indicated for use in neck rejuvenation spe-
cifically to target horizontal neck wrinkles.33 The
preparation of lipoaspirate necessitates multiple
steps. It requires two centrifugations with collec-
tion of the middle layer following the first centri-
fugation and re-centrifugation of that collected
layer. Various protocols to produce SVF gel exist.33
Once produced, the SVF gel is injected via a subcision
underneath neck wrinkles. A beveled hypodermic
needle is used to loosen up the tissue to which the
wrinkles are bound. Injections should be performed
at points 0.5 cm apart along the horizontal necklines,
depositing 0.05 to 0.1 mL of SVF gel at each injection
point.33 Overall, improvement in horizontal wrinkles
is evident. However, it is important to note that com-
plication rates tend to be higher with SVF gel. Com-
plications include erythema, edema, ecchymosis,
and hyperpigmentation.
2.3.2 Surgical Procedures
An overview of surgical treatment options based
on patient anatomical characteristics is presented
in ▶ Table 2.1.
Liposuction
Liposuction29,31,34,35,36,37 as a general aesthetic sur-
gery procedure is one of the most commonly per-
formed treatment modality worldwide.1
Multiple subtypes of liposuction devices exist:
● Suction-assisted liposuction (SAL).
● Ultrasonic-assisted liposuction (UAL).
● Laser-assisted liposuction (LAL).
● Radiofrequency-assisted liposuction (RFAL).
Liposuction has developed significantly since its
first use in the field of aesthetic surgery. Articles
dating back to 1996 described the comparative
benefits of suction lipectomy. It was then de-
scribed that the marriage of SAL and UAL en-
hanced results and minimized complications.35 As
of 2018, authors thoroughly explored the benefits
of UAL and LAL over SAL.36 These notably include
the following:
● UAL over SAL in the treatment of gynecomastia.
● LAL and UAL over SAL with decreased hemoglo-
bin/hematocrit in high-volume lipoaspirate.
● LAL over SAL with skin tightening in select areas
notably the submental area.

Table 2.1 Overview of surgical treatment options based on patient anatomical characteristics
Procedure Incision Skin excess
location
None Apparent
Liposuction Access incisions ++
Submental Submental ++ + +
rhytidectomy
Short scar Retroauricular
rhytidectomy
Full scar Periauricular
rhytidectomy
Apart from the aforementioned points, the litera-
ture revealed similar results in these techniques.
No other clear benefit to set one apart from the
other was found.36 On the other hand, RFAL is a
relatively newer subtype of liposuction.37 These
devices similarly to the lone radiofrequency device
described earlier in this chapter cause additional
soft-tissue/skin contraction. Interestingly, a recent
study compared the first- and second-generation
RFAL.37 The first-generation group exhibited 8.3%
minor complications, while the second-generation
group exhibited 0.7% minor complications.37
Some data from the second-generation RFAL de-
vice revealed a statistically significant reduction
in the overall complication rates compared with
the first-generation device and are worth further
investigation.37
Regardless of the device used, procedures can be
done under local or general anaesthesia.29 They all
entail tumescent anesthesia of the subcutaneous
neck and submental fat.31 Following this, access in-
cisions are performed. The submental and infra-
auricular are among the most common.35 Once
these incisions are made, percutaneous tunnelling
of the liposuction cannula is performed. It is im-
portant to note that one should avoid excessive,
superficial passes with the liposuction cannula
and not over-resecting the subcutaneous fat in or-
der to prevent complications.
In the neck region, patients with an obtuse cer-
vicomental angle due to submental fat mostly in
the preplatysmal plane with good skin quality
are good surgical candidates. The use of liposuc-
tion remains a gold standard therapy for these
patients.36 Recently, authors were able to achieve
a mean reduction of the cervicomental angle
2.3 Neck Rejuvenation Procedures
Skin elasticity Fat excess
Real Good Poor Subcutaneous Subplatysmal
+ ++ +
++ ++
++ ++ ++ ++
++ ++ ++ ++
from 158 to 124 degrees.31 Additionally, if con-
comitant facial rejuvenation is planned, liposuc-
tion is a useful adjunct. Indeed, the fat can be
harvested during the liposuction and used for fat
grafting.37 Due to the nature of the procedure, pa-
tients consuming large amounts of tobacco, on anti-
coagulant therapy, and with significantly elevated
blood pressure are usually contraindicated.29,31,34
Liposuctions still have risks. These include bleeding,
hematoma formation, swelling, infection, dimpling,
poor scar formation, contour irregularities, and
deeper structure damage.
Submental Anterior Neck Lift
General Approach
The neck is placed in extension and local anes-
thesia is infiltrated.38,39,40,41 The administration
of local anesthesia or tumescent solution can
assist in hemostatic dissection of the tissue. An
incision is performed just posterior to the sub-
mental crease, after which it is released anteri-
orly from underlying tissues. The dissection can
be performed forward and laterally to notably
release the mandibular ligaments. Following this
dissection, the skin must be undermined as much
as needed in order to visualize and address the
platysmal bands. Dissection is further carried lat-
erally as far as needed to expose the platysma.
While preplatysmal adiposity can be targeted
with liposuction prior to the neck lift, direct de-
fatting of the subcutaneous tissue may be cau-
tiously performed under direct vision as part of
the neck lift. Deeper subplatysmal fat can then be
treated with this anterior approach.
17
 Neck Rejuvenation: Evaluation and Management
Technical Considerations
The various structures previously described in this
chapter should now be reevaluated and careful
consideration of the state of these structures and
effects on the overall neck structure must be
made.38,39,40,41
The subplatysmal fat is the first of the anatomi-
cal characteristics that can be targeted for treat-
ment. The subplatysmal adipose tissue lies within
the midline of the neck and extends to some de-
gree toward the submandibular gland. In order to
reach this adipose tissue, the medial border of the
platysma should be elevated, and the fat excised
deep to the platysma. It is important to note that
the surgeon should keep in mind the pitfall of re-
moving excessive adipose tissue. It is vital for an
adequate subcutaneous layer of fat to be preserved
in order to prevent submental depression. The pla-
tysma is then repositioned, and sutures are ap-
plied to prevent the platysma from dehiscing due
to an unstable closure.
Digastric muscle excision is also a possibility,
but rarely done, in some patients. Following sub-
platysmal fat excision, it can be exposed via a sub-
mental incision. The anterior belly of the digastric
is then evaluated. Depending on the patient char-
acteristics, it can then be tangentially excised,
totally excised, or plicated.
Following the excision/retraction of the anterior
digastric, the submandibular gland can be entirely
visualized. It is important to note that prior to
removal of the gland, the neck should be flexed to
assess the neck contour. If an intervention is
warranted, multiple approaches may be taken. A
partial resection can be performed. The excision
involves an Allis clamp that is used to grasp the
gland, and then a needle tip cautery is used to par-
tial excision. A drain may be placed if the gland is
excised in order to prevent salivary accumulation,
which may require drainage. One should note that
even partial gland excision may result in a salivary
gland fistula and nerve injury. Suspension suture
to the mandibular border or transcervical suspen-
sion can also be placed if a minimal prolapse of the
gland not warranting excision is present.41
Subtypes of Neck Lift
Endoscopic Neck Lift
The first subtype of anterior neck lift is an endo-
scopic neck lift.42 This procedure provides endo-
scopic visualization. It is performed via a 3- to 4-cm
18
submental incision and 1-cm retroauricular inci-
sions with the aid of fiberoptic visualization using a
lighted retractor. However, it is important to note
that this procedure is now rarely performed.
Short Scar Neck Lift
The second subtype of neck lift is the short scar
neck lift.12,38,39,43,44 Patients are indicated for this
procedure to correct neck jowling, ideally in a
patient with minimal or moderate skin.
A few technical variances of this procedure exist
to best address the characteristics of the patient.
One may use a vertical vector on the superficial
musculoaponeurotic system (SMAS) as well as a
diagonal vector on the skin to improve the jawline
and neck. Additionally, the neck can also be con-
toured using one of the liposuction devices previ-
ously described.
The facial portion of the procedure is done
through a prehairline and a preauricular incision
ending at the earlobe. After this, a subcutaneous
skin flap is created and then extended to the pos-
terior border of the sternocleidomastoid muscle.
An SMAS platysma flap is then dissected and drawn
vertically in the face and posteriorly in the neck.
Alternatively, a SMAS ectomy or SMAS plication can
be performed through this limited incision. One
should note that permanent sutures are to be used
for the plication or fixation of the SMAS–platysmal
flap. Finally, excess skin is trimmed and tailored,
after which it is directly pulled upward with a diag-
onal vector posteriorly.
Full Scar Neck Lift
Comprehensive Approach
The third subtype of a neck lift is the full scar neck
lift.12,38,39,45,46 Patients indicated for this procedure
have several reasons. These include the aging
changes of the face and neck, ill-defined neck–face
interface, excess skin, and/or excess skin laxity.
Additionally, these also include static platysmal
bands and visible submandibular gland.
Similarly to the short scar neck lift, a full scar
neck lift has multiple technical variances depend-
ing on the patient. In significantly lax skin with
substantial excess in the neck, the retroauricular in-
cision is continued along the hairline to remove the
additional excess skin. The initial key aspect prior
to the removal of the excess skin is to align the hair-
line. After this, the retroauricular sulcus must be
closed with a three-point suture technique. This

will incorporate the deep fascia in order to prevent
scar migration. Further details on the facelift ap-
proach are discussed later in the book.
Skin Flap Procedures
In a youthful neck, a vertical vector of pull is present.
In order to recreate this natural vector in a neck lift,
a posterior and diagonal vector has to be created
when using the retroauricular approach.46,47
In a neck lift, managing the skin is different from
that of the facial skin. If skin excess is present and
warrant excision, a retroauricular or hairline inci-
sion can be considered. In patients with consider-
able anterior neck redundancy such as following
massive weight loss, skin should be removed using
a direct approach. In these cases, a T-Z incision can
be used when targeting the contour to the cervical
angle.47 The initial procedure is done through a
midcervical skin excision through which prepla-
tysmal and subplatysmal fat is excised and then
closed in the midline.
Platysmal Procedures
Once platysma diastasis is addressed, the surround-
ing skin is recruited in the midline.39,40,48,49,50,51 This
medial tightening leaves skin tethered laterally to
the attachments of the lateral platysmal fascia,
which provides a generally stronger anchorage. The
skin is then allowed to contract or is excised later-
ally through a facelift approach. A wide array of spe-
cific methods for treating the platysma have been
described.
These include the following:
● Platysma flap cervical rhytidoplasty. In this pro-
cedure, a sectional myotomy of the medial edge
of the platysma is performed in order to enable
a lateral rotation and advancement of the flap
edges. Following this, suturing of the flaps to
the mastoid fascia laterally prevents recurrence
of the vertical banding.
● Suspension sutures. Suspension sutures can aid
in the definition of the jawline. They are placed
along the inferior border of the mandible over
the superficial fascia. Sutures are interlocked at
the midline and tacked to the mastoid fascia.
● Facial and neck rejuvenation with absorbable
polydioxanone is a popular technique in Korea.
A recent study in 2017 in a population sample
of 33 patients showed outcomes consistent with
a low incidence of complications and high rate
of patient satisfaction (94.3%).48 The complica-
tion resolved without surgical intervention, but
2.3 Neck Rejuvenation Procedures
some asymmetry was present in some of the
patients.48 Ultimately, this procedure, which is
indicated in patients with moderate-degree lax-
ity, was shown to be a safe and effective treat-
ment modality within the Asian population.48
● Platysmal muscle sling. In a platysmal muscle
sling, the sling is made by dividing the platysma
horizontally across the entire width. The tissue
then clusters on the cephalad portion of the pla-
tysma. This creates a phenomenon known as
the window shading effect.
● Corset platysmaplasty. For this procedure, a sub-
mental incision is performed for an anterior ap-
proach, followed by skin elevation. The medial
edges of the platysma are then infolded with a
permanent suture. The neck skin is shifted pos-
teriorly, while the platysmal pull is anterior and
toward the midline. It is precisely this anterior
pull that defines the corset platysmaplasty. The
excess neck skin can then be either excised or
allowed to contract. Occasionally, a very low 3-
to 4-cm transection from the medial edge
allows comfortable rotation of the muscle flaps
to the midline for multilayered approximation.
A multilayered seam approximates the full
height of the midline platysma muscle edges,
creating a “waistline” to the neck from an ante-
rior platysmal shift. The plication of the muscle
then continues medially to three fingerbreadths
above the suprasternal notch. This is a highly ef-
fective and popular technique for recontouring
the submental area. If combined with lateral
plication, midline plication of the platysma can
define the jawline and neck–jaw transition suc-
cessfully.
● Hyo neck lift. The Hyo neck lift is a new techni-
que in neck rejuvenation introduced by Claude
Le Louarn, a French surgeon in 2016.49,50 It
involves a horizontal suturing of the platysma
toward the hyoid and then to the skin to recre-
ate a youthful cervicomandibular angle. The
Hyo neck lift was described as a less invasive
technique that showed improvement in the
contour and flattening of the submental area.
Since then, Claude Le Louarn proposed a major
change to the initial technique of the Hyo neck
lift. He has suggested performing a vertical an-
terior subplatysmal and subplatysmal adipose
tissue dissection. This anterior dissection would
ensure a precise fixation of the platysma to the
deep cervical fascia, thus enabling the creation
of a horizontal and posterior vector of tension.
19
 Neck Rejuvenation: Evaluation and Management
Additionally, the posterior border of the anteri-
or platysmal flap is suspended to the mastoid
fascia. Since the first 10 patients in 2016, 15 pa-
tients have undergone a new technique of neck
lift with fixation of the platysma to the deep
cervical fascia and suspension of the lateral
platysma.50
Challenges and Complications
A certain proportion of postoperative problems
tend to be the result of inappropriate patient eval-
uation leading to suboptimal choice of surgical
procedures.12 Notably, contour irregularities, espe-
cially in thin patients, may be the result of an
overzealous treatment of the subcutaneous and
subplatysmal fat. Inadequate redraping of the skin
because of inadequate undermining or poor skin
quality is an issue encountered by some plastic
surgeons. Undercorrection of the jowls, the jaw-
line, and the neck–face interface can also occur
sometimes. Ultimately, revision with a facelift may
often be required to correct the above issues.
Significant tension laterally to the retroauricular sul-
cus may also increase the risk of skin necrosis. For-
ward planning should occur when complications
occur in order to prevent the occurrence of subse-
quent complications. Indeed, hematoma or infec-
tion, especially in the retroauricular area, is usually
followed by skin slough.
Fat Interface Problems
The adipose layers may be either over- or under-
treated. Overtreatment usually occurs in the sub-
cutaneous plane, while undertreatment is often
seen in the subplatysmal plane and adjacent to
the submental incisions. Overtreatment can be
avoided by preserving 3 to 5 mm of subcutaneous
fat. This may be facilitated by using smaller-
caliber cannulas and limiting passes of suction in
the same locations.
Platysma
The remaining or appearance of new platysmal
bands is one of the most common complications of
platysmal procedures. These usually occur secon-
dary to suture failure or surgical dehiscence. When
these complications occur, correction is frequently
required. It then necessitates a revision surgery
where the procedure is reproduced, or new/addi-
tional resection is needed.
20
Submandibular Gland
Bulging in the submental triangle may occur post-
operatively. This is usually from an enlarged gland,
which now protrudes due to thinner or weaker
superficial tissues. Reoperation may be needed.
Digastric Muscle
As previously discussed, excess preplatysmal fat
removal may unmask the digastric muscle. Simi-
larly to the submandibular gland, issues with the
digastric muscle are often seen as a persistent
bulge along the submental area. In these cases,
excision of the muscle bellies may be warranted.
Inappropriate Vectors
Vector planning is a mandatory step in any suc-
cessful neck lift procedure. Failure to thoroughly
take this step into account may result in poor ret-
roauricular or anterior tragal scars. This is espe-
cially true in patients with significant neck skin
excess. One should be careful not to cause exces-
sive traction in any vector. This could result in
banding or bulging the neck area. Revision surgery
may be required to correct vectors.
Postoperative Care
Postoperative care is as important as good plan-
ning in ensuring a prompt recovery and good
results regardless of the procedure.12 A variety of
medications may be given postoperatively. Analge-
sia control is routine, and is usually supplemented
with sleeping pills, and antiemetics. Patients
should be instructed to minimalize any straining
of the neck, and flexion of the neck should also be
avoided. Strenuous activity is restricted until week
6 postoperatively.
In indicated patients, drains are used to eliminate
serum and a small amount of blood. They potentially
reduce postoperative edema and surgeons should
not shy away from using them. The drains can be re-
moved on postoperative day 1 after careful examina-
tion of the patient neck.
Dressings and an elastic garment should be ap-
plied over the neck and left in place overnight to
absorb any fluid. Operative dressings are replaced
with a neck strap for ≤ 4 weeks. When applying
these, the surgeon or nurse should ensure that no
excess pressure is applied in order to avoid pres-
sure necrosis. The wounds should be cleaned with
half-strength hydrogen peroxide and coated with

a topical antibiotic as needed. All nonabsorbable
skin sutures are removed by days 7 to 14.
2.4 Conclusion
Ultimately, one may conclude that many advance-
ments have been seen in the field of neck rejuve-
nation over the last decades. A careful evaluation
of the patient is paramount in guiding the aes-
thetic surgeon to select the best intervention for a
patient population that keeps growing in diversity
and complexity. Patients with very little excess
skin but an excess of submental fat, when prepla-
tysmal, can now undergo a wide array of effective
and safe nonsurgical procedures. Patients with
excess skin or platysmal banding should undergo a
surgical approach tailored to their characteristics. To
conclude, as neck rejuvenation grows in popularity,
aesthetic surgeons have the chance to personalize
treatment for their patients to ensure exceptional
results while minimizing complications.
2.5 Expert Commentary by
Dr. Slavin
This chapter provides a thorough review for clini-
cians on an approach to patients with aesthetic
dissatisfaction of their neck. It reviews each ana-
tomical contributor to neck contours and, more-
over, introduces nonsurgical techniques to the
reader. These nonsurgical techniques are an ever-
growing category of techniques that are important
for patients and surgeons alike. For patients who
either are not surgical candidates or choose to
forego surgery, knowledge of these devices will be
of utmost importance going forward.
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3 Management of the Aging Neck
Munique Maia and Alan Matarasso
Abstract
Multiple treatments are available for neck rejuve-
nation, ranging from medical grade skincare and
nonsurgical treatments to surgical neck lift. In con-
trast to the face, however, nonsurgical rejuvena-
tion of the neck provides limited improvement.
This chapter discusses patient selection, neck lift
procedures in isolation and in combination with
facial procedures, as well as complications and
their management.
Keywords: neck lift, aging neck, liposuction, sub-
mentalplasty, platysmaplasty
Key Points
● Preoperative analysis and a comprehensive
rejuvenation plan are necessary for optimal
results.
● Surgical neck rejuvenation can be performed
in combination or independently with facial
procedures.
● Surgical procedures address the three most im-
portant soft-tissue components of the aging neck
(fat, skin, and muscle). Procedures range from
liposuction and submentalplasty to neck lift.
3.1 Introduction
It is a common concept in the general population
that the appearance of the neck can be a sign of
aging and can appear more aged than the face
itself. Characteristics of a youthful neck include dis-
tinct mandibular border with the relative absence of
jowls, subhyoid depression, visible thyroid cartilage
bulge, distinct border to the sternocleidomastoid
(SCM) muscle, and a cervicomental angle between
105 and 120 degrees.1,2,3,4 Aging signs can be present
in the neck as early as the late 30 s. Consequently,
neck lift was ranked as the 12th most common cos-
metic procedure by the American Society for Aes-
thetic Plastic Surgery in the United States in 2019.5
Moreover, that number is greater when including
facelift surgery, which routinely incorporates the
neck. Methods for rejuvenation of the neck include
surgical (extended neck lift, neck lift, liposuction,
and submentalplasty) and nonsurgical (botulinum
toxin, deoxycholic acid, dermal fillers, threading,
energy-based treatments, and resurfacing). A com-
prehensive analysis of the neck is paramount for the
surgeon to choose the correct treatment for each
patient.
Evaluating and determining which components
of the aging neck are contributing to its appear-
ance is necessary to plan treatment. Neck lift can
be performed alone or in combination with a face-
lift or other facial or body contouring procedures.
Patients often present with a combination of poor
skin quality, excess skin laxity, excess fat, and hy-
pertrophied and attenuation of the platysma and
retaining ligaments. Furthermore, ptotic subman-
dibular gland and digastric muscle hypertrophy
can also contribute to the aging neck. Detailed
analysis of the area will determine if the patient is
a candidate for a surgical procedure and the extent
of the procedure. An algorithm for treatment of
the neck is described in this chapter (▶ Table 3.1).
3.2 Patient Analysis
Aging components of the neck should be individu-
ally analyzed and addressed accordingly (Box 3.1).
Systematic examination of the neck from superfi-
cial to deep is helpful. Evaluation begins with the
assessment of skin quality and skin quality. The
excess skin of the neck is ameliorated with a neck
lift; however, very little is derived from this in
Table 3.1 Decision analysis and patient education in
treating soft-tissue components in the aging neck
Fat Musclea Skin Treatment
+ No laxity Adequate Liposuction
+ + Adequate Submentalplasty
+ /− + + Neck liftb
Note: The three most important soft-tissue compo-
nents of the neck (skin, fat, and muscle) represent the
framework for analyzing a range of neck deformities.
aPlatysma muscle: visible or lax medial border platysma
bands (submentalplasty) muscle treatments include
resection, plication (Eiffel tower), or incising.
bNeck lift often includes submentalplasty.
23
 Management of the Aging Neck
patients with poor skin quality. Poor skin quality
requires skin care and ancillary procedures, such
as lasers, peels, microneedling, fat grafting, or
energy-based devices. This is an important topic of
discussion as it can cause dissatisfaction postoper-
atively if the patient is not clear on the distinction
and about the goals of the surgery. Next, the pres-
ence of platysmal bands should be evaluated in
repose and with muscle contraction. The subcuta-
neous fat (superficial fat) and subplatysmal and
interdigastric fat (deep fat) are assessed. Contour-
ing of excess adipose tissue with liposuction or
direct excision should be considered. The overall
assessment of the neck and lower face and analysis
of facial proportions should also be performed.
Digastric muscle hypertrophy, submandibular
gland descent or hypertrophy, bony deficiency of
the chin and mandible, jawline contour, and lower
face descent should all be analyzed and can be
treated with appropriate procedures. If the patient
also has concerns about his or her face, additional
procedures such as facelift, chin implant place-
ment, skin treatments, or buccal fat excision6
should be discussed.
Box 3.1 Related Components to
Correct Neck Aging
● Submandibular glands.
● Jowls.
● Marionette lines.
● Hypertrophic earlobes.
● Microgenia.
● Buccal lipodystrophy.
● Larynx.1
● Masseter muscle hypertrophy.
● Parotid gland enlargement.
3.3 Patient Selection and
Preoperative Planning
A successful outcome is essentially a satisfied pa-
tient. Consequently, during the consultation, under-
standing of patient’s concerns and expectations is
paramount. The discussion should also include the
treatment plan and what can be achieved with sur-
gery alone, where the incisions would be placed,
costs, recovery period, and possible complications.
To the extent foreseeable, the limitations and goals
1
Potentially addressed in conjunction with neck surgery.
24
of each alternative treatments and ancillary proce-
dures should be discussed.
Once the assessment of the neck is completed a
treatment plan is outlined. The treatment options
follow a laddered approach. Liposuction of the neck
is a straightforward procedure and is generally indi-
cated for younger patients with excess subcutane-
ous fat and good skin elasticity. Although the neck
can exhibit a surprising ability to contract even with
advanced age, submentalplasty surgery addresses
midline muscle laxity and excess fat with some skin
rearrangement, albeit without excision. A full neck
lift addresses all three soft-tissue layers of skin,
muscle, and fat.7 An extended neck lift that incorpo-
rates an additional short preauricular incision can
be considered if the patient desires to address the
lower face and jowl area, which is the transition
area between facial and neck surgery. This is partic-
ularly common in patients concerned with jowling
as this extends above the border of the mandible
and an extended neck lift will improve this area
also. Patients can be interested in less invasive pro-
cedures; therefore, it is of paramount importance to
educate patients about their anatomy and cause for
aesthetic dissatisfaction. A “downstaged” procedure
that minimizes incision length, discomfort, recovery,
or cost yields a different result than a more invasive
plan. The treatment plan should proceed only after
patient’s expectations are fully understood and they
accept the treatment proposed.
3.4 Operative Procedure
3.4.1 Surgical Technique
The neck lift is performed in an accredited ambu-
latory operating room under systemic anesthesia
administered by a board-certified anesthesiolo-
gist.8,9 The incisions are marked and wetting solu-
tion (1 mL 1:1,000 epinephrine and 100 mL 1%
lidocaine in 200 mL of normal saline) is injected
in the field. The ear canal is gently packed with a
cotton ball soaked in betadine. One gram of intra-
venous tranexamic acid is used 30 minutes preop-
eratively unless contraindicated. Liposuction is
performed first as indicated. A 2.4-mm Mercedes
cannula is used for neck liposuction and a 1.8-mm
Mercedes cannula is used for jowl liposuction. A
spatula tip cannula can be used for additional con-
tour in heavy fatty necks. ▶ Video 3.1
When submentalplasty is indicated (i.e., for mid-
line platysma surgery or deep structure contour-
ing), a 5-cm submental incision is made, just caudal

Video 3.1 Neck lift. This video shows injection, sub-
mentalplasty, medial and lateral platysmaplasty, skin
redraping, and closure.
or cephalic (in this case, it is undermined) to the
submental skin crease. Some surgeons advocate for
a slightly curvilinear incision to account for redrap-
ing of the skin in cases of full face and neck lift. The
midline neck is widely dissected and undermined
with the aid of a lighted retractor. Particular atten-
tion should be paid to undermining adjacent to the
incision and contouring any fat in this area. Medial
platysma bands are then identified. When redun-
dant medial platysma muscle is present, a strip of
excess muscle can be excised. Conservative subpla-
tysmal fat removal is performed, if necessary, by
either direct excision or melting with ball-tip elec-
trocautery. While deep fat can be safely contoured,
if removed, digastric excision and submandibular
gland removal should be considered.10,11,12 A back
cut (myotomy) is made from medial to lateral in
the platysma at the level of the cricoid to treat
hard dynamic bands. In order to stave off reat-
tachment of the muscle fibers, some surgeons
advocate for partial myectomy. If the muscle can
be reapproximated in the midline (based on the
extent of separation), it is done with interrupted
3–0 Mersilene sutures (Ethicon, San Lorenzo,
Puerto Rico) to achieve a snug, but not tight, ap-
proximation. Different techniques for platysmal
repair have been described.13 The hyoid fascia can
be incorporated into the repair with the intention
of avoiding recurrent banding.14 The submental
portal is inspected for hemostasis and packed
with moist gauze until final inspection and clo-
sure after the lateral incisions are closed.
The patient’s head is turned to the left and the
right-side neck lift incision is performed. The skin
flap is widely undermined (usually contiguously
with the area undermined via submental access).
3.5 Postoperative Care
This dissection proceeds and is completed under
direct vision with the scalpel and facelift scissors.
The lateral border of the platysma (and lower
superficial musculoaponeurotic system [SMAS] in
extended neck lifts) is identified. If laxity is
present, the lateral border of the platysma is
undermined and sutured to the SCM fascia, avoid-
ing undue tension on the midline platysmal repair.
In extended neck lifts, the platysma and lower
SMAS are plicated to the SCM fascia at three to
four points to address jowl laxity. Excess skin is
redraped, released as necessary from underlying
attachments, and excised. The earlobe should be
delivered prior to final skin flap excision to avoid a
pixie earlobe. The wound is irrigated with the
same solution used to infiltrate the skin. Final he-
mostasis is achieved; a drain (flushed with and
soaked in betadine) is inserted, brought through
the incision line, and the incision is closed. Careful
attention is paid to ensure that while redraping and
securing the skin, the hairline is preserved. Hair-
bearing skin is closed with staples. The region be-
tween the hair-bearing skin and the postauricular
incision is closed with half-buried absorbable mat-
tress sutures. The postauricular crease is closed
with 3–0 nylon. The preauricular area (extended
neck lift) is closed with 5–0 nylon sutures. The
closed-suction drain is placed in the postauricular
incision and secured with a suture. The head is
turned to the right, and the left-side neck lift is per-
formed with a similar technique. The submental
dissection is then inspected for final hemostasis
and closed with running subcuticular 4–0 Prolene
and simple 5–0 nylon sutures.
3.5 Postoperative Care
Antibiotic ointment is applied to all incisions and
around the drains. A facelift dressing consisting of
three layers of gauze strips covered with a Surginet
is placed (Dermapac, Shelton, CT). The dressings
are removed on postoperative day 1, and a neck
strap is used. Drains are removed as indicated by
volume and color over the first few days. The inci-
sions are kept moist with antibiotic ointment dur-
ing the healing process. The sutures and staples
are removed as indicated during the first 10 post-
operative days.
The patient is specifically instructed to avoid neck
flexion to minimize the risk of skin flap ischemia
and edema (S. Fredricks, personal communication).
25
 Management of the Aging Neck
Patients are additionally counseled to refrain from
any heavy lifting or strenuous activity for the first
2 weeks and to slowly return to normal levels of ac-
tivity over the third through fourth postoperative
weeks. Sun exposure and any topical therapies (fa-
cials, peels, etc.) are to be avoided for 2 to 3 months.
Laser removal of facial hair similarly cannot be per-
formed for a few months before and after surgery.
Telangiectasias and postoperative bruising can be
treated with V beam laser therapy in the immediate
postoperative period. Patients should be inspected
frequently for fluid collections, skin ischemia, or
other healing issues. Firm subcutaneous areas may
be apparent during recovery and can be gently mas-
saged, injected with intralesional steroids, or treated
with ultrasound.
3.6 Complications
Complications can vary depending on the extent of
the procedure that is performed. Most frequent
complications include hematoma and seroma. Se-
romas should be treated aggressively, and patients
should be examined frequently because seromas
tend to reoccur. Treatments include frequent aspi-
ration and compression. Small hematomas can be
treated in the office setting or emergency room
without return to the operating room (OR).15 In a
sterile environment, postauricular sutures are re-
moved, the area is irrigated with sterile cold sal-
ine mixed with local anesthetic and epinephrine,
and the blood is suctioned from under the flap.
Large hematomas should be treated emergently
in the OR. Our protocol for this is to suck out the
blood and remove suture prior to scrubbing. Then
the wound is widely opened, inspected, and he-
mostasis obtained. Rarely, but if indicated, fibrin
sealant can be used and the area irrigated before
drains are placed. Evidence has consistently sup-
ported an appropriate nontraumatic emergence
from anesthesia and a controlled postoperative
blood pressure (BP) ideally below 130 mm Hg in
avoiding a hematoma. Appropriate hypertensive,
anti-anxiolytic, antiemetic or pain medications,
and laxatives are administered as needed to
prevent spikes or elevation in blood pressure.
Although skin necrosis is infrequent, it can be a
significant complication when it occurs. We use
dimethyl sulfoxide (DMSO)16 and nitroglycerin
ointment for these issues. Facial nerve injuries
26
are less common than in facelifts but can occur.
Most often, the marginal mandibular branch and
the cervical branch are placed at risk during the
procedure if the overlying platysma muscle is
breached. This is more frequent in secondary
surgery particularly when midline surgery is
performed. It has a tendency to occur when de-
fatting just lateral to the submental incision cau-
dal to the mandible. The majority of injuries will
resolve in 6 months to 1 year. Injury to the great
auricular nerve is the most common nerve injury
in neck lift procedures. Careful attention is ad-
vised when dissecting in the lateral neck area in
the region of McKinney’s point.17
Deep vein thrombosis (DVT) and pulmonary
embolism (PE) are rare in neck lift surgeries. A
study in 2001 showed 0.35% DVT and 0.14% PE in
9,937 facelift procedures. Given the low incidence
of DVT and higher risk of postoperative bleeding
(16.2%) in patients treated with low-molecular-
weight heparin,18,19 it is not used; however, inter-
mittent compression devices are recommended, as
is early ambulation.
Infection in neck lift is also relatively infrequent.
Preoperatively patients use Hibiclens soap and hair
wash, intranasal mupirocin ointment, and oral anti-
biotics if needed. Intraoperative intravenous antibi-
otics, wound irrigation, and packing the external
auditory canal with betadine-soaked cotton plugs
are done. Infections tend to appear later, that is, 6 to
10 days postoperatively, manifested by fluid collec-
tion and erythema, and less ecchymosis than would
be seen with a hematoma. Wounds should be
cultured (including for methicillin-resistant Staphy-
lococcus aureus [MRSA] and broad-spectrum antibi-
otics coverage instituted until sensitivities return),
copiously irrigated, drained, and broad-spectrum
antibiotics used for an appropriate length of treat-
ment. The patient should be monitored frequently
and drained percutaneously as needed.
3.7 Ancillary Procedures and
Nonsurgical Treatments
Treatments to improve skin quality are important
adjuncts for optimizing outcomes. Photoaging,
perioral wrinkling, and dyschromia are treated in a
staged manner with chemical peel or laser resurfac-
ing. These procedures are safe and cost-effective

methods with significant results and a high degree
of patient satisfaction. Other surgical procedures
should be considered when analyzing the aging
neck. Neck contouring procedures can be per-
formed in combination with other surgical proce-
dures such as facelifts, rhinoplasty, and buccal fat
pad removal.6
Nonsurgical neck rejuvenation will be discussed
in detail in another chapter. These treatments
aimed at the same three treatable soft-tissue
layers. Energy-based devices treat the skin, pro-
moting collagen production texture and moderate
skin tightening as well as improving skin texture.
Fat reduction can be achieved with deoxycholic
acid or cryolipolysis. The platysma muscle and
bands can be treated with botulinum toxin, which
results in muscle relaxation and a lifting effect
(chemical neck lift, a Nefertiti lift).
3.8 Conclusion
Although emerging technologies and minimally
invasive procedures offer some degree of neck re-
juvenation, surgical procedures deliver a profound
improvement with long-lasting results. Therefore,
surgery remains the gold standard treatment for
the aging neck.
3.9 Case Examples
3.9.1 Case 1
▶ Fig. 3.1 shows the photographs of a 67-year-old
woman before and 6 weeks after a neck lift and
periocular erbium laser.
3.9.2 Case 2
▶ Fig. 3.2 shows the photographs of an 81-year-old
man before and 10 days after an extended neck lift.
3.9.3 Case 3
Case 3 is a 60-year-old woman. Her photographs
before and 3 weeks after neck lift, filler to lips,
erbium periocular/oral, and 20% trichloroacetic
acid (TCA) peel to face are shown in ▶ Fig. 3.3.
3.11 Expert Commentary by Dr. Lin
3.9.4 Case 4
▶ Fig. 3.4 shows the photographs of a 62-year-old
woman before and 6 weeks after neck lift.
3.9.5 Case 5
A 60-year-old woman a comprehensive facial and
neck rejuvenation after massive weight loss.
▶ Fig. 3.5 shows her photographs at 6 weeks after
the procedure that comprised facelift, neck lift,
brow lift, upper blepharoplasty, 30% TCA peel, and
neck lift.
3.10 Expert Commentary by
Dr. Slavin
This chapter offers an exceptional introduction to
rejuvenation of the neck. We have found that one
of the keys to a happy patient who has undergone
submentalplasty is limiting the scar to less than
3 cm so as to prevent it from riding up onto the
anterior jawline. Moreover, dog-ear corrections
can result in an unfavorable extension of the
scar. We find 3 cm keeps it hidden in the frontal
view. We caution that isolated submentalplasty
in older patients with loss of skin elasticity
should be approached with care as this problem
becomes more conspicuous posttreatment, lead-
ing to patient dissatisfaction; in such situations,
it may be necessary to bring the patient back for
skin tightening. Therefore, preoperative judg-
ment is of utmost importance.
3.11 Expert Commentary by
Dr. Lin
The authors have given an excellent summary of
their approach in the preoperative, intraoperative,
and postoperative course. I cannot agree more that
the goal of any surgery is a satisfied patient, and the
efforts to achieve that end may vary from patient to
patient. The use of TXA has definitely increased and
become routine in many practices. As we have seen
in recent studies, it can be routinely used through
several means of administration.
27
 Management of the Aging Neck

Fig. 3.1 (a–c) Case 1: A 67-year-old woman before and 6 weeks after neck lift and periocular erbium laser.

28
 3.11 Expert Commentary by Dr. Lin

Fig. 3.2 (a–c) Case 2: An 81-year-old man before and 10 days after extended neck lift.

29
 Management of the Aging Neck

Fig. 3.3 (a,b) Case 3: A 60-year-old woman before and 3 weeks after neck lift, filler to lips, erbium periocular/oral, and
20% trichloroacetic acid (TCA) peel to face.

30
 3.11 Expert Commentary by Dr. Lin

Fig. 3.4 (a–c) Case 4: A 62-year-old woman before and 6 weeks after neck lift.

31
 Management of the Aging Neck

Fig. 3.5 (a–c) Case 5: A 60-year-old woman after massive weight loss. Six weeks after comprehensive facial and neck
rejuvenation: facelift, neck lift, brow lift, upper blepharoplasty, 30% trichloroacetic acid (TCA) peel, and neck lift.

References
[1] Ellenbogen R, Karlin JV. Visual criteria for success in restor-
ing the youthful neck. Plast Reconstr Surg. 1980; 66(6):
826–837
[2] Greer SE, Matarasso A, Wallach SG, Simon G, Longaker MT.
Importance of the nasal-to-cervical relationship to the profile
in rhinoplasty surgery. Plast Reconstr Surg. 2001; 108(2):
522–531, discussion 532–535
[3] Matarasso A. Managing the components of the aging neck:
from liposuction to submentalplasty, to neck lift. Clin Plast
Surg. 2014; 41(1):85–98

32

[4] de Souza Pinto EB. Importance of cervicomental complex treat-
ment in rhytidoplasty. Aesthetic Plast Surg. 1981; 5(1):69–75
[5] American Society for Aesthetic Plastic Surgery. National Cos-
metic Surgery Databank Statistics. Accessed July 25, 2020 at:
http://www.surgery.org/media/statistics
[6] Matarasso A. Managing the buccal fat pad. Aesthet Surg J.
2006; 26(3):330–336
[7] Matarasso A, Sinno S. Isolated neck lift. In: Chung K, Thorne
C, Sinno S, eds. Operative Techniques in Facial Aesthetic Sur-
gery. Philadelphia, PA: Lippincott Williams & Wilkins;
2019:238–241
[8] Matarasso A. Managing the components of the aging neck:
from liposuction to submentalplasty, to neck lift. Clin Plast
Surg. 2014; 41(1):85–98
[9] de Pina DP, Quinta WC. Aesthetic resection of the submandibu-
lar salivary gland. Plast Reconstr Surg. 1991; 88:779–787
[10] Mendelson BC, Tutino R. Submandibular gland reduction in
aesthetic surgery of the neck: review of 112 consecutive
cases. Plast Reconstr Surg. 2015; 136(3):463–471
[11] O’Daniel TG. Understanding deep neck anatomy and its clini-
cal relevance. Clin Plast Surg. 2018; 45(4):447–454
[12] Auersvald A, Auersvald LA. Management of the submandibular
gland in neck lifts: indications, techniques, pearls, and pitfalls.
Clin Plast Surg. 2018; 45(4):507–525
References
[13] Ellenbogen R. Pseudo-paralysis of the mandibular branch of
the facial nerve after platysmal face-lift operation. Plast
Reconstr Surg. 1979; 63(3):364–368
[14] Yousif J, Matloub H, Sanger J. Hyoid suspension of the platys-
ma: a novel technique for the aging neck. Plast Reconstr Surg.
2014; 133(4 Suppl):976
[15] Baker DC, Chiu ES. Bedside treatment of early acute rhyti-
dectomy hematomas. Plast Reconstr Surg. 2005; 115(7):
2119–2122, discussion 2123
[16] Young VL, Boswell CB, Centeno RF, Watson ME. DMSO: appli-
cations in plastic surgery. Aesthet Surg J. 2005; 25(2):201–
209
[17] McKinney P, Katrana DJ. Prevention of injury to the great
auricular nerve during rhytidectomy. Plast Reconstr Surg.
1980; 66(5):675–679
[18] Durnig P, Jungwirth W. Low-molecular-weight heparin and
postoperative bleeding in rhytidectomy. Plast Reconstr Surg.
2006; 118(2):502–507, discussion 508–509
[19] Reinisch JF, Bresnick SD, Walker JW, Rosso RF. Deep venous
thrombosis and pulmonary embolus after face lift: a study of
incidence and prophylaxis. Plast Reconstr Surg. 2001; 107
(6):1570–1575, discussion 1576–1577
33
4 The Use of Platysma Window for Neck Contouring
Rod J. Rohrich, Justin Bellamy, and Nelson A. Rodriguez-Unda
Abstract
Neck aesthetics are a key component of a youthful
appearance. Mastering a safe, effective, robust, and
reproducible technique for neck contouring remains
essential for success in facial rejuvenation. Here we
describe our approach to neck and jawline contour-
ing using the lateral platysmal window, with or
without a central neck lift component. This approach
to neck rejuvenation can be performed alone; how-
ever, it becomes even more effective when com-
bined with rhytidectomy. An understanding of the
underlying anatomy contributing to neck deformity
guides the surgical approach. By using an anatomy-
driven, systematic approach as we describe here, this
technique can impart robust tightening of the lower
face and neck while simultaneously minimizing risk
of injury to nearby structures.
Keywords: neck lift, facelift, lateral platysmal win-
dow, neck contouring, neck rejuvenation
Key Points
● A sharp jawline and neck are essential to a har-
monious, youthful appearance.
● Lateral platysmal window is a safe, reproducible
approach to lateral neck rejuvenation that works
well alone or combined with rhytidectomy.
● It can be performed with or without central/
deep neck rejuvenation.
○ Dynamic bands greater than 2 cm off-midline
AND no deep neck deformity → lateral neck
only.
○ Dynamic bands less than 2 cm off-midline OR
deep neck deformity → add central neck com-
ponent.
● A 2-cm vertical incision in the platysma placed
1.5 cm below the mandibular angle and 1.5 cm
anterior to the sternocleidomastoid (SCM) muscle.
4.1 Patient Considerations,
Indications, and Contraindications
While neck aesthetics remain an essential compo-
nent of facial harmony, there are variable anatomical
contributions to poor neck contour. Careful consid-
eration to specific patient characteristics guides best
surgical interventions. In 1980, Ellenbogen and
Karlin1 highlighted the most important features of
the youthful neck, including a distinct mandibular
border, anterior border of sternocleidomastoid
muscle, subhyoid depression, thyroid bulge, and a
cervicomental angle of 105 to 120 degrees. For such
aesthetics to be realized, both the central and later-
al neck must be addressed. The treatment approach
must address skin excess, muscle laxity, fatty excess
in the deep and superficial planes, as well as skin
resurfacing. The lateral platysmal window provides
an effective, safe, and reproducible approach to
neck contouring.2 It can be easily combined with a
central neck component in severe cases, and natu-
rally fits into the flow of traditional rhytidectomy
and facial rejuvenation procedures.3
4.1.1 Who Is a Candidate?
Virtually all patients undergoing primary rhytidec-
tomy are candidates for lateral platysmal window
given the shared preauricular incision. Young pa-
tients with isolated central neck concerns who ex-
plicitly desire to avoid a preauricular incision may
be better treated with a deep central neck lift alone;
however, this is a relatively uncommon scenario. In
the revision neck lift patient, the platysmal window
remains highly effective, but the surgeon should
anticipate a potentially thin and friable platysma
requiring additional care to avoid cheese wiring of
the tissues with large movements.
4.1.2 Platysmal Bands
Particular attention should be paid toward the loca-
tion and nature of any neck bands, as this helps
determine whether a lateral-only approach is ad-
equate. Centrally located and dynamic bands (≤ 2 cm
from midline) may be difficult to adequately treat
from a lateral-only access. On the contrary, platysmal
bands greater than 2 cm from midline can be sharply
incised from above via the lateral access and redis-
tributed with the lateral platysmal window without
the need for central access.
4.1.3 The Central Neck
Preoperative assessment should evaluate for signifi-
cant subplatysmal fat, presence of dynamic central
35
 The Use of Platysma Window for Neck Contouring
bands, and the presence of ptotic submandibular
glands. The presence of any or all these features may
favor including a central neck component.
4.1.4 Contraindications
There are no absolute preoperative contraindica-
tions to lateral platysmal window. In the revisionary
case, an attenuated platysma may be encountered
with difficulty accomplishing lateral tension. Should
the lateral platysma become completely incompe-
tent intraoperatively, a central plication approach
may be preferred to avoid further cheese wiring of
the platysma.
4.2 What Technique to Use and
Why?
Patients can be stratified into three groups based
on anatomical needs and patient desires.
● Lateral neck-only. Patients with platysmal bands
greater than 2 cm off-midline and primarily sub-
mental fat can be managed with lateral platysmal
window only through face and neck lift incision.4
● Lateral and central neck. These patients may
also benefit from central neck incision to man-
age the deep neck or central bands if deformity
is present. We find, however, that in the absence
of significant subplatysmal fat, any bands lo-
cated greater than 2 cm off-midline can be man-
aged from the lateral access with myotomy/my-
omectomy.
● Central neck only. Young patients with isolated
submental adiposity without skin excess. These
patients do not require lateral platysmal window.
Their management depends upon the etiology of
their submental fullness. Central fullness attribut-
able entirely to subcuteanous adiposity may be
managed with either liposuction alone (with or
without adjunct skin tightening modalities), while
sub-platysmal fullness requires debulking of the
sub-platysmal structures and platysmaplasty. The
details of isolated deep central neck management
are beyond the scope of this chapter.
4.3 Technique: A Stepwise
Summary
● Facial/neck analysis. Paramount to safe and suc-
cessful neck rejuvenation is preoperative analysis
and planning. This involves classification of the
36
location of the platysmal band (central platysmal
bands < 2 cm off-midline, lateral bands > 2 cm off-
midline), evaluation for the presence of excess
subcutaneous fat versus deep subplatysmal fat,
submandibular gland ptosis, and any other neck
scars (e.g., prior neck lift, tracheostomy scar) that
could compromise skin perfusion.
● Incision. If deep central neck pathology must be
addressed, then the central neck component
must be performed first. A 2- to 2.5-cm incision
is made behind the submental crease. Incision
directly in the submental crease is avoided be-
cause it may exacerbate the indent at the crease.
By choosing a more posterior incision 5 to 8 mm
posterior to the submental crease, a smooth and
pleasing transition from the menton to the neck
may be accomplished. This dissection is carried
deep until the platysma is identified.
● Dissection. With an assistant applying counter-
tension on the anterior neck, dissection pro-
ceeds sharply with anterograde electrocautery
hemostasis as required. A 3-mm-thick subcuta-
neous flap is created down to the level of the
thyroid cartilage and as far laterally as ergo-
nomically achievable (this dissection will later
be communicated with the lateral neck dissec-
tion). Following skin flap elevation, residual of
the subcutaneous fat left on the platysmal sur-
face is excised under direct visualization. Prior
to proceeding, hemostasis is again confirmed
with care to avoid injury to the adjacent anteri-
or jugular veins.
● Platysmal plication. The medial platysmal bands
are identified under direct vision on both sides
and correlated to preoperative markings and pho-
tographs. Using a 4–0 braided/nonabsorbable su-
ture (Mersilene), the platysma is reapproximated
in the midline from the level of the caudal aspect
of the thyroid cartilage to the most cephalad mar-
gin of the platysma. We often perform this in a
two-layered, running fashion. Subsequently, using
an extended Bovie tip, a 2-cm platysmal wedge
myomectomy is performed at 1.5 cm below the
caudal platysmal plication. This avoids recurrent
or cicatricial banding.
● Palpation of the platysmal surface. Assess for a
smooth anterior neck surface. Any imperfec-
tions are addressed with additional undermin-
ing or excision of subcutaneous fat under direct
visualization, as needed.
● The lateral neck: incision and skin dissection.
With the central neck pathology corrected (as

indicated), the lateral neck can be addressed. The
standard intertragal incision for rhytidectomy is
adequate for lateral access. In cases of isolated
neck lift, this incision can be limited to just be-
low the tragus and carried posteriorly into the
hairline. Sharp dissection from posterior to the
midline follows. By dissecting from posterior to
anterior, the subauricular band is released and
skin mobilized. If central neck lift was performed,
this dissection should meet the previously created
space. Careful assessment of the jowl mandibular
septum area is done at this time to ensure they
have been properly dissected and are not creating
abnormal contour at the prejowl sulcus. Failure to
disrupt the mandibular retaining ligament super-
ficially can result in persistent jowling. Care must
be exercised to not penetrate deep in this area,
however, as the marginal mandibular nerve lies
just deep to the platysma/superficial musculoapo-
neurotic system (SMAS) in this region. Once the
skin has been mobilized and the cutaneous
mandibular ligament released, pulling the lateral
platysma superiorly and posteriorly should dem-
onstrate a sharp jawline. At this point, we are
ready to proceed with lateral platysmal window.
● The lateral platysmal window is made at a
point on the platysma one fingerbreadth
(1.5 cm) below the mandibular angle and one
fingerbreadth anterior to the sternocleidomas-
toid muscle. This position is selected as it avoids
injury to the adjacent great auricular nerve and
the cervical branch of the facial nerve.5,6 While
grasping this point with forceps, a 2-cm vertical
4.4 How to Avoid Bad Results/Common Pitfalls
platysmal window is created with electrocautery
or scissors. A small flap of platysma is created at
the window with 2-cm anterior dissection. Care
is taken to avoid tearing or macerating this pla-
tysmal flap as it will be used for suture purchase
(▶ Fig. 4.1).
● Fixation to the mastoid fascia. Using 4–0 Mer-
silene sutures, figure-of-eight sutures are placed
into the lateral platysmal window flap and
cabled to the retroauricular mastoid fascia in a
superior- and posterior-oblique vector (just be-
hind and below the ear lobule). Enough tension
is applied to achieve sharp mandibular pull
without cheese wiring the platysmal flap. A sec-
ond suture is placed in an equivalent fashion
just below or above the initial suture.
● Optional spanning suture. In selected cases
with thick subcutaneous tissues (e.g., in male
neck lift), a spanning resorbable suture (Vicryl,
PDS) from the submental area to the mastoid
can be placed to further define the mandibular
border (▶ Fig. 4.2).
4.4 How to Avoid Bad Results/
Common Pitfalls
While the lateral platysmal window approach to
neck rejuvenation is relatively simple and safe to
perform—fitting in most standard face and neck lift
approaches—there are some nuanced pitfalls that
should be avoided to optimize neck contour and
avoid recurrence. These are reviewed in ▶ Table 4.1.
Fig. 4.1 Inferomedial platysma is transected,
platysmal midline stitches are placed, and a
lateral window is performed.
37
 The Use of Platysma Window for Neck Contouring

Fig. 4.2 Spanning suture from the submen-

tal area to the mastoid.

Table 4.1 Pitfalls and how to avoid them

Pitfall Complication How to avoid

Incorrect location of Injury to the great Careful placement of 2 cm vertically oriented window one
platysmal window auricular nerve/cervical fingerbreadth below the angle of the mandible and one
branch of the facial nerve fingerbreadth anterior to the sternocleidomastoid muscle

Inadequate skin Contour abnormalities or Wide undermining of skin anteriorly, inferiorly, and
dissection bunching; persistent posteriorly. Focused superficial release of mandibular
jowling cutaneous ligament at prejowl sulcus. Redrape skin, assess,
and perform additional skin undermining anywhere bunching
or tethering is appreciated

Failure to divide bands Persistent or recurrent Mark bands preoperatively, identify these following skin
bands mobilization, and sharply divide the platysma from above at
the location corresponding to each band

Cheese wiring of the Inability to adequately Careful dissection of both the skin and platysmal window to
lateral platysma tension platysma; poor preserve thickness/integrity of the platysmal flap
neck contour and Tension distribution with figure-of-eight or mattress-type
persistent bands suture

Inadequate platysmal Inability to adequately Ensure tension is set adequately with the head in the neutral
flap excursion tension platysma; poor position; use posterior and superior oblique vectors
neck contour and
persistent bands

Failure to debulk Poor neck contour and Deliberate sharp debulking of preplatysmal fat along the
preplatysmal fat along the blunted jawline new mandibular border after securing the platysmal
inferior mandibular border window

38

4.5 Case Example
A 79-year-old male patient presented to the clinic
with concerns of a poorly defined jaw and neck,
with a “tired appearance.” From the facial analysis,
we can observe the following: transverse fore-
head rhytids, upper eyelid dermatochalasis, se-
vere tear trough deformities bilaterally, central fat
compartment atrophy and descent, prominent
nasolabial fold, lower third of face skin excess and
jowls, central platysmal bands (< 2 cm from mid-
line), submandibular gland prominence, blunting
of the mandibular border, and an overall oval-
shaped face.
4.5.1 Goals
● To restore central fat compartments and blend
the eyelid–cheek junction: (combination of lift
and fill facelift with lower lid blepharoplasty).
● To eliminate platysmal banding and skin excess of
the neck and restore a sharp, masculine mandibu-
lar border.
4.5.2 Approach
● Upper and lower lid blepharoplasty with lat-
eral canthopexy and release of the orbitoma-
lar ligament.
● Fat transfer to the deep central face, upper and
lower lids, lid–cheek junction, nasolabial folds.
● Submental incision, central platysma imbrica-
tion, and inferior wedge myomectomy.
● Intertragal preauricular incision and skin eleva-
tion of the face and neck.
● Deliberate release of cutaneous attachments of
the mandibular septum to address jowls.
● Supero-oblique SMAS manipulation/plication to
resuspend descended tissues of the lower face
and mandibular border.
● Lateral platysmal window for posterior-oblique
platysmal tensioning for neck and jawline con-
tour.
4.7 Expert Commentary by Dr. Lin
● Meticulous excision of residual fat on the anteri-
or surface of the platysma along and inferior to
the mandibular border.
● Sharp incision of the platysmal bands under
direct vision.
● Tension spanning suture from the menton to
the mastoid fascia for adjunct mandibular bor-
der enhancement.
The patient is shown before the procedure and at
2.5 years postoperatively in ▶ Fig. 4.3.
See narrated video for a step-by-step sequence
to the lateral platysmal window (▶ Video 4.1).
4.6 Expert Commentary by
Dr. Slavin
In patients with platysmal banding medially and
laterally, we find that the platysma needs to be ad-
dressed from both submental and lateral access.
One of the biggest challenges with platysmal
bands is recurrence of the band. In order to pre-
vent recurrence, surgeons will need to employ ag-
gressive plication techniques, as presented in this
chapter. Standard plication techniques or access
from only a submental incision is subject to a risk
of recurrence with the patient returning a year lat-
er requiring skin tightening and potential anterior
submentalplasty. While 2 cm works as a rule of
thumb in experienced hands, we caution the
young surgeon going forward with an isolated an-
terior access.
4.7 Expert Commentary by Dr. Lin
This is an excellent approach in the setting where a
submental incision is not preferred or in the cases
where central banding is not present. The platysma
layer/SMAS, as mentioned, on revision cases may be
attenuated, so care is required for meticulous tissue
handling in order to allow dissection to occur with-
out macerating this platysmal layer.
39
 The Use of Platysma Window for Neck Contouring

Fig. 4.3 (a–c) This is a 79-year-old

male patient who presented to the
clinic with concerns of a poorly defined
jaw and neck, with a “tired appear-
ance.” From the facial analysis, we can
observe transverse forehead rhytids,
upper eyelid dermatochalasis, severe
tear trough deformities bilaterally,
central fat compartment atrophy and
descent, prominent nasolabial fold,
lower third face skin excess and jowls,
central platysmal bands (< 2 cm from
midline), submandibular gland prom-
inence, blunting of the mandibular
border, and an overall oval-shaped
face.

40
 References

[3] Narasimhan K, Stuzin JM, Rohrich RJ. Five-step neck lift: inte-
grating anatomy with clinical practice to optimize results.
Plast Reconstr Surg. 2013; 132(2):339–350
[4] Cruz RS, O’Reilly EB, Rohrich RJ. The platysma window: an
anatomically safe, efficient, and easily reproducible approach
to neck contour in the face lift. Plast Reconstr Surg. 2012; 129
(5):1169–1172
[5] McKinney P, Katrana DJ. Prevention of injury to the great
auricular nerve during rhytidectomy. Plast Reconstr Surg.
1980; 66(5):675–679
[6] Rohrich RJ, Taylor NS, Ahmad J, Lu A, Pessa JE. Great auricular
nerve injury, the “subauricular band” phenomenon, and the
periauricular adipose compartments. Plast Reconstr Surg.
Video 4.1 Step-by-step sequence to the lateral platys- 2011; 127(2):835–843
mal window.

References
[1] Ellenbogen R, Karlin JV. Visual criteria for success in restoring
the youthful neck. Plast Reconstr Surg. 1980; 66(6):826–837
[2] Pezeshk RA, Sieber DA, Rohrich RJ. Neck rejuvenation
through the lateral platysma window: a key component of
face-lift surgery. Plast Reconstr Surg. 2017; 139(4):865–866

41
5 Triple Suture for Neck Contouring
Enzo R. Citarella, Ramil Sinder, Alexandra Condé-Green, Samir Janne Hasbun, and Esther Barrios
Abstract
Neck treatment is important for better contouring
and repositioning of structures that suffer from
ptosis over time. Global facial aging can be treated
by 6 vectors (V1–V6). The neck region corre-
sponds to vectors 4 to 6, which can be treated to-
gether or individually. This technique consists in
the placement of three types of sutures: a first
line of sutures tractioning the platysma and the
anterior belly of the digastric muscle, a second
single suture at the level of the thyroid cartilage,
and a third running suture starting at the level of
the thyroid cartilage up to the supramental re-
gion. With the triple-suture technique, the long-
term results are maintained in the experience of
the senior author.
Keywords: triple suture, lateral plication, liposuc-
tion, neck contouring, neck lift, facelift
Key Points
● Indications: skin excess, skin laxity, excess fat in
the submental region, and treatment of the
bands of the platysma muscles.
● Technique: triple-suture technique.
● Surgical technique: liposuction of the cervical
region. Treatment of the submental region and
platysmal bands: plication of the medial bor-
ders of the platysma muscle. Triple suture: first
line of sutures, second single suture, and third
suture line of running sutures.
● Treatment of the cervical region and the lower
face.
5.1 Introduction
Rhytidectomy was originally created as a simple
method for correction of the aging face, with resec-
tion of excess skin followed by suture of the skin
under tension. The procedure evolved to encompass
a wide range of techniques that reposition the tis-
sues of the face, in an attempt to rejuvenate the face.
The human face is composed of numerous ana-
tomical structures arranged in different depths and
proportions. It presents a high complexity in its
configuration due to the three dimensionality, with
the overlap of structures of different thickness and
consistencies, ranging from soft tissues and elastic
tissues to bone.
Since the first reports of surgical facial rejuvena-
tion by Miller1 and Kolle,2 better understanding of
the changes that occur in facial soft tissues and
that lead to an aged appearance allowed the devel-
opment of new techniques to address the specific
anatomy of facial aging.
Once the diagnosis is made, the ideal treatment is
individualized to each patient. There are different
dissection planes for each region of the face and
through these dissections, we identify six vectors of
traction. Vectors 1, 2, and 3 can be performed using
videoendoscopy. Vectors 4 and 5 are treated with a
stairlike superficial musculoaponeurotic system
(SMAS) plication with lateral traction of the platys-
ma. Vector 6 is tractioned after undermining of the
tissues of the face in a subcutaneous plane and a
subplatysmal plane, then the triple-suture technique
is performed.3
In the experience of the senior author, treating
the different regions of the face and neck through
different vectors of traction facilitates the surgical
planning indicated for each patient (▶ Fig. 5.1).4
5.2 Indications
The cervical region is a part of the surgical treat-
ment of the face. The neck lift and facelift treating
the lower third of the face are indicated when aging
is diagnosed in the superficial and deep structures
of the cervical region and also in varying degrees of
lipodystrophy.
5.3 Technique
The triple-suture technique for the submental region
combines the treatment of the vertical vector of the
submentum—V6—individually or in conjunction
with vectors 5 (lateral oblique) and 4 (SMAS stair-
step plication).
In this chapter, we describe step by step the
technique used by the senior author for treating
the superficial and deep structures of the neck.
43
 Triple Suture for Neck Contouring
Fig. 5.1 Regions and vectors: 1-V1. Vector 1 is divided
into three parts according to the areas to be treated: 1A—
head of the eyebrow; 1B—body of the eyebrow; 1C—tail of
the eyebrow. Vector 2: temporal region. Vector 3:
anteromedial middle third of the face. Vector 4: antero-
lateral middle third of the face. V5: retroauricular and
lateral cervical region. Vector 6: midline cervical region.
5.3.1 Position
This technique is performed with the patient in a
supine position, under intravenous sedation, with
the neck placed in hyperextension.
5.3.2 Infiltration
The cervical region is infiltrated with a vasocon-
strictive solution made of lidocaine 0.5%, bupiva-
caine 0.125%, and epinephrine 1:240,000.
5.3.3 Marking
Liposuction area marking and area to be treated in
the submental region is performed as shown in
▶ Fig. 5.2.
5.3.4 Liposuction
Liposuction is performed in the anterior middle
cervical region through a 0.5-cm incision in the
44
Fig. 5.2 Liposuction area marking and area to be
treated.
midline, 2 mm below the submental crease. In
patients with lateral lipodystrophy of the neck,
additional stab incisions are made under each
earlobe for lateral liposuction and improved ac-
cess to the supramandibular fat (jowl; ▶ Fig. 5.3).
Incision
The submental incision is then extended to 2.5 to
3 cm (▶ Fig. 5.4), and generous undermining is per-
formed in a subcutaneous plane in the mental and
supramental regions, as well as the central and
lateral cervical regions, releasing the mandibular
ligaments (▶ Fig. 5.5).
After undermining, we identify the medial fibers
of the platysma and its anatomical variation, as
well as its flaccidity and thickness (▶ Fig. 5.6).
Undermining is performed in a subplatysmal plane
in order to assess the medial borders of the platys-
ma and to remove any muscle excess in the midline
(▶ Fig. 5.7). The cephalic border of the platysma is
tractioned in order to remove any excess and fixate
it to the mental periosteum with repositioning of
the supra- and infrahyoid tissues.
 5.3 Technique

Fig. 5.3 Liposuction with a blunt-tip 3-mm-diameter

cannula with three holes. Fig. 5.4 Submental incision of 2.5 and 3 cm length.

Fig. 5.5 Subcutaneous undermining of the supramental

region when necessary and release of the mandibular Fig. 5.6 Visualization of the medial fibers of the
ligaments. platysma before subplatysmal dissection.

45
 Triple Suture for Neck Contouring
Fig. 5.7 (a–c) Resection of the cephalic border of the platysma then fixation to the periosteum of the mento with
MonoNylon (MN) 3–0.
Fig. 5.8 Beginning of the first line of sutures with
MonoNylon 3–0.
5.3.5 Triple-Suture Technique
First Suture
Once the fixation of the platysma to periosteum of
the mento is done, the first line of sutures approx-
imates the medial edges of the platysma in the
46
Fig. 5.9 The first line of inverted, separated MonoNylon
3–0 sutures is placed, approximating the edges of the
medial platysmal bands and the anterior belly of the
digastric muscles.
midline and the anterior bellies of the digastric
with an inverted interrupted MonoNylon (MN) 3–
0 sutures beginning in the submental region and
running down to the level of the thyroid cartilage
(▶ Fig. 5.8 and ▶ Fig. 5.9). We may observe in some
patients a herniation of the subplatysmal fat. How-
ever, since we do remove that fat, we do cauterize
it creating a lipolysis facilitating the complete pli-
cation of the midline reducing the content of the
subplatysmal fat.
 5.3 Technique

Fig. 5.10 (a,b) The second isolated MonoNylon 2–0 suture approximates in a deeper plane, the distal edges of the
medial platysmal bands at the level of the thyroid cartilage.

Second Suture
The second suture is a single MN 2–0 suture
placed at the level of the thyroid cartilage, approx-
imating the distal edges of the platysma muscles,
the anterior bellies of the digastric muscles, the
perihyoid fascia, and the superficial cervical fascia,
thereby assisting in the definition of the cervicofa-
cial angle and improvement of the flaccidity in this
region (▶ Fig. 5.10).

Third Suture
The third line of sutures is then placed, reinforc-
ing the previous ones described earlier over the
midline with running MN 3–0 or 2–0 sutures, be-
ginning approximately at the level of the thyroid
cartilage up to the supramental region depending
on each case. This suture does a vertical and supe-
rior traction of the infra- and suprahyoid tissues.
This also improves mental ptosis (▶ Fig. 5.11 and
▶ Fig. 5.12).
This line of sutures repositions the supra- and in-
frahyoid regions and deep tissues in the midline re-
positioning the submandibular glands. In patients Fig. 5.11 Marking with methylene blue of the third
who still present a herniation of the submandibular suture starting at the thyroid cartilage up to the mental
glands, we perform a plication at this level. By or supramental region.
extending above the mentum, these sutures also

47
 Triple Suture for Neck Contouring
Fig. 5.12 The third suture, a line of running MonoNylon
3–0 or 2–0 sutures, begins at the level of the thyroid
cartilage and proceeds to the supramental region,
tractioning the infra- and suprahyoid regions, finalizing
the treatment of the senile chin deformity and redefini-
tion of the cervico-facial angle.
48
correct any senile chin deformity, redefining the
cervicofacial angle (▶ Fig. 5.13 and ▶ Fig. 5.14).
5.3.6 Treatment of the Lateral
Cervical Region (V5)
It is important to note that some patients only
need the vector 6 corrected. However, in order to
obtain a better result overall, vectors 4 and 5 also
need to be addressed. The dissection is contin-
ued onto the face through a classic or reduced
retroauricular incision, which facilitates the sub-
cutaneous dissection of the lateral and posterior
parts of the neck. Undermining is continued in
the midline through the submental incision
made previously in order to join both dissec-
tions, permitting better redistribution of any ex-
cess skin.
A MN 2–0 suture is used to plicate the lateral
platysma approximately 1.5 cm inferior to the
mandibular line and the corresponding earlobe,
fixating it to the periosteum of the mastoid follow-
ing a posterior oblique vector. This further defines
the cervicomandibular angle (▶ Fig. 5.15).
The lateral platysma is then plicated parallel to
the anterior border of the sternocleidomastoid
muscle with MN 2–0 sutures, in continuation with
the previous suture placed in the periosteum of
the mastoid. In the majority of our cases, we also
treat the anterolateral middle third of the face (V4)
Fig. 5.13 Improvement of the cervical
contour after the triple-suture techni-
que.

Fig. 5.15 The posterior oblique traction of the lateral
platysma and its fixation to the periosteum of the
mastoid with MonoNylon 2–0 sutures.
5.4 Case Examples
Fig. 5.14 (a,b) A 42-year-old male pa-
tient before and after 2 years of
treatment vector 6 only.
with a classic preauricular incision following the
hairline5 and subcutaneous undermining followed
by a stairlike SMAS plication, which allows a better
definition of the mandibular contour and cervico-
facial angle, and improves the inferior one-third of
the nasolabial folds.
The technique presented here has the advantage
and differential of improving the contour of the
angle of the neck and the treatment of the deep
structures of the submentum. It is reproducible
and has shown long-term lasting results.
5.4 Case Examples
5.4.1 Case 1
MSC. A 65-year-old man who presented with
severe cervical skin laxity, ptosis of the deep struc-
tures of the neck, severe lipodystrophy, and wid-
ening of the platysmal bands. Three days after the
49
 Triple Suture for Neck Contouring

5.4.2 Case 2
triple-suture technique and lateral plication, better SC. A 53-year-old man where vectors 4, 5, and 6
definition of the cervicomental angle was achieved were treated, showing the long-term results of the
(▶ Fig. 5.16). technique at 18 years postop (▶ Fig. 5.17).

Fig. 5.16 Case 1: MSC, a 65-year-old

man who presented with severe cer-
vical skin laxity, ptosis of the deep
structures of the neck, severe lipodys-
trophy, and widening of the platysmal
bands. Three days after the triple-
suture technique and lateral plication,
better definition of the cervicomental
angle was achieved. Note the drains
used. Vectors 3, 4, 5, and 6 treated.

Fig. 5.17 (a,b) A 53-year-old man

showing the long-term results of the
technique at 18 years postop. Vectors
4, 5, and 6 were treated.

50
 5.4 Case Examples

5.4.3 Case 3 5.4.4 Case 4

LMC. A 66-year-old woman. Preoperative and 2- JCK. A 55-year-old patient. Preoperative and 2-year
year postoperative pictures showing improved postoperative pictures showing improved chin con-
jowl and chin contouring (▶ Fig. 5.18). touring (▶ Fig. 5.19).

Fig. 5.18 Case 3. LMC, A 66-year-old

woman. Preoperative and 2-year post-
operative pictures showing improved
jowl and chin contouring. Bilateral
upper blepharoplasty was performed.
Vectors 2, 4, 5, and 6 were treated.

51
 Triple Suture for Neck Contouring

Fig. 5.19 Case 4. JCK. A 55-year-old

patient. Preoperative and 2-year postope-
rative pictures showing improved chin
contouring. Vectors 1, 2, 3, 4, 5, and
6 were treated.

5.4.5 Case 5 5.5 Expert Commentary by

NFH. A 59-year-old patient. Preoperative and 3-year Dr. Slavin
postoperative pictures showing improved contour
This is a novel attempt to correct the senile chin
and angle of the jaw (▶ Fig. 5.20). deformity as most treatments do not address

52

Video 5.1 Triple suture for neck contouring.
this condition. While the second suture is a
powerful maneuver in experienced hands, it is
not clear how the third row of sutures improves
submandibular gland prominence and associated
5.6 Expert Commentary by Dr. Lin
Fig. 5.20 Case 5. NFH. A 59-year-old
patient. Preoperative and 3-year post-
operative pictures showing improved
contour and angle of the jaw. Bilateral
upper blepharoplasty was performed
and Vectors 1, 2, 3, 4, 5 and 6 were
treated.
ptosis. Usually, we find that problem needs to be
corrected lateral to midline. The authors’ results
are noteworthy for establishing a well-defined
anterior neck and hyoid contour. The illustra-
tions of patients with neck flexion are impres-
sive with the degree of improvement seen
▶ Video 5.1.
5.6 Expert Commentary by
Dr. Lin
The authors present an excellent approach to the
use of differential suture plication vectors for
maximizing neck contouring. The combination of
sutures including the second set is nicely shown
defining the cervicomental angle, which specifi-
cally fixates deeper structures.
53
 Triple Suture for Neck Contouring

[4] Citarella ER, Condé-Green A, Sinder R. Triple suture for neck

References contouring: 14 years of experience. Aesthet Surg J. 2010; 30
[1] Miller CC. Subcutaneous section of the facial muscles to erad- (3):311–319
icate expression lines. Am J Surg. 1907; 21:235 [5] Pitanguy I. Aesthetic Plastic Surgery of the Head and Body.
[2] Kolle FS. Plastic and cosmetic surgery. Ann Surg. 1911; 54:717 New York, NY: Springer Verlag; 1981
[3] Citarella ER, Pitanguy I. Videoendoscopia no rejuvenescimen-
to facial. In: Pitanguy I, ed. Cirurgia plástica: uma visão de
sua amplitude. São Paulo: Atheneu; 2016:165–180

54
6 Surgical Approach to Neck Rejuvenation
Ritwik Grover, Andrew L. Kochuba, Rafael A. Couto, Jacob N. Grow, and James E. Zins
Abstract
This chapter will highlight several important fac-
tors the surgeon must keep in mind when per-
forming a neck lift. While a brief history of the
evolution of face and neck lifting will be discussed,
the chapter primarily focuses on the anatomical
layers of the neck, with emphasis on the course of
the facial nerve, and how these layers can be ap-
proached safely and individually in order to opti-
mally improve neck aesthetics. The chapter further
expands upon the preferred techniques utilized by
these authors and also touches upon the important
pitfalls and complications that can lead the sur-
geon wayward during a surgical neck lift. We have
also added a video demonstration that highlights
our technique of establishing the most common
location of the great auricular nerve’s emergence
from the deep fascia of the neck where it is likely
to be injured. Included are figures showing the
various degrees of soft-tissue laxity of the neck
and the techniques employed to confront each of
them. Finally, given that the senior author of this
chapter is a world-renowned aesthetic surgeon of
the face and neck, we found it fitting to conclude
the chapter with expert commentary on how the
surgical approach to the neck has evolved over
time. In writing this book chapter, we truly hoped
to impart some wisdom for both novice and expert
surgeons for this alluring and delicate surgery, and
in the process, learned much about our own tech-
niques and results.
Keywords: neck lift, McKinney’s point, surgical neck
rejuvenation, great auricular, retaining ligaments
Key Points
● Thorough knowledge of the lower face, neck
anatomy, and retaining ligaments is critical to a
fundamental understanding of how to reshape
the neck with a surgical approach.
● Surgical rejuvenation of the neck can be tre-
mendously successful in reshaping not only the
aesthetic contour of the neck but also the cervi-
comental region as a whole.
● Success depends on thorough and methodical
evaluation that allows optimal patient selection
and the best chance of a pleasing aesthetic re-
sult: this includes comorbid medical conditions
that often accompany this age group.
● Surgical neck rejuvenation must be done from
an oblique and anterior approach to optimize
the vectors of soft-tissue tightening.
● Common mistakes with surgical neck rejuvena-
tion begin with a poor assessment of the etiol-
ogy of poor neck appearance: skin and subcutis
excess versus platysmal banding versus subpla-
tysmal fat excess or some combination of the
aforementioned. Failing to adequately treat
gland hypertrophy and erroneous vector of pull
on the soft tissue that may compromise the final
aesthetic appearance of the neck and cervico-
mental angle are also common pitfalls for the
novice facial aesthetic surgeon.
● Case-based examples with media supplements
and expert commentary complete this chapter.
6.1 Surgical Anatomy of the
Lower Face and Neck
Face and neck lift has changed tremendously in
the last century. Nearly 100 years ago, facial laxity
was treated with simple posterolateral skin excision
and suture closure—with only short-term success.
The modern-day face and neck lift has become an
amalgamation of decades of surgical advancement,
trial and error, and the addition of minimally inva-
sive techniques such as lipofilling. Today, most pa-
tients with concerns of soft-tissue laxity and aged
appearance of the face will arrive at their appoint-
ment with excellent background knowledge of the
available surgical and nonsurgical techniques to
treat this concern. However, few of these patients
understand the dynamic interplay between the face
and neck. To achieve maximum aesthetic success,
both the face and neck must be treated as one con-
tiguous unit. This principle must be communicated
to the patient during initial evaluation and surgical
planning. The reverse is also true: Patients with
principle aesthetic complaints regarding the neck
should also be evaluated for possible rejuvenation
of the face that will allow an elegantly blended
transition from the neck to the lower face and
beyond.
55
 Surgical Approach to Neck Rejuvenation
6.2 Anatomy
Prior to surgical intervention, it is imperative that
the plastic surgeon thoroughly understand the
anatomy of the superficial and deep planes of the
face and cervical region. One will quickly realize
that throughout the face and neck there is a fibrous
network of collagen that connects underlying fat
and soft tissue to overlying skin and dermis. This
reticular cutis creates a unique network of stringy
tetherings connecting deep tissue to superficial tis-
sue. However, there are certain regions of the mid-
face, lower face, and neck where these fibrous
strings coalesce into ribbonlike structures that may
run in transverse, oblique, or longitudinal fashions.
These ligamentous attachments connect superficial
layers of the face and neck to deep bony platforms
or fascial planes in the cervicofacial region. Accom-
panying these ligaments are nerves and vertical
perforating vessels that can make division of these
ligaments tedious and, at times, sanguineous. The
goal of the introductory portion of this chapter will
be to review the comprehensive ligamentous net-
work in the neck and lower face to help the surgeon
become familiar with this complex anatomy. Inti-
mate knowledge of these fibrous networks will
assist the surgeon in evaluating the present-day face
and neck lift patient and carry out the appropriate
surgical maneuvers to optimally correct soft-tissue
ptosis of the neck.
It is well known that the human body has con-
centric layers from superficial to deep that, despite
our contour irregularities, persist in all directions.
This is no different for the cervicofacial region. There
is a delicate layering from superficial to deep in the
face and neck that starts with skin. This is followed
by subcutaneous tissue, then the superficial muscu-
loaponeurosis incorporating the muscles of facial ex-
pression and platysma inferiorly. Then, a deep fascial
system and its associated deep muscle group lies
over the final layer, the bony platform. To review, the
superficial musculoaponeurotic system (SMAS) is a
defined aponeurotic layer laterally. It blends seam-
lessly with the temporoparietal fascia superolaterally
over the temporalis muscle and is in continuity with
the frontalis muscle superomedially. The SMAS be-
comes quite thin when advancing from lateral to
medial where it covers the orbicularis oculi. In the
lower face, the SMAS is more muscular and is in con-
tinuity with the platysmal extensions emanating
from the neck.1 Where the parotid covers the
branches of the facial nerve laterally, accidental or
56
purposeful invasion of the SMAS is allowed as the
parotideomasseteric fascia provides a protective
barrier between the surgeon and these important
neural structures. However, medial to parotid exten-
sions, it is imperative that the surgeon respect the
anatomy from superficial to deep in order to avoid
denervation of critical facial nerve branches.2,3,4
Remaining in a subcutaneous plane is always safe
with respect to facial nerve branches. SMAS plica-
tion or SMAS resection is also safe when performed
distal to the anterior border of the parotid gland
where fixed SMAS can be approximated to loose
distal SMAS. Here, muscles of facial expression are
under a well-defined SMAS layer and are also inner-
vated on their deep surface. The frontal branch is
just above the periosteum of the zygomatic arch
deep to the parotid masseteric fascia. Thus, it is safe
to delicately lift a SMAS-only layer or plicate it.
Medial to the temporal extension of the zygomatic
arch, the surgeon begins to drift into extremely
superficial muscles of facial expression such as the
orbicularis oculi where accidental SMAS injury,
muscle injury, and thus facial nerve zygomatic
branch injury are more plausible with potential
weakening of the lower eyelid.2,3,4,5,6,7,8,9
6.3 Retaining Ligaments
It is imperative to clarify the retaining ligament
anatomy throughout the lower face and neck in
order to obtain excellent surgical neck lift results.
As stated earlier, there are predictable patterns of
fibrous attachments between deep and superficial
tissues in the face and neck. These are “zones of
fixation” where gravity and soft-tissue atrophy are
unable to have an impact. Instead, these factors
will affect the soft tissue surrounding these zones
and will cause skin and subcutaneous tissue to
droop over these fixed points, creating hollows
and mounds as opposed to a smooth contiguous
surface characteristic of the youthful face. Not only
knowledge of these fibrous ribbons heralds impor-
tant landmarks for facial nerve branches but also
their adequate release is necessary to allow mobi-
lization of the soft tissue in the face and neck distal
to the ligamentous attachments in the appropriate
vector.2,10,11,12,13,14
We will begin by describing the retaining liga-
ments of the lower face. Facelift flaps have been
elevated in the standard fashion beginning in the
pretemporal hairline, advancing inferiorly in the
preauricular crease, around the lobule, and finally

into the postauricular hairline. As the surgeon
advances in a subcutaneous plan over the mandib-
ular ramus and body, along the anterior third of
the mandibular body, the surgeon will find the
cylindrical mandibular osteocutaneous ligament
attaching superficial soft tissue to the mandibular
bony platform. It is this fixed point that causes
jowling when soft-tissue descent droops over this
ligamentous attachment. Release of this ligament
will allow increased mobilization of the face and
neck lift flap. It is imperative to remember that
facial nerve branches are often closely associated
with these retaining ligaments. In addition, when
releasing the zygomatic retaining ligament in a
sub-SMAS plane, one will often find zygomatic
and buccal rami of the facial nerve just caudal to
this ligament. Further sub-SMAS dissection into
the midface and release of the masseteric retaining
ligament will also leave zygomatic, buccal, and
marginal mandibular rami vulnerable. The surgeon
must release these ligaments with patience and
diligence.11 The mandibular ligament will be
closely associated with marginal mandibular rami
that pass cranially to the ligament. The surgeon
should be aware of this location, although releas-
ing this ligament in the subcutaneous plane should
protect the surgeon from any harm to facial nerve
branches.12
Regarding facial nerve branch anatomy, Pitan-
guy’s line remains the most accurate description of
the course of the frontal branch, beginning 0.5 cm
below the tragus and progressing in a straight ob-
lique line over the middle third of the zygomatic
arch to a point 1.5 cm above the lateral brow. This
nerve stays at the level of the arch periosteum un-
til it becomes more superficial roughly 3 cm supe-
rior to the arch and innervates the orbicularis oculi
and frontalis muscles on their deep surfaces.15,16,17
The zygomatic branch passes approximately 1 cm
inferior and deep to the zygomaticus major muscle,
which has been coined the sub-SMAS danger zone.
Due to rich arborization between the zygomatic and
buccal facial nerve rami, accidental injury to one of
these branches will seldom manifest in clinical im-
plications. More relevant to this chapter, the mar-
ginal mandibular branches (1–2 rami) will be within
1 to 2 cm of the gonial angle. They are always
located superficial to the facial vessels at the antego-
nial notch. Proximal to the facial vessels they may be
cranial (80%) or caudal (20%) to the mandibular bor-
der. Distal to the facial vessels, however, they are
always cranial to the mandibular border.5,8,18 As one
6.4 Neck Anatomy
progresses even more distally to the mandibular
osteocutaneous ligament described earlier, the mar-
ginal mandibular nerve branches pass 1 cm above
this ligament where they continue to run medially
to innervate lip depressors.7
The cervical branches of the facial nerve innervate
the platysma and are likely the least encountered fa-
cial nerve branches by the cosmetic plastic surgeon.
However, the platysma muscle is an important lip
commissure depressor. Injury to these branches can
cause marginal mandibular pseudoparalysis but can
be differentiated from true marginal mandibular
nerve injury by a patient’s retained ability to pucker
and evert the lower lip.19,20 Regarding anatomical
landmarks, within 1.5 cm of the gonial angle, the
cervical branches are deep to the platysma muscle.
The cervical rami split into several branches 1.75 cm
inferior to the gonial angle. The most inferior of
these lies deep to the platysma muscle 4.5 cm cau-
dal to the gonial angle. Cross-connection between
the cervical branches, marginal mandibular ramus,
and transverse cervical nerve have previously been
described.21,22
6.4 Neck Anatomy
There are six important soft-tissue components in
the neck that one should be aware of when evalu-
ating and operating in this region:
● Fat compartments.
● Platysma muscle.
● Retaining ligaments and filaments.
● Anterior bellies of the digastric muscles.
● Submandibular glands.
● Great auricular nerve.
6.4.1 Fat Compartments
Beginning with the first component, there are
three layers of fat in the neck. The superficial-most
layer lies between the skin and platysma muscle,
known as supraplatysmal fat. The intermediate fat
layer lies within the platysma, or just deep to it
and superficial to the anterior digastric bellies.
This layer is known as subplatysmal fat. The deep
layer of fat lies deep to the submandibular glands
and anterior bellies of the digastric muscles.23
There is a decreasing amount of adipose tissue
when advancing from the superficial compartment
to the deep compartment. Most neck adipose tis-
sue is supraplatysmal, which is lobular medially
and becomes less dense laterally. Subplatysmal fat
57
 Surgical Approach to Neck Rejuvenation
can be significant to a lesser degree and oftentimes
requires excision during surgical neck rejuvena-
tion. The least amount of fat resides in the deep
compartment, and fat excision in this compart-
ment does not play a role in neck rejuvenation.23,24
6.4.2 Platysma Muscle
The platysma muscle is a filmy, thin muscle that
extends from the clavicle to the menton and crani-
ally connects with the SMAS. It separates the super-
ficial and intermediate layers of neck adipose tissue.
Seventy-five percent of patients have platysma
muscles that decussate for only 1 to 2 cm below the
symphysis menti. Fifteen percent of patients have
muscles that decussate from the symphysis menti
to the thyroid cartilage. Ten percent of patients
have no decussation whatsoever.24
6.4.3 Retaining Ligaments and
Filaments
The retaining ligaments and filaments of the neck
can be complex for the novice and even experi-
enced plastic surgeon to understand. Feldman
discusses six identifiable ligaments and three
identifiable filaments in the neck that may need
release to adequately mobilize face and neck lift
flaps. The ligaments are the mandibular, submental,
mastoid-cutaneous, platysma-auricular/ear lobe,
lateral sternomastoid-cutaneous, and platysma-
mandibular.25 The three filaments are the medial
platysma-cutaneous, medial sternomastoid, and
skin crease-platysma. There are three ligaments
that also connect the platysma muscle to deeper
soft and bony tissues. These are the hyoid, para-
median platysma, and submandibular ligaments.25
However, these three deeper ligaments are rarely
encountered during a neck lift as the platysma is
only undermined and plicated along the midline.
Regarding the six aforementioned retaining liga-
ments, the platysma-mandibular ligament con-
nects the platysma-SMAS layer to the mandibular
periosteum.25 There is some debate as to the ap-
propriate term for this ligament, some denoting it
as the mandibular septum. However, Feldman has
described the location of this ligament as inferior
and lateral to the mandibular retaining ligament.25
On cadaveric study, this ligament was consistently
found to originate from the anterior border of the
masseter at 45.6 mm from the gonial angle along
the mandibular border.7 The platysma-auricular
58
ligament has been described by Furnas as a fibrous
condensation connecting the platysma to the der-
mis in the inferolateral auricular region. The facelift
surgeon will be very familiar with this condensa-
tion when raising the postauricular portion of the
flap just inferior to the lobule. This condensation,
while irritating to transect due to associated perfo-
rating vessels, heralds an important warning to the
surgeon that the great auricular nerve is in close
proximity. Cutaneous nerve branches from the
great auricular nerve may be found among these
fibrous septa and furthermore, the tail of the paro-
tid gland may be superficial in the region of this
ligament as well.10
The submental ligaments form the submental
crease through fasciocutaneous filaments from the
platysma muscle to dermis. Often, the submental
crease is used as a natural landmark for incision
placement just above or below the crease to access
the neck from an anterior approach. However, trans-
ection of these fibers and surrounding soft tissue is
required for excess submental skin excision and
redraping in order to not accentuate the crease.26
6.4.4 Digastric Muscles
The digastric muscles play an important role in
shaping neck contour, specifically the submental
and submandibular triangles. The submental trian-
gle is bordered by the hyoid inferiorly, the anterior
digastric belly superolaterally, and the median raphe
of the mylohyoid medially with the mylohyoid mak-
ing up the floor and the symphysis menti making
up the apex of the triangle. The submandibular tri-
angle is bordered anteriorly and posteriorly by those
respective bellies of the digastric muscle, superiorly
by the mandibular border, and the floor is once
again made up of the mylohyoid muscle.27,28 Within
the submandibular triangle resides the submandib-
ular gland, facial vessels, and lingual and marginal
mandibular nerves. This triangle, of exceptional im-
portance during a neck dissection, can also be useful
in neck contouring during surgical neck rejuvena-
tion as will be described later in this chapter. Addi-
tionally, one can partially resect the anterior belly of
the digastric to smoothen the submental triangle
and allow unopposed stylohyoid pull, thus deepen-
ing and defining the cervicomental angle.29
6.4.5 Submandibular Glands
The submandibular glands can also play an impor-
tant role in neck rejuvenation. The submandibular
 6.5 Clinical Assessment, Patient Selection, and Evaluation
gland has two lobes: one superficial to the mylo-
hyoid muscle and one deep to it, with both lobes
connected by a bridge of glandular tissue. The
superficial lobe is often the larger of the two, and
when a face and neck lift flap is pulled superolat-
erally and has been defatted, the superficial lobe
may appear prominent and interfere with a
smooth cervicomental transition. While the deep
lobe of the submandibular gland is deep to the
mylohyoid and is closely associated with the lin-
gual and hypoglossal nerves, the superficial lobe
has a close association with other important facial
structures: the facial vessels and the marginal
mandibular nerve. The facial vessels have an
S-shaped anatomical course. Above the mandibu-
lar border at the gonial angle, the vessels are post-
erolateral to the submandibular gland. As one
courses anterior to the gonion, they bend just
superficial to the glandular fascia and then turn
superiorly to run above the mandibular border as
they course distally at the level of the anterior bor-
der of the masseter. Branches from the facial or lin-
gual artery provide the gland with blood supply.
The marginal mandibular nerve passes superficial
to the facial vessels and thus over the glandular
fascia deep to the platysma muscle. When sub-
mandibular gland resection is performed, only an
intracapsular partial resection of the superficial
lobe is performed to minimize risk to these impor-
tant neurovascular structures mentioned earlier.30
6.4.6 Great Auricular Nerve
While the great auricular nerve is a cutaneous
nerve of the cervical plexus and may seem less im-
portant than the aforementioned structures above,
injury to this nerve can have important ramifica-
tions on the postoperative neck lift patient. Injury
to the main trunk of the nerve can result in neuro-
mas and hypoesthesia in the cutaneous territory it
supplies. While this lack of sensation will often re-
turn, painful neuromas from the initial injury can
persist and be difficult to treat later.31 Thus, there
have been several attempts to describe the course
and location of this nerve when dissecting in the
cervical region in order to protect it. McKinney
first described the main trunk’s exit from the ster-
nocleidomastoid fascia 6.5 cm inferior to the exter-
nal acoustic meatus in the middle of the muscle
belly. This is now known as McKinney’s point.31
Further attempts have described the territory of
Video 6.1 Open anterior approach to the neck in a
65-year-old woman. This begins with wide under-
mining in the subcutaneous plane, ligamentous
release along the mandibular border, and removal of
excess supraplatysmal fat. Opening of the platysma is
routine, with dissection carried laterally to the
anterior belly of the digastric muscles. Excess sub-
platysmal fat is resected, as well as redundant
digastric muscle and submandibular gland when
necessary. Formal corset platysmaplasty concludes
this portion of the procedure.
the nerve from the sternocleidomastoid muscle
belly to its cutaneous destination. Ozturk et al
described the danger zone that is bordered by an
imaginary line perpendicular to Frankfurt’s hori-
zontal plane that bisects the lobule of the ear.
Another line is drawn from the midlobule at a 30-
degree angle posterior to the first line. This triangu-
lar territory will almost always encompass the
nerve, and dissection should become more superfi-
cial when advancing inferiorly toward McKinney’s
point (▶ Video 6.1).3,7
6.5 Clinical Assessment, Patient
Selection, and Evaluation of the
Neck Lift Patient
It is important to begin the evaluation of any sur-
gical patient with a methodical history and phys-
ical to assess if they can tolerate the physiological
rigors and potential complications of surgery. A
thorough listing of their medical comorbidities
and medications should be accounted for. This
allows the surgeon and his ancillary staff to opti-
mize every patient prior to surgery if they are a
candidate. Preoperative hypertension should be
documented and controlled with medication if
needed. Patients who are discovered to be labile
59
 Surgical Approach to Neck Rejuvenation
postoperatively should be controlled with antihy-
pertensives, such as clonidine, to avoid hematoma
collection. Additionally, having a patient quit smok-
ing temporarily for 4 weeks prior to surgery has
shown to be beneficial, although permanent cessa-
tion is ideal. It is well known that facelift flaps are
10 to 12 times more likely to have wound complica-
tions in active smokers, and routine nicotine metab-
olite testing should be employed if there is suspicion
of noncompliance.32 Supplements and nonsteroidal
anti-inflammatory drugs (NSAIDs) that can cause
bleeding diatheses should also be discontinued 2
weeks prior to surgery. Finally, women on oral con-
traceptives will have an increased likelihood of
deep vein thrombosis (DVT) during a prolonged
surgery, especially when combined with smoking,
so a discussion should be had with patients regard-
ing temporary cessation for 2 weeks prior to sur-
gery. The surgeon should be capable of calculating
the Caprini score on all patients to fully and objec-
tively evaluate DVT/pulmonary embolism (PE) risk
prior to prolonged surgery. It is important to re-
member the importance of thorough evaluation of
the face and neck lift patient as they often present
at an advanced age with natural progression of
comorbid illnesses.
Rarely does rejuvenation of the face and neck
exist in isolation of one another. While the focus of
this chapter will be on the neck and the lower face,
when planning operative intervention, a thorough
and methodical evaluation of every patient’s face
and cervical region together is imperative to
achieving excellent results. For nearly a century,
facelifts relied purely on posterolateral preauricu-
lar skin excision with primary closure to re-elevate
ptotic facial soft tissue. However, just as the masto-
pexy evolved into reshaping and anchoring the
structure of the breast as opposed to simply re-
draping skin, so has the face and neck lift evolved
to encompass longer-lasting structural maneuvers
as opposed to skin-only procedures.
When evaluating the neck lift patient, in addition
to a full-face examination as mentioned, soft-tissue
quality should primarily be assessed from the ster-
nal notch to the lower lip. It is important for the
cosmetic surgeon to assess every soft-tissue layer of
the face and neck, beginning preoperatively with
the most superficial layers, and then intraopera-
tively under direct vision of the SMAS/platysma
and subplatysmal fat. During initial clinical assess-
ment, the patient’s skin quality should be noted.
60
It is important to educate the patient that skin
quality will naturally decline with age: a result
of apoptosis in the epidermal layer, reduction in
the number of melanocytes, as well as atrophy of
dermal collagen and appendages.33,34 Outside of
these intrinsic factors, the patient should also be
educated on the external forces that alter skin qual-
ity such as smoking, weight fluctuation, sun expo-
sure, medical comorbidities, and collagen vascular
diseases. All of these forces can cause skin elastosis,
or an inability for the skin to recoil as it once did.
This is important to note, and also to discuss with
the patient because neck rejuvenation relies heav-
ily on skin recoil in order to achieve excellent
results.35 When skin quality is a significant problem,
ancillary techniques such as filler, chemical peels,
and injectable lipolysis can be helpful and will be
touched upon in other chapters of this book.
When evaluating the face, it is important to do
so in a standardized fashion that allows consistent
analysis of problem regions. We prefer to divide
the face in vertical thirds and horizontal fifths to
allow side-to-side comparison and plan for surgi-
cal or minimally invasive maneuvers that can help
achieve the patient’s goals. Evaluation should be
done with the patient seated so that the surgeon
can assess the full effects of gravity on the soft tis-
sues. The patient should also be assessed in both
repose and with dynamic animation, not only to
evaluate facial nerve function but also to under-
stand the power of that patient’s muscles of facial
expression and their effect on skin wrinkling. As
the surgeon’s assessment moves toward the lower
face and neck, it is important to notice the natural
differences in soft-tissue characteristics between
these two regions. Neck skin tends to be thinner
than facial skin and has less elasticity. The neck
soft tissue exists in layers just as in the face: skin
followed by superficial subcutaneous fat overlying
the SMAS/platysma unit, followed by a deeper
subcutaneous layer, and finally the deep fascia
overlying critical cervical structures. Knowledge of
these contiguous layers in the face and neck allows
the surgeon to navigate the cervicofacial region
freely, blending these regions seamlessly. Patients
should also be thoroughly educated on the impact
of a neck lift. It will have its most powerful influ-
ence on the neck profile, helping turn an obtuse
cervicomental angle into a narrower one. It will
have little effect above the lower mandibular
border, so patients with concerns of lower face
 6.5 Clinical Assessment, Patient Selection, and Evaluation
ptosis and jowling should be educated that these
concerns may not be completely corrected by
neck rejuvenation alone. In fact, an improved
neck contour can further highlight contour defi-
ciencies of the lower face.
Aging of the neck can be due to a multitude of
factors in any of the aforementioned layers of the
neck from superficial to deep: excess skin of poor
quality, excess preplatysmal fat, platysmal laxity
and banding, digastric hypertrophy, submandibu-
lar gland ptosis, and hyoid anomalies.36 True and
moderate excess skin of the neck requires at least
a postauricular facelift incision in order to excise
skin and pull the soft tissues in the appropriate
posterolateral vector. Mild to moderate skin excess
may be treated with a minimal-access facelift inci-
sion and submental incision with neck skin redrap-
ing. Many cosmetic surgeons feel that minimal skin
excision is necessary in the patient with mild to
moderate skin excess.37,38,39,40,41,42,43,44 This is be-
cause centrally, platysmal plication and concomi-
tant facelifting with posterolateral traction on neck
skin will create a more submandibular surface area
that will need skin coverage. These maneuvers con-
vert an obtuse cervicomental angle into an acute
one, requiring the excess skin for redraping this
increase in surface area and definition.45
Assessment of the face and neck can be done
rapidly in the clinical setting as well as with pho-
tographs taken at the time of the consultation.
When assessing the face in vertical thirds, the low-
est third is the most relevant to neck rejuvenation
due to proximity. Lower face deficiency, whether it
be in the sagittal, axial, or coronal plane, can signif-
icantly impact facial aging.46 The lower face ex-
tends from the oral commissure to the menton. It
is imperative to remember that all layers of the
face age with time, including the bony platform,
and all layers need to be assessed and corrected in-
dividually. In the lower face, this includes atrophy
of the bony mandible and menton. A deficient
menton in the vertical or horizontal plane fails to
put appropriate stretch on the neck soft-tissue
envelope and can thus contribute to skin and pla-
tysmal banding as well as an obtuse cervicomental
angle. Performing a vertical or horizontal genio-
plasty (or implant) at the time of neck lift may be
required to expand the neck soft-tissue envelope
and achieve the appropriate cervicomental angle.
Further, the gonial angle in the lower face should
be thoroughly assessed as a part of neck rejuvena-
tion. Defining the inferior mandibular border is
essential to a youthful appearance. The gonial
angle can at times be masked by excess subcutane-
ous tissue directly overlying it, or just posterior
and inferior to it.47 This can leave the lower face
looking widened and aged, and can contribute to
the appearance of jowling. Fat resection over the
gonial angle, posterior and inferior to it, can define
the mandibular border and narrow the lower face.
Rotational SMAS flap tightening in the postauricular
region followed by central platysmal tightening will
help polish these landmarks. Platysmal banding
should also be assessed. Treating muscle laxity and
dehiscence with skin redraping only will inevitably
result in recurrence. Pre- and postplatysmal fat
should also be assessed in the clinical setting. Prepla-
tysmal fat excess can be evaluated by asking the pa-
tient to grimace to note laxity in the muscle versus
the subcutaneous layer covering the muscle. Postpla-
tysmal fat is exceedingly difficult to assess in the
clinical setting. Any doubt should warrant platysmal
division and fat assessment intraoperatively.48
6.5.1 Classification System
Our preferred method of isolated surgical neck re-
juvenation is the anterior approach that has been
well described by numerous authors. While minor
variations exist within the anterior approach
method, they all rely on the same principles of di-
vision of neck retaining ligaments and cutaneous
septa, relying on the neck skin’s unique ability to
contract and scar down to the platysma in a re-
draped fashion. This ability was discovered almost
on accident by early proponents of neck liposuc-
tion.29,49 However, while liposuction addresses the
preplatysmal fat and skin excess with its promo-
tion of scarring, the anterior open approach allows
for more finesse maneuvers to be added to neck
rejuvenation. Three main advantages of the open
approach are as follows: removal of fat in all layers
relative to the platysma, the ability to open the
platysma to treat digastric hypertrophy or sub-
mandibular gland ptosis, and the ability to plicate
the platysma and treat banding in order to restore
a youthful cervicomental angle.50,51 All neck ma-
neuvers accomplished with a traditional facelift
can be accomplished with the anterior open ap-
proach as well, except for the rotational SMAS flap
that tightens the platysma around the gonial angle
of the face.52
We used the Knize classification system based
on the obliqueness of the cervical mental angle.
61
 Surgical Approach to Neck Rejuvenation
Grade I patients have no neck skin laxity, grade II
patients have mild neck skin laxity, grade III
patients have moderate neck laxity, and grade IV
patients have severe neck skin laxity (▶ Fig. 6.1).53
A four-tier grading system allows the surgeon to
classify patients appropriately during their clinic
assessment and mentally prepare for the optimal
treatment approach to be executed in the operative
setting. Typically, grade I patients can be treated
with liposuction alone, as this maneuver treats pre-
platysmal fat excess and allows the overlying skin
to adhere tightly to the underlying platysma layer.
However, if a grade I patient is suspected of having
mostly intraplatysmal or subplatysmal fat, then
the anterior incision must be made to allow the
surgeon to treat these problem regions directly.
However, in the clinical setting, it is difficult to
determine how much excess neck subcutaneous
tissue is preplatysmal versus subplatysmal. The
grimace maneuver can be useful here. If the skin
flattens over the platysma with this maneuver,
more subcutaneous tissue can be expected to be
intra- and subplatysmal rather than overlying the
platysma muscle (▶ Fig. 6.2).
Grade II patients who also have an obtuse cervi-
comental angle are good candidates for the anterior
approach. Both preplatysmal and subplatysmal fat
Fig. 6.1 (a–h) Knize’s classification system. Reproduced with permission from Kochuba AL, Surek CC, Ordenana C,
Vargo J, Scomacao I, Duraes E, Zins JE. Anterior Approach to the Neck: Long-Term Follow-Up. Aesthet Surg J. 2021
Jul 14;41(8):861–870.
62
can be resected. Skin can be widely undermined
laterally to the gonial angle and sternocleidomas-
toid, and inferiorly to the level of the thyroid carti-
lage. This allows for clear visualization of the entire
platysma for plication, treatment of banding, as
well as redraping of skin to fit the new, narrower
cervicomental angle. Again, because an obtuse an-
gle is turned into a narrow one, more skin, not less,
is needed to cover this increased distance. Thus,
after the aforementioned maneuvers, neck skin is
never resected anteriorly. In fact, neck skin should
be preserved to adequately redrape over the in-
creased submandibular surface area (▶ Fig. 6.3).45
Grade III patients can become challenging with
moderate skin laxity. Again, adequate undermin-
ing to the borders of the platysma is necessary in
order to break up cutaneous ligaments in order for
skin redraping and scarring over the platysma. It is
important to note that with greater undermining
and preplatysmal fat resection comes greater re-
sponsibility of creating uniform neck lift flaps. The
increased surface area on which the neck skin will
scar down to the platysma creates more opportu-
nity for contour deformities to expose themselves.
Thus, the more maneuvers exercised in an open
approach neck lift, the more care must be taken.
When a full face and neck lift is being performed,
 6.5 Clinical Assessment, Patient Selection, and Evaluation

Fig. 6.2 A 52-year-old woman presenting with an obtuse cervicomental angle and neck laxity (top). She underwent isolated
submental lipectomy and platysmaplasty. Postoperative photographs were obtained at the 12-month follow-up (bottom).

this presents less of a challenge as postauricular possible.45,54 Similarly, ptotic submandibular

flaps allow for excellent visualization of the neck
from several angles. However, when doing an an-
terior approach only, maintaining uniformity of
the flaps while excising pre- and postplatysmal
fat takes undivided attention and careful prog-
ress. While skin laxity may dictate the treatment
algorithm the majority of the time, certain patient
characteristics may require different maneuvers.
Patients with heavy necks, regardless of skin lax-
ity and fat excess, may require some skin excision
to allow the smoothest cervicomental contour
glands can also become exposed when preplatys-
mal fat is thinned and platysmal banding is pli-
cated. These glands can then become a bulging
nuisance in the submandibular triangle and the
superficial lobe may need to be excised to restore
smooth neck contour. Others, such as our group,
suspend the submandibular gland rather than ex-
cise it, which reduces, but does not completely
resolve, the ptosis (▶ Fig. 6.4).
Grade IV patients have severe neck skin laxity,
which will not have a good result from an open

63
 Surgical Approach to Neck Rejuvenation

Fig. 6.3 A 57-year-old woman who presented with an obtuse cervicomental angle with submental and submandibular
lipodystrophy and prior thyroidectomy scar retraction (top). She underwent anterior lipectomy and platysmaplasty in
addition to transconjunctival lower lid blepharoplasty. Postoperative photographs were obtained at the 14-month
follow-up (bottom).

neck lift alone. These patients need a standard face-
lift in combination with a neck lift to resect excess
skin and pull the neck skin in the appropriate vector.
A final option for these patients is direct excision
with opposing Z-plasty closure to allow for as much
neck mobility as possible (▶ Fig. 6.5).54,55,56
We as a group do not believe in spanning sutures.
Again, the success of neck lifting depends on the
elasticity of the skin and its ability to scar down
to the underlying muscle platform once cutaneous
septa are divided. The undermined region of neck
skin should progress as far as skin laxity extends. For
instance, in patients with lateral skin laxity, under-
mining can be done as far as over the entire sterno-
cleidomastoid muscle. In our hands, we find that
contouring the neck with this approach, along with
fat resection and primary muscle plication, gives a
long-term, natural-appearing neck as opposed to the

64
 6.6 Operative Technique

Fig. 6.4 A 50-year-old woman who presented with an obese neck, neck laxity, and lipodystrophy of the neck (top). She
underwent anterior lipectomy and platysmaplasty in addition to bilateral upper eyelid blepharoplasty. Postoperative
photographs were obtained at the 18-month follow-up (bottom).

tight, bandlike appearance in the submandibular tri-
angle that sometimes accompany spanning sutures.
6.6 Operative Technique
It is imperative that the patient be marked in the
seated or standing position to understand the full
nature of neck skin, fat, and platysma laxity. Mark-
ings can incorporate a variety of planning steps.
The incision can be marked over or below the sub-
mental crease. Additionally, the lateral extent of
skin undermining can be marked as well. Platys-
mal banding can be marked and further delineated
with the grimace test, as well as differences in re-
gions of pre- versus subplatysmal fat. After induc-
tion, the patient’s neck is infiltrated with 50 mL of
0.5% lidocaine with epinephrine 1:200,000. This is
infused in the preplatysmal plane, with extra care
laterally where the external jugular vein is superfi-
cial and can be accidentally cannulated. The sur-
geon should have already decided at this point
whether or not liposuction of the neck will be the

65
 Surgical Approach to Neck Rejuvenation

Fig. 6.5 A 57-year-old woman who presented with facial aging including jowling and an obtuse cervicomental angle with
skin laxity in the neck (top). She underwent rhytidectomy with an extended superficial musculoaponeurotic system
(SMAS) and anterior lipectomy with platysmaplasty. Postoperative photographs were obtained at the 12-month follow-up
(bottom).

primary mode of intervention. If this is the case,
well-disguised stab incisions in the submental
crease and postauricular region should be made.
Liposuction should be performed with utmost
care as uneven preplatysmal liposuction or overly
aggressive maneuvers can result in an uneven
contour of the neck with poor scarring to the pla-
tysma. It should be done in a crosshatch fashion
to ensure an even plane of subcutaneous tissue
remains over the platysma muscle for optimal
contour and scarring.
If direct surgical rejuvenation is the modality of
choice, liposuction should be avoided at the start
of the case as blunt cannula trauma to the platysma
and preplatysmal fat will bruise and distort the
plane necessary for supraplatysmal dissection. Once
the submental incision is made, usually 3.5 cm in
length, the supraplatysmal fat is undermined in an

66

even plane laterally to the level of the anterior ster-
nocleidomastoid muscle and inferiorly to the level
of the thyroid cartilage. The skin flap can be ele-
vated from the platysma leaving all the fat on the
skin flap or the skin flap can be raised leaving 3 cm
of fat on the flap with the remainder on the platys-
ma. Ultimately, it is the surgeon’s choice. An even
layer of fat should be left on the platysma. This
avoids having to defat the elevated flaps, which can
sometimes result in uneven contour when they scar
back down to the platysma.
Once the fat to be resected is removed from the
platysma, the actual muscle belly is opened mid-
line from the level of the submental incision to the
thyroid cartilage. This is done with cautery as the
muscle and subplatysmal fat are much more vas-
cular, and not infiltrated with epinephrine solution
as compared to the supraplatysmal fat. Once the
muscle has been divided in the midline, the sub-
platysmal fat becomes visible and is shaved as nec-
essary until it is flush with the anterior digastric
bellies. The dividing of the platysma muscle and
deep fat resection should extend down to the level
of the thyroid cartilage and laterally to the anterior
belly of the digastric muscle. At this point, maneu-
vers for contouring the deeper layers of the neck
can be carried out. Plication of the anterior digas-
tric muscle bellies can be done, and conversely,
shaving can be done if they are bulky and contri-
buting to the poor appearance of the medial neck.
The superficial lobe of the submandibular gland
can also be excised or partially excised for a
smoother-appearing submandibular triangle. It is
important to remember that anastomosing veins
from the internal jugular system are often encoun-
tered and should be avoided along the neck mid-
line at the level of the hyoid.
Before the final platysmaplasty is performed, a
short postauricular incision is made behind the
ear to allow for the lateral and posterior most dis-
section of the subcutaneous neck flaps. This is es-
pecially useful in severe neck skin laxity patients,
where the entire cutaneous septa overlying the
sternocleidomastoid fascia should be divided as in
a full face and neck lift. This posterior incision also
serves as a potential site for skin excision if needed
and can serve as a drain insertion site. Finally, we
choose to perform a corset platysmaplasty. With
two forceps, the horizontal laxity of the platysma
can be measured and marked with brilliant green.
Then, a 3–0 PDS suture can be used in a running
fashion to plicate the platysma from the chin to
6.8 Complications
the level of the thyroid cartilage. The same suture
can be run back superiorly to gather further excess
platysma, completing the stitch with a buried knot
superiorly. The incisions are closed by surgeon pref-
erence, although over time we have chosen to close
both of these potentially tense and mobile regions—
the submental and postauricular incisions—with
interrupted 4–0 Monocryl subcuticular and run-
ning 5–0 FAST sutures.
6.7 Postoperative Care
A 7-Fr channeled drain is used on each side of the
neck, exiting through the postauricular incision
site or adjacent to it. The patient is fitted with a
chin strap dressing that allows even coaptation of
the neck flaps to the platysma and minimizes dead
space for fluid collection. Patients are instructed to
wear this at all times aside from showering. The
drains are removed at 24 hours after surgery dur-
ing routine follow-up on postoperative day 1. At
this time, as long as the drains have egressed less
than 30 mL in a 24-hour period, they are removed.
If they remain high, then we keep them in place
until they fall under that mark. On the first post-
operative day visit, the patient’s dressing is also re-
moved, and the contour of the neck skin is checked
for smooth inset and vector of pull. This is a time
for potential gentle manipulation and massage if
unevenness is noted, although whether it helps in
smoothing the contour is strictly anecdotal. The
neck dressing is to be worn at all times for 5 days
after surgery. At that point, it can be transitioned
to nighttime wearing for the following 2 weeks.
6.8 Complications
The most common complications encountered
after surgical neck lifting are results of judgment
or technical errors. Skin irregularities are often
the result of inadequate skin undermining, and
patients must be counseled on the need for po-
tential revision postoperatively if this occurs.
Contour irregularities, on the other hand, are the
result of uneven fat resection in the supraplatys-
mal or subplatysmal plane. We advise finding a
uniform thickness on the neck lift flap as the sur-
geon begins the procedure, with constant check-
ing to make sure the undermining is even. What
fat remains on the platysma should then be re-
sected. This minimizes the chances of contour
67
 Surgical Approach to Neck Rejuvenation

irregularities as opposed to undermining a complete
adipocutaneous flap off of the platysma and then at-
tempting to shave the skin flap uniformly. Irregular-
ities will also have to be discussed with the patient
postoperatively for potential revision. Inadequate fat
resection is easier to manage, as it requires a redo
secondary procedure. Over-resection can result in a
skeletonized-appearing platysma and may require
fat grafting and skin redraping. Thus, it is much bet-
ter to err on the side of conservative resection.
There can be areas of fullness caused by seromas
or hematomas. Diligent intraoperative hemostasis
is the most assured way to combat this postopera-
tive complication. However, if fluid collections do
occur, they should be aspirated immediately and
followed by consistent compression with a chin strap
dressing in order to allow collapse of dead space.
Finally, there can be submental ridging or fullness
that results from a poorly performed platysmaplasty.
Again, diligent intraoperative decision-making, and
constant palpation of the platysmaplasty to make
sure there is smooth transition from the menton to
the submental region, is imperative. If the muscle is
plicated poorly, dog-ears will most certainly show
through the neck skin. The bulges in this region can
also be the result of inadequate resection of digastric
hypertrophy or submandibular gland ptosis. Many of
these complications can be avoided by a thorough,
methodical operative routine that the surgeon will
come up with as he or she experiences more neck
lifting cases. Raising the patient’s back and head at
the end of the case prior to completion can also
allow the surgeon to see the “finished product” with
gravity in play. This is also an opportune time to
check for any of the aforementioned complications
or judgment errors.
6.9 Commentary by Dr. Zins
The anterior approach to the neck has been de-
scribed by numerous authors including Feldman,
Knize, Ramirez, and myself. The operation requires
a submental incision only. No skin is excised. It is
not technically challenging; the recovery is rapid
and the results are consistent in properly selected
individuals. And yet I am repeatedly surprised that
when presenting this technique many plastic sur-
geons remain unaware of its benefits and utility.
The procedure yields more consistent results
and has as rapid a recovery as minimally invasive
techniques such as Kybella and radiofrequency
devices. It requires only minimally more time,
effort, and expertise than isolated submental and
submandibular lipoplasty alone. The operation
should be in the armamentarium of every plastic
surgeon performing cosmetic surgery.
6.10 Expert Commentary by
Dr. Slavin
The authors’ meticulous attention to anatomical
detail is to be applauded, and it is clear that they
are masters of facelift anatomy. It is a careful ana-
lytical, anatomical, diligent approach that works
well in the authors’ hands. One of the keys to a
happy facelift patient is preventing skin irregular-
ities and contour deformities, as highlighted by the
authors. Correcting skin irregularities can be a
time-consuming correction that requires complete
re-elevation of the skin flaps, so they are best man-
aged at the time of the initial operation. Moreover,
when the fatty component of the deep compart-
ment is causing contour irregularities, our prefer-
ence is to excise it, particularly anteriorly. In the
heavier (grade III–IV) necks, we agree with the
authors’ preferred management. I would add, we
are wary of liposuction on the neck in older
patients and restrict it to patients with grade I
laxity. In these young patients (in general, under
40), the need for skin excision can be obviated
with thoughtful liposuction alone. With regard to
submandibular gland ptosis, it can be effective
initially to pexy the gland and in our practice, the
results with pexy of the gland have lasted 3 to
5 years.
6.11 Expert Commentary by
Dr. Lin
In an era where numerous devices for nonsurgical
soft-tissue tightening and injectables are available, I
agree that a direct open approach, for instance, to
the anterior neck is effective. By the time patients
have had several Kybella injections, which are often
painful, without enough improvement, a more
open approach is not only warranted but also likely
may have been indicated in the appropriate patient
at the outset. Wide undermining is key for smooth
redraping, and it is important to counsel the patient
on the potential recurrence of neck banding and
jowling over time.

68

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7 Deep Plane Neck Lift Concepts and Technique
Benjamin Talei, Hedyeh Ziai, and Daniel J. Gould
Abstract
Modern approaches to the neck involve different
concepts including distributed tension, platysmal
manipulation, and varying degrees of interventions
to the deep neck space. The benefit of a deep plane
approach lies in the ability to release tension in the
neck and face. Once the platysma has been released
from the components of the deep neck space and
surrounding tethering points, it can be repositioned
and redraped in a tension-free manner. Aside from
lifting, one must realize the importance of restoring
the deep space compartments internally. This pro-
vides improved contour restoration as well as a
tension-free excision of any excess skin, which con-
sequently helps avoid earlobe-related complications,
widened scars, and an odd or pulled look. The deep
plane is a more logical and natural approach to lift-
ing of the face and neck, lifting along the natural
anatomical glide planes.
Keywords: deep plane facelift, deep plane neck lift,
direct neck lift, facial rejuvenation
Key Points
● Deep plane neck lift involves release from the
deep facial cervical structures.
● Tension is released, then soft tissues are redis-
tributed with a deep plane neck lift.
● Re-compartmentalization is a key concept in
neck contour restoration in all dimensions.
● There are danger zones to avoid risk of depressor
anguli oris (DAO) weakness or facial paralysis.
● With the release of tension, the skin closure is
tension free and the appearance is distinctly
natural.
7.1 Patient Considerations,
Indications, and Contraindications
7.1.1 Patient Considerations
To properly understand deep plane lifting, a better
understanding of prior and modern techniques is
required.1,2,3,4,5 In our opinion, the optimal techni-
que for neck lifting is the deep plane lift with full
release and tension-free suspension.4,5,6,7
Patient complaints about the neck typically pre-
cede those of the face.8 The neck may experience
accelerated aging relative to the remainder of the
face for a variety of reasons. With age, each side of
the face gravitates and descends into the neck in a
pendular fashion, meaning an additive effect of
bilateral descent may occur in the neck. This direc-
tion of aging continues over the sternum and
clavicles, causing changes in skin quality and loss
of radiance over time. Additionally, midline verti-
cal descent may occur in the submentum. Droop-
ing in the neck may occur with or without skin
laxity. Volume excess may also be present during
youth or it may worsen with age. Superficial to the
platysma, we typically only consider subdermal or
supraplatysmal fat. Maintenance of a layer of fat is
essential to avoid visible banding and a deflated
appearance in the skin. The submandibular glands
commonly descend with age, although hypertro-
phy may be present in a subset of patients as well.
Bulging of the anterior belly of the digastric may
be present from hypertrophy in some cases or
from incorrect vector of pull in revision cases. In
some patients, aberrant excess volume lateral to
the hyoid may exist. This could be from fatty or
lymphatic tissue and in some cases glandular tis-
sue presenting as an anterior and medial extension
of the lower pole of the submandibular gland.
With age, the parotid glands tend to bulge out-
ward as the strength of overlying encapsulation
from the superficial musculoaponeurotic system
(SMAS) and platysma diminishes. The tail of the
parotid may become more prominent as well,
blunting gonial angle definition substantially. On
the face, the lateral cheek may become hollower as
the soft tissue of the cheeks descends in a pendu-
lar fashion. The physician must analyze the charac-
teristic changes noted in each individual face to
plan the most appropriate course of action. If the
cervicomental distance appears short, the physi-
cian must determine if it should be lengthened
internally by contouring around the lifting against
the hyoid or by performing chin augmentation. All
too often, gratuitous chin augmentation is per-
formed to camouflage issues with inadequate lift-
ing. In some cases, prominent dentition may lead
the practitioner to believe that chin augmentation
would provide better balance. In many of these
71
 Deep Plane Neck Lift Concepts and Technique
cases, the female patient may become more mas-
culinized when all that was needed was a more
thorough neck surgery. Rather than adding vol-
ume to the chin, one might benefit more from
gently excavating the pre- and peri-hyoid region
to create depth without hollowing. Blunting of
the cervical angle may also be addressed this way
by contouring the deep cervical fascia.
Aging and lifting of the neck need to be under-
stood in three dimensions in order to perform
adequate treatments. The surgeon must restore
depth and contour to a neck that has aged out-
ward, anteriorly and inferiorly. Hence, the vectors
of lifting should be inward, posterior, and superior
all at once. Releasing the neck in a deep plane
allows the surgeon to manipulate the platysma as
a sling or hammock around deep compartments,
using the submandibular gland zone and lateral
hyoid as the fulcrum for submental and lateral
neck lifting. Vectors of suspension must always fol-
low the natural anatomy. In the face, the cheek
mostly ages along the vector of the zygomaticus
musculature, perpendicular to the nasolabial folds.
Hence, lifting occurs in the opposite direction. In
the neck, the lateral platysma ages around the hy-
oid and must be lifted vertically in the direction of
the posterior digastric muscle to avoid residual
laxity or improper pull on the anterior belly of the
digastric. Lateral lifting of the platysma may cause
a bulge in the submandibular triangle along the
line of the digastric. This is commonly and errone-
ously described as digastric muscle or submandib-
ular hypertrophy. Realistically, deep plane release
and a proper vector of pull would have prevented
this from occurring.
The surgeon must analyze the neck from all
directions. From the anterior view, the width and
circumference of the neck should be diminished to
maintain proper depth relative to the jawline. One
may use the image of placing a hand around the
neck and squeezing in order to narrow the radius of
the internal angle of the neck extending from the
mastoid to the hyoid to the contralateral mastoid.
This will assist the surgeon in envisioning the
changes needed in order to restore depth and re-
compartmentalize the deep space components in
the neck while avoiding untoward pull and tension.
7.1.2 Indications
Patients with laxity, drooping, sloping, or aging of
the neck are deep plane neck lift candidates. Jowl
72
formation often indicates that drooping and aging
in the face and neck have occurred. Some patients
may present with an obtusely angled neck from a
very young age. These patients are candidates as
well if they would not benefit adequately from lip-
osuction or radiofrequency (RF) treatments. Ptosis
of the submandibular triangle and submandibular
glands typically requires vertical vector deep plane
lifting to correct. Skin laxity may or may not be
present. Platysmal banding may also be treated
with deep plane neck lifting by treating the platys-
ma from a midline or lateral approach. In some
cases, the deep cervical fascia may contribute to
banding and this may be treated as well during a
neck lift. Patients with prior face or neck lifting
with inadequate results or those who have aged
out of their prior lifts are also good candidates for
this procedure.
7.1.3 Contraindications
There are few contraindications to deep plane neck
lift as a method. Prior neck surgeries, including
parotidectomy, are not contraindications although
greater care must be taken with these patients.
There are relative contraindications to neck lifting
in general, such as uncontrolled hypertension,
blood thinners, and generalized anxiety disorder,
but this is not the desired scope of this chapter.
7.2 What Technique to Use and
Why?
The authors recommend a modified extended ver-
tical vector deep plane face and necklift in patients
with soft-tissue ptosis and skin laxity. It is incor-
rect to assume that younger patients would bene-
fit from miniature forms of lifting as they typically
have denser tissues and require more substantial
release of tension to obtain a noticeable result and
avoid scarring. If it appears as though drooping
has occurred in the neck without any substantial
skin excess, an internal neck lift may be performed.
An internal neck lift encompasses a lateral and mid-
line platysmaplasty through minimal access inci-
sions and is typically combined with Profound RF—a
bipolar RF treatment to improve skin tightness and
quality.
It is very important to consider the three-
dimensional aspects along with the contrary lift-
ing that is required to re-compartmentalize the
submandibular contents and lift the neck naturally

and effectively. As the face and neck descend with
age, the major salivary glands commonly protrude
and descend as well. The platysmal drape can be
manipulated to resuspend the submental contents
and restore the submandibular angulation while
also lifting the lower neck across the clavicle.
Although most authors discuss the vertical vectors
of lifting only, it is of equal or greater importance
to understand the depth of lift that is required to
achieve the best result. The contents of the subman-
dibular region and gonial angle tend to lateralize
with age; hence, upon lifting, they must be inter-
nalized. Internalization and deepening of the lateral
platysma insertion upon lifting results in a much
more substantial improvement of the gonial angle,
submentum, and submandibular triangle. Although
a small percentage of the population experiences
anterior digastric muscle and submandibular gland
hypertrophy, the majority of patients solely demon-
strate ptosis. What most surgeons perseverate
about as being digastric hypertrophy and subman-
dibular gland enlargement is more likely bulging
and residual ptosis caused by inadequate lifting or
improper vector utilization. This chapter will
explain a proper and effective technique.
7.3 Technique
We perform two differing techniques to lift the
neck using a deep plane technique. Younger pa-
tients without skin excess or need for skin excision
may undergo an internal neck lift, which in our
practice is combined with the Profound RF treat-
ment to obtain skin quality improvements. Patients
with more laxity and skin excess may undergo a
more substantial face and neck lift. Releasing and
lifting the face along at the same time as the neck
allows a much more substantial and fluid lift of the
neck, with less need for compensatory techniques.
7.3.1 Deep Plane Face and Neck
Lift
A 2-cm submental incision is placed in the submen-
tal line. The position of the crease is delineated by
drawing a line around the internal border of the
mandible, meaning in some patients the line may
be straight and in others it may be curved. The inci-
sion should always sit in this line, at the junction of
the mentalis and platysma, allowing surgical access
to the entire platysma. Naturally existing creases
that do not fall within this line should not be used.
7.3 Technique
Dissection is initiated sharply, opening a plane
directly over the platysma, while ensuring a fatty
layer is left attached to the skin. Liposuction is per-
formed in some cases, although fat must be left in
situ on the underside of the dermis to avoid crepi-
ness of the skin and prominent muscle banding in
the future. Elevation of the flap is then continued
down toward the top of the thyroid cartilage using
a lighted Aufricht elevator and blunt spreading dis-
section with a Kaye facelift scissor. The platysmal
borders are then identified in order to determine
the degree of laxity. Intraplatysmal deep cervical
fascia may be excised without subplatysmal fat re-
duction. The platysma is then elevated bilaterally
over the anterior belly of the digastric muscles,
continuing to the lateral hyoid. There may be
dense ligamentous attachments at the lateral cer-
vical angle around the lateral hyoid that require
sharp dissection.
At this point, the submental and submandibular
compartments are assessed for potential reduction.
Lateral reduction should always be performed first
to avoid any relative central hollowing. The anterior
belly of the digastric may be reduced if it appears to
be bulging. A laryngeal mask airway may cause arti-
ficial bulging. Digastric reduction may be performed
by stripping the top layer of the digastric using
bipolar electrocautery. This may cause postoperative
myositis for 2 to 3 weeks. The volume around the
lateral hyoid is then assessed. A pocket of fat and
lymphoid tissue on the lateral borders may be re-
duced. In some cases, the submandibular gland may
be pushing toward or caudal to the lateral hyoid.
This inferior or medial pole of the gland may be
delivered gently out of the capsule and reduced if
needed. Only judicious reduction should be per-
formed to avoid hematoma, seroma, sialocele, and
nerve damage.
Using a substantial vertical vector deep plane lift
obviates the need for submandibular gland exci-
sion in the large majority of patients. Intermittent
irrigation is regularly performed during subman-
dibular gland reduction to minimize heat disper-
sion around the motor nerves. Damage to medial
cervical branches may occur if the surgeon is not
careful. The central fat compartment may then be
reduced minimally only if needed. It is best to
leave fullness in the central compartment to avoid
hollowing and cobra neck deformities. The fullness
will flatten as a corset platysmaplasty is per-
formed. A horizontal fasciotomy is then performed
through the prehyoid deep cervical fascia to relieve
73
 Deep Plane Neck Lift Concepts and Technique

deeper contributions to banding and to allow bet-
ter angulation through an obtuse cervicomental
angle. Overaggressive hollowing or reduction must
be avoided in the neck to prevent forming a rigid,
vacuous appearance in the neck. A youthful neck
should have adequate volume and smooth, soft
contours.
A corset platysmaplasty is then performed. The
goal should be to have the edges of the platysma
meet at the midline with a minimal amount of ten-
sion to avoid medialization of the jowls or future
dehiscence. Overtightening of the central neck will
also limit the amount of vertical lift possible.5,9,10
The key is to try and balance the medial pull against
the lateral pull from the vertical neck lift, which
will be performed next. The fulcrum to consider is
the lateral hyoid at the junction of the anterior and
posterior bellies of the digastric muscle at the inter-
mediate tendon and fibrous sling. Release of the
platysma from the anterior belly of the digastrics
helps avoid medialization and bunching of the di-
gastrics. A buried 3–0 PDS may be placed at the cer-
vical angle as the first suture. The primary author
advises against tacking to the deeper fascia to avoid
tethering during swallowing and to avoid a choking
sensation, which may occur from impaired move-
ment or increased awareness of sensation. Several
other buried sutures are placed while advancing
from the cervical angle toward the submental inci-
sion (▶ Fig. 7.1).
It is important to remember that the proximal
platysma is most commonly dehiscent at midline
in its native state and that excessive approximation
may cause medialization of the jowls or require
subcutaneous release of the mandibular ligaments.
If the thyroid–laryngeal complex is prominent, the
platysma must remain intact in front of the
thyroid cartilage as well to avoid exaggeration of
Adam’s apple and cervical angle when lifting. Back
cuts of the platysma around the cervical angle are
advised against to avoid a harsh or angular appear-
ance. If severe or recurrent banding is present,
lower platysmal myotomies may be performed.
Partial myotomies are sufficient and avoid step-
offs and bleeding from violating the external jugu-
lar venous system. The cavity is then irrigated with
a dilute sodium hypochlorite solution (0.057%),
which appears to have gentle hemolytic, anti-
bruising, and anti-inflammatory benefits.
The vertical portion of the lift is performed next
in the form of a combined deep plane face and
neck lift. The face and neck are treated as a single

Fig. 7.1 (a–c) A demonstration of the au-

thors’ approach to the neck. The submental
access allows for deep plane neck dissection
to fully release the platysma from the
digastrics while accessing the submental fat
Submental incision compartment for reduction if needed and
the submandibular glands as well. This is
Digastric muscle
followed by several key steps to deepen the
cervicomental angle including division of the
Submental fat
deep cervical fascia in a horizontal incision
Submandibular above the thyroid cartilage.
gland

Hyoid bone

Platysma

Thyroid cartilage

(Continued)

74
 7.3 Technique

Fig. 7.1 (b, c) (Continued)

Resected fat

Partially resected
gland

Horizontal
fasciotomy

Hyoid bone

Corset
platysmaplasty

Occasional
partial myotomy

unit to allow a more substantial and fluid lift.
Access is achieved through a temporal tuft incision
extending around the helical root. Incisions within
the hairline are avoided as this will result in eleva-
tion and retroplacement of the sideburns and an un-
natural lengthening of the lateral cheek. Temporal
tuft incisions heal exceptionally well if tension is
avoided upon closure and skin excision between the
lateral canthus and the anterior limb of the incision.
The temporal skin ages in the inferior vector, so lat-
eral skin excision would only provide unwanted ten-
sion. The incision may then proceed in a pretragal or
retrotragal fashion. A pretragal incision is preferred
if the patient has an ear with strong architecture
including a prominent auricular incisura. The inci-
sion is then carried in the postauricular crease, tra-
versing to the posterior hairline at the point the
mastoid flattens, and the temporalis muscle inserts.

75
 Deep Plane Neck Lift Concepts and Technique
This continues down the posterior hairline for 3 to
4 cm in most patients. Again, incisions hidden within
the hairline are avoided as they tend to cause distor-
tion, scarring, and limitations in vertical lifting
(▶ Fig. 7.2).
The skin is then incised and elevated using a no.
10 blade scalpel and then proceeding with micro-
dissection scissors. The surgeon holds tension with
an Anderson Bear Claw retractor, while the assis-
tant holds counter-tension. Transillumination may
be used to maintain uniform flap thickness. A thin
layer of fat is left on the reticular dermis to avoid
compromising the blood supply of the subdermal
plexus in this random flap. Dissection is carried up
to the modified deep plane entry point shown in
the figure. The entry point is delineated preopera-
tively by performing a “sailboat modification”
upon the classic deep plane entry point. This
allows a greater preservation of SMAS on the ele-
vated flap, resulting in improved vascularity,
greater ease of dissection, and a lower rate of skin
and muscle irregularities in the upper lateral
cheek.
The postauricular skin is then elevated in the
same fashion in a subdermal plane. Upon reaching
the border of the sternocleidomastoid (SCM)
muscle, blunt dissection may be used to continue
Temporal
tuft
Not past lobe Mastoid process
76
in the preplatysmal plane. A lighted facelift retrac-
tor (BriteTrac) is used to provide retraction and
lightning, while Steven’s Kaye scissors are used to
bluntly separate the subdermal fat from the pre-
platysmal fascia. Dissection is carried anteriorly
until the submental cavity is connected to the lat-
eral dissection space. Inferiorly the dissection typi-
cally stops at the horizontal plane of the thyroid or
cricoid cartilage to avoid vascular compromise of
neck skin. If tethering or dimples are present at
the conclusion of lifting, these should be released.
The deep plane dissection is performed next.
The Anderson Bear Claw retractor is used to
place tension along the border of the facial platys-
ma. A gentle and deliberate incision is made using
a no. 10 blade scalpel until the deep glide plane is
exposed. The lateral platysmal border is scored in
a broad, serial fashion until the areolar plane is
slightly visible. Dissection is then carried out with
blunt spreading with the Steven’s Kaye scissors.
Gentle spreads are performed in the mostly avas-
cular plane immediately deep to the platysma. A
thin areolar fat plane typically exists under the
platysma and the tip of the scissors may be gently
pushed forward into this without damaging the
platysma. The flap is raised anteriorly until reach-
ing the facial artery. Extending past this may cause
Fig. 7.2 A demonstration of the standard
temporal tuft and periauricular incisions with
landmarks. Importantly, the authors do not
recommend violating the hairline, as a deep
plane approach offsets tension, and thus the
risk of a scar is particularly low. Addressing
the critical concept of tension is the best way
to prevent a scar. One key benefit of the
deep plane approach is that the deep plane
work offloads the tension and then excess
skin is removed. There is no pulling of skin
and no tension on the skin.

motor nerve damage and dehiscence of the platys-
ma over the submandibular gland where support
is of paramount importance. Superior or caudal
dissection from this zone is avoided because this
will likely end in a plane deep to the mimetic
muscles.
The midface dissection is performed next. A flu-
id release encompassing the entire platysma–
SMAS complex allows the most natural, vertical,
and tension-free lift. Again, the facelift retractor
and Steven’s Kaye scissors are used to bluntly dis-
sect in an inferomedial direction directly atop the
zygomaticus muscles. The orbicularis oculi muscle
may overlay the muscles. Dissection may be car-
ried over the plane of the lower orbicularis as well,
although the SMAS is very thin and difficult to dis-
sect this far superiorly. The zygomatic dissection is
carried toward the nasolabial fold while using a
combination of sensation and vision to guide prog-
ress in the correct plane. Once complete, the re-
maining decussation zone at the junction of the
SMAS and facial platysma must be performed to
join the upper and lower dissections. This zone
may be roughly 1 to 2 cm broad, including the
zygomaticocutaneous ligaments at the lateral
superior border and the buccal retaining ligaments
following the course of the parotid duct and fat
pad at the caudal border of the zygomaticus major
muscle.
To complete the release of the SMAS–platysma
complex, the cervical retaining ligaments are re-
leased next. Again, this is a fibrous decussation
zone between the lateral platysma and the deep
cervical fascia overlying the SCM muscle. The
superior extent is marked by the lateral platysmal
line at the gonial angle, while the inferior portion
of the dense tissues terminates at the crossing of
the external jugular vein as it transverses beneath
the platysma. Inferior to this point, only loose con-
nections exist. A partial incision is performed
using a no. 15 blade scalpel and serially continued
with the flap on superior tension using DeBakey
forceps. Incision is continued until the platysma
fibers begin to splay. Blunt dissection is then used
to complete the dissection and release in order to
avoid any marginal or cervical facial nerve branch
damage. Dissection must not carry past the plane
of the facial artery in order to avoid nerve damage
and platysmal dehiscence.
Irrigation is again performed at this point using
antibiotic solution followed by the dilute Dakin’s
solution. Meticulous hemostasis is then obtained
7.3 Technique
using bipolar electrocautery. The shelf along the
deep plane entry point is matured with blunt dis-
section to deliver a 5-mm flap for suturing. Exces-
sive dissection may compromise blood flow to the
distal dermal–epidermal flap. Suspension is then
performed along the facial deep plane entry points
prior to finalizing the neck suspension. The most
substantial benefit of using a comprehensive re-
lease is that the angle or vector of lifting need not
be determined with guesswork or by reading
articles discussing angles of lifting. The direction
of lifting is uniquely determined by the vector of
descent for each individual. This typically occurs in
a pendular fashion, and the vectors of descent vary
from patient to patient and from one side of the
face to the other. Hence, the suspension vector that
provides the greatest amount of lift and distrac-
tion should be used. To determine the anchoring
position intraoperatively, a horizontal mattress is
placed through the flap and elevated with one side
of the suture being pulled at 90 degrees vertical
and the other at 45 degrees. The resultant angle
typically ranges around 70 degrees, which is a use-
ful guideline for novice facelifting surgeons. One
must gauge this vector by observing tactile feed-
back to move in the direction of least resistance,
without pleating on either side of the suture pull.
Of note, this vector typically pulls against a per-
pendicular plane that extends from the nasolabial
fold, down the prejowl fold, and continuing to the
submandibular triangle. The vectors of aging in the
face and neck equally demonstrate ptosis along
this line. The most effective and restorative techni-
que for lifting should pull directly perpendicular to
this line.
Six points of suspension are used on the face
beginning with 2 × 3–0 nylon sutures on the facial
platysma. Drawing these sutures upward in the
proper vector will result in an immediate and visi-
ble improvement in the submandibular triangle.
These sutures are left tacked and hanging. Next,
2 × 4–0 nylon sutures are placed on the vertical
limb of the sailboat line of the SMAS and 2 × 5–0
nylon sutures on the horizontal limb. All sutures
are drawn superiorly and anchored to a dense point
along the border of the ear or temporal incision.
Lore’s fascia, also known as the temporoparotid or
tympanoparotid fascia is a dense fibrous region that
exists around the preauricular region and allows for
more predictable and secure lifting without any
descent of soft tissues during healing.11 Absorbable
sutures may be used as well with minimal potential
77
 Deep Plane Neck Lift Concepts and Technique

of causing an inflammatory response during the hy-
drolysis phase of absorption. The knots are secured
sequentially and without any tension on the SMAS–
platysma complex to avoid compromise of vascu-
larity to the distal flap (▶ Fig. 7.3).
The cervical platysma is suspended next. The
intent is to lift this as vertically as possible while in-
ternalizing the insertion point and providing depth
beneath the gonial angle. The tacking point of the
platysma superiorly should mirror the insertion
and angle of the posterior belly of the digastric. A
vector of roughly 85–90 degrees in the vertical
plane should be followed. Forty-five degree or later-
al pull will result with lateral distraction of the sub-
mentum rather than tucking and internalization of
the submandibular triangle contents. This will ap-
pear as a digastric and submandibular gland bulge
postoperatively. The tacking point of the platysma
superiorly should move as vertically as possible
while tucked deep to the gonial angle and pulling
from a point above the horizontal plane of the
hyoid. The most effective point of insertion thus lies
at the anterior border of the mastoid bone. To gain
adequate exposure, a crevasse is formed vertically
along the anterior border of the mastoid. The mas-
toid crevasse provides greater depth, a higher an-
choring point for more vertical elevation, a secure
point of attachment to avoid drooping or medializa-
tion of the posterior hairline, and a continuous line
of depth from the hyoid extending to the mastoid
once the platysma is pulled into place.9 This also
provides a method of creating depth around the go-
nial angle without cutting away tissue, which could
damage the greater auricular or facial nerve. The
parotid gland is also re-compartmentalized and left
unexposed, slimming the entire jawline and avoid-
ing risk of gustatory sweating. The crevasse is
formed using monopolar needle tip electrocautery
along the vertical line of the anterior border of the
mastoid bone extending from the conchal bowl
superiorly to the insertion of the SCM inferiorly. The
dissection typically carries 5 to 7 mm deep and 15 to
20 mm in height. A 2-mm back and fore cut may be
made at the superior extent if needed. This is a safe
zone to incise and excavate as the anterior branch of
the greater auricular nerve typically lays 8 to 12 mm
anterior and the posterior branch 4 to 10 mm poste-
rior to the anterior mastoid line (▶ Fig. 7.4).
Prior to securing the platysma, the muscle is
pulled superiorly and deep around the gonial
angle, and a partial myotomy is performed. The my-
otomy is placed along the inferior border of the go-
nial angle to permit stretching of the muscle around
the mandible, which provides greater relative depth

Deep sutures

Lift

a b

Fig. 7.3 A demonstration of the “sailboat” modification of the deep plane entry point. This modification allows for greater
preservation of vascularity to the skin along with preservation of volume and lymphatic flow in the area of the flap.
(a) Design of this modification, whereby the entry point follows the shape of the hairline and periauricular incisions on the
face. (b) Once lifted, the flap preserves the greatest volume right over the cheek, the area where greatest preservation of
volume is valuable. The lower platysmal sutures have some tension because they are not connected to skin.

78
 7.3 Technique

Partial Deep
platysmal sutures
mytomy

60° Lift
T-incision over Line of hyoid Platysma inset
a the mastoid b into T-incision

Posterior
fascia Incision

Platysma
inset
Platysma muscle

Anterior fascia
Medial vector,
Parotid gland pushing into the
anterior wall of
the mastoid tip
Sternocleidomastoid
muscle
Upward vector,
into the neckline
Mastoid Great auricular nerve
Inward vector,
c d toward the airway

Fig. 7.4 (a–e) A demonstration of the Crevasse technique as described, with an incision in the mastoid fascia to allow
for inset of the platysma, as well as a true deepening of the neckline, bringing the tissues up and in to better expose
the mandible and jawline. This helps tuck the parotid and the submandibular glands into place, in essence restoring
the balance of the lower face by recreating the platysmal sling and reorienting the vectors in alignment with the
digastrics.

(Continued)

79
 Deep Plane Neck Lift Concepts and Technique
Anterior border
of mastoid
Mastoid process
Anterior digastric
muscle belly
Posterior digastric Lateral facial sling
muscle belly on hyoid bone
e Platysma muscle
while still encapsulating and slimming the area
around the parotid gland. Next, the platysma is pur-
chased with a 2–0 Mersilene horizontal mattress
suture at a point roughly in line with the horizontal
plane of the hyoid. A second supporting suture is
placed just inferior to this. The superior suture is
then lifted as vertically as possible while securing
to the superior and internal border of the mastoid
bone. Tension with lifting is permissible along the
platysma as it has been detached from the skin and
has no risk of vascular compromise.
At this point, the facial soft tissues along with
the cervical contents have all been lifted and skin
simply needs to be trimmed without excess and
without tension. The peak of the skin flap that be-
gan at the helical root is lifted in the same vector
as the SMAS was lifted in. Biplanar or multivector
lifting should be avoided as this will leave excess
in some areas and age poorly. A tacking suture is
thrown using a 4–0 nylon suture without any
tension. Tenets of redistribution of tension have
proven repeatedly to cause scarring with other
facelifting techniques. The skin overlying the tem-
poral tuft is then trimmed, avoiding removal of
skin anterior to the temporal tuft, which would
cause undue tension, scarring, and hair loss. The
anterior limb of the temporal tuft is a zone of re-
distribution, and interrupted or vertical mattress
80
Fig. 7.4 (e) (Continued)
sutures should be used. A 10-Fr round drain is
then placed in the neck, remaining only overnight,
to lessen bruising and provide negative pressure
for skin adherence. The postauricular flap is then
elevated and tacked to the highest incision point in
the postauricular crease. Again, this is elevated in
the same vector of lifting and where maximal ver-
tical and horizontal distraction is noted. The skin
flap posterior to this suture over the mastoid bowl
should be pulled vertically and trimmed. Inadver-
tent lateral or superolateral lifting will result in a
dog-ear and an excessively long incision that must
be chased along the posterior hairline. Of note, the
posterior hairline continues inferior and posteri-
orly along the scalp hairs at the base of the occipi-
tal bone and not the nape hairs, which are inferior
to this. Finally, the skin around the ear is trimmed,
again without any tension and with the neck skin
kissing the base of the earlobe. The zone around
the anterior earlobe is also a point of redistribu-
tion and closure should be performed by zipping
downward from the tragus to the base of the ear-
lobe to avoid pleating within the lobe. Following
closure, the flaps are milked to remove any fluid.
Two percent nitroglycerine cream or ointment is
placed along the lateral skin flaps to reverse the
effects of epinephrine and overall ischemic time as
well as to lower the postoperative blood pressure.

Video 7.1 Deep plane neck lift.
A cotton-cushioned cling wrap is placed over-
night to provide minimal compression and avoid
accumulation of fluid in the dead spaces. This is
removed the next morning, and no further com-
pression is required. A summarized version of the
deep plane face and neck lift technique is shown
in ▶ Video 7.1.
7.3.2 Internal Neck Lift
The internal neck lift combined with the RF treat-
ment in our practice is called a “weekend lift.” The
procedure typically takes 1 hour and may be per-
formed under local or deep sedation anesthesia.
Incisions are placed similarly in the submental
crease for submental access and from the frontal
base of the earlobe extending halfway up behind
the ear. These incisions improve access without
leading to visible exposure. They are good options
for patients seeking lifting of the neck who do not
require any substantial improvements above the
jowls or removal of skin. The jowls may improve
from a combination of RF skin tightening and off-
loading of the jawline. The concept of off-loading
is noted during facelifts as the brow may rise in
the absence of the downward tension from a ptotic
cheek. In the neck, the effect may be observed as
the jowls and jawline lift slightly in the absence of
neck drooping. Downtime and incisions are mini-
mal using this technique.
A submental incision is performed to mirror the
procedure described for the deep plane face and
neck lift. Once the submental work is complete,
the lateral access points are opened by placing an
incision around the earlobe extending up the post-
auricular crease to the point where the mastoid
flattens at the insertion of the temporalis muscle.
Subcutaneous dissection is performed to connect
7.4 How to Avoid Bad Results/Common Pitfalls
the lateral and central cavities. The lateral platysma
is then marked along the line of the cervical
retaining ligaments extending from the lateral bor-
der of the platysma over the mandible superiorly
down to the crossing point of the external jugular
vein. The line is put on tension and scored using a
no. 15 blade scalpel until the internal side of the
deep cervical fascia is seen. Blunt dissection is then
performed for 3 to 4 cm.
The cavity is then irrigated and hemostasis is
obtained. A very gentle partial myotomy may be
performed to allow the platysma to wrap around
the gonial angle if needed. Full myotomy must be
avoided as the deep side has not been fully dis-
sected to avoid nerve injury. The platysma is then
suspended in a similar fashion as described earlier.
The contralateral dissection and elevation must
then be performed prior to skin closure to avoid
unnecessary trimming of skin while the neck is
pulled to one side. After both sides have been lifted
and the position of the neck has been neutralized,
the skin is closed. Minimal skin excision may be
performed as needed. Drains are inserted over-
night as well.
Prior to or following the procedure, Profound RF
is used to tighten the skin quality of the face and
neck. This contributes to an overall improvement
in appearance and reduces the chance of irregular-
ities or redundancy in the neck skin. Results im-
proved over 12 months as increasing amounts of
elastin, hyaluronic acid, and collagen are formed.
Standard dressings are then applied overnight, in-
cluding head and neck wrap with light compres-
sion (▶ Fig. 7.5).
7.4 How to Avoid Bad Results/
Common Pitfalls
It is crucial to completely release the deep structures.
Partial release will lead to a poor or compromised
result, and will often lead to unnatural-looking
necks, or animation deformities. The steps above
allow the avoidance of these problems. Addition-
ally, overtightening the platysma centrally may
lead to the inability to laterally tighten the neck
appropriately.12 Excess skin dissection must also
be avoided to minimize chance of irregularities,
vascular compromise, and postoperative neovas-
cularization. Limiting or hiding incisions in face
and neck lifting may inadvertently lead to more
scarring, limitations in lifting, and poorer overall
81
 Deep Plane Neck Lift Concepts and Technique

Blue lighted
facelift retractor
Platysmal
window

a b
Lateral access
incision
Submental
incision

Fig. 7.5 (a,b) A demonstration of the modifications to incisions for the direct neck lift or “weekend lift” procedure,
which is essentially a minimal access incision from the submentum along with a postauricular incision, which comes
around the front of the earlobe and up approximately 4 mm. This incision is for access to the deep neck, not for excess
skin removal. It is a good option for young patients with deeper neck structure ptosis and good skin and is best
performed in conjunction with radiofrequency microneedling either before or after the procedure.

results. Tension must be avoided in the deep 7.5.2 Case 2

plane closure as well as in the skin closure. Soft
tissues will eventually drop if any tension is
present. Performing a deep plane lift permits
dissociation of the SMAS from the mimetic mus-
culature, avoiding the often-overlooked dynamic
facial changes and untoward pull lines seen in
some SMAS plication techniques.
(▶ Fig. 7.7)
This 58-year-old man elected to have a deep
plane face and neck lift to improve the excess skin
and laxity of the jawline. His postoperative views
demonstrate improved balance and facial har-
mony. This is a 6-month result.

7.5 Case Examples 7.5.3 Case 3

7.5.1 Case 1
(▶ Fig. 7.6)
This 56-year-old patient was treated with a
deep plane face and neck lift in combination with
a blepharoplasty and modified lip lift. Note the
deepening of the jawline and improvement in the
lateral photographs. Shown is a 1-year result.
(▶ Fig. 7.8)
This 34-year-old patient presented with excess
heaviness in the lower face. She was treated with a
combination of a lower face and neck lift through a
limited preauricular incision with minimal skin re-
section. This was performed in concert with Pro-
found RF microneedling to improve skin texture
and collagen. This is a 10-month result.

82
 7.5 Case Examples

Fig. 7.6 (a–e) 56-year-old patient pre- and post-deep plane face and neck lift, upper and lower blepharoplasty and lip lift.

83
 Deep Plane Neck Lift Concepts and Technique

Fig. 7.7 (a–e) 58-year-old patient pre- and post-deep plane face and neck lift.

84

Fig. 7.8 (a–c) 34-year-old patient pre- and post-deep plane internal neck lift and Profound radiofrequency.
7.5.4 Case 4
(▶ Fig. 7.9)
This 51-year-old patient had a full face and neck
lift with blepharoplasty to address the signs of
aging. She has great improvement in jawline and
the depth of her neckline from the lateral view.
7.5.5 Case 5
(▶ Fig. 7.10)
This 37-year-old patient had a limited incision
weekend lift performed with deep plane neck lift
7.6 Expert Commentary by Dr. Slavin
in combination with a symmetrizing modified lip
lift procedure. Post-op, the neck is lighter and
more balanced, and all of her features are more
natural and balanced.
7.6 Expert Commentary by
Dr. Slavin
We commend the authors on an excellent chapter.
The authors’ description of their deep plane techni-
que successfully rearranges soft tissues (and skin)
to a degree that less extensive techniques may not
85
 Deep Plane Neck Lift Concepts and Technique

Fig. 7.9 (a–e) 51-year-old patient pre- and post-deep plane face and neck lift and upper blepharoplasty.

86
 7.6 Expert Commentary by Dr. Slavin

Fig. 7.10 (a–f) Pre- and postoperative views of a 37-year-old female from a weekend lift and lip lift.

87
 Deep Plane Neck Lift Concepts and Technique
be achievable. We appreciate their diligence on
offloading tension from the skin closure. Addition-
ally, the suspension sutures of the composite mo-
bile SMAS and skin flap powerfully reverse aging in
the lower and midface.
For surgeons undertaking this technique, extreme
caution is required operating in deep plane danger
zones to reduce risk of the cervical and mental nerve
branches. Our rhetorical question would be: How
many facial nerve injuries (whether temporary or
permanent) are acceptable? Right now, there are
only a small number of surgeons who can claim a
very high degree of safety. Furthermore, we find the
“aberrant excess volume” lateral to the hyoid to be
quite common. Failure to recognize can lead to a
fusiform fullness laterally. Generally, we find this tis-
sue to be comprised of fat and we carefully excise it.
We strongly agree with the authors’ belief that
vertical vector lift can obviate the need for sub-
mandibular gland excision in the large majority of
patients and have found this to be true over the
years. Although the chapter is not focused on the
use of nonsurgical techniques, we agree that RF
devices can be an extremely important element in
the rejuvenation of facial and neck skin. In our
practice, we prefer RF tightening 3 to 6 months
after the surgical necklift.
7.7 Expert Commentary by
Dr. Lin
We greatly appreciate this detailed technical de-
scription of their technique and excellent results.
It is interesting and makes sense that a generally
more substantial thickness to support that six
88
points of fixation for the facial soft-tissue structures
is utilized. As we know from years of experience
with nondeep plane techniques, SMAS plication or
fewer sutures may be used for vector displacement.
References
[1] Robenpour M, Fuchs Orenbach S, Hadash-Bengad R, Robenpour
O, Heller L. The Wide Suture Suspension Platysmaplasty, a
revised technique for neck rejuvenation: a retrospective cohort
study. J Cosmet Dermatol. 2021; 20(11):3603–3609
[2] Pérez P, Hohman MH. Neck Rejuvenation. Treasure Island, FL:
StatPearls Publishing; 2021
[3] O’Daniel TG. Optimizing outcomes in neck lift surgery.
Aesthet Surg J. 2021; 41(8):871–892
[4] Jacono A, Bryant LM. Extended deep plane facelift: incorpo-
rating facial retaining ligament release and composite flap
shifts to maximize midface, jawline and neck rejuvenation.
Clin Plast Surg. 2018; 45(4):527–554
[5] Jacono AA, Talei B. Vertical neck lifting. Facial Plast Surg Clin
North Am. 2014; 22(2):285–316
[6] Hodgkinson D. Total neck rejuvenation, harnessing the pla-
tysma in the lower neck and décolletage. Aesthetic Plast Surg.
2022; 46(1):161–172
[7] Feldman JJ. Neck Lift. Boca Raton, FL: CRC Press; 2006
[8] Connell BF, Sundine MJ, eds. Aesthetic Rejuvenation of the
Face and Neck. New York, NY: Thieme; 2016
[9] Jacono AA, Parikh SS, Kennedy WA. Anatomical comparison
of platysmal tightening using superficial musculoaponeurotic
system plication vs deep-plane rhytidectomy techniques.
Arch Facial Plast Surg. 2011; 13(6):395–397
[10] Kamer FM, Frankel AS. Isolated submentoplasty. A limited
approach to the aging neck. Arch Otolaryngol Head Neck
Surg. 1997; 123(1):66–70
[11] Athanasiou A, Rempelos G. Lore’s fascia a strong fixation
point for neck rejuvenation procedures. Clin Plast Surg. 2014;
41(1):43–49
[12] Jacono AA, Malone MH. The effect of midline corset platys-
maplasty on degree of face-lift flap elevation during concom-
itant deep-plane face-lift: a cadaveric study. JAMA Facial Plast
Surg. 2016; 18(3):183–187
8 Lateral Skin-Platysma Displacement Technique
Mario Pelle-Ceravolo and Matteo A. Angelini
Abstract
The most common techniques for neck rejuvena-
tion, despite their aggressiveness, present high pla-
tysma bands and skin laxity recurrence rate. The
lateral skin-platysma displacement (LSD) technique
entails only a lateral approach to the neck, avoiding
the submental incision. It is based on one or two
composite platysma-cutaneous flaps, which are re-
positioned laterally through cable sutures. This tech-
nique, besides transecting the platysma completely,
skews the anatomy of the muscle, displacing it in a
more lateral position and thus decreasing the risk of
paramedian band recurrence. The traction, applied
to the midbody of the myocutaneous flaps, achieves
also good results on skin remodeling. The advantage
of the LSD technique compared to other techniques
entailing full neck undermining are limited neck
undermining, absence of submental scar, shorter
operating time, faster patient recovery, satisfactory
results on platysma bands and skin laxity, and easier
approach to submandibular gland reduction. Other
supplemental technical details are mentioned based
on modification of the LSD technique, on a new cya-
noacrylate glue, and on a new technique named
“partial platysmectomy” used in selected cases.
Keywords: neck rejuvenation, platysma flaps, pla-
tysma bands, platysma transection, platysmec-
tomy, anterior neck flaccidity, submandibular
gland reduction
Key Points
● The most effective techniques commonly used
for neck rejuvenation, besides complications and
long postoperative course, present high platysma
bands and anterior laxity recurrence rates.
● The LSD technique is based on full platysma
transection and on composite skin-platysma
flaps, which are pulled through different vec-
tors and anchored to solid structures.
● The advantages of the LSD technique are limited
neck undermining, absence of submental scar,
short operating time, fast patient recovery, sat-
isfactory result on platysma bands and skin lax-
ity, and easy approach to submandibular gland
reduction.
● Different types of LSD techniques exist based on
diverse vectors (LSD V and LSD P) and number
of flaps (LSD 1 and LSD 2). Each variation ap-
plies to specific anatomical features.
● A new cyanoacrylate glue offers an exciting tool
that enhances the result of the skin traction and
allows the removal of cutaneous laxity with no
tension on the suture lines.
8.1 Patient Consideration,
Indications, and Contraindications
Skin laxity and platysma bands are the most com-
mon features of aging in the anterior neck area.
The excess skin is usually confined to the lateral
neck areas in younger people (< 40 years). In most
older patients (> 60 years), overabundant skin ac-
cumulates particularly in the anterior neck region.
Skin laxity of the neck is commonly treated
through skin–muscle undermining, traction apply-
ing specific vectors, and removal of overabundant
tissue.
Platysma bands may be any of the following:
● Hypertonic: The underlying muscle is thick and
appears like a violin string, also when relaxed.
● Hypotonic: The platysma is flaccid and thin.
● Pseudobands: The bands consist only of a skin-
fold without muscle inside.
The hypertonic bands are the most difficult to
eradicate and present a high recurrence rate in
spite of aggressive treatments.
8.2 What Technique to Use and
Why?
For more than 25 years (1983–2009) we have used
a technique based on complete neck undermining
and full-width platysma transection to treat pla-
tysma bands and anterior neck skin laxity.1,2
In a study published in 2016, we evaluated the
recurrence rate of anterior skin laxity and platysma
bands. At 1 year postoperatively, 48% of patients
showed recurrent anterior skin excess and 45% had
recurrence of bands.3
Due to the disappointing results of this techni-
que, along with all the disadvantages of a complex
89
 Lateral Skin-Platysma Displacement Technique
operation, we studied and experienced another ap-
proach to treat platysma bands and anterior skin
laxity and developed a new technique named lateral
skin-platysma displacement (LSD) technique.4
8.3 The Rationale of Lateral
Skin-Platysma Displacement
This technique entails only a lateral approach
without any submental incision and anterior neck
undermining. The platysma is undermined, up to
its medial border starting on its midbody and not
on its posterior border, with the aim of rendering
it mobile. This is followed by horizontal muscle
transection, strong skin–muscle flap traction in a
lateral direction, and then suturing to the flap to
the mastoid fascia or to the platysma-auricular lig-
ament using cable stitches.
This maneuver results in a shift of the muscle
from the anterior to the lateral neck area, leaving
little muscular tissue in the anterior neck. This ma-
neuver also completely skews the anatomy of the
platysma by relocating the muscle in a more later-
al and horizontal position, thus definitely decreas-
ing the risk of formation of new bands.
Physics teaches us that the pulling effect of trac-
tion on elastic tissue decreases as the distance
between the place where the traction is applied
and the target area increases.
Most classical techniques pull the skin or skin/
muscle cervical flap from its lateral border to redrape
the skin of the anterior neck.5,6,7,8,9,10,11,12,13,14,15
This action has only a modest effect on remodeling
the anterior neck skin, as the site where traction is
applied is 12 to 14 cm away from the target area
where the effect of the traction is desired (i.e., the
anterior neck).
In contrast, exerting traction on the midbody of
the platysma-skin flap, that is, closer to the anteri-
or neck, is more effective in treating anterior skin
laxity.
Moreover, pulling the platysma flap without
undermining it, as we do during the full transec-
tion technique, means that the traction is exerted
on a muscle that is adherent to the deep tissue,
which means after it has been pulled laterally and
sutured under tension, it will have the tendency to
resume its previous position. A more efficient re-
modeling of the anterior skin is obtained if traction
is exerted on the platysma, after having under-
mined it from the deep investing fascia. This is fol-
lowed by tacking the muscle at a shorter distance
90
from the midline, pulling it laterally together with
the skin and suturing the myocutaneous flap to the
mastoid fascia or the platysma-auricular ligament.
The traction exerted on the midbody of the
musculocutaneous flap allows for the removal of a
larger quantity of excess skin at the retroauricular
area without exerting excessive tension.
Guerrero-Santos et al,16 Guerrerosantos,17 and
Gonzalez13,18 have published a technique based on a
similar rationale but with different technical details.
When other factors are responsible for different
blemishes over the anterior neck (digastric muscle
hypertrophy, presence of perihyoid fascia, etc.), the
LSD technique is not the appropriate technique, as
an anterior approach would be indicated to treat
each specific issue.
8.4 Technique
The patient is marked in the upright position. The
anterior vertical platysma bands are marked, and a
5- to 6-cm vertical line indicating the incision into
the midbody of the platysma is drawn parallel and
6 to 7 cm lateral to the midline, keeping its upper
end at 4 cm from the lower mandibular border. A
horizontal line is marked between the lowest point
of the vertical platysma incision and a point at 2 cm
below the lower border of the hyoid bone to indi-
cate the line of the platysma transection (▶ Fig. 8.1).
After having prepared and infiltrated the area to
be undermined with 250 mL of saline containing
20 mL of mepivacaine 2% and 2 mg of epinephrine,
we carry out cutaneous undermining, which, in
the neck area, extends to approximately 1.5 cm be-
neath the marked vertical incision on the platys-
ma. Thus, approximately 5 to 6 cm of anterior neck
skin on each side is not undermined and remains
attached to the platysma (▶ Fig. 8.2; ▶ Video 8.1).
After carrying out good hemostasis, we make a
5- to 6-cm vertical eyelet using Metzenbaum scis-
sors on the platysma parallel to its fibers, following
the preoperative marking, that is, 1 cm lateral to
the limit of the cutaneous undermining. The high-
est point of this incision is never closer than 4 cm
to the mandibular border to avoid any injury to
the mandibular branch (▶ Fig. 8.3).
A horizontal tunnel under the muscle is carried
out by spreading the scissors in the subplatysmal
plane to reach a point beyond the medial border of
the anterior platysma band (▶ Fig. 8.4).
We undermine the platysma from lateral to
medial bluntly, taking care not to injure the facial

Fig. 8.2 The cervical skin flap is undermined up to 5 to
6 cm from the midline. The undermining overcomes
about 1.5 cm of the vertical incision on the platysma.
vein, which is frequently visible underneath the
muscle at the level of the posterior border of the
submandibular gland (SMG). This maneuver is es-
sential to obtain an adequate mobilization of the
platysma. Then we insert a slim retractor under
the muscle to check that no muscular tissue is left
behind and to avoid injury to any structure deep
to the muscle. We divide the platysma in its full
thickness horizontally to its medial border, ensur-
ing that all medial platysma fibers were sectioned
(▶ Fig. 8.5 and ▶ Fig. 8.6).
Once the platysma has been mobilized, we carry
out the traction of the myocutaneous flap.
8.5 Vectors of Traction
The vector of traction may vary, resulting either in
a posterior (“LSD P”; ▶ Fig. 8.7) or in a vertical vec-
tor (“LSD V”; ▶ Fig. 8.8).
8.5 Vectors of Traction
Fig. 8.1 First we mark the hyoid bone
(single green spot), then the parame-
dian platysma band (vertical red line),
then the 5- to 6-cm-long vertical
incision on the platysma (lateral vertical
blue line) at 6 to 7 cm from the midline,
and then the platysma transection line
from the bottom of the vertical
incision on the platysma to a point
that is 1.5 to 2 cm lower than the
hyoid bone.
Video 8.1 The lateral skin-platysma displacement
(“LSD”) technique: a new and proven technique for
neck rejuvenation.
When we opt for LSD P, we pass a 3–0 PDS su-
ture into the mastoid aponeurosis. The needle then
takes a solid bite into the lower portion of the
upper platysma flap and then is passed again into
the mastoid aponeurosis (at ~5 cm behind and 10–
12 cm below the tragus) in an area posterior to the
course of the greater auricular nerve. The suture is
not tied at this time (▶ Fig. 8.9).
A second similar suture is placed to reinforce the
first between the lower flap and a site 1 to 1.5 cm
cranial than the first one on the mastoid fascia.
One or two additional sutures are placed be-
tween the upper platysma flap and the mastoid
fascia 1 to 1.5 cm cranially to the previous ones. At
the end of suturing, we pull on the sutures to eval-
uate the adequateness of the traction.
Since the platysma does not reach the mastoid
aponeurosis, we use “cable” sutures to hold the
muscle in position (▶ Fig. 8.10).
Once the four sutures are in place, they are tied,
starting with the lower ones, securely but not
tightly to avoid cheesewiring the muscle.
91
 Lateral Skin-Platysma Displacement Technique

Fig. 8.3 (a,b) The scissors carry out the vertical incision on the platysma at 4 cm lower than the mandibular border to
avoid the risk of injuring the mandibular nerve.

Fig. 8.4 (a,b) The subplatysmal undermining is carried out beyond the medial border of the muscle. Medially to the
vertical line, the whole platysma is still attached to the skin.

Fig. 8.5 (a,b) The platysma is completely transected from its lateral incision to its medial border.

The lower platysma flap is treated only when
excess skin is obvious in the lower neck area. In
these patients, similar cable suturing is carried out
between the lower platysma flap and the lower
mastoid area.
When we opt for “LSD V,” the anchor point is no
more on the mastoid area but the platysma-
auricular ligament, about 2 cm caudad to the
tragus. When two platysma flaps are used, the
upper flap is anchored to the platysma-auricular

92
 8.5 Vectors of Traction

Fig. 8.6 Inspecting the transection

line, checking out that no muscular
fibers has been left behind. Used with
permission from Pelle-Ceravolo M,
Angelini M. Lateral Skin-Platysma
Displacement: A New Approach to
Neck Rejuvenation Through a Lateral
Approach. Clin Plast Surg. 2019
Oct;46(4):587–602.

Fig. 8.7 (a,b) The skin-platysma flap may be pulled through a horizontal vector and attached to the mastoid fascia (“LSD P”).

Fig. 8.8 (a,b) The skin-platysma flap may be pulled through a vertical vector and attached to the platysma-auricular
fascia (“LSD V”).

ligament and the lower flap is anchored to the
mastoid fascia.
Each suture is passed back and forth (catching
first the mastoid fascia or the platysma-auricular
ligament, then the platysma, and again the mastoid
fascia or the platysma-auricular ligament), leav-
ing approximately 1 cm of space between the two
threads to decrease the amount of fat bulging
through the sutures. Sometimes fat protruding
between the sutures is treated by cauterization.

93
 Lateral Skin-Platysma Displacement Technique
Fig. 8.9 Passing a suture between the myocutaneous
flap and the mastoid aponeurosis.
The choice between the two vectors is based on
the anatomy of the cervicomandibular area.
LSD V has more power in defining the cervico-
mandibular angle but creates a certain fullness
below the mandibular angle (▶ Fig. 8.11), whereas
LSD P has less power on the cervicomental angle
but achieves a better outlining of the mandible line
and avoids any excess volume over the subman-
dibular area (▶ Fig. 8.12).
Furthermore, in patients in whom the SMG is al-
ready visible and no reduction is planned, LSD P is,
usually, the selected option. When in doubt, we
try both vectors and then choose the one that
shows the best result.
8.6 Lateral Skin-Platysma
Displacement Variations
The level of platysma transection may vary accord-
ing to the patient’s features and mainly the pres-
ence of lower cervical skin flaccidity. In a patient
without low cervical skin flaccidity, the transec-
tion line starts at about 9 cm from the mandible
94
Fig. 8.10 Cable sutures are used (due to the long
distance between the myocutaneous flap and the
mastoid aponeurosis) to avoid excessive tension and
“cheesewiring.”
Fig. 8.11 (a) Preoperative image of a
57-year-old female patient showing fat
neck treated trough LSD V-1 associ-
ated with supra- and subplatysmal
liposuction. (b) At 6 months post-
operatively. Improvement of the cer-
vicomandibular angle with satisfactory
skin remodeling.
ending at 2 cm below the hyoid bone, and only one
myocutaneous flap is used for traction (“LSD 1”;
▶ Fig. 8.13).
This is the most frequently used technique at
the present time.
When lower neck cutaneous laxity is present,
the transection line is higher, starting at about
7 cm from the mandible and ending at 2 cm be-
low the hyoid bone, and two myocutaneous flaps
are confectioned and (“LSD 2”; ▶ Fig. 8.14 and
▶ Fig. 8.15).
The strong traction on the mobilized platysma
skews the alignment of the muscular fibers and
moves the muscle away from the anterior neck,
displacing it laterally. Little platysma is left over
the anterior neck, which explains why this tech-
nique entails a low risk of band recurrence
(▶ Fig. 8.16).
As the platysma maintains its attachments to
the skin of the anterior neck, traction on the pla-
tysma creates a powerful pull on the anterior neck
skin, which is displaced laterally. Moving the ex-
cess skin closer to the mastoid area facilitates the
 8.6 Lateral Skin-Platysma Displacement Variations
removal of a larger amount of skin on the retroaur-
icular area without tension.
The lateral portion of the platysma is mostly
left undisturbed unless some lateral platysma
bands required treatment. In this case, we remove
a horizontal strip of the lateral platysma starting
from its lateral border at 5 to 6 cm from the lower
mandibular border to avoid injury to the mandibu-
lar nerve, which runs more cranially to this point.
Fig. 8.12 (a,c) Preoperative image of a
63-year-old female patient with mod-
erate skin laxity and obvious subman-
dibular gland protrusion. (b,d) At 18
months postoperatively after LSD P-1
with submandibular gland reduction
and secondary mentoplasty. Good
cervicomandibular angle was achieved.
The gland treatment is mandatory in
such a case to obtain adequate neck
contour. (a,b,c) Used with permission
from Pelle-Ceravolo M, Angelini M.
Lateral Skin-Platysma Displacement:
A New Approach to Neck Rejuvenation
Through a Lateral Approach. Clin Plast
Surg. 2019 Oct;46(4):587–602.
(d) Reproduced from Araujo M, Boggio
R, Maino M, Uebel C, Viterbo F.
Cirurgia Plástica da Face e Cosmiatria.
Thieme; Brazil, 2024.
Fig. 8.13 (a,b) An L-shaped incision
creates one single myocutaneous flap.
Nothing is done on the lower flap in
the absence of lower neck flaccidity
(“LSD1”).
Fig. 8.14 (a,b) In the presence of lower
cervical flaccidity, two myocutaneous
flaps are created and pulled laterally
through cable sutures (“LSD 2”).
In patients with excess fat over the anterior
neck, liposuction is performed at the beginning of
the procedure, that is, before the skin undermin-
ing phase. Superficial liposuction is carried out
through a small incision in the submental fold.
Subplatysmal liposuction is done after the tunnel
under the muscle has been created through the
same tunnel or through a minimal submental
incision.
95
 Lateral Skin-Platysma Displacement Technique

Fig. 8.15 (a,c) Preoperative image of a

60-year-old female patient with the
presence of platysma bands and skin
laxity also in the lower neck. (b,d) At
2 years postoperatively after LSD P-2,
there is absence of the platysma
bands. The lower cervical skin laxity
has noticeably improved. Used with
permission from Pelle-Ceravolo M,
Angelini M. Lateral Skin-Platysma
Displacement: A New Approach to
Neck Rejuvenation Through a Lateral
Approach. Clin Plast Surg. 2019
Oct;46(4):587–602.

Fig. 8.16 On a specimen. (a) LSD 1: Pulling the platysma flap displaces the muscle laterally and the skin that is attached
to it. (b) The procedure has been carried out only on the right side. Very little platysma is left on the anterior neck. On
the opposite untreated site, the whole platysma is on the anterior neck. Used with permission from Pelle-Ceravolo M,
Angelini M. Lateral Skin-Platysma Displacement: A New Approach to Neck Rejuvenation Through a Lateral Approach.
Clin Plast Surg. 2019 Oct;46(4):587–602.

8.6.1 Submandibular Gland constitutes an easy approach for gland reduction

Resection
SMG reduction is disliked by many surgeons who
consider it too aggressive to be combined with a
facelift. In our opinion, which is shared by many
other authoritative colleagues,4,5,11,19,20,21 this treat-
ment is indicated in a considerable number of pa-
tients (about 30–35% of our patients), and in many
of them, it represents a “conditio sine qua non” if
satisfactory results are to be obtained. Even slightly
(▶ Fig. 8.17, ▶ Fig. 8.18, ▶ Fig. 8.19).
For many years we have carried out gland re-
duction through a submental approach.6,7,9,18,22,23
Indeed, from the year 2010 onward, in all pa-
tients with obvious SMG and submitted to LSD, we
began to use the retroauricular transplatysmal ap-
proach routinely to reduce the gland, as we found
that it offers numerous advantages compared to
the submental approach:
● Wider exposure.

visible glands preoperatively may become obvious ● Easier hemostasis.

after neck contouring maneuvers. ● Faster execution.

The horizontal incision on the platysma carried ● Absence of submental scar.

out via the LSD technique exposes the SMG and ● No risk of compressing hematoma.

96
 8.7 Other Options to Avoid Inadequate Results in Difficult Necks
Fig. 8.17 The horizontal muscle splitting exposes the
right submandibular gland. The periglandular capsule is
opened, and the gland is freed from its adhesions and
mobilized.
The submandibular space is in continuity with the
anterior neck due to the horizontal platysma split.
In the case of hemorrhage, the blood collection
will not remain in a closed space, creating com-
pression on the airways, but will spread into the
anterior neck and can be treated like a neck hema-
toma, avoiding life-threatening situations.23
8.7 Other Options to Avoid
Inadequate Results in Difficult
Necks: Cyanoacrylate Glue and
Platysmectomy
Despite the LSD technique and its good efficacy in
treating skin laxity, in patients with considerable
excess skin, we still have had some disappointments
due to recurrent excess anterior skin excess. During
last 2 years, we have been using a different techni-
que based on the use of a powerful cyanoacrylate
glue that can create instant adhesion between the
skin flaps and the deep tissues, allowing us to ameli-
orate the result of our traction maneuvers on the
skin.
Nowadays, in some patients with overabundant
and flaccid excess skin on the anterior neck, a
modified variation of the LSD technique is carried
out. The neck is widely undermined in the subcu-
taneous plane up to 2 to 3 cm from the midline.
The platysma muscle, which, in this case, has no
more adherence to the skin, is transected and su-
tured, as in the above-described LSD technique.
Fig. 8.18 The protruding portion of the gland is
resected “step by step.”
Fig. 8.19 A large piece of the submandibular gland has
been resected.
Eventually this consists of a two-plane facelift
but with lateral platysma displacement.
When we are ready for flap traction, we apply
a layer of glue on the surfaces of the flaps and
deep tissues, through its specific sprayer device
(▶ Fig. 8.20a, b). We then strongly pull the flap
following the selected vectors (▶ Fig. 8.20c) and
apply pressure for 90 seconds to let the glue pol-
ymerize (▶ Fig. 8.20d). This creates immediate
adhesion between the skin flap and the deep tis-
sue (▶ Fig. 8.20e). A second pull applied more
laterally on the flap followed by an additional
glue application enables us to remove a greater
amount of skin with no tension on the suture line
(▶ Fig. 8.20f, ▶ Fig. 8.21, and ▶ Fig. 8.22). Cyanoa-
crylate glue is much more powerful than any
fibrin glue as, besides having analogous benefit
97
 Lateral Skin-Platysma Displacement Technique

Fig. 8.20 (a) The cyanoacrylate glue with its CO2 reservoir and applicator device. (b) Spraying the glue on the neck.
(c) The flap is strongly pulled following the appropriate vector. (d) Uniform pressure is applied on the flap for 90
seconds. (e) Complete adhesion of the skin flap has been achieved by the glue. (f) The excess skin can be removed
without applying any tension on the suture line.

Fig. 8.21 (a,c,e) Preoperative image of a 65-year-old female patient (status post rhytidectomy 10 years before) with
moderate amount of anterior excess skin and fat, platysma bands, and ill-defined neck contour. (b,d,f) At 18 months
postoperatively after atypical LSD 1 with full neck undermining and glue application. The cervicomandibular angle is
nicely contoured, with absence of redundant skin.

98

Fig. 8.23 The marking outlines the areas of the
platysma muscle to be removed.
in terms of sealing and hemostasis, the former
has also a great capacity in fixating the flaps and
holding the traction.
In some patients with real thick hypertonic pla-
tysma, we carry out a localized platysmectomy in-
stead of using the LSD technique (▶ Fig. 8.23).
This technique entails the following:
● A wide subtotal subcutaneous (▶ Fig. 8.24a) and
subplatysmal undermining (▶ Fig. 8.24b).
● The removal of a 3- to 4-cm-wide strip of pla-
tysma from its lateral to its medial border
(▶ Fig. 8.24c–e and ▶ Fig. 8.25).
● Suturing the upper platysma flap to the mastoid
area with a posterior and slightly oblique vector
(▶ Fig. 8.26).
● Using the glue to create a strong traction on the
anterior skin flap.
This technique has been rendered effective by the
use of the glue that fulfills the physical principles
on which the LSD technique is based, that is, “The
8.9 Discussion
Fig. 8.22 (a) Preoperatively under
forced platysma contraction. Para-
median and lateral bands are evident.
(b) Postoperatively under forced pla-
tysma contraction. There is absence
of visible bands.
closer to the target area is the point of traction, the
more effective is the traction4” (▶ Fig. 8.27 and
▶ Fig. 8.28).
8.8 Lateral Skin-Platysma
Displacement Limitations
There are some patients in whom the LSD techni-
que cannot achieve optimal results:
● Patients who present considerable amount of
subcutaneous fat in the anterior neck. In these
individuals, an aggressive liposuction over the
anterior neck necessary to obtain a good cervi-
comandibular angle would destroy most of the
attachments between the platysma and the
skin, rendering the traction on the myocutane-
ous flap less effective.
● Patients with abundant subplatysmal fat.
Although suction carried out through the lateral
subplatysmal incision can remove much of this
fat, a more precise sculpturing can be obtained
through a submental incision.
● When digastric hypertrophy is present and sub-
mental approach is necessary to shave or to
remove the digastric muscles.
● In very difficult necks, that is, necks with anteri-
orized hyoid bones, “frozen necks,” or secondary
situation with irregularities of the contour.
8.9 Discussion
All techniques based on complete neck undermin-
ing1,2,5,6,7,9,19,20,21,22,24,25,26,27,28,29,30,31,32,33 entail cer-
tain risks, such as blood flow impairment, perioral
muscular disturbances, visible irregularities, and
certainly a long recovery, due to the extensive
undermined area in some cases (“leather neck”).
Another drawback of full neck undermining is that
a certain number of patients cannot be treated
99
 Lateral Skin-Platysma Displacement Technique

Fig. 8.24 On a specimen. (a) Marking the area of platysma to be removed. (b) Undermining the platysma. (c,d) Upper
and lower incision of the muscle. (e) The muscle strip is ready to be removed.

whom there is a clear indication for a full neck

undermining, and we still carry out this approach in
a certain number of our patients. On the other hand,
we think that the LSD technique represents a valid
alternative for neck rejuvenation that can provide a
good outcome but with fewer drawbacks.
The main advantages of the LSD technique are
the following3,4:
● Partial neck undermining means less time and

less risk.
● No submental scar.
● Good results in treating platysma bands and an-

terior skin laxity in many patients.

● It has been shown that the LSD technique produ-

ces a notable decrease in the length of the post-

Fig. 8.25 On a patient: The strip of removed platysma is
placed on the platysmectomy area. operative recovery period of the LSD procedure
when compared to other techniques with similar
results.
● A 9-year experience with this technique con-
with this technique due to other factors, such as
smoking, different therapies, and skin conditions firmed a very high patient satisfaction rate and
that increase the risk of long flaps. an extremely low complication rate.
● An evaluation of our patients showed that at 1
The length of the postoperative recovery period
is one of the most important factors influencing year the recurrence rate of platysma bands and,
the patient’s decision in our practice. The patients’ to a lesser extent, anterior neck skin laxity is
happiness is frequently related to the time neces- lower in patients treated with the LSD techni-
sary to return to a normal working or social life. que compared to those treated with the full
The full neck undermining technique is becoming neck undermining technique.
● The horizontal platysma transection allows an
anachronistic and not applicable in many patients,
as it constitutes an extended withdrawal from nor- easier reduction of the SMG through the retro-
mal life, a condition that is unacceptable for many auricular approach than through the submental
patients. However, there are some patients in approach.

100
 8.9 Discussion

Fig. 8.26 Tractioning the platysma flap. (a) The dotted line indicates the platysma flap after the platysmectomy. (b) A 3–
0 polydioxanone suture catches the mastoid fascia. (c) The suture catches the platysma flap. (d) The suture is passed
back to the mastoid fascia. (e) The two sutures are tied.

Fig. 8.27 (a,c,e) Preoperative images of a 55-year-old female patient with noticeable paramedian platysma bands at
rest and anterior excess skin. (b,d,f) At 1 year postoperatively after platysmectomy was carried out with the application
of cyanoacrylate glue. Used with permission from Pelle-Ceravolo M, Angelini M. Lateral Skin-Platysma Displacement:
A New Approach to Neck Rejuvenation Through a Lateral Approach. Clin Plast Surg. 2019 Oct;46(4):587–602.

101
 Lateral Skin-Platysma Displacement Technique
8.10 Conclusions
Currently, patient demands include not only the
surgical outcome but also the length of postopera-
tive recovery period. The duration of the period in
which patients must abandon their normal life
constitutes a critical issue in making treatment de-
cisions. This is one of the important reasons why
many patients opt for simpler and easier solutions,
which are often inappropriate for treating impor-
tant deformities, especially in the neck.
Neck rejuvenation is a very challenging issue.
Several authors have lately emphasized the impor-
tance of maneuvers directed to achieve good cervi-
cal contouring through aggressive lipectomy and
reduction of the SMG and digastric muscles in the
large majority of patients. This approach can pro-
duce precise neck sculpturing, but, in our opinion,
should not be applied indiscriminately to all pa-
tients, as it represents an aggressive solution that
entails long postoperative recovery time and a cer-
tain risk of complications.
The LSD technique represents, in our opinion, a
technique that can achieve satisfactory results
with low complication and recurrence rates and
can be carried out successfully in about 70% of the
patient candidates for neck rejuvenation.
Until 2011, we opened the neck in approximately
65% of our patients during a cervicofacial facelift.
After the year 2012, the percentage of neck
openings dropped to approximately 15 to 20% due
to the advantages provided by the LSD technique,
which has now become our technique of choice in
neck rejuvenation.
8.11 Expert Commentary by
Dr. Slavin
Dr. Pelle-Ceravolo and Dr. Angelini present an inno-
vative technique that achieves a high degree of
102
Fig. 8.28 (a) Preoperative image of
the same patient in ▶ Fig. 8.27 under
forced platysma contraction. The
muscular contraction shows impres-
sive paramedian and lateral platysma
bands. (b) At 1 year postoperatively.
Under forced platysma contraction,
there is absence of both paramedian
and lateral platysma bands and excess
skin.
lateral platysmal tightening that mobilizes the
entire unit of a myocutaneous flap to tighten the
neckline. Moreover, it obviates the need for a
submental incision. Although the technique has
been proven to be safe in authors’ hands, it could
increase the risk of a marginal mandibular nerve
injury as it approaches an area anteriorly where
there are multiple variations in the anatomy of
the nerve.
Two of the more frustrating problems that occur
in the context of neck rejuvenation—recurrent pla-
tysmal bands and skin laxity—are addressed by
this technique. The authors perform a platysmal
transection up to the most anterior band. Their
technique differs from the common practice of
anterior corset platysmaplasty, a fundamental ma-
neuver for plastic surgeons, but also one that may
not completely eliminate all platysmal bands from
reappearing postoperatively. Certainly, this novel
approach produces excellent results with limited
neck dissection. It is also a very flexible technique,
as described in the section on lateral skin displace-
ment variations, allowing adjustments for different
patient features. Finally, the addition of cyanoacry-
late glue provides another reassurance that the
mobilized myocutaneous flap will be adherent to
the deep tissues and remain affixed.
8.12 Expert Commentary by
Dr. Lin
The authors present an excellent representation of
the evolution of their technique over time with
modifications to the correction of platysmal band-
ing and other challenging anatomical features of
the neck. The creation of platysmal flap(s) to reor-
ient the anatomy of the neck in order to prevent
the recurrence of vertical neck banding is creative
and has been studied by the authors, with a recent
series of patients.

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103
9 Surgical Techniques for Treatment of the Aging Neck
Munique Maia and Marcelo Cunha Araujo
Abstract
Early signs of aging can be seen on the neck before
they appear on the face. A number of noninvasive
procedures are available to reverse the signs of
aging in these areas. Although these procedures
can delay the need for a facelift, they are less effec-
tive on the neck. A neck lift is a highly beneficial
and effective procedure to address the major com-
ponents of aging (skin, muscle, and adipose tissue).
We present a systematic approach to analyze and
treat the aging neck based on anatomy and indi-
vidual features. Different techniques are discussed
for each particular concern.
Keywords: aging neck, surgical neck lift, facial
analysis, neck rejuvenation
Key Points
● The systematic approach guides surgical plan-
ning and delivers consistent outcomes with low
morbidity.
● Skin excision is the least important step in neck
rejuvenation surgery.
● Submandibular resection should be reserved
only for severe cases. It should not be a routine
procedure.
● We can frame the face and neck, modify angles
and shadows, and ultimately create beauty.
9.1 Introduction
When looking at a beautiful face and neck, our eyes
are directed to a well-defined mandibular border
and the elegant contour of the cervical region.
When considering neck rejuvenation, nonsurgi-
cal procedures are less effective and surgical op-
tions are the gold standard in this region. Surgical
treatments for the aging face and neck result in
better and long-lasting outcomes. The traditional
idea of lifting the neck to reverse the signs of aging
is shortcoming. We believe that modern techni-
ques and refinements allow the surgeon to not
only lift the lax tissue but also remodel, sculpt, and
even modify and enhance features of patients
who are young and attractive. As plastic surgery is
constantly evolving, we need to amplify our goals,
accept new concepts, and develop a surgical plan
at the tridimensional level. We can frame the face
and neck, modify angles and shadows, and ulti-
mately create beauty!
The goal of this chapter is to demonstrate the
techniques utilized by the senior author in a sys-
tematic way. The systematic approach guides sur-
gical planning and delivers consistent outcomes
with low morbidity.
9.2 Facial Analysis and Applied
Anatomy
The transitional zone between the lower face and
neck has unique features. The cervical region has
been studied by many authors. As described by
Feldman, the cervical region has eight subunits.
The operative planning is guided by preopera-
tive assessment of the anatomical structures and
takes into consideration each of the following
subunits:
● Skin, which covers all subunits. Evaluation of
the skin will determine the optimal incision and
the direction of the skin pull.
● Subcutaneous fat. Careful analysis should be done
to determine fat removal, preservation, or fat
grafting. Two approaches are considered: closed
approach with liposuction or open approach with
direct excision.
● Chin. Assessment of microgenia, prognathism,
and ptosis (▶ Fig. 9.1).
● Mandibular border and jowls. Careful analysis of
the mandibular contour, jowls, and prejowl sul-
cus should be done (▶ Fig. 9.2).
● Submental region. This is an important area and
needs a detailed analysis and accurate diagnosis.
Ellenbogen described the visual criteria of the
youthful neck46:
● A distinct inferior mandibular border from the
mentum to the angle of the mandible with no
jowl overhang.
● Subhyoid depression.
● Visible thyroid cartilage.
● Visible anterior border of the sternocleidomas-
toid muscle, distinct in its entire course from
the mastoid to the sternum.
105
 Surgical Techniques for Treatment of the Aging Neck

Fig. 9.1 (a–c) The preoperative pictures show a 30-year-old woman with excess subcutaneous fat. The postoperative
pictures were taken 4 months after neck liposuction under local anesthesia.

Fig. 9.2 The left picture shows a thin

patient with a well-defined mandibular
border. The right picture shows a heavy
neck with an obtuse cervicomental
angle.

● A cervicomental (CM) angle between 105 and bands, subplatysmal and interplatysmal fat, anteri-
120 degrees (90-degree sternocleidomastoid to or digastric muscles, and perihyoid fascia and
the submental line). hyoid bone.
● Infrahyoid region. Evaluate the platysmal bands.

We utilize the layered approach for diagnosis and ● Lateral aesthetic triangle: anterior to the sterno-

treatment. From superficial to deep, all structures cleidomastoid muscle. Evaluate the tissue and the
are analyzed. Skin, subcutaneous tissue, platysmal submandibular glands.

106

● Lateral cervical region (posterior to the sterno-
cleidomastoid muscle). Evaluate skin pull and
plan incisions.
9.3 Patient Evaluation and
Surgical Goals
● Important considerations and reflections on
choosing the best treatment for each particular
patient. Skin excision is the least important step
in neck rejuvenation surgery.
● Given its cylindrical shape, the removal of adi-
pose tissue in the neck is very important. This is
different from the face that should be sculpted
in a three-dimensional (3D) manner and treated
with redistribution of fat.
● Excision of excess superficial or deep fat should
be performed carefully. We must preserve a
healthy layer of subcutaneous tissue, approxi-
mately 2 mm, to avoid contour irregularities.
● When analyzing the platysma bands, the first
step is the differentiation between hypotonic
and hypertonic bands (see ▶ Fig. 9.6; Connell BF,
personal communication, June 2005)1,2,3,4,5,6,7:
○ Hypotonic bands are treated with suturing
techniques (▶ Fig. 9.3).
○ Hypertonic bands: The transection of the
bands is done with or without suturing in or-
der to transfer them to a more favorable and
less visible position. Transection can poten-
tially minimize recurrence.
● Platysma bands can be treated in two ways, sep-
arately or in combination1,2,3:
○ Lateral traction: Transmission forces are pre-
dominantly infrahyoid.
○ Central traction (submental): The forces are
transmitted mainly to the suprahyoid region.
● A well-defined CM angle is the most important
part of the treatment (▶ Fig. 9.4).
● The end goal of a well-defined CM angle should
have not only a technical but also an artistic in-
terpretation. It should be planned specifically
for each patient according to their characteris-
tics, especially in relation to gender.8,9
● Thinner necks with a good CM angle can be
treated by lateral traction alone; however, in
the obtuse and heavy necks, the central access
should be added.10,11,12,13
It is important to note that treatment of the neck
can be done alone or in conjunction with facial
rejuvenation surgery (▶ Fig. 9.5, ▶ Fig. 9.6, ▶ Fig. 9.7).
9.4 Surgical Techniques
9.4 Surgical Techniques
The procedure starts with infiltration of 0.5% xylo-
caine solution and epinephrine 1:200.00 of the
entire cervical area (▶ Video 9.1).
9.4.1 Skin
In the senior author’s personal experience, sub-
mental or central access is needed in 80% of cases.
For this reason, we first turn our attention to the
central area; dissection can be blunt with the aid
of liposuction cannulas and/or with electrocautery
and scissors under direct vision, through the sub-
mental incision.
Care should be taken to maintain a good layer
of subcutaneous fat in the skin flap; dissection
continues to approximately 4 cm from the ster-
nal notch.6,7,14 Similarly, to the face,15 the neck
has ligamentous attachments and those need to
be released for proper mobilization of the skin.
The mandibular ligament16 can be released
through submental incision.
9.4.2 Fat Layer
After undermining of the central submental skin
flap, wide undermining is performed. The excess
subcutaneous fat is excised under direct visual-
ization. We then evaluate interplatysmal fat and
distribution of platysma muscle fibers.17,18
9.4.3 Platysma Muscle and
Subplatysmal Structures
Subplatysmal exposure is achieved with medial
opening of the platysma muscle and elevation of
the muscle. Dissection proceeds until adequate
mobilization of the platysma bands or platysma
edges is achieved. When needed, conservative
excision of subplatysmal fat is performed. At this
point, we evaluate the anterior belly of the digas-
tric muscles and the perihyoid fascia.
In the cases where the CM angle needs improve-
ment, we make a relaxing incision in the perihyoid
fascia, which can be above or below the hyoid bone
or both.12,19
These incisions allow a superior and posterior
repositioning of the hyoid bone by the muscular
forces resulting from the posterior belly of the
digastric muscles and suprahyoid muscles.3,5 If
107
 Surgical Techniques for Treatment of the Aging Neck

Fig. 9.3 (a–e) A 70 year-old patient, 3 months after facelift, neck lift, fat grafting, and CO2 laser.

108

Fig. 9.4 (a–d) A 59 year-old patient, 2 months after facelift, neck lift, upper blepharoplasty, brow lift, facial fat grafting,
TCA Peel and skincare treatments.
treatment of the digastric muscles is needed, the
senior author’s first choice is partial excision of
the hypertrophic muscles (anterior digastric)
with electrocautery, as described by Connell and
Feldman.6,45
The approximation of the anterior belly of the
digastric muscles with PDS 3–0 can be made when
they are far apart, when there is a marked intermus-
cular depression (e.g., by previous over-resection of
fat) or when hypertrophy is minimal.4,6,7 Treatment
of digastric muscles presents low morbidity and
9.4 Surgical Techniques
does not cause any impairment to the masticatory
function.
Treatment of the submandibular glands will be
discussed in detail later in this chapter.
After treatment of the submental floor, we pro-
ceed with medial approximation of the platysma
muscle edges. Suturing is performed in one or two
layers according to the amount of tension
needed.20,21,22,23,24 The first suture is a simple 4–0
nylon placed at the deepest point of the CM angle.
We then proceed with a continuous suture of the
109
 Surgical Techniques for Treatment of the Aging Neck
Fig. 9.5 (a–c) A 67 year-old patient, 3 months facelift, neck lift, upper and lower blepharoplasty, brow lift, facial fat
grafting, TCA Peel and skincare treatments.
platysma with nylon 4–0 suture, from the hyoid to
the menton, in one or two layers. We then perform
a full transection of the platysma bands (marked
preoperatively) as low as possible.
The last step of the central access is the approxi-
mation, without tension, of the platysma bands of
the infrahyoid region until just above the lateral
transection. Muscle resection is avoided, except in
cases with excessive muscle laxity. The skin clo-
sure of the submental incision is made with a run-
ning 5–0 nylon suture.
We then proceed with skin undermining from
the lateral approach utilizing the planned
incisions.10,24,25,26,27
The retroauricular access allows us to access
the lateral edge of the platysma muscle that will
be treated alone or together with the elevation
of the superficial musculoaponeurotic system
(SMAS).28,29,30,31
110
After undermining of the skin flap, we proceed
with direct excision of excessive fat present along
the mandibular border, jowls, and anterior edge of
the sternocleidomastoid muscle.19
Lateral traction of the platysma muscle can be
performed in two ways:
● Plication without muscle elevation and re-
leases, as described by Pitanguy and others—
technically simpler and applied in cases of
laxer and thinner necks.9,11,22 Fixation should
be based on fixed points such as the mastoid
region and platysma-auricular ligament. How-
ever, this technique tends to be slightly less
long lasting.30,31,32,33
● Partial or total elevation of the lateral edge of the
platysma muscle. This technique is longer last-
ing, and it is used in tight and difficult necks
where the plication cannot reach the points for a
rigid fixation such as the mastoid region.3,12,13,20
 9.4 Surgical Techniques

Fig. 9.6 (a–d) A 67 year-old - facelift, neck lift, upper and lower blepharoplasty, brow lift, facial fat grafting, TCA Peel
and skincare treatment. (e,f) A 67 woman showing advanced signs of aging. Postoperative picture 1 year and 2 years
after surgery shows improvement of the mandibular border and youthful contours.

111
 Surgical Techniques for Treatment of the Aging Neck
Fig. 9.7 (a–c) A 49 year-old patient before and 2.5 months after facelift and neck lift.
Video 9.1 The aging neck: subplatysmal techniques.
After the platysma muscle is mobilized and su-
tured in place, the redistribution and redraping of
the skin is performed, showing the shape and an-
gles created in the submental and submandibular
region. It is important to emphasize that skin trac-
tion is not so important and that only the excess
skin will be excised without tension. This makes it
possible to perform shorter scars and often with-
out penetrating the hairline.9,24,34
Case examples below performed by the first au-
thor, Dr. Munique Maia. No submandibular gland
resection was performed in these cases.
9.4.4 Submandibular Glands
The treatment of the submandibular glands has
already been purposely left for a separate discussion,
due to the strong and conflicting opinions of experi-
enced authors on the subject.3,5,6,7,17,19,21,35,36
The first question that comes to the surgeon’s
mind is whether the bulging in the cervical region
112
is due to a significant increase of the gland by in-
flammatory or neoplastic processes or whether
this occurs from poor positioning and/or ptosis of
these glands. Sullivan’s studies with magnetic res-
onance imaging (MRI) mainly suggest ptosis and
poor positioning than actual augmentation. How-
ever, many surgeons believe in a real increase of
the gland due to recurrent episodes of ductal ob-
struction by stones, which are more common in
these glands than in the parotid glands. If there is
any doubt in the distinction between benign in-
crease of the gland or malignant neoplasms, we
suggest aspiration biopsy with a needle, which
yields a high degree of accuracy.37
It is important to note that the submandibular
glands produce approximately 50% of the total
saliva, and this percentage can reach 70% of basal
production outside the stimulatory periods such
as during meals. The parotid glands are responsi-
ble for another 45% and the sublingual glands 5%.
Whether by ptosis, poor positioning, or actual
increase of the gland due to chronic inflamma-
tions, many patients present an evident bulging
in this region, which is present in the preopera-
tive examination.
There are different options to treat this deformity:
● Acceptance of the deformity and no treatment.
● Botulinum toxin injection: Be careful not to affect
adjacent structures such as the lip depressor
muscles.38,39
● Camouflage with fat graft4,12 (Connell BF, per-
sonal communication, June 2005) and alloplas-
tic mandibular implants.40

● Elevation or repositioning of the glands for
smaller glands; this is less efficient with a higher
recurrence rate.
Several techniques for glandular elevation or reposi-
tioning have been described.30,31,32 The authors’ pref-
erence is the direct platysma muscle reinforcement
as described by Feldman, which, in addition to being
performed in the median region, can also be added
to other lateral sutures right on top of the lateral
protrusion or bulging.7 This suturing technique can
be done continuously vertically or at separate
stitches in “figure of eight.” This technique is applied
in the vast majority of cases, reserving partial resec-
tion only for the larger glands (5% of the total cases).
● Partial resection of the glands (more effective
but presents more risks).
The first author to propose partial reduction of the
submandibular glands was Bruce Connell in 1965
and then in 1976 at the American Society for Aes-
thetic Plastic Surgery (ASAPS) Symposium in Denver,
Colorado (Connell BF, personal communication, June
2005). In 1991, de Pina and Quinta published the
first article on partial resection, by lateral incision of
the cervicofacial facelift.41 In 1994, Aston et al pub-
lished submental access to approach these glands
because it is a plane with less vascularization and
better access. They proposed partial resection of the
superficial lobe, leaving the most functional aspect
of the gland and avoiding the more vascularized
lateral region, which unites the superficial and deep
lobes.14 This same access was also described by other
authors such as Guyuron,42 Nahai,33 and Singer and
Sullivan,37 among others.15
In the senior author’s personal experience, par-
tial resection of the superficial lobe is performed
in 5% of cases of face surgery. The submental access
is utilized. Three important maneuvers are high-
lighted to make the procedure safer:
● Opening the glandular capsule, which causes her-
niation of these glands before resection. This ma-
neuver avoids the larger vessels of the capsule.
● Repair the gland with two or three “U” sutures,
with Vicryl 4–0, below the desired resection
part. This facilitates exposure of the glands and
after the resection is finished, these stitches are
tied to prevent bleeding, sialoma, or sialocele.
● Final suture of the capsule to prevent dead
space and herniation of the remaining portion
of the gland, also with Vicryl 4–0.
9.6 Expert Commentary by Dr. Lin
Partial resection is probably the most effective and
long-lasting treatment of gland bulging; however,
undoubtedly it adds morbidity and brings some
associated severe risks. In addition to these risks,
we should discuss the extent to which we should
interfere in the function only for better aesthetic
results.41,43
The risks associated with partial resection are
the following:
● Intra- or postoperative bleeding that is difficult
to control.
● Potential risk of injury to the mandibular, cervical,
and hypoglossal nerves.44
● Risk of salivary fistulas and sialomas, described
in the series of experienced authors.
● Risk of dryness of the oral mucosa, especially in
patients who have some predisposing factors
such as diabetes mellitus, Sjogren’s syndrome,
dry eye, and others.
● Risk of contour irregularities or lateral depression
when the entire superficial lobe is removed.
Therefore, in the authors’ opinion, the indication
for this procedure should be very judicious, widely
discussed with patients, and reserved only for
severe cases. It should not be a routine procedure.
9.5 Expert Commentary by
Dr. Slavin
This is an excellent method analysis of the ap-
proach to the aging neck. The authors evaluate
each factor that contributes to an aged experience
and comment how their technique will correct the
aged anatomy.
9.6 Expert Commentary by
Dr. Lin
I commend the authors for this systematic and
thoughtful review of their approach to the neck. The
authors bring up the aspects of neck lifting that re-
late to careful preoperative planning. Aspects of sub-
cutaneous fat preservation for prevention of contour
irregularity that seem like minor points can optimize
the postoperative result. I appreciate the thorough
discussion of submandibular gland management,
which continues to be an active topic of discussion
even decades after it was introduced.
113
 Surgical Techniques for Treatment of the Aging Neck
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(2):482–486
[17] de Castro CC. The anatomy of the platysma muscle. Plast
Reconstr Surg. 1980; 66(5):680–683
[18] Cardoso de Castro C, Aboudib JH, Jr. Extensive cervical and
lower face lipectomy: its importance and anatomical basis.
Ann Plast Surg. 1980; 4(5):370–375
[19] Mendelson BC. SMAS fixation to the facial skeleton: rationale
and results. Plast Reconstr Surg. 1997; 100(7):1834–1842,
discussion 1843–1845
[20] Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg.
1979; 3(6):529–539
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1980; Monterey, CA
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[23] Fuente del Campo A. Midline platysma muscular overlap for
neck restoration. Plast Reconstr Surg. 1998; 102(5):1710–
1714, discussion 1715
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[24] Marchac D. Julien Bourguet. The pioneer in aesthetic surgery
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necklift: a retrospective analysis of 504 patients. Aesthet Surg
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112(4):1150–1154, discussion 1155–1156
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10 Neck Lift after Massive Weight Loss
Dennis J. Hurwitz
Abstract
A neck lift after massive weight loss must artisti-
cally reduce hanging inelastic skin damage by obe-
sity, starvation, and at times aging. For most, the
neck is optimally lifted during a superficial muscu-
loaponeurotic system (SMAS) vertical suspension
facelift with removal of considerable skin around
the ears and scalp. For those refusing a facelift or
simply focused on the neck deformity, either bipo-
lar radiofrequency skin shrinkage or submental
Z-plasty with platysma suspension and optional
nearby liposculpture are offered. The delivery of
these therapies is explained with clinical examples.
Knowing what you can accomplish and the inher-
ent risks helps you manage patient expectations.
Keywords: facelift, neck lift, Z-plasty, submental
Z-plasty, vertical facelift, FaceTite, AccuTite, InMode
Aesthetics, platysmaplasty, liposuction
Key Points
Isolated neck lift after weight loss:
● It is indicated for loose neck skin with or without
excess adiposity with minimal jowls.
● The patient desires face and neck rejuvenation
but refuses facial scars or risks of facelift surgery.
● Bipolar radiofrequency with liposuction tightens
mild to moderate skin laxity.
● Bipolar radiofrequency tightens skin laxity after
prior facelift.
● Submental Z-plasty is the best for submental
laxity, especial with medial platysma bands.
● Submental Z-plasty is offered for recurrent sub-
mental skin laxity after facelift.
● The best neck lift starts with a vertically sus-
pended facelift.
10.1 Patient Considerations,
Indications, and Contraindications
10.1.1 Considerations
Excess skin with and without adiposity of the neck
occasionally occurs in young adults, but it is most
often an untoward byproduct of massive weight
loss (MWL) and/or aging. In addition to the excess
skin, reduced structural and elastic quality of the
skin and subcutaneous tissue may contribute to
the sag. Neck deformity is both vertical and hori-
zontal. Treatment ideally considers both vectors.
Following MWL deflation, facial and neck skin
excess tends to be considerable, requiring large
resections. Neck lift tightens and suspends loose
neck skin and platysma along with removal of ex-
cess adipose, and partial excision of hypertrophied
diagastric muscles and submandibular glands.
10.1.2 Indications
An isolated neck lift for tissue redundancy of the
neck is indicated when jowls are minimal. More
often the patient feels that the high expense, prolong
recovery, facial scars, and/or risks of facelift surgery
are best avoided, but desires reduced neck laxity.
Neck lift can also correct the occasional partial recur-
rence of submental laxity after a facelift. The author
chooses between the following three neck lifts.
● Bipolar radiofrequency tightening: When the
neck contains significant adipose tissue, liposuc-
tion is performed first. For the skin excess, bipolar
radiofrequency subcutaneous tissue tightening
such as FaceTite or AccuTite are employed. For
skin inelasticity, dermal contraction is achieved
through bipolar radiofrequency-coated micro-
needling such as Morpheus8. InMode calls the
combination of subcutaneous probe heating and
superficial bipolar microneedling Embrace.1
Contraindications are unrealistic expectations,
cardiac pacemaker, poor health, and perhaps
Fitzpatrick 6 skin type.
● Submental Z-plasty with oblique skin excisions:
When the problem is primarily considerable
submental skin excess, especially with platysma
bands, a direct Z-plasty with parallel oblique
elliptical excisions of skin and adipose is offered
to both women and men. Not only is tissue
removed in both the vertical and horizontal
planes, but also the transposition flaps of the
Z-plasty flatten both the submental and neigh-
boring upper neck. This operation is not to be
confused with a secondary skin Z-plasty after a
full-thickness vertical excision of skin.2,3,4,5 With
the wide exposure after opening the Z-plasty ex-
cision, direct submental maneuvers can remove
115
 Neck Lift after Massive Weight Loss
subplatysmal fat, correct medial platysma bands,
and reduce prominent submandibular glands and
hypertrophied digastric muscles. A simple medial
approximation of the platysma bands2,4,5 or
Z-plasty of the platysma muscle3,6,7 has been re-
placed by firm suture of the medial platysma to
the hyoid fascia.8 The single Z-shaped scar mostly
hides under the upper horizontal neck plane.
Contraindications are poor health, minimal skin
redundancy, nonacceptance of Z-pattern sub-
mental scar, and unrealistic expectations. While
the closure may reduce jowls and liposuction of
the lateral neck may reduce submandibular adi-
pose, the patient must accept that only signifi-
cant recontouring of the central upper neck can
be assured.
● Neck lift as part of a vertical facelift: A neck lift
for moderate to severe skin laxity due to aging
and/or MWL best starts with a tight vertical
SMAS/platysma imbrication during a facelift.9,10
Our no. 1 Quill barbed suture suspension elimi-
nates most of the vertical upper submandibu-
lar skin excess. Most horizontal and remaining
vertical neck skin is taken out with posterior
and superior redraping of skin excess. Contra-
indications are poor health, hypertension,
minimal skin redundancy, nonacceptance of
risk of thickened facelift scars, facial nerve in-
jury, hematoma or skin necrosis, and unrealis-
tic expectations of recovery or results. Patients
must understand the likelihood of residual
perioral, periocular, and late submental wrin-
kles and skin laxity.
10.2 Isolated Neck Lift: What
Techniques to Use and Why?
An independent neck lift is indicated when adi-
pose excess and/or skin laxity of concern is pre-
dominantly cervical. For patients with facial and
neck skin laxity, who request an isolated neck lift, I
attempt to convince them that temple, preauricu-
lar, and mastoid skin excision with wide lower fa-
cial and neck undermining and Quill suture SMAS
suspension, followed by scars around and slightly
beyond their ears is their optimal operation. They
are more likely to accept this when the offer is
made to perform the facelift under local anesthesia
with oral sedation in my office AAAASF (American
Association for Accreditation of Ambulatory Sur-
gery Facilities, Inc.) certified operating room, in-
stead of general anesthesia with an endotracheal
116
tube in the university hospital. When a combined
lift of the lower face and neck is rejected, either
FaceTite or submental Z-plasty is offered.
10.2.1 FaceTite, AccuTite, and
Morpheus8 to the Face and Neck
Bipolar radiofrequency subcutaneous lipolysis and
dermal microneedling are effective, interactive ad-
vanced technologies for mild to moderate skin lax-
ity of the neck.1 When sagging jowls are a concern,
the lower face is also treated. The tightening is
caused by partial coagulation necrosis of adipose
and connective tissue followed regenerative colla-
gen reformation.11 Necrotic fat is aspirated and/or
resorbed. A substantial inflammatory response
leaves mild to moderate swelling and some indu-
ration. Over subsequent 6 months, regenerative
collagen and elastin cause up to 30% soft-tissue re-
traction and elasticity. When treated within safe
temperature and kilojoule limits, a second FaceTite
treatment, with the expectation of significant fur-
ther skin tightening, is easy to perform due to the
paucity of restrictive scarring.
Adiposity is commonly an issue in the submental
neck deformity, which may extend throughout the
upper neck. A pre-FaceTite partial lipoaspiration is
performed, which is then completed after the radio-
frequency energy has been applied. This approach
allows for residual safe amount of infused saline to
dissipate the radiofrequency energy and enough
retention of the fluid-filled cytoarchitecture for even
effect from the hot bipolar energy probe.
Whether the FaceTite is performed under gener-
al anesthesia or simply oral sedation, a super wet
infusion of saline with xylocaine with epinephrine
is used. Dilute anesthetic is made up with 50 mL of
1% xylocaine and 0.5 mg of epinephrine and 5 mL
of sodium bicarbonate added to a 250-mL intrave-
nous bag of saline. Three milliliters of 1% xylocaine
with 1/100,000 epinephrine is injected along
the posterior border of the sternocleidomastoid
muscle 6 cm inferior to the ear to block the cervi-
cal sensory plexus and great auricular nerve. Mi-
nutes later, the dilute anesthetic is slowly infused
along the supraplatysmal plane, through a 20-
gauge spinal needle inserted at the cervical plexus
block. Continuous 50 mL/min injection, which is
just perceptible under the skin, is deposited ante-
grade as the needle is pushed toward the submen-
tum. Upon pullback, a bolus of distending fluid is
deposited. The process marches across the neck
 10.2 Isolated Neck Lift: What Techniques to Use and Why?

with insertion of the needle and start of injection
within previously numbed areas. This subcutaneous
soft-tissue plane offers little resistance to the infu-
sion of the deposited fluid. Since the fluid pressure
and not the sharp spinal needle creates the space
for the local anesthetic, there is negligible pain and
no laceration of vasculature. When submental fat
deep to the platysma is a target, fluid infusion fills
that space as well. Resistance to infusion along the
jawline resistance is also minimal, but the more ad-
herent lateral and midfacial skin is tightly adherent
and thus mildly painful to inject, even with slow in-
fusion. Preliminary syringe liposuction is performed
in adipose-laden necks (▶ Fig. 10.1a).
In nonobese necks, upon completion of the neck
and lower facial infiltration of dilute anesthetic,
FaceTite or an AccuTite handpiece is inserted
through an 18-gauge needle (▶ Fig. 10.1b, c). Over
the past 4 years of frequent experience, the author
now recommends the FaceTite handpiece for the
lower face and neck. For the treatment of this pa-
tient, the smaller AccuTite just became available.
Its rapid heating, 7-cm reach, and 2-mm thickness
makes it ideal for this patient’s thinner mid cheek
and periorbital region, but not so much for the
neck. I now recommend the 11-cm reach of the
3-mm-wide FaceTite for the neck.
Regardless of the handpiece, tightening of the
upper neck is through three 18-gauge needle
punctures that subdivide three zones. The central
submental port is the origin to a fan-shaped sweep
of the central zone. Along the midlateral border of
the sternocleidomastoid muscle, a puncture wound
is made for medially directed sweeps under the
mandibular border and over the central platysma.
As a bipolar handpiece is stroked with energy trav-
eling from an active deep electrode to a passive
superficial receiving disk gliding along the skin sur-
face (▶ Video 10.1), the operator must set the tem-
perature upper limits for both the superficial disk
and deep probe. The upper limits of temperature
for the skin surface are from 37 to 40 °C, and the
deep emitting electrode is for ≤ 60 °C. The tempera-
ture end points are adjusted to the response of the
tissues, with slow elevation to the limit encouraging
a lower setting. Multiple passes are needed to reach
selected temperature end point. A foot pedal con-
trols the release of energy with a readout of the
sensed temperature on the console. The steady
cadence of clangs speeds up as the cutoff temper-
ature is being reached with suspension of emit-
ting energy at triple sounds. A liberal crisscross of
lateral to central zone is performed. Upon com-
pletion of treatment, a partial shrinkage with

Fig. 10.1 Bipolar radiofrequency tightening of the neck with liposuction. (a) A 20-mL syringe with a 1.5-mm three-
holed cannula is hand aspirating 15 mL of adipose from the central neck, which undoubtedly includes subplatysmal fat.
(b) AccuTite handpiece with its 4.5-cm probe is held over the suctioned area, and (c) then lies within the defatted neck.

117
 Neck Lift after Massive Weight Loss
Video 10.1 AccuTite of the neck, face, and forehead.
tightening of the skin is appreciated with im-
proved neck contours.
Crepe and wrinkled skin are not improved with
FaceTite, and in fact may even be more obvious
because of subcutaneous tissue shrinkage. In those
cases, and when in doubt, proceed with topical bi-
polar radiofrequency microneedling. The compan-
ion to the FaceTite is the Morpheus8 24-pin tip,
which ejects coated needles with from 20 to 50 kJ.
The previous infusion of local anesthetic is adequate
numbing, but if extension to the lips and periorbital
region is desired, then high-concentration topical
anesthetic is applied. For thick neck skin, a 4-mm
depth of penetration is selected with 50% overlap.
A second overlapping pass is customarily done at
2-mm depth, which synergistically injure and con-
tract both immediate subdermal and deep dermal
tissues.
Avoid Bad Results
● Avoid disappointment in aesthetic improvement.
Realistically estimate the improvement and be
sure the patient not only understands but also
accepts an incomplete result. Be meticulous and
rhythmic in passes with adequate energy and
high enough temperature cutoff with adequate
kilojoule in each zone. Clearly prepare the pa-
tient for possible follow-up FaceTite or even a
surgical neck lift after 6 months.
● Avoid prolonged induration or depression at en-
try site. Take care not to overexpose the entry
site area to radiofrequency energy.
● Avoid facial animation weakness. Avoid injury to
the mandibular branch of the facial nerve by not
crossing the distal mandible from the lateral
neck or lower face. A direct lateral sweep from a
puncture wound near the mental foramen best
118
avoids mandibular branch injury during lower
facial treatment.
● The finer and more controllable AccuTite allows
for reliable subdermal movement to avoid in-
jury to the buccal, zygomatic, and frontal
branches of the facial nerve. Also, reduce energy
to under 30 kJ in those areas.
● Avoid blistering skin injury. Do not push the pedal
until you know where the subdermal probe is. Do
no torque the probe against the dermis. Immedi-
ately apply cold saline or ice for skin blisters.
● Avoid prolong swelling and induration. When
high cutoff limits are chosen, avoid overtreat-
ment. Apply reliable, comfortable, and pro-
longed elastic skin support. Early posttreatment
lymphatic massage, preferably with HiVamat
and external ultrasound, works and is reassur-
ing. Percutaneous bipolar radiofrequency early
scar modulation with InMode’s Forma has soft-
ened many indurated areas of healing.
Two recent cases are presented. The first is a near
ideal case of a mild sagging of the lower face and
neck with excess submental adiposity. The second
case is an elderly MWL patient who desires correc-
tion of her skin laxity through excision of large
stretches of skin throughout her body but not her
face.
Case Examples
Case 1
A 57-year-old woman preferred a minimally invasive
approach to recontouring her face and neck to a
facelift. Her focus was the fullness of her neck, which
while loose would predictably be very loose with
hanging skin after liposuction (▶ Fig. 10.2a and
▶ Fig. 10.3a). Sixteen milliliters of fatty emulsion was
removed from the super wet neck (▶ Fig. 10.1a).
Then AccuTite was applied for 2 kJ each to the neck,
lower face, and periorbital region (▶ Fig. 10.1b, c;
▶ Video 10.1). The correction of neck and facial skin
rolls and laxity is seen 1 year later (▶ Fig. 10.2c and
▶ Fig. 10.3b).
Case 2
A 66-year-old woman desired noninvasive reduction
of her sagging neck (▶ Fig. 10.4a and ▶ Fig. 10.5a).
After infusion of saline with xylocaine and epinephr-
ine, FaceTite bipolar radiofrequency was applied
with external limit of 38 °C and internal limit of
 10.2 Isolated Neck Lift: What Techniques to Use and Why?

Fig. 10.2 Right lateral marked face (a) before and (b) 4 months after AccuTite treatment was applied to the submentum
and lateral neck (2 kJ), midface (1 kJ), and orbital regions (1 kJ) as planned in purple. The green prejowl sulcus receives 3 mL
of injected fat. In total, 16 mL of fat was aspirated, and skin laxity of the submentum was corrected. (c) The jawline was
clearly defined, and the jowls flattened. The periorbital regions are smoother.

Fig. 10.3 Frontal views of the patient

in ▶ Fig. 10.2 (a) before and (b) 4
months after AccuTite treatment was
applied to the face and neck.

68 °C for a total of 12 kJ for the entire neck. Twenty months but dissipated through the use of HIVAMAT
milliliters of fatty fluid was syringe aspirated. Eight electrophysiological lymphatic massage. Six months
milliliters of aspirated fat was Telfa rolled and in- later, she is pleased with her new neck and jawline
jected to her prejowl sulcus. Swelling lasted several contours (▶ Fig. 10.4b and ▶ Fig. 10.5b).

119
 Neck Lift after Massive Weight Loss
10.2.2 Submental Z-Plasty with
Parallel Oblique Elliptical Excisions
of Skin
When moderate to severe deformity is predomi-
nantly submental, and especially when there are
prominent medial platysma bands, Z-plasty is fa-
vored. The patient needs to see pictures of the Z-
shaped scar, which zigzags from the menton to
near the thyroid cartilages. The scars tend to heal
favorably but on rare occasion may hypertrophy.
As such, patients must accept that risk. If the
lengthy Z-pattern scars are unacceptable, then a
more limited U-plasty or FaceTite is offered.
The Z is designed starting with the central inci-
sion extending vertically from the chin menton to
120
Fig. 10.4 (a) Frontal pre-FaceTite and
20-mL syringe liposuction of the neck
and lipoaugmentation of the jawline in
a 65-year-old woman. (b) One year
later, a tighter and better suspended
neck can be seen. Her underlying
platysma bands are more obvious, but
are of no concern to her.
Fig. 10.5 Left lateral facial view of the
same patient as in ▶ Fig. 10.4 with
(a) before and (b) 1 year after FaceTite
and 20-mL syringe liposuction of the
neck.
near the thyroid cartilages (▶ Fig. 10.6). Each limb
is angled 60 degrees from the central line. An ellip-
tical excision of skin is drawn with two-thirds the
width toward the center and one-third lateral to
each limb. The inner small Z can be incised, and
the triangular flaps elevated full thickness over the
underlying platysma. Once these flaps are trans-
posed, the accuracy of the drawn elliptical exci-
sions down to the platysma muscle is verified and
adjusted accordingly. Subplatysmal dissection can
remove excess adipose and even hypertrophied
digastric muscle and submandibular glands. The
medial platysma bands can be imbricated, sutured
down to the hyoid fascia (preferably) and trans-
ected as desired. After defatting the Z-plasty flaps,
the left side triangular flap is suture advanced
 10.2 Isolated Neck Lift: What Techniques to Use and Why?
along the right jaw line. Then the right flap is su-
tured toward the thyroid cartilages. As the deep
sutures are placed between the flaps, the submen-
tum is flattened and the tension at the base of
these flaps beautifully depresses the skin inferior
to the mandibular border. If not, then more skin
and/or adipose has to be recovered. The interpo-
lated transposition flaps lengthen the distance
from the menton to the thyroid cartilages, which
is needed to span the increase surface of the now
deeper upper neck midline.
Submental Z-Plasty
● Easily executed within 90 minutes, including
administering local infiltration of anesthesia.
● Excision of both horizontal and vertical excess
skin of the midneck.
● Adjustable extent of skin resection.
● Access to modify the platysma and deeper
structures.
● Scar hidden under the chin.
● Can be combined with liposuction of the lateral
neck.
Avoid Bad Results
● Avoid residual submental laxity or excessively
tight closure. An adequately sized Z-plasty is de-
signed, which extends from the menton to the
thyroid cartilage. The width of the short limb el-
liptical resections needs to be just right. Too
narrow and there will be residual laxity. Too
Fig. 10.6 (a) A submental Z-plasty
with ellipses aligned over the short
limbs, having one-third of the width
lying to the outside of the limbs. The
tip of the right flap is labeled “A” and
the left flap is labeled “B.” (b) Four
years later, the transposed limbs are
on a flat submentum with faint, thin
scars. The tips labeled “A” and “B” are
seen in their interposed positions.
wide and the tight closure may dehisce or leave
wide scars. Be conservative in the initial cut-
out, but be prepared to excise more skin if pre-
liminary alignment reveals laxity.
● Avoid recurrent platysma medial bands. Not only
should medial platysma bands be securely su-
tured together, but the complex should also be
sutured to the suprahyoid fascia.
● Avoid standing cones. The standing cones of the
Z-plasty corners will be prominent unless defat-
ted or T-plasty excised.
● Avoid excess submental adiposity. After the two
triangular flaps of the Z-plasty are elevated off
the platysma muscle, evenly trim the deep fat
from the flaps. Also, conservatively excise excess
midline subplatysmal fat overlying the digastric
and mylohyoid muscles.
● Avoid triangular flap tip necrosis due to excessive
tension. The transpose triangular flaps are sewn
into position with subdermal interrupted ab-
sorbable suture from the base to the tip to pro-
gressively advance the skin under even tension.
Then they are sutured together, creating the
central transverse closure.
● Avoid uneven closure. Using operative magnifi-
cation, a running 6–0 monofilament suture pre-
cisely aligns the skin edges with a transdermal
bite in setting the corners.
● Avoid a gap in the beard along the closure using
operative magnification and proper angulation
of the skin incision to preserve hair follicles and
align the skin closure to minimize trauma to the
follicles along the edge.
121
 Neck Lift after Massive Weight Loss
Clinical Case Examples for
Submental Z-Plasty
Case 1
Submental laxity without jowls. A 52-year-old
woman lost 50 lb, leaving her with sagging and full-
ness of the central neck without jowls (▶ Fig. 10.7a).
Her Z-plasty is shown in ▶ Fig. 10.6. The 2-month
lateral neck image result shows complete correction
of her central laxity (▶ Fig. 10.7b), which remained
unchanged 4 years later (▶ Fig. 10.7c). Her frontal
before (▶ Fig. 10.8a) and after (4 year) views
(▶ Fig. 10.8b) also show the maintained correction
with no jowls and minimally visible scar.
Case 2
Recurrent submental skin laxity. A 62-year-old
woman lost 110 lb after gastric bypass. Most con-
cerned about her pelicanlike neck, she requested a
complete vertical facelift (▶ Fig. 10.9a). As lateral
facial images show 2 months later, her entire sag-
ging neck was much improved (▶ Fig. 10.9b). As
typical for MWL-damaged skin, a year later, she
Fig. 10.7 Left lateral facial views of the patient in ▶ Fig. 10.6. (a) Immediately pre-op with minimal jowls and obtuse and
full mentocervical angle. (b) Four months after the Z-plasty, deep and flat submentum with defined distal jawline can be
seen. (c) Four years later, the early postoperative contours are maintained.
122
had partial recurrence of the hanging skin, so a
submental Z-plasty was planned (▶ Fig. 10.9c). The
submental improvement remains 6 years later
(▶ Fig. 10.9d). A submental Z-plasty with a central
vertical limb and obliquely oriented elliptical exci-
sions were cut as drawn (▶ Fig. 10.10a). The medial
edges of the platysma muscle were sutured to the
hyoid fascia. The faintly, thinned scarred Z lies
on the still-flattened submentum 6 years later
(▶ Fig. 10.10b).
10.3 Role of Facelift for Neck
Excess
Candidates for neck lifts after MWL have consid-
erable excess skin and tissue laxity of both the
face and neck. Due to the generalized severity of
the skin laxity, an isolated neck lift is rarely indi-
cated. Having a practice with emphasis on body
contouring, from time to time, I perform a face-
lift on MWL, using a modified version of the
MACS lift.11
The most impactful neck lift is an extension of
a facelift that includes distinctly superior vertical
 10.3 Role of Facelift for Neck Excess

Fig. 10.8 The frontal facial views of

the patient in ▶ Fig. 10.6 (a) before
and (b) after the Z-plasty. The sub-
mental fullness is gone and a faint end
of the Z-plasty scar overlies her thyroid
cartilages.

Fig. 10.9 Right lateral facial views of a 63-year-old massive-weight-loss (MWL) patient with Z-plasty for partial
recurrence of neck laxity after vertical facelift. (a) Before vertical facelift with obtuse neck and poorly defined jawline
and jowls. (b) Two months after vertical facelift showing tight and flat submentum and well-defined jawline without
jowls. (c) Two years after her facelift, she shows 50% recurrence of submental skin laxity and less definition of her jawline
with a Z-plasty drawn. (d) Six years later, the submentum remains deep and flat, although the jawline is not well defined.

123
 Neck Lift after Massive Weight Loss
suture advancement of the SMAS platysma complex
(▶ Fig. 10.11, ▶ Fig. 10.12, ▶ Fig. 10.13, ▶ Fig. 10.14).
For the past 15 years, I realized that both the most
effective and natural-appearing facelift has both a
vertical plication lifts of the SMAS platysma com-
plex and the overlying skin. Following a vertical lift
with a no. 1 PDO barbed suture deep imbrication of
the SMAS/platysma complex (▶ Fig. 10.12), a verti-
cal skin excision with lipoaugmentation of the mid-
face was done. Compare the preoperative pictures
(▶ Fig. 10.13) with the postoperative 18-month
result (▶ Fig. 10.14).
10.4 Expert Commentary by
Dr. Slavin
This is an outstanding chapter by one of the ex-
perts in the field of reconstruction and aesthetic
Fig. 10.11 Vertical facelift with midface fat grafting. Right lateral face on operating room table (a) before with markings
and (b) immediately after the procedure.
124
improvement in the MWL patient. He tackles a dif-
ficult problem, recognizes the intrinsic changes to
the skin in this population, and comes up with a
thoughtful, multimodal approach, appreciating
that an isolated skin pull will have variable results.
10.5 Expert Commentary by
Dr. Lin
The treatment of the neck following significant
weight loss is a challenge. As noted by the author,
oftentimes external scars (i.e., Z-plasty) will be re-
quired to achieve the optimal result for neck con-
touring. Counseling of the patient that trading off
contour for visible scars with understanding of this
concept is emphasized in the chapter. Finally, as
mentioned, revisions may be required with contin-
ued laxity of the skin with time.
Fig. 10.10 Submental views of the
patient in ▶ Fig. 10.9. (a) Preoperative
with drawn Z-plasty and obliquely
oriented ellipses. The tips are labeled
“a” and “b.” Six years postoperatively
with transposed flaps lying flat with
the tips labeled “a” and “b.” (b) The
scars are faint and thin.
 10.5 Expert Commentary by Dr. Lin

Fig. 10.12 Right lateral face of the patient in ▶ Fig. 10.11 with facelift skin flap elevated. The pattern of the planned
vertically oriented superficial musculoaponeurotic system (SMAS)/platysma imbrication with a single double-armed no.
1 PDO Quill is drawn. There are 10 essential imbrications. The first four throws securely elevate the SMAS and upper
platysma several centimeters. 1 bite is the initial oblique pass of the double-armed barbed suture deeply through the
temporalis muscle (cranial suspension). 2 and 3 are each two slightly divergent descending bites through SMAS, which
are then cinched pulling the SMAS/platysma about 1 cm cephalad. 4 is the continuation of the posterior limb through
the parotid fascia to below the angle of the mandible, which is then cinched for further vertical pull on the platysma. 5 is
the horizontally oriented series of bites through platysma taking a hairpin turn and then continuing through 6 and 7
before being cinched up to the anchoring first bites. The platysma is now lifted and pulled posterior and since the
submental skin is still attached (no open neck), it has been tightly pulled. Suture tracts 8 and 9 obliquely efface the
jowls. 10 and subsequent tidying bites flatten and secure the mushrooming imbricated tissues.

Fig. 10.13 Preoperative marked photos of the patient in ▶ Fig. 10.11 and ▶ Fig. 10.12 showing severely hanging skin in
(a) frontal, (b) right oblique, and (c) right lateral views.

125
 Neck Lift after Massive Weight Loss
Fig. 10.14 (a–c) Postoperative views of the patient in ▶ Fig. 10.11, ▶ Fig. 10.12, ▶ Fig. 10.13 at 18 months showing
absence of loose and hanging skin and appropriate fullness of the midface.
References
[1] Dayan E, Chia C, Burns AJ, Theodorou S. Adjustable depth
fractional radiofrequency combined with bipolar radiofre-
quency: a minimally invasive combination treatment for skin
laxity. Aesthet Surg J. 2019; 39 Suppl_3:S112–S119
[2] Cronin TD, Biggs TM. The T-Z-plasty for the male “turkey
gobbler” neck. Plast Reconstr Surg. 1971; 47(6):534–538
[3] Gradinger GP. Anterior cervicoplasty in the male patient.
Plast Reconstr Surg. 2000; 106(5):1146–1154, discussion
1155
[4] Miller TA. Excision of redundant neck tissue in men with pla-
tysma plication and Z-plasty closure. Plast Reconstr Surg.
2005; 115(1):304–313
[5] Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;
85(3):333–343
126
[6] Hamilton JM. Submental lipectomy with skin excision. Plast
Reconstr Surg. 1993; 92(3):443–447, discussion 448
[7] Weisman PA. Simplified technique in submental lipectomy.
Plast Reconstr Surg. 1971; 48(5):443–446
[8] Yousif NJ, Matloub HS, Sanger JR. Hyoid suspension neck lift.
Plast Reconstr Surg. 2016; 138(6):1181–1190
[9] Hurwitz DJ. Comprehensive Body Contouring Surgery, Face-
lift in the MWL Patient. Geneva: Springer Verlag; 2016
[10] Labbé D, Franco RG, Nicolas J. Platysma suspension and pla-
tysmaplasty during neck lift: anatomical study and analysis
of 30 cases. Plast Reconstr Surg. 2006; 117(6):2001–2007,
discussion 2008–2010
[11] Dayan E, Burns AJ, Rohrich RJ, Theodorou S. The use of radio-
frequency in aesthetic surgery. Plast Reconstr Surg Glob
Open. 2020; 8(8):e2861–e2867
11 The Use of Radiofrequency for Facial Rejuvenation
Erez Dayan and Christopher T. Chia
Abstract
A treatment gap exists among patients who are
not candidates for or prefer to not undergo tradi-
tional facelift and/or necklift. In these cases, radio-
frequency has been shown to achieve approximately
30% soft-tissue contraction through thermal injury
to the dermis and underlaying fibroseptal networks.
Subsequent collagen remodeling angiogenesis, lym-
phangiogenesis, as well as elastin reorganization
function to visibly improve soft-tissue laxity in these
cases.
Keywords: radiofrequency skin tightening, radio-
frequency, FaceTite, bipolar radiofrequency
Key Points
● Through impedance of electromagnetic cur-
rent, radiofrequency (RF) energy leads to dif-
ferential heating across distinct tissue types
consistent with Ohm’s law (energy = current2 ×
impedance × time). For example, adipose tissue is
less conductive than water (higher impedance),
and leads to generation of higher temperatures
than muscle. Once soft-tissue temperatures reach
50 °C and skin surface reaches from 40 to 42 °C,
there is a trigger to induce neocollagenesis, angio-
genesis, and elastogenesis.
● Through different applications of RF energy (i.e.,
monopolar, bipolar, multipolar, microneedling),
subdermal adipose remodeling (SAR) and long-
term soft-tissue contraction can be safely and
consistently achieved.
11.1 Patient Considerations
Radiofrequency (RF) treatment of the face and
neck area is intended for the “treatment gap”
patient population (30s–50s). This typically refers
to patients who have some soft-tissue laxity that is
not severe enough for an excisional procedure
(▶ Fig. 11.1 and ▶ Fig. 11.2). A detailed medical his-
tory and physical is obtained on all patients prior to
treatment. Exclusion criteria include the following:
pregnancy, open wounds, active infection, dermato-
logic conditions, bleeding disorders, immunocom-
promised state, and implantable devices. Patients
who have excessive laxity (i.e., advanced age,
massive weight loss) require excisional proce-
dures and are not optimal candidate for RF skin
tightening.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18
Risks and benefits are discussed at length includ-
ing the possibility for thermal injury, sensory and/
or motor nerve injury, or poor contour/scarring.
Patients are counseled at length regarding ex-
pectations. It is important for patients to have a
clear understanding that RF treatments deliver a
controlled thermal energy, which ultimately is in-
tended to upregulate growth factors such as vascu-
lar endothelial growth factor (VEGF) to allow for
neocollagenesis, angiogenesis, elastin remodeling,
and lymphangiogenesis.1 The result can be variable
and dependent on the patients’ overall soft-tissue
contraction after treatment. Often, we counsel pa-
tients on excisional options ahead of time as poten-
tial revisional procedures (i.e., mini-facelift/neck
lift) in the event that the RF treatment does not
provide satisfactory soft-tissue contraction.
Patients are marked in the sitting position by
first identifying the mandibular border and jowls
bilaterally. The jowls were subdivided into zone 1
(above the mandibular border) and zone 2 (below
the mandibular border). Areas of localized adipos-
ity in the lower face and neck region are marked.
Nontreatment zones are identified by carrying a
line inferiorly perpendicular to the lip commissures
(i.e., marionette lines). The area medial to these
lines are avoided to preserve marginal mandibular
innervation to the depressor anguli oris, mentalis,
and depressor labii inferioris. Five access points are
identified: (1) the submental midline, (2) 1 to 2 cm
inferior to the mandibular parasymphyseal/body
junction, and (3) two postauricular sites. Depending
on clinical circumstances and patient desires, cases
were performed under either general or local
anesthesia. In cases of local anesthesia, patients
were premedicated with oxycodone (5 mg) and/or
benzodiazepine (5 mg).
11.2 Technique
The patient is placed in a supine position and is
prepped and draped in the standard fashion.
Water-soluble sterile ultrasound gel is placed over
the treatment areas. Access sites are each injected
127
 The Use of Radiofrequency for Facial Rejuvenation
with 2 to 4 mL of 2% lidocaine with epinephrine.
Typically, these access ports are inferior to each
ear lobule and at the submental midline for full
access to the central and lateral neck. A 14-gauge
needle is then used to make access ports that are
slightly dilated with Stevens scissors. A spinal needle
was used to slowly infiltrate tumescent solution (1 g
lidocaine per liter of lactated Ringer’s solution) from
deep to superficial, starting in the preplatysmal
plane and moving to the subdermal plane (~100–
150 mL of tumescent total). At the conclusion of tu-
mescent infiltration, the cannula was passed through
the subdermal plane to confirm adequate analgesia
and to allow for discontinuous undermining.
Bipolar RF is performed first using the FaceTite
(InMode, Lake Forest, CA) probe. The device’s in-
ternal and external thermometer is tested on the
surgeon’s hand prior to treatment and confirmed
to be appropriately recording temperatures. The RF
settings included an internal temperature cutoff of
68 °C and external cutoff temperature of 38 °C.
These temperatures are preset and the device will
automatically regulate temperatures to not exceed
these limits. Soft-tissue contraction is a function of
time versus temperature in an Arrhenius relation-
ship. This means that a similar soft-tissue contrac-
tion can be achieved in two scenarios: (1) higher
temperature for a shorter time or (2) lower temper-
ature for a longer time. We believe that the afore-
mentioned temperature settings allow for a safe yet
efficient soft-tissue contraction. The RF cannula is
used to pretunnel treatment areas for ease of treat-
ment and to ensure that the cannula does not
become misguided during treatment. The predeter-
mined treatment areas are systematically heated
row by row to avoid heat loss when treating wide
areas. RF application is applied on retrograde move-
ment of the cannula and stopped within 1 cm of
the access port to prevent overheating this area at
each pass. Audible and visual cues from the RF con-
sole are used to assess temperature of tissues and
treatment is stopped after 1 minute of reaching tar-
get internal and external temperatures. The device
automatically provides a double and subsequent
triple beep once target temperatures are reached
internally and externally.
Fractional RF (Fractora modified to Morpheus8,
InMode) is subsequently used at a depth of 4, 3,
and 2 mm and energy of 30 with 50% overlap. The
handpiece is applied firmly and perpendicular to
the treatment area prior to delivery of RF energy
pulses. In patients with thinner skin or darker Fitz-
patrick types, energy settings are reduced by 20%.
128
The addition of fractional RF provides subdermal
thermal injury, which remodels reticular dermis
and also improves soft-tissue texture, as opposed
to bipolar RF, which focuses energy on the fibrosep-
tal networks. At the conclusion of the treatment,
the patients’ facial nerve function is assessed. This
is compared to the assessment performed preoper-
atively. Specific attention is paid to the patients’
marginal mandibular nerve function. In cases of
neuropraxia, it is noted in the patients’ record and
reassessed in follow-up visits to ensure that it is ei-
ther from the local anesthesia effect or temporary
due to heat or traction injury. In the authors’ expe-
rience, neuropraxia is uncommon (2–3% of cases)
and resolves over the coming 4 to 8 weeks. Patients
are seen at intervals of 1 week and 1, 3, and 6
months for follow-up.
11.3 Postoperative Care
● Patients are seen at 1-week and 1-, 3-, and 6-
month intervals.
● Patient are instructed to not use any skin prod-
ucts for the first 3 to 4 days after fractional RF
treatment.
● The usual postoperative course involves some
edema and ecchymosis. This typically resolves
in 1 week.
● A facelift-type headwrap with moderate com-
pression is applied for 3 to 4 days.
● Patients are instructed to not use cold com-
presses.
● Most patients return to work the next day.
11.4 Common Pitfalls
● Proper marking of the patient and identifying
danger zones are key to avoid heating distal as-
pects of the marginal mandibular nerve.
● Avoid patients with excessive soft-tissue laxity
who are more fit for excisional procedures.
● Use of ample tumescent functions as a “heat
sink” to avoid thermal injury and also allows for
optimal transmission of RF injury.
11.5 Case Examples
11.5.1 Case 1
A 34-year-old woman 6 months after
radiofrequency-assisted liposuction of the lower face
and neck using FaceTite (InMode; ▶ Fig. 11.1).
 11.6 Conclusion

Fig. 11.1 (a–e) A 34-year-old woman 6 months after radiofrequency-assisted liposuction of the lower face and neck
using FaceTite (InMode).

11.5.2 Case 2 11.6 Conclusion

A 24-year-old woman 8 months after Internal and external generation of heat via com-
radiofrequency-assisted liposuction of the lower bined bipolar RF and fractional RF serves to initiate
face and neck using FaceTite (InMode; ▶ Fig. 11.2). neocollagenesis, elastogenesis, and subdermal

129
 The Use of Radiofrequency for Facial Rejuvenation

Fig. 11.2 (a–e) A 24-year-old woman 8 months after radiofrequency-assisted liposuction of the lower face and neck
using FaceTite (InMode).

130

Video 11.1 Marking for bipolar radiofrequency of the
lower face and neck.
adipose remodeling. This, in combination with
fibroseptal network tightening, allows for safe
and consistent soft-tissue contraction to improve
lower face and neck soft-tissue laxity. This particu-
larly benefits patients who previously may have
fallen into a treatment gap.
11.7 Expert Commentary by
Dr. Slavin
The advances in this area are impressive in terms
of their ability to address the treatment gap on pa-
tients who, for a number of reasons, are either not
surgical candidates or prefer to not have a mini-
facelift or neck lift. The RF technique addresses this
growing population of patients that a plastic sur-
geon sees daily. It is extending skin tightening to
an ever-younger population who may otherwise
not seek treatment by plastic surgeons. It is reas-
suring that the incidence of nerve injury remains
low—estimated by the authors at 2 to 3%—and we
hope that it continues to decline. We appreciate
the authors’ point that a mini-facelift may be re-
quired, in addition.
The plastic surgeon will need to determine
which patients would best benefit from RF com-
pared with the traditional techniques. It will be
important to stress to the patients that the results
may be variable and we foresee challenges in cau-
tioning patients on the degree of improvement
that can be delivered. Looking into the future, it is
reasonable to expect every plastic surgeon per-
forming cosmetic surgery on the face and neck to
be very knowledgeable about these techniques
(▶ Video 11.1 and ▶ Video 11.2).
References
Video 11.2 Fractional radiofrequency using Morpheus8
(InMode; Lake Forest, CA).
11.8 Expert Commentary by
Dr. Lin
The authors have addressed an important aspect of
caring for the aesthetic patient: those who are not
surgical candidates who wish to have treatment
who fall into the “treatment gap.” Devices for deliv-
ering energy have been developed over a long peri-
od of time, and in this current state I appreciate the
authors’ ability to realistically balance the results of
various minimally invasive results. The use of en-
ergy in higher Fitzpatrick score patients poses a risk
and so the authors describe their treatment modifi-
cation in their chapter. In these patients, I would
personally consider a test area away from the
planned treatment area as an option.
References
[1] Dayan E, Chia C, Burns AJ, Theodorou S. Adjustable depth
fractional radiofrequency combined with bipolar radiofre-
quency: a minimally invasive combination treatment for skin
laxity. Aesthet Surg J. 2019; 39 Suppl_3:S112–S119
[2] Theodorou SJ, Del Vecchio D, Chia CT. Soft tissue contraction
in body contouring with radiofrequency-assisted liposuction:
a treatment gap solution. Aesthet Surg J. 2018; 38 suppl_2:
S74–S83
[3] Alster TS, Tanzi E. Improvement of neck and cheek laxity
with a nonablative radiofrequency device: a lifting experi-
ence. Dermatol Surg. 2004; 30(4, Pt 1):503–507, discussion
507
[4] Bassichis BA, Dayan S, Thomas JR. Use of a nonablative radio-
frequency device to rejuvenate the upper one-third of the
face. Otolaryngol Head Neck Surg. 2004; 130(4):397–406
[5] Burns AJ, Holden SG. Monopolar radiofrequency tissue tight-
ening: how we do it in our practice. Lasers Surg Med. 2006;
38(6):575–579
[6] Burns JA. Thermage: monopolar radiofrequency. Aesthet Surg
J. 2005; 25(6):638–642
131
 The Use of Radiofrequency for Facial Rejuvenation
[7] Dierickx CC. The role of deep heating for noninvasive skin re-
juvenation. Lasers Surg Med. 2006; 38(9):799–807
[8] Doshi SN, Alster TS. Combination radiofrequency and diode
laser for treatment of facial rhytides and skin laxity. J Cosmet
Laser Ther. 2005; 7(1):11–15
[9] Abraham MT, Mashkevich G. Monopolar radiofrequency
skin tightening. Facial Plast Surg Clin North Am. 2007; 15
(2):169–177, v
[10] Abraham MT, Vic Ross E. Current concepts in nonablative ra-
diofrequency rejuvenation of the lower face and neck. Facial
Plast Surg. 2005; 21(1):65–73
[11] Alexiades-Armenakas M, Dover JS, Arndt KA. Unipolar versus
bipolar radiofrequency treatment of rhytides and laxity using
a mobile painless delivery method. Lasers Surg Med. 2008;
40(7):446–453
[12] Kaplan H, Kaplan L. Combination of microneedle radiofre-
quency (RF), fractional RF skin resurfacing and multi-source
non-ablative skin tightening for minimal-downtime, full-
face skin rejuvenation. J Cosmet Laser Ther. 2016; 18(8):
438–441
132
[13] Lee HS, Lee DH, Won CH, et al. Fractional rejuvenation using
a novel bipolar radiofrequency system in Asian skin. Derma-
tol Surg. 2011; 37(11):1611–1619
[14] Levy AS, Grant RT, Rothaus KO. Radiofrequency physics for
minimally invasive aesthetic surgery. Clin Plast Surg. 2016;
43(3):551–556
[15] Narurkar VA. Lasers, light sources, and radiofrequency devi-
ces for skin rejuvenation. Semin Cutan Med Surg. 2006; 25
(3):145–150
[16] Sadick N, Rothaus KO. Minimally invasive radiofrequency de-
vices. Clin Plast Surg. 2016; 43(3):567–575
[17] Sadick N, Rothaus KO. Aesthetic applications of radiofre-
quency devices. Clin Plast Surg. 2016; 43(3):557–565
[18] Zelickson BD, Kist D, Bernstein E, et al. Histological and ultra-
structural evaluation of the effects of a radiofrequency-based
nonablative dermal remodeling device: a pilot study. Arch
Dermatol. 2004; 140(2):204–209
12 Neck Lift and Fat Grafting to the Neck
Aris Sterodimas
Abstract
Facial rejuvenation is becoming increasingly chal-
lenging because patients request minimally inva-
sive surgery and rapid surgical course and recovery,
along with fast, tangible, and long-term results. Reju-
venation of face, neck, and periorbital areas needs to
be addressed at the same surgery. At our institution,
a systematic approach comprising all of these proce-
dures has been developed, with consistent results.
Our research group has already described the meth-
od of stromal enriched lipograft (SEL) in various
parts of the body, a procedure combining fat with
enzyme-based extraction of the stromal vascular
fraction (SVF), with the aim to increase the take and
duration of the grafted fat and the related volume,
thereby determining a more predictable and stable
result in terms of graft survival in the face, and also
improving the skin quality. Recently, a helium-based
plasma technology has been introduced for the per-
cutaneous delivery of plasma energy for the purpose
of soft-tissue coagulation and contraction. A signifi-
cant skin and soft-tissue contraction in a smooth
and even manner is accomplished in the neck area.
Facial harmony not only depends on achieving a
more natural, tense, and young conformation but
also on restoring volumes and improving the quality
of the facial and neck skin.
Keywords: stromal enriched lipograft, fat grafting,
face, neck tightening, facelifting, skin tightening,
radiofrequency, minimally invasive, helium plasma
Key Points
● In this chapter, the technique, the pearls, and
the pitfalls of the SEL technique for facial fat
grafting and the application of cool helium plas-
ma radiofrequency technology for neck tighten-
ing are described in detail. A series of patients
who underwent contouring of the neck and
facial lipotransfer assisted by SEL are presented.
● Careful selection of patients and proper surgical
technique help avoid contour irregularity, and
outcome expectations should be based on real-
istic preoperative evaluation of the patient’s
age, skin elasticity, and volume of fat to be
transplanted.
● The SEL technique aims at filling facial atrophy
areas with adipocytes and adipose-derived stem
cells that will survive and become incorporated
into the recipient bed.
● Improvement of the neck contour can be attained
and maintained through the application of the
percutaneous delivery of plasma energy (Renu-
vion) for the purpose of soft-tissue coagulation
and contraction.
● The SEL technique and the application of Renu-
vion technology can play a significant role as
minimally invasive techniques for face and neck
rejuvenation when properly indicated.
12.1 Introduction
The aging of the face is a complex set of events,
determined by skin and superficial musculoapo-
neurotic system (SMAS) laxity and redundancy, re-
absorption of fat, and diminution of projection on
many face prominences, as well as thinning of the
dermis and decreased quality of the cutaneous
draping.1 The outward signs of aging can be very
evident in the face. Changes affecting the appear-
ance of the neck can include an increase or
decrease of subcutaneous fat, platysmal banding,
jowling, and skin laxity. Depending on the severity,
a range of treatment options is available for use
alone or in combination for treating the aging
neck. Face rejuvenation is increasingly challenging
as patients expect minimally invasive procedures
and rapid posttreatment course and recovery,
along with fast, tangible, and long-term results.
Rejuvenation of the face frequently requires sur-
gery to multiple areas (the lateral face, the mid-
face, the neck, and periorbital areas), in addition to
the increasing procedures of face sculpturing and
biostimulation through fat injection. At our insti-
tution, a systematic approach including all of these
procedures has been developed, with consistent
results.2,3 Although the gold standard continues to
involve the traditional facelifting surgical proce-
dure, there is a continuous shift toward minimally
invasive techniques that have promoted the advent
of techniques and devices that offer an alternative
to the traditional facelifting techniques.
Our research group has already described the
method of stromal enriched lipograft (SEL) in various
133
 Neck Lift and Fat Grafting to the Neck
parts of the body, a procedure combining fat with
enzyme-based extraction of the stromal vascular
fraction (SVF), with the aim to increase the take and
duration of the grafted fat and the related volume,
thereby determining a more predictable and stable
result in terms of graft survival.4,5,6,7
The debulking of fat with suction-assisted lipo-
suction has been shown to provide approximately
10% shrinkage as a result of a simple deflation effect
on the skin envelope and nonthermal inflammation
of the fibrocollagenous matrix that in turn gener-
ates new blood vessels, collagen, and scar tissue.8
Several technologies including laser, ultrasound,
and radiofrequency (RF) have demonstrated some
skin tightening after liposuction beyond the normal
deflation that accompanies the removal of fat and
beyond the nonthermal skin contraction that ac-
companies subdermal inflammatory stimulation by
the cannulas. The mechanisms of action for subcu-
taneous RF devices include the generation of heat
through tissue resistance within the dermis and fat
that results in neocollagenesis, elastin and dermal
matrix remodeling, and mild adipocyte loss. The
contraction of the subcutaneous tissue by deeper
application of cool helium plasma RF technology is
felt to be an additional mechanism that results in
additional neck contouring by soft-tissue contrac-
tion. The reduction in volume and tissue surface
area is the result of protein denaturation and colla-
gen contraction after a thermal energy threshold
has been transmitted to the tissue.9 Recently, a
plasma-driven RF device, Renuvion, was introduced
and Food and Drug Administration (FDA) cleared
for soft-tissue coagulation. The Renuvion system for
the neck utilizes cold helium plasma via a gas ion-
ization process to produce a stable, focused beam of
energy.
12.2 Patients and Methods
Accurate photographic documentation has become
essential in cosmetic plastic surgery for both clinical
and scientific purposes. Generally, informed con-
sent requires that a patient be informed of the risks
of treatment, prognosis, and alternative treatments
before consenting to treatment. Surgical consent is
an ongoing process of communication that contin-
ues throughout preoperative, perioperative, and
postoperative care. Areas to be treated typically are
marked with a circle in a topographic pattern.
Zones of adherence and areas to avoid are marked
with hash marks. Grid markings are made in order
134
to standardize resection and reduce contour irregu-
larities. Incisions should be placed in natural
creases to minimize visibility. It is important to re-
view all markings and access incision locations with
patients in front of a mirror before performing the
surgical procedure.
12.3 Surgical Technique and Fat
Processing and Grafting
● Markings of the neck area to be lipoaspirated
and treated with Renuvion are made while the
patient is in the standing position, as well as
markings on the face lipograft recipient sites.
● Preoperative sedation in the surgical suite is
administered. The procedure is performed
under sedation, in the supine position. Intra-
operative intravenous cefazolin is administered
at induction.
● After injecting into the neck subcutaneous tissue
normal saline wetting solution containing
1:500,000 of adrenaline by a small-bore cannula
and waiting 15 minutes, a 20-mL syringe attached
to a 2-mm blunt cannula is inserted through
small incisions in the postauricular crease. Fat is
aspirated by a 2-mm four-hole aspiration blunt-
tip cannula connected to a 20-mL Luer-Lok
syringe. The distal openings of the harvesting can-
nula are of an appropriate size and shape for har-
vesting the largest intact fatty tissue parcels that
can readily pass through the lumen of a Luer-Lok
syringe. The combination of slight negative pres-
sure and the curetting action of the cannula’s
motion through the tissues allows parcels of fatty
tissue to move through the cannula, through the
Luer-Lok aperture, and into the barrel of the
syringe with minimal mechanical damage.
● When liposuction is done, the specific Renuvion
probe for the neck region produced by Apyx
Medical (Clearwater, FL) is then used. The cool
helium plasma RF technology has been adapted
to draw skin closer to underlying fascia via coag-
ulation of the interstitial connective tissue
bands. In the Renuvion system, RF energy from
an electrosurgical generator unit is delivered to
a handpiece and used to energize an electrode.
Helium plasma is generated as helium gas
passes over the energized electrode, allowing
heat to be applied to tissue in two different and
distinct ways. The plasma beam provides heat
through the ionization and rapid neutralization
of helium atoms. A portion of RF energy that
 12.3 Surgical Technique and Fat Processing and Grafting
passes through the tissue impedance generates
a small amount of additional heat. The device is
activated until a preset subcutaneous tempera-
ture in the range of 75 to 85 °C is achieved and
maintained. The neck tissue being treated must
be maintained at that temperature for greater
than 120 seconds for maximal contraction to
occur. The handpiece is moved in the subdermal
plane in a manner similar to that of a liposuc-
tion cannula. Emitted energy is fractional. The
pistol grip device is deployed in a retrograde
● The adipose tissue aspirated by liposuction is
Video 12.1 Performing neck liposuction using the
syringe method.
Aspirated fat
Saline Collagenase
purification digestion
Centrafugation
Fig. 12.1 Schematic representation of stromal enriched lipograft.
manner. The system provides a total of 40 W,
and the energy can be changed based on a per-
centage of the 40 W. Sixty percent setting is rec-
ommended for the neck.10 Once engaged, the
device is drawn backward from the end of the
treatment area toward the entry site. No more
than five strokes are performed for every 2 cm.
The device is disengaged 2 cm from the entry
site to prevent incision burns. The helium gas
needs at least two stab incision sites to have ad-
equate space to escape. The author typically ex-
pels the gas manually between moving areas
and uses the 2-mm cannula for liposuction to
gently suction out the helium once completed
in order to reduce the risk of subcutaneous em-
physema (▶ Video 12.1).
processed in the following manner, as previ-
ously described in the medical literature.11 First,
two-thirds of the aspirated fat are used to iso-
late the SVF (▶ Fig. 12.1). Digestion is obtained
with 0.075% collagenase type II GMP grade
(ClZyme AS), produced by VitaCyte LLC (Indian-
apolis, IN) in buffered saline, and agitation for
45 minutes at 37 °C is performed. Separation of
Stem cell-rich
fat graft
Concentrated
adipose-derived Stromal enriched lipograft
stem cells (ADSC) ready for injection
Stromal vascular
fraction (SVF)
Purified fat
135
 Neck Lift and Fat Grafting to the Neck
the SVF containing adipose-derived stem cells
(ADSCs) is then done by using centrifugation at
1,200 rpm for 5 minutes, according to the proto-
col already published.12 The SVF is located in
the pellet derived from the centrifuged fat at
the bottom of the lipoaspirate. All of these
stages of fat procession are obtained through
the Automatic Cell Station, produced by BSL Ltd
(Seoul, Korea). The SVF is derived from the fat
processed in automated cell processing unit
(▶ Video 12.2). The remaining one-third of the
aspirated fat is treated in the following way: with
the syringe held vertically with the open end
down, the fat and fluid are separated. Isotonic sal-
ine is added to the syringe, the fat and saline are
separated, and the exudate discarded. The proce-
dure is repeated until the fat becomes yellow in
color, free of blood and other contaminants,
Video 12.2 The adipose tissue aspirated by liposuction
is processed.
Fig. 12.2 Schematic representation of autologous fat transplantation to the face and neck.
136
purified, and concentrated. No emulsification is
performed, as this portion of tissue will act as the
scaffold for the processed fraction; therefore, it is
treated as delicately as possible to maintain an in-
tact architecture. The process only involves wash-
ing and gravity separation. SVF containing ADSCS
and the purified fat are finally mixed and trans-
ferred into 20-mL syringes for application. Each
syringe contains 1.5 mL of SVF and 18.5 mL of pu-
rified fat and then transferred into 1-mL syringes
ready for injection. This whole procedure is done
inside the operating theater, by two tissue engi-
neers, and the time required is approximately
45 minutes.
● Upon completion of the liposuction procedure,
access to the face regions is gained through inci-
sions in the malar, lower mandibular, perioral,
and neck regions (▶ Fig. 12.2).
● The adipose tissue graft enriched with SVF is
injected through the incisions. The lipograft is
injected at various levels of depth, from the sub-
cutaneous–dermal junction, down to the deep
subcutaneous fat, until the desired projection;
therefore, a structural sculpturing and symme-
try between the two facial sides are obtained.
The fat is introduced as the cannula is with-
drawn. Fat molding is performed by gentle digital
manipulation to achieve a uniform distribution
(▶ Video 12.3).
● Immediate postoperative dressing is applied in
the neck area that was lipoaspirated.
● The patient remains hospitalized for 24 hours.
Analgesics and anti-inflammatory medications

Video 12.3 Lipografting of the malar area assisted by
stromal enriched lipograft.
are prescribed during the following 7 postope-
rative days. Return to mild physical activities is
allowed after the third postoperative week.
Bimodal compression is recommended.
12.4 Problem-Based Examples/
Cases
12.4.1 Case 1
A 43-year-old lady presented to our department re-
questing face and neck rejuvenation (▶ Fig. 12.3a–d).
She underwent SEL contouring of the face and
nose using 43 mL of lipograft and Renuvion appli-
cation in the neck area. Postoperative photo-
graphs taken 18 months after the procedure are
shown in ▶ Fig. 12.3e–h.
12.4.2 Case 2
A 45-year-old lady presented to our department re-
questing face and neck rejuvenation (▶ Fig. 12.4a–c).
She underwent SEL contouring of the face using
39 mL of lipograft and Renuvion application in
the neck area. At the same time, she had closed
rhinoplasty performed. Postoperative photo-
graphs taken 24 months after the procedure are
shown in ▶ Fig. 12.4d–f.
12.4.3 Case 3
A 63-year-old lady presented to our department re-
questing face and neck rejuvenation (▶ Fig. 12.5a–d).
She underwent round facelifting and SEL con-
touring of the face and nose using 62 mL of lipo-
graft and Renuvion application in the neck area.
She had at the same time upper and lower
12.5 Discussion
blepharoplasty performed. Postoperative pho-
tographs taken 12 months after the procedure
are shown in ▶ Fig. 12.5e–h.
12.4.4 Case 4
A 73-year-old lady presented to our department re-
questing face and neck rejuvenation (▶ Fig. 12.6a–c).
She had undergone two previous facelifting pro-
cedures in a different clinic. She underwent SEL
contouring of the face and nose using 54 mL of
lipograft and Renuvion application in the neck
area. She had at the same time upper and lower
blepharoplasty performed. Postoperative photo-
graphs taken 18 months after the procedure are
shown in ▶ Fig. 12.6d–f.
12.5 Discussion
Facial aging presents a challenging problem for
plastic and aesthetic surgeons; it is a multifactorial,
multistep process that involves structural and volu-
metric changes in the skin, muscles, skeleton, and
adipose tissue.13 Facial tissue descent is caused not
only by gravity but also by reabsorption and reposi-
tioning of the facial adipose system. Sterodimas et
al recommend, as a rule, slight undercorrection of
the contour of the neck to allow for postoperative
fat lysis, which amplifies the result.14 Using small
cannulas, not performing superficial liposuction,
turning the suction off when exiting incisions, criss-
crossing areas, constantly analyzing areas by visual
and tactile means, and proper positioning all can
help reduce the chance of contour irregularities.
Facial rejuvenation with autologous fat has the ad-
vantage of replacing or augmenting tissue with like
tissue.15 Autologous fat transplantation to the face
can correct cosmetic defects that are caused by loss
of subcutaneous tissue, such as atrophy of the face
due to significant weight loss, wrinkles, and facial
involution due to aging. Clinical use of autologous
fat grafts for facial soft-tissue augmentation has
grown in popularity in the plastic surgery com-
munity in the past 10 years. Regenerative cell-
based strategies such as those encompassing the
use of stem cells have shown that autologous ADSCs
offer the possibility of finally fulfilling the key prin-
ciple of replacing like with like as an aesthetic
filler.16 ADSCs are multipotent mesenchymal stem
cells that display a regenerative capacity by the
paracrine release of growth and differentiation fac-
tors. ADSCs are responsible for the rejuvenation
137
 Neck Lift and Fat Grafting to the Neck

Fig. 12.3 (a–d) Preoperative photographs of a 43-year-old lady requesting face and neck rejuvenation. (e–h) Postoperative
photographs of a 43-year-old lady, 18 months after the procedure.

138

Fig. 12.4 (a–c) Preoperative photographs of a 45-year-old lady requesting face and neck rejuvenation. (d–f) Postoperative
photographs of a 45-year-old lady, 24 months after the procedure.
capabilities of fat grafts, and their use has shown
lower reabsorption rate due to improved angiogen-
esis and reduced inflammatory response. In SEL,
ADSCs are used in combination with lipoinjection.17
An SVF containing ADSCs is freshly isolated from
the aspirated fat and recombined with the adipose
scaffold. This process converts relatively ADSC-poor
aspirated fat to ADSC-rich fat. ADSCs remain the
most widely used by cosmetic surgeons as they
have the potential and capability to differentiate
into mesenchymal, ectodermal, and endodermal
lineages and are easily accessible to harvest. The re-
generative effects of ADSCs on facial aesthetics have
been shown at the histologic and cellular level.18
Regeneration of elastin and collagen fibers, im-
provement in capillary density, and reduction of in-
flammation have been reported. Understanding of
the facial anatomy lends greater precision to our
12.5 Discussion
ability to rejuvenate the aging face. The diminished
volume of a specific facial fat compartment leads to
an excess skin envelope and the illusion of a more
prominent facial fold. The SEL technique can be
applied to the lateral two-thirds of the brow, the
nasojugal fold, the malar and buccal fat pads, the
nasolabial fold, the lips, and the perioral region.1
Augmentation of fat compartments by the SEL tech-
nique has the following effects: it increases the
anterior projection; it diminishes the ptotic fold
pseudoprojection; and a youthful facial contour and
harmony is recreated.
Electrosurgical energy flows into the application
site for a brief interval, then quickly disperses out.
This results in precise, predictable effects on the
skin and underlying connective tissue. Rapid heat-
ing of the subcutaneous tissue, and subsequent
skin tightening, occurs as the plasma rapidly gives
139
 Neck Lift and Fat Grafting to the Neck

Fig. 12.5 (a–d) Preoperative photographs of a 63-year-old lady requesting face and neck rejuvenation. (e–h) Postoperative
photographs of a 63-year-old lady, 12 months after the procedure.

140

Fig. 12.6 (a–c) Preoperative photos of a 64-year-old lady requesting face and neck rejuvenation. (d–f) Postoperative
photos of a 64-year-old lady, 2 months after the procedure.
up energy to the surrounding tissue with each
pass of the device. With each stroke of the Renu-
vion device, the RF energy encounters tissue with
varying impedance and will continuously change
paths of heat transfer. There is minimal depth of
thermal effect and prevention of overtreating tis-
sue even with multiple passes while maximizing
treatment of untreated tissue. The release of heli-
um gas in the subdermal tissue helps rapidly dissi-
pate the accumulated thermal energy. Because the
device rapidly heats a small segment of subcutane-
ous collagen to 85 °C, strong immediate contrac-
tion is generated within 0.044 seconds.19 A rapid
postliposuction tissue treatment is followed by
very visible improvement at the 24-hour post-op
mark. Results can continue to improve over a year,
as infiltration of new collagen within the adipose
stroma occurs. Restoration of the adipose frame-
work can recreate a firm rather than flabby feel of
the soft tissue, along with a defined shape. Although
these devices have proven effective in achieving
soft-tissue contraction, the process of heating and
maintaining that temperature for extended periods
12.5 Discussion
can be time-consuming. In devices without an ex-
ternal temperature monitor, the skin surface can
become overheated, causing occasional blisters or
burns. One of the main challenges associated with
percutaneous delivery of energy for the purpose of
thermal-induced collagen tissue contraction is the
balance that must be achieved between heating the
internal tissues enough to achieve the desired con-
traction while maintaining safe external tissue tem-
peratures. Patients who should not be treated with
Renuvion for neck contracture include women who
are pregnant or breastfeeding; patients with an
open sore in the treatment region; patients with
compromised healing such as oxygen dependence,
diabetes if poorly controlled, and autoimmune dis-
ease; and patients with severe tissue laxity in the
neck region.
The regenerative effect of fat has been widely
proven, both clinically and histologically, and in-
cludes neoangiogenesis and collagen synthesis,
which determine an increased density of the ex-
tracellular matrix, stem cell transformation into
fibroblasts secreting collagen, and better volume
141
 Neck Lift and Fat Grafting to the Neck

retention when combining plain lipotransfer with 12.6 Conclusion

enzymatically processed adipose tissue. With SEL,
a combination of effects is achieved: better take of The ideal substance for soft-tissue augmentation still
the injected fat because adipocytes are more prone eludes physicians, but fat grafting through a blunt
to survive and the isolated stem cells rejuvenate cannula seems to be the safest of all of the fillers
the skin, improving its quality, as shown by pre- used; in the hands of an experienced surgeon, it can
vious studies.1,15 Lost fat volume, reabsorbed provide long-lasting, natural-appearing structural
bone volume, and a rejuvenated skin are restored changes. SEL restores the three-dimensional projec-
in a single procedure. The fat is naturally stem tion and overall shape of the face to more youthful
cell deficient in terms of their concentration for contours and eliminates shadowing and muscle to
the surgeon’s purpose, and SEL allows the con- skin interactions. The Renuvion technology appears
centration of regenerative elements and thereby to be safe and well tolerated by patients for neck
biologically supercharging the fat to increase the tightening. SEL is an effective and novel antiaging
possibility of engraftment for a tissue that has therapeutic agent in cosmetic surgery.
been completely disconnected from its vascular
network and freely transferred into variably hos-
tile bioenvironments. Conversely, the SVF is rees-
12.7 Expert Commentary by
tablished into its native niche, the adipose tissue, Dr. Slavin
which will help its engraftment, durative survival,
The author describes a novel and highly personal-
proliferation, and biological activity. Basically, all
ized approach to fat grafting of the neck, address-
the significance of the action is transferring fat
ing the vexatious issue of fat graft volume loss
containing a higher concentration of stem cells,
with new technology. The SEL method provides a
pericytes, and other bioactive elements of the SVF
more sustained retention of adipocytes. In keeping
to counteract the inevitable ischemic damages de-
with current trends of nonsurgical rejuvenation of
riving to the transferred devascularized tissue. The
the face and neck, the author stresses on the im-
two histological components of SEL assist each
portance of combinations of techniques and mo-
other in overcoming the biological challenge of de-
dalities in order to achieve multiple goals: volume
vascularization and transfer.6 With SEL, a lower
replenishment, skin tightening, and improvement
volume of fat is necessary to obtain a durable lipo-
in skin surface quality.
graft, thanks to the combination with the stromal
These nonsurgical approaches are also useful
fraction. This implies a lower risk of causing a puffy
adjuncts to surgical treatment of more extreme
face intraoperatively. In our series of treated pa-
degrees of skin laxity, suggesting that the future of
tients, a single session of SEL-based lipografting
facial and neck rejuvenation will be a palette of
has been successfully performed in all cases.
choices and combinations. For the patient with de-
Although the desirable outcome is to produce the
grees of facial atrophy and skin laxity—a common
requested augmentation and cutaneous biostimu-
finding—filling areas of deficiency with reliable fat
lation of the facial region by autologous fat grafting
cell additives has become the primary treatment.
in one stage, the patient should be advised that a
As always, it is the experienced clinician who
secondary procedure may be needed to accom-
understands all of the available options—both sur-
plish the desired result. More basic and clinical re-
gical and nonsurgical—who is best able to meet
search is necessary, but the preliminary encourag-
the often-complex needs of this group of patients.
ing impression is that the combination of SEL to
traditional face procedures is safe and effective
and the prolonged duration of the grafted fat is 12.8 Expert Commentary by
such that repeat procedures are rare, and this may
be attributable to a more stable inhabitation of the
Dr. Lin
recipient site thanks to the stromal component The author presents an excellent summary and re-
and its proregenerative action. The long-term ef- sults of their technique using minimally invasive
fect of Renuvion contracture to the neck needs to techniques. With a plethora of new devices and
be further assessed in a controlled double-blind technologies, we are progressively learning what
study. works for what areas, and this chapter outlining,

142

among other techniques, plasma-based tightening
brings us closer to more widespread adoption
of these new technologies for rejuvenation of the
neck.
References
[1] Sterodimas A, Nicaretta B, Boriani F. composite face lifting:
the combination of stromal enriched lipograft with face
minilift and upper and lower blepharoplasty: a review of 210
cases. Ann Plast Surg. 2020; 85(6):e20–e23
[2] Sterodimas A. Stromal enriched lipograft for rhinoplasty
refinement. Aesthet Surg J. 2013; 33(4):612–614
[3] Sterodimas A, Huanquipaco JC, de Souza Filho S, Bornia FA,
Pitanguy I. Autologous fat transplantation for the treatment
of Parry-Romberg syndrome. J Plast Reconstr Aesthet Surg.
2009; 62(11):e424–e426
[4] Sterodimas A, Boriani F, Nicaretta B, Pereira LH. Hand rejuve-
nation by stromal enriched lipograft. J Plast Reconstr Aesthet
Surg. 2018; 71(10):1507–1517
[5] Sterodimas A, Boriani F, Nicaretta B, Pereira LH. Revision
abdominoplasty with truncal liposculpting: a 10-year experi-
ence. Aesthetic Plast Surg. 2019; 43(1):155–162
[6] Sterodimas A, de Faria J, Nicaretta B, Boriani F. Autologous fat
transplantation versus adipose-derived stem cell-enriched li-
pografts: a study. Aesthet Surg J. 2011; 31(6):682–693
[7] Sterodimas A, de Faria J, Nicaretta B, Pitanguy I. Tissue engi-
neering with adipose-derived stem cells (ADSCs): current
and future applications. J Plast Reconstr Aesthet Surg. 2010;
63(11):1886–1892
[8] Sterodimas A, Boriani F, Magarakis E, Nicaretta B, Pereira LH,
Illouz YG. Thirtyfour years of liposuction: past, present and
future. Eur Rev Med Pharmacol Sci. 2012; 16(3):393–406
[9] Gentile RD, McCoy JD. Pulsed and fractionated techniques for
helium plasma energy skin resurfacing. Facial Plast Surg Clin
North Am. 2020; 28(1):75–85
References
[10] Doolabh V. A single-site postmarket retrospective chart
review of subdermal coagulation procedures with renuvion.
Plast Reconstr Surg Glob Open. 2019; 7(11):e2502
[11] Sterodimas A. Adipose stem cell engineering: clinical appli-
cations in plastic and reconstructive surgery. In: Illouz YG,
Sterodimas A, eds. Adipose Stem Cells and Regenerative
Medicine. Berlin: Springer-Verlag; 2011:165–179
[12] Sterodimas A. Tissue engineering with adipose-derived stem
cells (ADSCs) in plastic and reconstructive surgery: current
and future applications. In: Di Giussepe A, Shiffman M, eds.
New Frontiers in Plastic and Cosmetic Surgery. Philadelphia,
PA: The Health Sciences Publisher; 2015:3–11
[13] Pereira LH, Sterodimas A. Long-term fate of transplanted
autologous fat in the face. J Plast Reconstr Aesthet Surg.
2010; 63(1):e68–e69
[14] Sterodimas A, de Faria J, Nicaretta B, Papadopoulos O, Papal-
ambros E, Illouz YG. Cell-assisted lipotransfer. Aesthet Surg J.
2010; 30(1):78–81
[15] Gentile P, Sterodimas A, Calabrese C, et al. Regenerative appli-
cation of stromal vascular fraction cells enhanced fat graft
maintenance: clinical assessment in face rejuvenation. Expert
Opin Biol Ther. 2020; 20(12):1503–1513
[16] Illouz YG, Sterodimas A. Conclusions and future directions.
In: Illouz YG, Sterodimas A, eds. Adipose Stem Cells and
Regenerative Medicine. Berlin: Springer-Verlag; 2011:273–
276
[17] Sterodimas A. The role of stem cells in body contouring. In:
Theodorou S, Chia C, eds. Liposuction & Emerging Technolo-
gies in Body Contouring. New York, NY: Thieme; 2018
[18] Sterodimas A, De Faria J, Correa WE, Pitanguy I. Tissue engi-
neering in plastic surgery: an up-to-date review of the cur-
rent literature. Ann Plast Surg. 2009; 62(1):97–103
[19] Gentile RD. Renuvion/J-plasma for subdermal skin tightening
facial contouring and skin rejuvenation of the face and neck.
Facial Plast Surg Clin North Am. 2019; 27(3):273–290
143
13 Neck Rejuvenation: Noninvasive Techniques
Mathew N. Nicholas, Sara R. Hogan, Michael S. Kaminer, and Jeffrey S. Dover
Abstract
Noninvasive neck rejuvenation treatments can
make significant differences for patients and have
less recovery time and less risk of adverse effects
when compared to surgical approaches. The choice
of which noninvasive treatment to use requires
identifying individual patient concerns. Patient
concerns can be divided into five distinct catego-
ries: (1) dyschromia, (2) horizontal necklines,
(3) platysmal banding, (4) skin laxity, and (5) sub-
mental fullness. Dyschromia is largely caused by
ultraviolet radiation exposure. It can be targeted
with cosmeceuticals, chemical peels, intense
pulsed light, and various nonablative lasers. Hori-
zontal necklines are caused by a combination of
skin laxity, underlying fascial attachments, and
downward pull of the platysma. Neuromodulators,
fillers, and laser and energy-based devices can
work in combination to target these causes. Platys-
mal banding results from the chronic contraction
of the platysma muscle in the setting of increasing
skin laxity. Neuromodulators are the primary non-
invasive treatment; however, multiple different
techniques in using them have been described.
Skin laxity can be mild, resulting in rhytids and
wrinkling, or severe, creating jowls and submental
sagging. Fillers and energy-based devices, including
microfocused ultrasound with visualization, mo-
nopolar capacitive-coupled radiofrequency, and ra-
diofrequency microneedling target more severe
laxity, while chemical peels, dermarolling or micro-
needling without radiofrequency, and platelet-rich
plasma can target more mild laxity. Submental
fullness is a common patient concern and more
resistant to improvement through exercise and diet.
Deoxycholic acid injections, cryolipolysis, energy-
based devices, and laser lipolysis all work by
decreasing subcutaneous fat with different mecha-
nisms of action. In this age of numerous noninvasive
techniques, a combination of techniques is used to
target different patient concerns and optimize
outcomes. In this chapter, we describe currently
available noninvasive techniques and illustrate our
approach to tailored treatments for an individual
patient.
Keywords: neuromodulators, lasers, energy-based
devices, fillers, deoxycholic acid, cryolipolysis
Key Points
● Identifying specific patient concerns guides
appropriate noninvasive neck rejuvenation
treatment.
● Patient concerns can be categorized as dyschro-
mia, horizontal necklines, platysmal banding, skin
laxity, and submental fullness.
● Typical noninvasive techniques require a combi-
nation of multiple different treatments to target
different patient concerns and enhance results.
13.1 Introduction
The demand for noninvasive cosmetic procedures,
including neck rejuvenation, increases each year.1
The five key criteria of a youthful neck appearance
include the following: (1) a clear inferior mandibu-
lar border, (2) a subhyoid depression, (3) visible
thyroid cartilage bulge, (4) visible anterior sterno-
cleidomastoid border, and (5) a cervicomental an-
gle between 105 and 120 degrees.2 As the neck
ages, these criteria are lost. Available noninvasive
neck rejuvenation treatments can make significant
differences for patients with less recovery time
and less risk of adverse effects when compared to
surgical approaches. This chapter provides a com-
prehensive review of noninvasive neck rejuvena-
tion techniques and illustrates our approach to
tailored treatments for an individual patient.
13.2 The Aging Neck
The extent of skin aging is dictated by both intrin-
sic factors, such as ethnicity, anatomical variations,
and hormonal changes, and extrinsic factors in-
cluding lifestyle, smoking, and ultraviolet radiation
(UVR) exposure.3 Pigmentary changes are often
first noted as this is more closely associated with
UVR exposure, regardless of age.4 Chronic UVR ex-
posure contributes to uneven pigment distribution
and the development of ephelides, solar lentigines,
and telangiectasias.5 Rhytids, meanwhile, are more
strongly associated with increasing age. Skin aging
is associated with fragmentation of collagen, re-
sulting in poor fibroblast attachment and, conse-
quently, fibroblast collapse. Collapsed fibroblasts
produce lower amounts of collagen and increased
145
 Neck Rejuvenation: Noninvasive Techniques
amounts of collagen-destroying enzymes, expedit-
ing the aging process.6 Overall this process leads to
laxity of the skin and subsequent formation of rhy-
tids and jowls. Aside from the skin, other anatomi-
cal changes occur with age, including subcutaneous
and subplatysmal fat accumulation, formation of
platysma muscle bands and horizontal necklines,
digastric muscle ptosis and hypertrophy, as well as
submandibular salivary gland ptosis and atrophy.7,8
The combination of all of these changes over time
drives the need for neck rejuvenation.
13.3 Patient Considerations,
Indications, and Contraindications
Recognizing patients appropriate for noninvasive
neck rejuvenation first requires a proper physical
examination. Evaluation of the patient starts with
identifying the patient’s greatest concern(s),
whether it be skin dyschromia, laxity, submental
fullness, or prominence of vertical or horizontal
necklines. During evaluation, the patient should sit
upright in neutral alignment and be given a mirror
to allow them to point out their personal concerns.
Note should be taken of color or texture changes of
the skin. Skin laxity and jowl appearance should
be examined at rest and during head and neck
movement. Palpation should be performed to es-
timate subcutaneous fat volume and identify any
hypertrophied digastric muscles. Ptotic subman-
dibular salivary glands or lymphadenopathy
should be noted given their contribution to sub-
mental fullness.8 Since platysmal bands can be
observed in younger patients with active muscle
contraction, evaluation of necklines should be
done at rest with both frontal and lateral views.
Patient expectations need to be addressed during
the evaluation. Targeting patient concerns involv-
ing deeper anatomical structures including the
digastric muscles, submandibular salivary glands,
and the subplatysmal fat are contraindicated for
noninvasive neck rejuvenation as these require
more invasive techniques.
13.4 Which Technique to Use
and Why?
Patient concerns regarding the neck can be catego-
rized into five distinct categories: dyschromia, hori-
zontal necklines, platysmal banding, skin laxity,
and submental fullness. Identifying and prioritizing
146
patient concerns will help guide the choice of non-
invasive treatment.
13.4.1 Dyschromia
Dyschromia or uneven skin pigmentation in the
aging neck is due to the presence of melanin, in
the form of ephelides or solar lentigines; vascular
changes from prominent telangiectasias; or hypo-
pigmentation secondary to photodamage and loss
of collagen.5 Although a single pigmentary change
may predominate, neck dyschromia is often due to a
combination of the aforementioned factors. Poikilo-
derma of Civatte is a pigmentary/vascular condition
of the neck and upper chest caused by photodamage
and is characterized by hyperpigmentation, hypo-
pigmentation, atrophy, and increased vascularity.
Dyschromia is treated similarly in the neck as in
other areas of the body, with one important distinc-
tion. Compared to the face, the skin of the neck is
thinner and contains less pilosebaceous units. These
features render neck skin more susceptible to scar
formation. As such, noninvasive techniques should
be administered with less aggressive settings.
Cosmeceuticals
Cosmeceuticals were originally defined as “some-
thing in between a drug and a cosmetic” in 1984.9
Cosmeceuticals are designed to address aesthetic
issues in skin not needing a medical prescription,
and often work in tandem with topical prescrip-
tion medications. Demand for cosmeceuticals is
continuously increasing, with antiaging skin care
products accounting for over half of available skin
care cosmeceuticals.10 A number of studies have
shown that cosmeceuticals create significant neck
antiaging effects.11,12,13,14 These products often in-
clude retinoids, alpha-hydroxy acids, antioxidants,
depigmenting agents, peptides, and physical and
chemical sunscreens.
Chemical Peels
A number of chemical peels target dyschromia and
pigmentation. Chemical peels, such as Jessner or 70%
glycolic acid and 40% trichloroacetic acid, have been
studied in improving neck pigmentation.15,16 Higher
concentrations of chemical peels should be used
with caution given the neck’s increased risk of scar-
ring. The addition of lightening agents, such as in
modified Kligman’s formula, may also increase the
benefits of peels that target pigmentation.17

Lasers and Energy-Based Devices
Intense pulsed light (IPL) targets vascular and pig-
mented lesions, and thus is quite effective at treating
poikiloderma of Civatte, with over 80% of patients in
one study showing a marked 75 to 100% clearance
after three or fewer treatments spaced 1 month
apart.18,19 Side effects include swelling, erythema, or
bruising, as well as “striping” and persistent hypo-
pigmentation due to imprecise technique or inap-
propriate energy settings, respectively.18,19
Vascular lasers such as the 595-nm pulsed dye
laser and 532-nm potassium titanyl phosphate
(KTP) and lithium triborate (LBO) lasers are effec-
tive in improving the appearance of dilated blood
vessels but are not as effective at targeting pig-
mented lesions.20,21
Nonablative fractional photothermolysis, includ-
ing the 1,927-nm thulium laser, 1,540-nm erbium-
glass fiber laser, 1,550-nm erbium-glass fiber laser,
and Q-switched 1,064-nm Nd:YAG (neodymium:yt-
trium aluminum garnet) laser can also address neck
dyschromia.22,23,24 Behroozan et al suggest that these
lasers selectively damage the dermal vasculature in
poikiloderma in two ways. First, these wavelengths
target water, a main component of blood, likely caus-
ing subsequent microvascular destruction. Second,
microthermal zones of injury within the dermis also
likely affect dermal vasculature.22 Combining the
1,550-nm laser wavelength, which targets deeper
dermal structures, with the 1,927-nm wavelength,
which targets the epidermal and superficial dermal
structures, is thus particularly effective in treating
dyschromia, hyperpigmentation, and texture. The
Fraxel Re:Store DUAL (Solta Medical, Bothell, WA)
utilizes both these wavelengths and is an increas-
ingly popular treatment choice for poikiloderma of
Civatte. Typically, three or more treatments, spaced
4 to 6 weeks apart, are needed for noticeable results.
Patients should be counseled on common side
effects with nonablative fractional photothermolysis,
such as swelling, erythema, discomfort, and mild
scaling. Fractional photothermolysis may also be
combined with IPL, Q-switched, or picosecond lasers
to achieve even better pigmentary improvement in
the treatment of poikiloderma of Civatte.
13.4.2 Horizontal or Transverse
Necklines
Horizontal or transverse necklines are caused by
a combination of skin laxity, underlying fascial
13.4 Which Technique to Use and Why?
attachments, and the downward pull of the
platysma.25 Horizontal necklines are found in nor-
mal physiology and can be observed at any age, in-
cluding younger patients at rest. As the neck ages,
horizontal necklines become more prominent. A
validated 5-point assessment Transverse Neck Lines
Scale (▶ Table 13.1) can be used when evaluating a
patient for horizontal necklines, with values ranging
from none (no transverse necklines) to extreme
(noneffaceable transverse neck furrows with redun-
dant skin; ▶ Fig. 13.1).25
Neuromodulators
When injected directly into horizontal necklines,
neuromodulators relax the downward pull of the
platysma. Neuromodulators do not address skin
laxity and thus when administered alone can be
suboptimal in treating horizontal necklines. Botu-
linum toxin A injections of 1 to 2 units spaced 1 to
1.5 cm apart along the lines may create an im-
provement and satisfaction rate of up to 50%.26
From our clinical experience, injection of botuli-
num toxin A along the platysma bands may also
create a small effect on horizontal lines. Yet, when
combined with other methods such as dermal fill-
ers, botulinum toxin A can play a successful role in
significantly decreasing the horizontal neckline
size.27
Fillers
Dermal fillers lessen the appearance of horizontal
necklines by addressing volume loss. Calcium hy-
droxylapatite (Radiesse; Merz North America,
Inc., Raleigh, NC) diluted 1:1with 1% lidocaine can
be injected between the dermal and subdermal
Table 13.1 Five-point Allergan Transverse Neck Lines
Scale as adapted by Jones et al25
0 None: no transverse necklines
1 Minimal: superficial transverse necklines
2 Moderate: moderate, effaceable transverse
necklines
3 Severe: deep, noneffaceable transverse
necklines
4 Extreme: noneffaceable transverse neck
furrows with redundant skin
147
 Neck Rejuvenation: Noninvasive Techniques

Fig. 13.1 A patient with prominent horizonal necklines showing (a) frontal and (c) lateral pretreatment views and (b) frontal
and (d) lateral posttreatment views after one treatment of Belotero hyaluronic acid fillers injected intradermally to horizontal
necklines followed by 6 mL of hyperdiluted Radiesse calcium hydroxylapatite injected subdermally 4 weeks later.
(Reproduced with permission of Sara Hogan, MD.)

junction along the horizontal necklines or Lasers and Energy-Based Devices

throughout the neck in a fanlike manner with a
25- or 27-gauge cannula.28,29 Soft malleable hya-
luronic acid fillers (Belotero Balance, Merz North
America, Inc.; Belotero Soft; Merz North America,
Inc.; Restylane Silk, Q-Med AB, Uppsala, Sweden;
Teosyal RHA 2; TEOXANE SA, Geneva, Switzer-
land; Juvederm Volbella XC; Allergan, Inc., Dublin,
Ireland) injected in the dermal plane have dem-
onstrated continued efficacy of up to at least 36
weeks in the literature.27,30,31,32 Patients should
be counseled on potential side effects of filler
injection, including redness, itching, bruising,
swelling, and, rarely, nodule formation.30 Nodule
formation is most often due to superficial place-
ment of fillers.
Ablative fractional CO2 laser has been used to signif-
icantly improve the appearance of horizontal neck-
lines, with results lasting 1 year posttreatment after
a single treatment. The therapeutic window is nar-
row, however, bringing to question whether benefit
outweighs the risk of scarring.33 Nonablative frac-
tional 1,440- or 1,550-nm lasers may be considered
an alternative approach to decrease the risk of scar-
ring. Laser treatment may also be combined with
neuromodulators, which are typically administered
1 week beforehand.34
Microfocused ultrasound with visualization
(MFU-V) and monopolar capacitive-coupled radio-
frequency (MRF) can decrease the appearance of

148

horizontal necklines by inducing neocollagenesis
and improving skin laxity.27,29 Both MRF and MFU-V
can be combined safely with subsequent same-day
dermal filler use for neck rejuvenation. In one study,
MFU-V (Ultherapy; Ulthera, Inc., Mesa, AZ) with
subsequent same-day injection of diluted calcium
hydroxylapatite (Radiesse; Merz North America,
Inc.) decreased the Transverse Neck Lines Scale
scores from an average of 2.6 at baseline to 1.3 at 90
days posttreatment.29
13.4.3 Platysmal Banding
Vertical necklines are caused by chronic contrac-
tion of the platysma muscle in the setting of in-
creasing skin laxity.35 Younger patients are able to
create platysmal bands with active contraction,
which disappear at rest. When evaluating a patient
for platysmal banding, a validated 5-point Dynam-
ic Platysmal Band Photonumeric Assessment Scale
(▶ Table 13.2) can be used with scores ranging
from no relevant prominence of platysmal bands
to very severe prominence of platysmal bands
(▶ Fig. 13.2).35
Neuromodulators
Brandt and Bellman first described botulinum tox-
in A as a treatment for platysmal bands in 1998.36
Neuromodulators are a safe and noninvasive
approach to decrease platysmal bands; however, the
treatment effect is temporary lasting 2 to 4 months.
Early studies endorsed high doses of botulinum tox-
in A, with up to 250 of onabotulinum-equivalent
units being used. The most recent consensus,
however, is that no more than 100 units be in-
jected into the platysma given the potential for
side effects.37,38 In fact, excellent results can be
achieved with doses of as little as 28 to 36 units
Table 13.2 Five-point Dynamic Platysmal Band Photo-
numeric Assessment Scale as adapted by Geister et al35
0 No relevant prominence of platysmal bands
1 Mild prominence of platysmal bands
2 Moderate prominence of platysmal bands
3 Severe prominence of platysmal bands
4 Very severe prominence of platysmal bands
13.4 Which Technique to Use and Why?
of onabotulinum-equivalent units. Safe injection
technique involves pinching the skin and underly-
ing platysmal bands upward and away from other
neck structures. Two to three onabotulinum toxin-
equivalent units are then injected every 1 to 1.5 cm
vertically along each band.39 Studies show a mean
2-point improvement on the Dynamic Platysmal
Band Photonumeric Assessment Scale by day 14,
which decreases to 1.2 points by 3 months.40 The
most common side effect is bruising. Prolonged
dysphagia and neck weakness are most frequently
seen in doses higher than 100 units, but can still oc-
cur rarely at lower doses.38,40 When combined with
lasers, neuromodulators may be administered the
same day as vascular and pigment lasers, 1 week
after nonablative fractional lasers, and 3 weeks
after ablative fractional lasers.34
The Nefertiti lift targets the platysma to redefine
the jaw line while also improving the appearance
of the neck. First described by Levy, the Nefertiti lift
involves injecting 30 to 40 total onabotulinum-
equivalent units along the lower mandible and the
upper platysmal bands. The resulting release of the
downward pull from the platysma muscle improves
the sight of platysmal bands while also contouring
the lower face.41 The original technique addresses
only posterior platysma fibers, creating mandibular
contour improvement in mostly lateral views only.
The modified Nefertiti lift reported by De Almeida et
al also targets anterior platysma fibers and incorpo-
rates two lines of mandibular injections points along
the entire mandible, improving mandibular contour
in both lateral and anterior views.42
Finally, the Microbotox technique, first described
by Wu in 2015, involves approximately 150 injec-
tions of botulinum toxin A into the superficial der-
mis in a gridlike pattern across the anterior neck and
mandible. When compared to the Nefertiti lift, the
Microbotox technique is less effective at targeting
platysmal bands but may play a better role in target-
ing jowls and soft-tissue laxity.43
13.4.4 Skin Laxity
Laxity in the lower face and neck both contributes
to the aging neck. Mild forms of laxity present as
rhytids and wrinkles. More severe forms of laxity
contribute to jowls and submental sagging with the
formation of a convex cervicomental angle.44 The
validated Fasil Face and Neck Laxity Grading Scale
is used to evaluate laxity in the upper, middle, and
lower face and upper neck.45 ▶ Table 13.3 contains
149
 Neck Rejuvenation: Noninvasive Techniques

Fig. 13.2 A 58-year-old woman showing (a) frontal and (c) lateral views of the platysmal bands pretreatment and
(b) frontal and (d) lateral posttreatment views 2 weeks following botulinum toxin injections. (Adapted from Nahai F,
Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 3rd ed. New York, NY: Thieme; 2020.)

a modified version of the scale to highlight the clin-
ically relevant portions for neck rejuvenation.
Dermal Fillers
Dermal fillers stimulate collagen production to de-
crease skin laxity. Calcium hydroxylapatite (Radiesse,
Merz North America, Inc.), when hyperdiluted with
1% lidocaine and injected into the neck and décollet-
age, shows histopathologic evidence of increased
collagen, elastin, and angiogenesis, even 7 months
postinjection.46 Consensus recommendations advise
two to three sessions spaced 1 to 2 months apart for
maximum results in biostimulation and skin tight-

150
 13.4 Which Technique to Use and Why?

ening lasting over 18 months.47 Dilution varies with
patient skin thickness, with older patients typically
requiring greater dilution. For the neck in particular,
a dilution of 1:2 or 1:4 is satisfactory for most
patients. One syringe per session is generally recom-
mended. The filler is injected by cannula via retrojec-
tion in a fanlike manner at each of three to five
entrance points or alternatively with serial punctu-
res using a needle creating short horizonal lines
around the neck.47 Alternatively, poly-L-lactic acid
can be used in a similar fashion to stimulate neocol-
lagenesis and has good evidence for treating neck
skin laxity. A single treatment can create physician-
noted improvement in neck laxity 60 days posttreat-
ment in 81 to 100% of patients.48
Lasers and Energy-Based Devices
MFU-V and MRF provide another option to tradi-
tional methods of skin tightening such as surgical
and laser resurfacing, where potential side effects
and subsequent recovery time may be worrisome
to patients.
The first MRF device (Thermage CPT; Solta Medi-
cal, Haywood, CA) was Food and Drug Administra-
tion (FDA) approved for periorbital rhytids in 2002
and subsequently FDA approved for all rhytids in
2005. MRF uses electric current transmitted
through the neck to create a broad thermal coagu-
lation zone from the resistance of the tissues
affected. The amount of energy and resulting heat
increases with increasing current, tissue resistance,
and time of exposure. The system uses superficial
cryogen cooling alongside the generated current to
create dermal temperatures of 65 to 75 °C while
preventing the epidermis from rising above 40 °C
and thus preventing epidermal damage. Clinical im-
provement in upper neck skin laxity is reported in
▶ Table 13.4. Thermage uses a stamping motion
technique, creating short pulses of energy at each

Table 13.3 Modified Fasil Face and Neck Laxity Grading Scale as adapted by Alhaddad et al45

Class 0 Class 1 Class 2 Class 3 Class 4 Class 5

Lower Jowls Absent Slightly Protruding Protruding Forward Forward sagging

face noticeable forward forward and protrusion and lateral loss of
downward with definition in the
downward neck
sagging

Upper Platysma Absent Absent Slightly Prominent Sagging Sagging to the

neck bands noticeable point where
bands or folds
Horizontal Absent Absent Absent Slightly Prominent are no longer
bands noticeable distinguishable

Table 13.4 Clinical results using monopolar radiofrequency (Thermage) in neck rejuvenation

Study Design Energy No. of Follow-up No. of Significant outcomes

level patients after final treatments
settings treatment

Alster Prospective, 74–134 20 6 mo 1 85% of patients had improvement

and nonrandomized J/cm2 Average physician-reported
Tanzi50 improvement score of 1.27, where
0 = < 25%, 1 = 25–50%, 2 = 50–75%,
3 = > 75% improvement

Fritz Prospective, 85–135 20 4 mo 1 or 2 Physician reported improvement

et al51 randomized J/cm2 treatments 1 treatment: 11% overall
improvement
2 treatments: 15% overall
improvement

151
 Neck Rejuvenation: Noninvasive Techniques

location (▶ Fig. 13.3). Other MRF devices have since
been created and rely on different delivery methods
such as a continuous motion technique (Exilis, BTL
Aesthetics, Prague, Czech Republic; Pelleve, Ellman
International, Inc., Oceanside, NY) or the use of a
subcutaneous probe to completely bypass the epi-
dermis and heat the dermis from underneath
(ThermiTight, ThermiAesthetics, Southlake, TX).49
In 2012, MFU-V (Ultherapy, Ulthera, Inc.) gained
FDA approval for the noninvasive lift of skin on the
neck and under the chin. MFU-V uses focused
ultrasound waves to create 1 mm3 thermal coagu-
lation zones of 65 °C up to 8 mm below the surface
of the skin. By combining the technology with vis-
ualization, the provider can image the tissue and
provide heat at the exact intended depth. The co-
agulation zones immediately alter the targeted col-
lagen and stimulate neocollagenesis to improve
skin elasticity and firmness over time while com-
pletely avoiding damage to the epidermal layer.52
Clinical results with MFU-V are summarized in
▶ Table 13.5 (▶ Fig. 13.4).

Fig. 13.3 A patient presenting with neck skin laxity showing (a) pretreatment, (b) 2 months posttreatment, and (c) 4
months posttreatment views following one treatment with Thermage. (Adapted from Papel I, Frodel J, Holt R et al., ed.
Facial Plastic and Reconstructive Surgery. 3rd ed. New York, NY: Thieme; 2009.)

Table 13.5 Clinical results using microfocused ultrasound with visualization in neck rejuvenation

Study Design Device No. of Follow-up No. of Significant outcomes

patients after final treatments
treatment

Kerscher Prospective, Ultherapy 22 24 wk 1 Gross skin elasticity

et al52 nonrandomized (Cutometer
measurement)
significantly improved
compared to baseline

Kerscher Prospective, Ultherapy with 9 48 wk 1 89% of patients with ≥ 1

et al53 nonrandomized calcium improvement in Merz
hydroxylapatite Aesthetic Scale54
filler

Werschler Prospective, Ultherapy 20 1y 1 treatment, 95% of patients had

and nonrandomized 2 passes physician- and subject-
Werschler55 rated improvement
95% of patients were
satisfied or very
satisfied

Oni et al56 Prospective, Ultherapy 103 90 d 1 65.6% of patients

nonrandomized reported improvement
58.1% of patients had
physician-reported
improvement

152

Fig. 13.4 A patient presenting with neck skin laxity showing (a) pretreatment and (b) 90 days posttreatment views
following one treatment with Ulthera. (Adapted from Few JW Jr. The Art of Combining Surgical and Nonsurgical
Techniques in Aesthetic Medicine. 1st ed. New York, NY: Thieme; 2018.)
In 2019, Alhaddad et al published a prospective,
randomized, evaluator-blinded, split-face clinical
trial to compare the efficacy and safety of MFU-V
and MRF.45 The primary end point was a difference
in the Fasil Face and Neck Laxity Grading Scale
(▶ Table 13.3).44 Twenty patients had a single
treatment of MRF on one side of the face and neck
and a single treatment of MFU-V on the other.
There was significant decrease in the Fasil Face
and Neck Laxity Grading Scale for both treatments
starting at day 30 posttreatment, which was main-
tained up to day 180 posttreatment. There was no
statistical difference between sides of the face and
neck treated with MRF compared to MFU-V,
although as noted by the authors, this study was
limited by the small sample size used. One patient
had mild erythema on day 30 posttreatment on
the MFU-V-treated side, but no erythema, edema,
contour irregularity, or bruising were noted at day
90 or 180 posttreatment in any patient. Although
not statistically significant, there was a statistical
trend toward a less painful experience with MRF as
reported by patients when compared to MFU-V.45 A
comparison of MFU-V and MRF is summarized in
▶ Table 13.6.
The addition of radiofrequency energy with mi-
croneedling allows the delivery of thermal energy
at controlled depths to stimulate neoelastogenesis
and neocollagenesis while supporting increased
13.4 Which Technique to Use and Why?
absorption of topical products and skin remodeling
due to the mechanical needling effects. A number
of different radiofrequency microneedling (RFMN)
devices exist and vary in depth of penetration, nee-
dle material and diameter, use of insulated versus
noninsulated needles, use of monopolar or bipolar
energy, and ability to deliver consistent energy
throughout an entire treatment with real-time im-
pedance monitoring.59 RFMN has been studied
extensively for skin rejuvenation with excellent
results.60 When compared to three sessions of
2,940-nm fractional Er:YAG (erbium-doped:yttrium
aluminum garnet) laser treatments administered at
1-month intervals, three sessions of RFMN deliv-
ered at the same time intervals to treat facial and
neck wrinkling produced significantly higher pa-
tient satisfaction rates.61 It was theorized that
RFMN created deeper and broader microscopic
thermal zones, leading to increased efficacy in skin
tightening.61 RFMN settings for greatest efficacy
include thermal energy delivered for 3 to 4 sec-
onds at a temperature of 67 °C, 1.3 to 2 mm depth
of penetration, and applications spaced 3 to 4 mm
apart.60 Typically 50 insertions are used for the
neck area.62 A single treatment at these settings
yielded a 100% response rate in blinded evalua-
tions of skin laxity and skin wrinkling of the neck
area 6 months posttreatment.62 Pain can be the
most treatment-limiting side effect. Other side
153
 Neck Rejuvenation: Noninvasive Techniques

Table 13.6 Comparison of monopolar capacitive-coupled radiofrequency and microfocused ultrasound with
visualization57,58

Monopolar capacitive-coupled Microfocused ultrasound with visualization

radiofrequency (MRF) (MFU-V)

Mechanism of Tissue resistance-induced thermal 1 mm3 thermal coagulation zones created by

action coagulation zone from current source focused ultrasounds

Invasiveness Noninvasive Noninvasive

Indications Mild to moderate skin laxity Mild to moderate skin laxity

No. of treatments Usually one treatment Usually one treatment

Procedure length 30–90 min 60–90 min

Adverse effects Transient mild erythema, edema, burns, Transient mild erythema, edema, tingling, and
nerve damage/neuropathy, and scarring tenderness, nerve damage/neuropathy, and
possible scarring possible

Efficacy Comparable to MFU-V Comparable to MRF

Advantages May be less painful than MFU-V Depth can range from 1.5 to 4.5 mm, able to
visualize area affected with ultrasound, and
thermal coagulation zones can be more precise

Disadvantages Depth limited as it must transmit through Poorer results in high BMI patients and patients
tissue, no visualization of area targeted, and who smoke
poorer results in high BMI patients and
patients who smoke

Durability of 12–24 mo 12- to 18-mo treatment intervals for

results maintenance (up to 24 mo in select populations)

Absolute Patients with cardiac pacemakers or other Patients with cardiac pacemaker or other active
contraindications active implants and pregnant women implants are candidates except over area of
implant, and pregnant women

Abbreviations: BMI, body mass index.

effects for RFMN are mild and transient and in-
clude erythema, swelling, purpura, and postin-
flammatory hyperpigmentation.60
Dermarolling, Microneedling,
Chemical Peels, and Platelet-Rich
Plasma
Other treatments for skin laxity exist, but target
mild laxity in the form of rhytids and wrinkling.
Studies examining the benefits of chemical peels
in neck dyschromia, namely, Jessner or 70% gly-
colic acid and 40% trichloroacetic acid peels, also
noted decreased wrinkling when used on the
neck.15,16 Similar findings were also seen with
three sessions of platelet-rich plasma injections
into the face and neck spaced 1 month apart,
with 52% of patients stating their wrinkles had
improved.63 Dermarolling and microneedling
without radiofrequency can be used to treat tex-
tural change, with almost 90% of patients seeing
noticeable results after two treatments.64
13.4.5 Submental Fat and Fullness
In the American Society for Dermatologic Surgery
2019 Consumer Survey on Cosmetic Dermatologic
Procedures, 73% of consumers were bothered by
excess fat under the chin and neck.65 Submental
adipose tissue is less likely to respond to traditional

154

diet and exercise and thus, noninvasive submental
contouring can have profound effects on neck reju-
venation. Submental fat is divided into two com-
partments: subcutaneous or preplatysmal fat and
subplatysmal or postplatysmal fat. Nonsurgical
submental contouring typically targets subcuta-
neous fat alone as subplatysmal fat removal could
lead to concavity.66 Patients with large amounts
of subplatysmal fat, however, may not experience
significant improvement when using noninvasive
methods compared to more invasive, deeper
methods of fat removal. Furthermore, patients
should be examined for digastric muscle hyper-
trophy, submandibular salivary gland ptosis, and
cervical lymphadenopathy, as these may be mis-
taken for submental fat and are not amenable to
noninvasive therapies.8
Deoxycholic Acid
Deoxycholic acid was first FDA approved in 2015
for targeting moderate to severe submental fat.
Classically known at ATX-101, but now clinically
sold as Kybella in the United States and Belkyra in
Canada (Allergan Bio-pharmaceuticals, Inc, West-
lake Village, CA), the drug is a synthetic compound
identical to endogenous deoxycholic acid, a secon-
dary bile acid created in the intestine for emulsifi-
cation of fat.67 ATX-101 is administered in multiple
injections of 1 to 2 mg/cm2 under the chin in a grid-
like fashion causing adipocytolysis and removal of
excess submental fat.68 Three to six treatments
spaced 1 to 3 months apart may be required for a
desired result to be noted. Patients with an active
Fig. 13.5 A patient presenting with submental fullness showing (a) pretreatment and (b) posttreatment views following
treatment with Kybella injections. (Adapted from Gerecci D, Perkins S. The graduated approach to surgical neck
contouring. Facial Plast Surg 2019;35(5):516–524.)
13.4 Which Technique to Use and Why?
submental infection should not be considered for
deoxycholic acid (▶ Fig. 13.5).
Clinical results of deoxycholic acid are summar-
ized in ▶ Table 13.7. Commonly reported out-
comes include a greater than 1 point improvement
in the Clinician-Reported Submental Fat Rating
Scale (CR-SMFRS), the Patient-Reported Submental
Fat Rating Scale (PR-SMFRS), or a combination of
the two when compared to baseline (▶ Table 13.8).
The first phase III clinical trial by Rzany et al in
2014 used a maximum of four treatments and both
1 and 2 mg/cm2 concentrations were used with a
trend toward greater efficacy with the higher dose,
although the trial was not conducted to compare
the two doses.69 REFINE-1 and REFINE-2 trials used
the higher concentration of 2 mg/cm2 and a maxi-
mum of six treatments with excellent efficacy.70,71
Although up to six treatments were allowed, post
hoc analysis from pooled trial data showed that sig-
nificant improvements were achieved after only
two to four treatments.72 In the Condition of Sub-
mental Fullness and Treatment Outcomes Registry
(CONTOUR) study, a prospective, multicenter, non-
interventional study of 570 patients receiving sub-
mental deoxycholic acid injections, 25 and 30% of
patients who achieved their treatment goals did
not have improvement of greater than 1 point on
CR-SMFRS and PR-SMFRS, respectively.73 Therefore,
patients can be satisfied with treatment even with-
out reaching the end points used in clinical trials.
Side effects of deoxycholic acid are generally
mild to moderate in severity. Among the clinical
studies, nearly all side effects resolved by study
end. The most frequent side effects include pain,
155
156
Table 13.7 Clinical results using deoxycholic acid in the submental region

Study Design No. of Dosage Follow-up No. of % with ≥ 1 % with ≥ 1 % with ≥ 1

patients after final treatments improvement on improvement on improvement on
treatment CR-SMFRS PR-SMFRS CR-SMFRS and
PR-SMFRS

Rzany et al69 Multicenter, Placebo: 122 Placebo, 12 wk 1–4, separated Placebo: 23.0% Placebo: 32.4% Not reported
randomized, 1 mg/cm2: 119 1 mg/cm2, by 28 ± 5 d 1 mg/cm2: 59.2% 1 mg/cm2: 67.0%
double-blind, 2 mg/cm2: 121 and 2 mg/ intervals 2 mg/cm2: 65.3% 2 mg/cm2: 73.6%
placebo cm2
controlled

REFINE-1: Multicenter, Placebo: 250 Placebo, 12 wk 1–6, separated Placebo: 36.2% Placebo: 38.5% Placebo: 18.6%
Jones et al71 randomized, 2 mg/cm2: 256 2 mg/cm2 by 28 ± 5 d 2 mg/cm2: 79.1% 2 mg/cm2: 82.3% 2 mg/cm2: 70.0%
double-blind, intervals
placebo
controlled
Neck Rejuvenation: Noninvasive Techniques

REFINE-2: Multicenter, Placebo: 258 Placebo, 12 wk 1–6, separated Placebo: 34.5% Placebo: 37.8% Placebo: 22.2%
Humphrey et randomized, 2 mg/cm2: 258 2 mg/cm2 by 28 ± 5 d 2 mg/cm2: 77.9% 2 mg/cm2: 78.4% 2 mg/cm2: 66.5%
al70 double-blind, intervals
placebo
controlled

Shridharani74, Single-center, 2 mg/cm2: 100 2 mg/cm2 5–7 wk 1–6, separated 2 mg/cm2: 88.0% Not reported Not reported
75 single-arm, by at least 1 mo
open label apart

Beer et al76 Multicenter, 2 mg/cm2: 165 2 mg/cm2 12 wk and 1–6, separated 12 wk: 86.8% 12 wk: 83.8% Not reported
single-arm, 12 mo by ~1 mo 12 mo: 90.4% 12 mo: 80.7%
open-label

CONTOUR: Multicenter, 570 Not 12 mo 1–5 treatment, Out of patients who Out of patients who Not reported
Behr et al73 single-arm, reported separated by on met treatment met treatment
open-label average 8.9–16.7 goals: 75% goals: 70%
wk between Out of patients who Out of patients who
treatments did not meet did not meet
treatment goals: treatment goals:
58% 48%
(Continued)
 Table 13.7 (Continued) Clinical results using deoxycholic acid in the submental region

Study Design No. of Dosage Follow-up No. of % with ≥ 1 % with ≥ 1 % with ≥ 1

patients after final treatments improvement on improvement on improvement on
treatment CR-SMFRS PR-SMFRS CR-SMFRS and
PR-SMFRS

Glogau et al77 Multicenter, 93 Placebo, 12 wk 1–6 treatments Mild SMF Mild SMF Mild SMF
randomized, Mild SMF 2 mg/cm2 at least 28 days Placebo: 20% Placebo: 33.3% Placebo: 6.7%
double-blind, Placebo: 16 apart ATX-101: 72.2% ATX-101: 67.7% ATX-101: 61.3%
placebo ATX-101: 31 Extreme SMF Extreme SMF Extreme SMF
controlled Extreme SMF: Placebo: 26.7% Placebo: 46.7% Placebo: 13.3%
Placebo: 16 ATX-101: 96.4% ATX-101: 89.3% ATX-101: 89.3%
ATX-101: 30

Shome et al. Single-center, 50 3 mg/cm2 12 wk 1–4 treatments 90% Not reported Not reported
201978 single-arm, spaced ~2 mo
open label apart

Abbreviations: CR-SMFRS, Clinician-Reported Submental Fat Rating Scale; PR-SMFRS, Patient-Reported Submental Fat Rating Scale.
13.4 Which Technique to Use and Why?

157
 Neck Rejuvenation: Noninvasive Techniques
Table 13.8 Submental Fat Rating Scales (SMFRS) used
as outcomes in REFINE-1 and REFINE-2 trials70,71
Grade Clinician- Patient-reported (PR-SMFRS)
reported
(CR-SMFRS)
0 Absent No chin fat at all
1 Mild A slight amount of chin fat
2 Moderate A moderate amount of chin fat
3 Severe A large amount of chin fat
4 Extreme A very large amount of chin fat
hematoma/bruising, edema, anesthesia/numbness,
and erythema. In the REFINE clinical trials, more
serious, but temporary, side effects seen included
marginal mandibular nerve injury (4.3% of patients),
dysphagia (1.9% of patients), skin ulceration (0.2% of
patients), and injection-site alopecia (0.4% of pa-
tients).70,72 In practice, marginal mandibular nerve
injury can mostly be avoided by ensuring no injec-
tions are within 1.0 to 1.5 cm of the inferior mandib-
ular border.66 Skin ulceration can also be avoided by
ensuring appropriate injection technique by avoiding
superficial injections placed in the dermis. Although
rare in the clinical trials, real-world experience of 39
men receiving deoxycholic acid had 9 men (23.1%)
with injection-site alopecia lasting 6 weeks to 12
months, showing that this side effect may be more
common than previously reported.74
Off-label, deoxycholic acid can be used to target
the jowls in certain populations with good results.
A recent single-site prospective study treated 66
adults with excess jowl fat with deoxycholic acid
at a dose of 2 mg/cm2 with a mean 1.8 treatments
spaced, on average, 8.6 weeks apart. Improvement
in jowls was noted in 65 (98%) of patients. Com-
mon side effects included edema, numbness, pain,
and bruising. As it is rare to have increased jowl fat
without associated submental fullness, the use of
deoxycholic acid in jowls is intended to be done in
conjunction with treatment of submental fat. All
patients within the study had the submental area
treated with deoxycholic acid injections prior to or
at the same time as the jowl area.79
Cryolipolysis
Cryolipolysis (CoolSculpting, Zeltiq Aesthetics/
Allergan, Pleasanton, CA) is a noninvasive
158
temperature-based treatment targeted at per-
manent localized fat reduction. CoolSculpting
secured FDA approval for cryolipolysis for the
submental area in 2015. Patients with a history
of cold agglutinin disease, cryoglobulinemia, or
paroxysmal cold hemoglobinuria should not be
considered for cryolipolysis.
Clinical results are summarized in ▶ Table 13.9.
Submental cryolipolysis treatment parameters in
studies vary and involve one or two separate
treatments, but outside of clinical trials, three
treatments spaced 6 to 10 weeks apart may be
necessary, with full results not appearing until
after 4 months.68 Unlike with ATX-101, there is
no consensus of outcome measures and therefore
a variety of tools have been used including cali-
pers, 3D imaging, radiographic imaging including
magnetic resonance imaging (MRI) or ultrasound,
and physician’s and patient’s subjective evaluations.
Mean fat layer reduction by caliper or radiographic
imaging ranges from 1.78 to 4 mm. Calculation of to-
tal fat volume reduction has been attempted; how-
ever, the two studies using 3D imaging to calculate
this significantly differed in outcomes, likely secon-
dary to the absence of a standardized area of which
to calculate the volumes from.80,81 Even without
standardization of outcomes, the vast majority of pa-
tients were ultimately satisfied with the treatment
and reported at least some improvement.
Side effects of cryolipolysis are generally mild
and include localized erythema, bruising, edema,
numbness, paresthesia, and mild pain.80,85 Neuro-
pathic pain extending outside treatment area and
lasting up to 1 week has also been reported.86
Comparison of deoxycholic acid and cryolipoly-
sis as treatment for submental fat is presented in
▶ Table 13.10. Additionally, cryolipolysis can be
combined with deoxycholic acid, with cryolipoly-
sis used first used to reduce the bulk of adipose tis-
sue and deoxycholic acid injections subsequently
used to target the remaining areas and sculpt the
submental area as needed.87
Laser and Energy-Based Devices
Laser lipolysis uses laser energy to liquefy adipocytes
with the added benefit of stimulating collagen.
Lasers showing efficacy in the submental region in-
clude but are not limited to 980-nm diode, 1,470-
nm diode, and 1,440-nm Nd:YAG lasers.88,89,90,91 A
1,060-nm diode laser (SculpSure; Cynosure, West-
ford, MA) was FDA approved for lower face and neck
 Table 13.9 Clinical results of submental cryolipolysis

Study Design No. of Device Treatment No. of Follow-up Objective Patient-reported

patients parameters treatments results results

Jain et al81 Retrospective, 35 CoolMini applicator, 45-min treatment One treatment 12 wk 3D imaging: Pleased with results:
nonrandomized, and CoolSculpting with a maximum mean volume 76%
open label, System, Allergan cooling reduction:
interventional cohort USA Ltd, Dublin, temperature of 22.30 cm3
study Ireland –11 °C, one cycle

de Gusmão Prospective, single- 20 CoolMini applicator, 45-min One treatment 3 mo Ultrasound: Not reported
et al82 center, nonrandomized, CoolSculpting treatment, mean reduc-
and open label System, Allergan temperature not tion in meas-
interventional cohort stated, two cycles ured region:
study −31.1%

Suh et al83 Prospective, single- 10 CoolMini applicator, 45-min duration One treatment 8 wk Caliper: mean Reported at least
center, nonrandomized, CoolSculpting at a cooling fat layer reduc- “some improve-
and open label System, Zeltiq temperature of tion of 4 mm ment”: 100%
interventional cohort Aesthetics −11 °C, two Ultrasound:
study cycles mean fat layer
reduction of
2.8 mm

Bernstein Prospective, single- 14 CoolMini applicator, –11 °C, 45-min Two treatments 12 wk Caliper: mean Satisfaction rate: 93%
and Bloom80 center, nonrandomized, CoolSculpting cooling cycles, 2 spaced 6 wk fat layer reduc-
and open label system; ZELTIQ cycles except for apart tion of 2.3 mm
interventional cohort Aesthetics 2 patients 3D imaging:
study receiving 1 cycle mean reduc-
for second tion in fat
treatment thickness of
3.77 mm
Mean volume
reduction:
4.82 cm3
(Continued)
13.4 Which Technique to Use and Why?

159
160
Table 13.9 (Continued) Clinical results of submental cryolipolysis

Study Design No. of Device Treatment No. of Follow-up Objective Patient-reported

patients parameters treatments results results

Leal Silva Prospective, single- 15 Prototype small- First treatment: Two treat- 12 wk Caliper: mean Satisfaction rate: 80%
et al84 center, nonrandomized, volume applicator, −12 °C, 45-min ments spaced fat layer
and open label CoolSculpting cooling cycle, 10 wk apart reduction:
interventional cohort System, ZELTIQ one cycle 3.2 mm
study Aesthetics, Second treat- MRI: mean fat
Pleasanton, CA ment: −15 °C, layer reduction
30-min cooling of 1.78 mm
cycle, one cycle

Kilmer et al85 Multicenter, 60 CoolMini −10 °C, duration Two 12 wk Ultrasound: Satisfaction rate: 83%
prospective, open label, applicator, 60 min, one treatments mean fat layer
nonrandomized CoolSculpting cycle spaced 6 wk reduction of
Neck Rejuvenation: Noninvasive Techniques

interventional cohort system, ZELTIQ apart (one 2 mm

study Aesthetics patient had
one treatment
only)

Abbreviations: MRI, magnetic resonance imaging; 3D, three-dimensional.

 13.5 Conclusions

Table 13.10 Comparison of deoxycholic acid (ATX-101) and cryolipolysis68

Deoxycholic acid (ATX-101) Cryolipolysis

Mechanism of action Bile acid-induced adipocyte membrane Cold-induced adipocyte apoptosis

destruction

Invasiveness Minimally invasive Noninvasive

Indications Moderate to severe submental fat Submental fat in patients with a BMI
of ≤ 46.2

Number of treatments Up to 6 treatments with significant 1–3 treatments with average of 2

improvements noted at 2–4 treatments treatments

Procedure length 30 min 45 min

Adverse effects Swelling, bruising, discomfort, necrosis, Swelling, altered sensation, temporary
dysphagia, temporary nerve damage, and nerve damage hyperpigmentation, and
alopecia neuropathic pain

Efficacy 61.3–89.3% of patients ≥ 1 improvement Mean submental fat thickness decrease

on CR-SMFRS and PR-SMFRS of 1.78–4 mm

Advantages Minimal downtime and controlled Minimal downtime and controlled

placement placement

Disadvantages Multiple treatments necessary, cost of Multiple treatments may be necessary,

drug, and inability to accurately control fat dedicated room for treatment
reduction required, and inability to accurately
control fat reduction

Durability of results Sustained long term (at least 4 y) Permanent

Absolute contraindications Patients with active submental infection Patients with history of cold agglutinin
disease, cryoglobulinemia, or
paroxysmal cold hemoglobinuria

Abbreviations: BMI, body mass index; CR-SMFRS, Clinician-Reported Submental Fat Rating Scale; PR-SMFRS, Patient-
Reported Submental Fat Rating Scale.

contouring in 2017. In the supporting prospective,
multicenter non-placebo-controlled study, 57 sub-
jects were treated with up to two 25-minute treat-
ments with SculpSure. Twelve weeks postfinal
treatment, submental fat was reduced by 1.785 mm
and 100% of the patients were satisfied with the
treatment. Side effects were mild to moderate and
transient in all but one case; these included swel-
ling, pain, erythema, numbness, hair loss, bruising,
firmness, and blisters.92
Radiofrequency is more recently being utilized
to target submental fat. A high-powered monopo-
lar radiofrequency device (truSculpt, Cutera Inc.,
Brisbane, CA) was shown in an exploratory study to
effectively target the submental area with a cycle of
2 minutes at 43 °C and 3 minutes at 45 °C. Two treat-
ments spaced 1 month apart on 21 patients yielded
a reduction of 5.8 mm in submental fat thickness as
seen by ultrasound 6 months posttreatment.93 Side
effects were mild and self-resolving and included
erythema, edema, and vesicles without scarring or
hyperpigmentation.93
13.5 Conclusions
Numerous noninvasive treatments are available
for neck rejuvenation, allowing for significant im-
provement to be achieved with less recovery time
and decreased risk of adverse effects compared to
surgical approaches. ▶ Table 13.11 summarizes
our approach, which starts by targeting individual
patient’s concerns and selecting treatments to en-
sure the best patient outcomes. Most often, a com-
bination of treatments is needed in order to

161
 Neck Rejuvenation: Noninvasive Techniques

Table 13.11 Summary of noninvasive neck rejuvenation techniques based on primary concern

Dyschromia Horizontal necklines Platysmal Skin laxity Submental

banding fullness

● Cosmeceuticals ● Neuromodulators ● Neuro- ● Hyperdiluted calcium ● Deoxycholic

● Chemical peels: ● Hyaluronic acid filler modu- hydroxylapatite acid
TCA, Jessner, ● Diluted calcium lators ● Poly-L-lactic acid ● Cryolipolysis
glycolic acid hydroxylapatite ● MFU-V ● MRF
● IPL ● Nonablative fractional ● MRF ● Laser lipolysis:
● Nonablative laser: 1,550, 1,440 nm ● Radiofrequency 1,060 nm
fractional laser: ● Ablative fractional laser: microneedling diode
1,550 ± 10,600 nm ● Chemical peels: TCA,
1,927 nm ● MFU-V Jessner, glycolic acid
● MRF ● Dermarolling and
microneedling
● Platelet-rich plasma

Abbreviations: IPL, intense pulsed light; MFU-V, microfocused ultrasound with visualization; MRF, monopolar capacitive-
coupled radiofrequency; TCA, trichloroacetic acid.

achieve desired and lasting results. Further studies References

are needed to help identify which specific combi-
nation treatments work best when used together.
13.6 Expert Commentary by
Dr. Slavin
This is a comprehensive chapter focusing on dys-
chromia, skin quality, subcutaneous fat, and contour
irregularities of the head and neck. It is written by
pioneers in developing and applying laser technol-
ogy for cosmetic improvement of the face. In their
meticulous analysis of facial features—from pigmen-
tary issues to loose skin—they give a systematic,
well-organized approach. These techniques are be-
coming increasingly important for clinicians going
forward. Although the techniques do not replace
surgery, they provide excellent alternatives, particu-
larly in patients who are not surgical candidates.
13.7 Expert Commentary by
Dr. Lin
The authors bring forth their vast experience of
noninvasive approaches of the skin and underlying
structures. They outline the most commonly ad-
dressed areas noninvasively, with structures at the
platysmal layer and above, while comprehensively
outlining the treatments available. Using these as
adjunct procedures with procedures addressing the
deeper structures provides an all-encompassing
approach to the neck.
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165
14 Revisional and Secondary Neck Lifts
Ashley N. Boustany, Vickram J. Tandon, and Sumner A. Slavin
Abstract
The neck contour and laxity are common concerns
in patients seeking facial rejuvenation. Patients
seek a secondary neck lift due to the unrelenting
natural aging process, unsatisfactory results, early
recurrence, or iatrogenic deformities. It is impor-
tant to identify the patient’s goals and determine
the etiology. Technical challenges arise due to al-
tered anatomy in the previously operated field and
scarred tissue planes. One must strategically plan
incision placement for optimal scar camouflage
and prevention of complications. Acquired de-
formities should be approached methodically. Lon-
gevity of results may be optimized with treatment
of the deeper planes and maintenance regimen ad-
juncts.
Keywords: revision neck lift, secondary neck lift,
neck lift complications, aging neck, rhytidectomy
longevity, reoperative neck lift
Key Points
● Revisional and secondary neck lifts present chal-
lenges related to incision placement, fibrotic tis-
sue planes, altered anatomy, and a potentially
older patient population.
● Revisional neck lifts are performed when results
are unsatisfactory or in the presence of soft-
tissue complications.
● Secondary neck lifts are performed when initial
results were satisfactory, but progressive loss of
correction occurs due to the natural aging proc-
ess, often years following the primary procedure.
Coexisting deformities related to the primary
rhytidectomy may also be present.
● Patients should be counseled on risk factors for
early recurrence including poor skeletal support,
significant tissue laxity, and advanced age.
● Patient goals should be clearly elucidated with
an accurate identification of the anatomical
etiology.
● Anterior platysmal bands are common. Treat-
ment often requires a submental approach with
platysmaplasty, along with maximal preserva-
tion of skin flap thickness.
14.1 Revisional versus Secondary
Rhytidectomy
The reoperative neck lift carries certain challenges
that necessitate additional attention, particularly
when the primary technique is unknown or in the
presence of significant scarring or deformity. The
surgeon must first identify patient goals and diag-
nose the anatomical etiology. Caution should be
employed as the dissection planes are often ob-
scured and critical structures may be repositioned.
Patients should be counseled on the potential for
increased complication profiles. Revisions may be
reduced by maintaining an awareness of the
potential sequelae. Narasimhan et al found the
most common reason for reoperation was recur-
rent platysmal bands and jowling.1 Skouras et al
identified hairline malposition as the primary
motivation.2 Despite the additional complexity,
patient satisfaction outcomes remain high and
adverse outcomes may be minimized with proper
surgical technique.3,4
14.1.1 Revisional Neck Lifts
The distinction between a secondary rhytidectomy
and a revisional rhytidectomy remains poorly de-
fined. In general, a revisional rhytidectomy is one
that is performed to address unsatisfactory results
related to undercorrection or the presence of sur-
gical deformities (▶ Table 14.1).5,6 Revisional neck
lifts may be pursued to address undercorrection or
the presence of surgical stigmata such as scar visi-
bility, ear deformities, hairline distortion, or con-
tour irregularities. Prevention is key, as discussed
in Chapter 15’s outline of complications.
Table 14.1 Types of reoperative neck lift procedures
Revisional neck lift Secondary neck lift
Primary neck lift with Primary neck lift with
unsatisfactory results satisfactory results
Undercorrection Natural aging recurrence
Complications/stigmata ± Complications/stigmata
of surgery of surgery
167
 Revisional and Secondary Neck Lifts
14.1.2 Secondary Neck Lifts
A secondary rhytidectomy is performed in those
who achieved satisfactory results, but subse-
quently pursue surgery for age-related recurrence
(▶ Fig. 14.1, ▶ Fig. 14.2).5,6 Their outcomes are
assessed by evaluating the cervicomental angle, pla-
tysmal bands, skin tightness, skin quality, rhytids,
and overall contour. Prior authors have attempted to
investigate the longevity of rejuvenation with varia-
ble findings, understandably limited by differences
in operative technique and patient-specific factors.
Fig. 14.1 The patient is shown before and after a secondary facelift.
168
The subjective nature of a patient’s desire for reope-
ration further complicates this analysis, as well as
individual aging patterns.7
Consistent objective measures of longevity are
lacking but have included cervicomental angle, sur-
geon ratings, wrinkle scores, and patient-reported
outcomes (▶ Table 14.2).7,8 A study by Jones and Lo
suggested that rhytidectomy results are maintained
for approximately 5.5 years, regardless of technique.9
However, the neck presents unique challenges as it
relapses earlier than other facial regions such as the
nasolabial folds, marionettes, and jowls.9,10 Sundine

Fig. 14.2 The patient is shown before and after her secondary facelift.
et al’s review of 299 patients undergoing rhytidec-
tomy with superficial musculoaponeurotic system
(SMAS) manipulation found that the average time
to a secondary procedure was 11.9 years.5 Simi-
larly, Guyuron et al found that the average time
was 8.5 years.4
14.2 Patient Considerations
The patient evaluation for reoperative neck lift
procedures should follow the standard approach
as discussed in previous chapters. Patient goals,
14.2 Patient Considerations
medical history, physical examination, and pho-
tography should proceed systematically. Patients
present at a more advanced age with potential co-
morbidities. Guyuron et al found that 42% of sec-
ondary rhytidectomy patients had acquired a new
medical condition since their primary operation.4
They were also more likely to have hypertension
and perioperative blood pressure fluctuations.4
Appropriate workup and medical clearance should
be obtained to avoid systemic complications. Pa-
tient expectations should be reasonable and psy-
chologic factors should be explored. It is important
169
 Revisional and Secondary Neck Lifts

Table 14.2 Studies reporting longevity of rhytidectomy results

Study End point Technique Longevity (y) Note

Narasimhan et al1 Time to SNL Variable 10.3 NL alone

Pelle-Ceravolo Surgeon rating Complete transection + midline 45% < 1 NL alone

et al15 platysmal bands plication + lateral anchor

Jones and Lo9 Scoring system Variable < 5.5 FL/NL

Guyuron et al4 Time to SR Unknown 8.5 FL/NL

Funk and Adamson6 Time to SR Primarily deep plane 9.95 FL/NL

Sundine et al5 Time to SR Variable 11.9 FL/NL

Friel et al11 Patient reported SMAS–platysma lift 68% at 12.6 FL/NL

Abbreviations: FL, facelift; NL, neck lift; SFL, secondary facelift; SNL, secondary neck lift; SR, secondary rhytidectomy.

to note any prior nonsurgical and surgical rejuve-
nation procedures. Prior operative notes should be
obtained and reviewed.
14.2.1 Identification of Deformity
The physical examination should assess prior scar
placement and quality. There may be elongation
or tethering of the earlobe in the form of a “pixie
ear.” The tragus of the ear may be obliterated,
tensioned anteriorly (“shot gun ear deformity”),
or distorted.12 Subcutaneous fat may be atrophic
or irregular. Submental hollowing commonly oc-
curs from excessive fat resection or inadequate
platysmal plication, and it may lend a “cobra
neck” appearance. Horizontal submandibular
bands may be visible at rest or with neck rotation
and are often a result of poor distribution of skin
tension. The vertical band deformity presents
with a single central skin fold extending from the
submentum. They result from an overzealous mid-
line platysmal plication, inadequate release and
redistribution of the skin envelope, or fibrosis.1
Contour irregularities can come in many varieties,
ranging from fat deposits to unnatural soft-tissue
repositioning. The cranial nerve examination
should pay particular attention to any preexisting
paresis or asymmetry. Tissue mobility can be as-
sessed by manually simulating lateral skin dis-
placement. Photographic documentation should
be obtained at rest, with facial animation, and with
neck rotation. All scars should be visible in the
images.
14.2.2 Factors Influencing
Longevity and Outcomes
Several patient-dependent factors may influence the
longevity of results. Younger patients or those with
mild-deformity typically have superior outcomes.8,13
The tissue quality is often better in this population,
allowing for more secure repairs and subsequent
soft-tissue contraction.14 Earlier recurrences are seen
in those with thin skin and less subcutaneous fat.15
Those with greater skeletal support, such as those
with prominent cheekbones, chins, and mandibles
tend to maintain their results in the long term.8,14
Alternatively, a more caudal or anteriorly posi-
tioned hyoid bone may restrict the degree of im-
provement in the cervicomental angle.8 Patients
with a deeper cervicomental angle preoperatively
generally show improved outcomes.8 Patients
should be counseled to adhere to healthy lifestyles,
reduce sun exposure, and consider maintenance
regimens in the interim.8,10,16
The rhytidectomy technique associated with the
greatest overall longevity remains in question. For
facelifts, a twin study comparing SMAS plication,
SMAS-ectomy, and SMAS flaps resulted in equiva-
lent outcomes.17 Some report more sustained
results with use of deep plane rhytidectomy.18
However, other authors found no difference be-
tween SMAS plication and deep plane approaches,
particularly in patients under the age of 70 years.19
For neck lifts, failure to plicate midline platysmal
bands may impart suboptimal results. Narasimhan
et al reported earlier recurrence in patients who

170

did not undergo an open midline platysmaplasty.1
Jacono et al report a deep plane approach that ad-
vocates for use of the submental approach when
anterior bands are greater than 2 cm apart, obtain-
ing 1.2 cm of lateral pull per side.20 Moreover, they
recommend performing an anterior plication
when performing non–deep plane rhytidectomies
and in those with predisposing characteristics,
such as a low hyoid or a short neck.20 Other au-
thors recommend opening the neck when anterior
bands are less than 2 or 3 cm apart.21
Pelle-Ceravolo et al’s earlier technique of com-
plete platysmal transection, midline plication,
and lateral anchoring revealed band recurrence in
45% of patients at 1 year.15 Guyuron et al showed
no difference in band recurrence with or without
platysmal transection.22 They found no recur-
rences in over 26 years with the vest-over-pants
midline platysmaplasty.22 Clear conclusions are
difficult as most studies are limited by technical
variations, use of concomitant procedures, selec-
tion bias, small sample sizes, anatomical varia-
bles, and the subjective nature of evaluation.17 It
is generally accepted that a platysmaplasty with
fat contouring provides an acceptable degree of
improvement.23,24 The surgical approach should
prioritize patient safety, address the anatomical
deformity, and provide consistent results in the
surgeon’s hands.23
Table 14.3 Technical considerations in the reoperative neck lift
Challenge
Skin incision Poorly placed scars
Wide scars
Flap dissection Fibrotic tissue
Less mobility
Displaced structures
Thin tissues
Reduced cross-innervation
SMAS management Attenuated SMAS
Poorly mobile SMAS
Skin excision Inelastic envelope
Adjunctive procedures Fat atrophy
Poor skin quality
Abbreviation: SMAS, superficial musculoaponeurotic system.
14.3 Problem-Based Technical Considerations
14.3 Problem-Based Technical
Considerations
The selection of surgical technique is a multifacto-
rial process that considers the prior operative ap-
proach, surgical sequalae, tissue quality, laxity, and
patient preferences (▶ Table 14.3). In general, inci-
sions are placed in the ideal location when suffi-
cient laxity allows for scar excision. Dissection is
typically within the scarred plane, aiming to max-
imize the subcutaneous fat thickness of the skin
flap. Attenuation of the SMAS in secondary opera-
tions should be expected.6,25 As such, SMAS plica-
tion may be favored over sub-SMAS approaches in
these patients.25 Importantly, skin excision is typi-
cally more limited in secondary cases.6,25 A thor-
ough analysis and operative plan are essential to
correct and prevent deformities (▶ Table 14.4).
14.3.1 Poor Scar Placement
Widened or visible scars are common complaints
in patients seeking reoperative neck lifts. In the
presence of clearly adequate skin laxity, the inci-
sions may be placed in the new ideal location and
the old scars excised. It is generally advisable to
use the old incisions at the start of the procedure
and then resect tissue as able to avoid undue ten-
sion on closure or double incision lines.3 Tertiary
Recommendations
Place incision in ideal location if adequate laxity to excise
scars; otherwise, use old scars
Meticulous dissection in or above the same plane
Midline flat fat preservation
Limit dissection if anatomy is obscured
Plane definition may improve after a few centimeters
Often plication over SMAS flaps
Midline platysmaplasty with skin redraping
Partial platysma transection
Less skin excision, wider undermining
Fat grafting
Skin resurfacing in areas not undermined
171
 Revisional and Secondary Neck Lifts

Table 14.4 Deformities encountered following primary rhytidectomy

Condition Management Options

Poor scar quality Excise scars if sufficient laxity Use old scars, refine closure

Occipital hairline step-off deformity Proper closure alignment Rotation/advancement flap

Proper incision selection Preserve hair follicles

Tragal deformity Avoid tension and necrosis Suture flap into depression
Loss of pretragal sulcus, straight Use pretrichial incision Release pretragal fascia
tragus, and “shot gun deformity” Thin flap at pretragal sulcus Place tension > 2 cm above EAC,
Triangular flap from excess superior-posterior to the helix

Earlobe deformity “pixie ear” Place tension on the mastoid fascia Wedge excision
Ear axis angulation Deliver lobule last at closure Flap readvancement
Lobule pexy SMAS to mastoid or conchal anchor
Leaving caudal lobule closure open Correct axis

Submental hollowing “cobra neck” Avoid fat over-resection Partial platysmal transection
Treat lateral subplatysmal fullness Skin redraping
(fat, digastric, gland) Fat grafting
Midline platysmaplasty

Recurrent platysmal bands Identify other etiologies Partial transection

Neurotoxin Platysmaplasty

Vertical band deformity Scar release Wide undermining

Wide undermining Midline skin excision

Midline ridge deformity Neurotoxin, steroids, massage Plication release and redo
Ensure smooth palpation Bury knots, avoid overtightening

Subauricular band deformity Release subauricular membrane

Abbreviation: EAC, external auditory canal.

rhytidectomy patients may present with two sets
of scar lines when the same incision is not utilized
in the secondary case.2 Treatment involves incising
the more posterior scar and recruiting enough tis-
sue to excise the more anterior scar.2
Occipital hairline step-off deformities may result
from a malaligned skin closure, substantial skin
excision with prior post-trichial incisions, or from
alopecia secondary to damaged hair follicles.12 The
“2-cm rule” may be applied to identify proper
placement. If more than 2 cm of skin is estimated
to be excised, a pretrichial occipital incision is pre-
ferred to prevent superior hairline displacement.12
Correction often requires wide undermining and
lateral platysmaplasty to recruit tissue for scar ex-
cision. This allows subsequent advancement and
rotation of the flap to realign the hairline, particu-
larly when skin redundancy is more limited.12
Similarly, when a concomitant redo facelift is per-
formed, the temporal hairline incision should be
analyzed. A new pretrichial incision may be se-
lected if the distance from hairline to orbital rim is
greater than 5 cm, preventing an abnormally wide
cutaneous temple. It may also be selected if the
sideburn is short or obliterated.12 Beveling the
incision can allow additional camouflage on hair
regrowth through the scar line. Follicular hair
transplantation may also be considered.26
The submental incision may be placed within
the natural crease, anterior to the crease, or 1 to
1.5 cm posteriorly.22,27 The latter placement is gen-
erally preferred as the subcutaneous tissues are
thicker, thereby preventing postoperative accentu-
ation and a double-chin deformity.28 Guyuron et al
advocate for an anteriorly placed incision to aid in
obliteration of the submental crease.22 If the prior
submental scar is of poor quality, a very cautious
resection may be performed. Care must be taken
not to over-resect tissue here as a tethered midline
vertical band along the anterior neck may result.

172

14.3.2 Scarred Tissue Planes
Scarred tissue planes should be approached with
caution as critical structures may be repositioned
or more superficial. Although the delay phenom-
enon may augment the vascularity of the skin
flaps, it should not be relied upon to perform more
aggressive maneuvers. In the absence of prior
nerve injury, dissection within the scarred plane
itself may prevent surgical misadventure. Hydro-
dissection with tumescent solution can assist in
plane development and hemostasis, even though
the scarred plane is typically less bloody.24 The dis-
section will often extend past that of the previous
surgery to obtain adequate mobility.24 Care should
be taken to maximize preservation of subcutane-
ous fat, particularly in the midline and postauricu-
lar areas. In general, the dissection proceeds with
greater ease after 2 to 3 cm of elevation in the
scarred plane.
One must also consider a potential reduction in
facial nerve cross-innervation from prior asympto-
matic transections. Some studies have shown an
increased incidence of facial nerve injury in secon-
dary rhytidectomy with sub-SMAS flaps (11%).5
Although no comparative studies have been per-
formed, others report nerve injury incidences sim-
ilar to primary cases with SMAS-ectomy or SMAS
plication (2%).29 The SMAS layer may be attenu-
ated, and in the presence of altered anatomy, any
sub-SMAS dissection should be guarded. Overall,
the approach should be consistent with surgeon
experience and comfort level.6,30 Surgeons should
also anticipate more conservative skin resections
compared to primary cases given reduced tissue
pliability and fibrosis.29 Funk and Adamson
showed a threefold reduction in SMAS thickness
with revision cases. They also showed an average
skin resection of 17 versus 26 mm in primary rhy-
tidectomies.6
14.3.3 Platysmal Bands
Recurrent platysmal bands are a common com-
plaint in those presenting for secondary neck lifts,
with an incidence of almost 90% according to some
studies.1 They tend to recur sooner than other
areas of facial laxity.2,12 Patients with significant
skin excess or laxity, as in massive-weight-loss
patients, may be predisposed to early recurrence.1
Bands may also become more visible with age, fol-
lowing the atrophy of camouflaging subcutaneous
14.3 Problem-Based Technical Considerations
fat. Although recurrence is unavoidable in some,
they may result from poor technique selection, su-
ture failure, accelerated aging, or scarring. Nara-
simhan et al found that 76% of their secondary
neck lift patients did not undergo a primary mid-
line platysmaplasty.1
An accurate diagnosis is key to correct the de-
formity. The recurrence is typically in the anterior
midline, which may be corrected with a submental
approach and muscle plication.1 Lateral bands may
be treated with lateral platysma displacement and
muscle suspension. Platysmal bands are classified as
hypertonic, hypotonic, or pseudobands (skin only).15
Dynamic bands may be injected with neurotoxin for
short-term improvement. Some advocate partial
platysmal transection for the definitive manage-
ment of thick hypertonic bands. However, recur-
rence may still occur due to muscle regeneration,
incomplete transection, or continued contraction.27
Complete platysmal transection has been discour-
aged following observations of linear depressions,
prolonged edema, thyroid cartilage accentuation,
and hematomas.1 The absence of neck bands in
facial paralysis patients supports the potential
utility of muscle denervation with cervical nerve
transection.31 Yet, concerns remain regarding
variable nerve anatomy, weakness in lip depression,
and laxity of the supportive neck “hammock.”32
In the presence of tethered scars or poor tissue
redraping, wide undermining of the skin flap may
be required. Subplatysmal structures may not have
been addressed previously and may require treat-
ment. The digastric muscles or submandibular
gland may require debulking or suture suspension.
In the presence of a hollowed submentum, the
digastric muscles may be plicated at the midline to
fill the depression. Pre- or subplatysmal fat depos-
its may also need to be addressed.27
14.3.4 Midline Ridge Deformity
Patients who have previously undergone midline
platysmaplasty may present with a palpable ridge
of scar, suture, or muscle. The use of a continuous
suture plication, as in the corset platysmaplasty,
may be contributory.22 Guyuron et al utilize a vest-
over-pants platysmal plication to prevent this
deformity.22 With all approaches, it is important to
ensure a smooth repair on palpation prior to closure.
Suture knots should be buried. The midline ridge
may require operative release, undermining, and
reclosure.27 If identified early in the postoperative
173
 Revisional and Secondary Neck Lifts
course, one can consider massage, neurotoxin injec-
tion, or steroid injection.
14.3.5 Submental Hollowing
The submentum may present with an unnatural
depression at rest with increased prominence on
animation, often referred to as the “cobra neck de-
formity” or “dug out deformity.”3,12,28 Treatment
involves proper identification of the anatomical
etiology and methodical contouring. Submental
hollowing may be prevented with conservative
preplatysmal fat resection. Appropriate liposuction
techniques should be utilized with the suction
holes directed away from the dermis. When sub-
platysmal fat is resected, it should not be limited
to the midline alone as the fat pad extends later-
ally. An untreated prominent digastric muscle or
submandibular gland may also exacerbate the
deformity.27 Skin tethering should be massaged in
the early phases and steroid injections may also be
considered. Restorative fat grafting may be appro-
priate in the absence of other anatomical contribu-
tions. Reoperation may require wide undermining,
treatment of lateral subplatysmal fat, digastric pli-
cation, or midline platysmaplasty.27
14.3.6 Vertical Band Deformity
Patients may present with a vertical band extend-
ing from the submentum to the lower neck, re-
ferred to as a “vertical band deformity.” It may be
the result of limited undermining and poor tissue
redrape. Scarring of the skin flap to deeper struc-
tures may also alter the tissue redistribution. A
revision neck lift with wide undermining and skin
excision may be adequate. A midline Z pattern skin
resection in male patients may be considered
when skin is particularly redundant.27
14.3.7 Subauricular Band
Deformity
A prominent vertical or oblique skin fold extending
from behind the ear to the lateral neck has been
described as the “subauricular band deformity.”33 It
results from incomplete release of the vertical sub-
auricular membrane, traveling along the sternoclei-
domastoid. Correction is achieved by careful release
on skin flap elevation while avoiding injury to the
great auricular nerve.33
174
14.3.8 Ear Deformity
The tragus and ear lobule may be distorted after
prior rhytidectomy. The pretragal depression may be
obliterated or the tragal edge blunted, often telltale
signs of prior surgery. Cautious defatting anterior to
the tragus may prevent or correct the blunted de-
pression. Some advocate suturing the undersurface
of the flap to the SMAS to highlight the sulcus.3,4
Others release the overlying pretragal fascia and su-
ture it anteriorly to produce a concavity.34 Inten-
tional sculpting of distinct tragal angles, after tissue
mobilization, may restore tragal shape. With pre-
tragal skin deficiency, a new tragus may be fash-
ioned from a triangular flap of redundant skin
superiorly.4,26 When excessive tension is placed on
the tragal closure, it may be pulled anteriorly creat-
ing the “shot gun deformity.”12 A pretragal incision
is preferred in those with preexisting tragal flexion
or soft tragal cartilage.3 Tension should be directed
greater than 2 cm cranial to the external auditory
canal, superior and posterior to the helical–temple
junction.26
Elongation of an attached earlobe, or “pixie
ears,” results from excessive tension on the lobule.
The lobule should not be delivered until the sur-
rounding incisions are closed, with tension directed
toward the superior helix and mastoid. Lobule–
facial flap closure should be loose with zero tension.
Some advocate for division of the SMAS flap and su-
turing it to the mastoid fascia to support the lobule
position.3 Others leave the inferior aspect of the lo-
bule closure open to prevent contraction caudally.12
Correction can be achieved with mobilization of the
flap and reclosure, wedge excision, or suturing the
flap to the posterior concha.3 The lobule may also
be suspended superiorly to the SMAS to prevent
inferior migration.26
14.4 Expert Commentary by
Dr. Lin
My coeditors have outlined the numerous etiolo-
gies and treatment of various secondary findings
of the revision face and neck lift patient. While
there is often more than one proposed solution to
any individual physical finding, one must first
make an accurate diagnosis of the physical finding
and formulate a plan for the assessed area. Patient
education is paramount to communicate the natural
causes or time frame regarding the need for secon-
dary face and neck lift procedures.

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175
15 Neck Rejuvenation: Complications
Trina G. Ebersole, Amer H. Nassar, and Sumner A. Slavin
Abstract
Knowledge of complications in rhytidectomy re-
mains an integral part of the surgical procedure
that all aesthetic plastic surgeons should be aware
of. Complications in facial aesthetics are often chal-
lenging for the patient–physician dynamic. This
chapter describes common complications as well as
those that appear more infrequently and provides
evidence-based management that all aesthetic sur-
geons should be familiar with.
Keywords: facelift, neck lift, complications, manage-
ment, hematoma, seroma, skin necrosis
Key Points
● Perioperative normotension should be main-
tained, with emphasis on avoidance of post-
operative hypertension. Avoid intraoperative
hypotension, as this might lead to unrecog-
nized bleeding that will become evident post-
operatively in the form of a hematoma.
● The most commonly injured sensory nerve dur-
ing a facelift is the great auricular nerve.
● The most commonly injured motor nerve is the
buccal branch of the facial nerve.
● Smoking greatly increases the incidence of skin
flap necrosis. Cessation of all nicotine-containing
products is imperative in the perioperative peri-
ods.
15.1 Hematoma
Hematoma is the most common complication fol-
lowing facelift. In nonhyptertensive patients, the
incidence of hematoma is approximately 3%;
however, in males or patients with a history of
hypertension, hematoma rates rise to approxi-
mately 8%.1,2 A proper review of the patient’s home
medications is prudent as the risk of hematoma in-
creases in patients taking aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDs). There are no
consensus guidelines regarding perioperative dis-
continuation of anticoagulants and platelet inhibi-
tors. Joint decision-making with the patient and
their primary care physician regarding the safety of
transitioning off certain anticoagulants to proceed
with an elective surgery may be necessary. Routine
supplements such as ginger, vitamin E, and fish oils
should be discontinued prior to surgery as they
may lead to increased bleeding risk.3,4 While re-
viewing that patient’s medications, estrogen ma-
nagement is equally important as it is a known risk
factor for thromboembolism.5 Combining rhytidec-
tomy with platysmaplasty also increases the risk of
hematoma; strict hemostasis is crucial in prevent-
ing this complication.3 Blood pressure control dur-
ing the case is key to preventing postoperative
hematoma in facelift surgery. Postoperatively, hy-
pertension can be averted with beta blockade (such
as labetalol) or an alpha agonist (such as cloni-
dine).6 Adequate analgesia and control of nausea, as
well as strenuous activity restrictions, should be
stressed, as each of these may decrease chances of
developing a postoperative hematoma.3
Tranexamic acid (TXA) is a synthetic lysine ana-
log that temporarily prevents plasmin from acting
on fibrin clots to dissolve them as well as blocking
platelet activation.7 TXA has been shown to safely
decrease bleeding during rhytidectomy.8,9 There
are several ways to employ TXA varying from
topical administration to infiltration, and even
intravenously during rhytidectomy. Topical TXA
placed on pledgets on the undersurface of the
skin flap after completion of flap elevation has
been shown to decrease ecchymoses; however,
this was in a low-powered study.10 Others have
shown that 1.5 mL of TXA mixed into tumescent
solution infiltration subcutaneously into the face
and neck prior to incision significantly reduces
the operative time.11 Intravenous TXA (1 g pre-
operatively, with a second 1-g dose 4 hours later)
has also been shown to significantly reduce post-
operative ecchymosis.12
Hematomas are most likely to occur in the first
24 hours after surgery and should be evacuated
immediately. Earlier surgical management will
prevent postoperative skin necrosis and tissue
edema.3 In a very select few cases of a small fluid
collection, it is possible to aspirate this and ob-
serve, but overwhelmingly, most cases require sur-
gical evacuation, as continued pressure on the skin
and soft tissue will ultimately result in a poor cos-
metic outcome with tissue retraction and excess
skin laxity.
177
 Neck Rejuvenation: Complications
15.2 Skin Necrosis
Skin necrosis is more common in subcutaneous
facelifts at a rate of approximately 3.6% and further
decreases in the sub-superficial musculoaponeurotic
system (sub-SMAS) techniques to approximately
1%.13 It is most common in the postauricular sulcus.
Skin necrosis increases with thin flaps or if there is
excess tension on the skin during closure or from a
postoperative hematoma. Skin necrosis is often
managed conservatively with local wound care.
Smoking increases the incidence of skin flap necrosis
by approximately 12.5 times.14
15.3 Infection
Infections after rhytidectomy are uncommon. Pre-
incisional surgical prophylaxis should be routinely
administered and covers for routine skin flora.
Pseudomonas aeruginosa does colonize the otic
canal and can thus lead to infections, which can be
treated by oral fluoroquinolones, but may need
surgical drainage. In rare instances, Mycobacteria
can colonize the wound. Sterile technique should
be maintained throughout the procedure, like with
any other operation.
15.4 Nerve Injury
Regardless of technique, the incidence of nerve in-
jury is reported in approximately 1% of cases, after
either a subcutaneous or a sub-SMAS facelift.13
More than likely, these rates are underreported. A
meta-analysis of complication rates in different
rhytidectomy techniques shows a significant in-
crease in temporary nerve injury in composite rhyti-
dectomy and high lateral SMAS-ectomy as compared
to SMAS plication.15 Nerve deficits seen immediately
postoperatively are common and can be due to local
anesthetic.16 Typically, spontaneous recovery of tran-
sient neurapraxia of motor branches is seen in 3
months, and thus initial management is observation
and management of patient expectations. The most
commonly injured motor branch of the facial nerve
is the buccal branch. However, this is often clinically
insignificant as there exists rich arborization be-
tween various facial nerve branches in this region.3
Patients should be offered chemodenervation of the
unaffected side to improve symmetry while awaiting
nerve recovery.
The great auricular nerve is the most common
sensory nerve injured during rhytidectomy, often
178
resulting in numbness to the region of the earlobe
and the inferior pinna. It is imperative to take pre-
caution while elevating the cervical flap from the
sternocleidomastoid to avoid injury to the great
auricular nerve. If it is identified that the nerve
was inadvertently transected intraoperatively, it
should be repaired using microsurgical techniques.
15.5 Recurrent Platysmal Bands
Most commonly, platysmal bands will recur cen-
trally after several years. This may require reopera-
tion or treatment with chemodenervation.
15.6 Dystonia
There is a fine balance between excess tension and
restoring youth. The tension on the resuspended
tissue should allow for some flexibility for natural
movement in the face and neck for activities of
daily living. If it is too tight, this can cause dysto-
nia, difficulty articulating speech, grimacing, pain
with swallowing, and the sensation of tightness.
This can be treated with valium or botulinum toxin
if seen.17
15.7 Scars
Thoughtful surgical scar placement is crucial and
contributes to the final aesthetic result of a facelift.
Excess tension or skin resection can lead to wid-
ened scars, alopecia, or hypopigmentation. Unfav-
orable scarring is often seen postauricularly, due
to skin tension, and submentally, due to inad-
equate approximation of the tissue. This can also
result in alteration of the hairline or the ear. Inci-
sions placed in the hairline should be beveled so as
to allow hair follicles to grow through and conceal
the scar in the future.18 Preoperative discussion of
a history of hypertrophic scarring or keloids is
important to discern.
15.8 Case Example
15.8.1 Case 1
A 67-year-old woman who had previously under-
gone facelift and neck lift 12 years prior was inter-
ested in rejuvenation of her neck (▶ Fig. 15.1). She
underwent neck lift and did well without issues at
her first postoperative visit. Eight days later, she
called and reported swelling of her left neck

(▶ Fig. 15.2). She was seen in the clinic, and the
area was fluctuant. Approximately 5 mL of serous,
straw-colored fluid was aspirated from the left
neck. We continued a head wrap and light pres-
sure with gauze in this area. Her postoperative
course was otherwise uncomplicated, and she
healed well. Her postoperative photographs at 3
months are shown in ▶ Fig. 15.3 and ▶ Fig. 15.4.
Fig. 15.1 Preoperative photograph showing neck skin
laxity.
Fig. 15.3 Postoperative photograph about 3 months
after surgery.
15.9 Expert Commentary by Dr. Slavin
15.9 Expert Commentary by
Dr. Slavin
Preoperative discussion with the patient is key to
ensuring good results. Showing the patient their
particular anatomy is vital prior to proceeding
with surgery. The submandibular glands and their
relation to the jowl are one of the key anatomical
Fig. 15.2 Left-sided neck seroma that developed about
8 days postoperatively. This was aspirated and was
about 5 mL of straw-colored fluid.
Fig. 15.4 Postoperative photograph showing the left
neck further after aspiration.
179
 Neck Rejuvenation: Complications
areas I discuss with my patients preoperatively. It
is also important to take note of the patient’s ear-
lobe preoperatively and discuss this with them in
terms of whether it is hanging or attached. Addi-
tionally, a neck with wrinkling around the thyroid
area is a warning sign, as they often get recurrent
puckering in this region, despite adequate treat-
ment during the procedure.
15.10 Expert Commentary by
Dr. Lin
I commend my coeditors on this important chapter.
Personally, I counsel patients on the differences
between medical/surgical complications and “aes-
thetic” complications. Clearly, the medical/surgical
complication risk relates to conditions that may re-
quire additional procedures for scarring or wound
healing or others related to life-threatening condi-
tions such as an expanding neck hematoma. Also,
“aesthetic” complications may also translate to
additional procedures, and these may relate to re-
current jowling, neckbands, and skin contour asym-
metries. It is imperative that the patient is informed
of these risks preoperatively on all aspects of neck
lifting. As one progresses in practice, it is key that
one constantly critically evaluates one’s results to
continue improving. Earlier in practice, maintaining
vigilance for prevention of medical/surgical compli-
cations then includes developing experience opti-
mizing what one can offer the individual patient in
order to maximize a lasting aesthetic result over
many procedures.
References
[1] Rohrich RJ, Sinno S, Vaca EE. Getting better results in facelift-
ing. Plast Reconstr Surg Glob Open. 2019; 7(6):e2270
[2] Baker DC, Stefani WA, Chiu ES. Reducing the incidence of
hematoma requiring surgical evacuation following male rhy-
tidectomy: a 30-year review of 985 cases. Plast Reconstr
Surg. 2005; 116(7):1973–1985, discussion 1986–1987
180
[3] Stuzin JM. MOC-PSSM CME article: face lifting. Plast Reconstr
Surg. 2008; 121(1) Suppl:1–19
[4] Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks
of herbal, homeopathic, and dietary supplements: a hidden
nightmare for plastic surgeons? Aesthet Surg J. 2012; 32(3):
332–346
[5] Chattha A, Brown E, Slavin S, Lin S. Oral Contraceptive ma-
nagement in aesthetic surgery: a survey of current practice
trends. Aesthet Surg J. 2018; 38(3):NP56–NP60
[6] Barton FE, Jr. Aesthetic surgery of the face and neck. Aesthet
Surg J. 2009; 29(6):449–463, quiz 464–466
[7] Rohrich RJ, Cho MJ. The role of tranexamic acid in plastic sur-
gery: review and technical considerations. Plast Reconstr
Surg. 2018; 141(2):507–515
[8] Kochuba AL, Coombs DM, Kwiecien GJ, Sinclair NR, Zins JE.
Prospective study assessing the effect of local infiltration of
tranexamic acid on facelift bleeding. Aesthet Surg J. 2021; 41
(4):391–397
[9] Laikhter E, Comer CD, Shiah E, Manstein SM, Bain PA, Lin SJ. A
systematic review and meta-analysis evaluating the impact
of tranexamic acid administration in aesthetic plastic sur-
gery. Aesthet Surg J. 2022; 42(5):548–558
[10] Butz DR, Geldner PD. The use of tranexamic acid in rhytidec-
tomy patients. Plast Reconstr Surg Glob Open. 2016; 4(5):
e716
[11] Couto RA, Charafeddine A, Sinclair NR, Nayak LM, Zins JE.
Local infiltration of tranexamic acid with local anesthetic re-
duces intraoperative facelift bleeding: a preliminary report.
Aesthet Surg J. 2020; 40(6):587–593
[12] Cohen JC, Glasgold RA, Alloju LM, Glasgold MJ. Effects of
intravenous tranexamic acid during rhytidectomy: a random-
ized, controlled, double-blind pilot study. Aesthet Surg J. 2021;
41(2):155–160
[13] Barton FE Jr. The Aging Face: Rhytidectomy and Adjunctive
Procedures. Selected Readings in Plastic Surgery. Vol. 6.
Dallas, TX: Selected Readings in Plastic Surgery, Inc.; 2001
[14] Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking
on skin-flap survival in the face lift patient. Plast Reconstr
Surg. 1984; 73(6):911–915
[15] Jacono AA, Alemi AS, Russell JL. A meta-analysis of complica-
tion rates among different SMAS facelift techniques. Aesthet
Surg J. 2019; 39(9):927–942
[16] Warren RJ, Aston SJ, Mendelson BC. Face lift. Plast Reconstr
Surg. 2011; 128(6):747e–764e
[17] Hoefflin SM. The youthful face: tight is not right, reposition-
ing is right. Plast Reconstr Surg. 1998; 101(5):1417
[18] Barton FE Jr. Facial Rejuvenation. Boca Raton, FL: Quality
Medical Publishing/CRC Press; 2008
Index
Note: Page numbers set bold or italic indicate headings or figures, respectively.
A – cervical triangles 1
Ablative fractional CO2 laser
148
Absorbable polydioxanone,
facial and neck rejuvenation
with 19
AccuTite 115, 116
Adipose tissue graft 136
Adipose-derived stem cells
(ADSCs) 135, 137
Adiposity 13, 116
ADSCs, see Adipose-derived
stem cells (ADSCs)
Aging neck
– criteria for 12
– management of
–– ancillary procedures and
nonsurgical treatments 26
–– case examples 27
–– complications 26
–– operative procedure 24
–– patient analysis 23
–– patient selection and
preoperative planning 24
–– postoperative care 25
–– surgical technique 24
– management of 23
– treating soft-tissue
components in 23
Aging neck, subplatysmal
techniques for treatment of
– facial analysis and applied
anatomy 105
– patient evaluation and
surgical goals 107
– surgical techniques
–– fat layer 107
–– platysma muscle and
subplatysmal structures
107
–– skin 107
–– submandibular glands 112
– surgical techniques 107
Aging neck, subplatysmal
techniques for treatment of
105
Allis clamp 18
American Society for Aesthetic
Plastic Surgery 23
Anatomical structures in neck
and lower face 5
Anatomy of neck
– anterior digastric and
mylohyoid muscles 7
– critical structures
surrounding neck muscles
–– external jugular vein 4
–– superficial veins 4
– critical structures
surrounding neck muscles 4
– digastric muscles 58
– facial nerve and lower lip,
mandibular and cervical
nerve branches 8
– facial nerve and lower lip 8
– fasciae of the neck
–– carotid sheath 2
–– deep 2
–– infrahyoid muscle fascia 2
–– prevertebral fascia 2
–– superficial 1
–– visceral fascia 2
– fasciae of the neck 1
– fat compartments 57
– great auricular nerve 59
– platysma and lower lip 3
– platysma muscle 58
– retaining ligaments and
filaments 58
– retaining ligaments of the
face and neck 6
– sensory distribution in the
neck
–– great auricular nerve 4
–– lesser occipital nerve 5
–– spinal accessory nerve 6
– sensory distribution in the
neck 4
– submandibular glands 58
– subplatysmal fat 7
Anatomy of neck 1, 57
Anderson Bear Claw retractor
76
Anterior digastric and
mylohyoid muscles 7
Anterior jugular veins 4
Antibiotic ointment 25
Apyx Medical 134
Arrhenius relationship 128
Aspirin 177
ATX-101 155
B Cryolipolysis 15, 158, 161
Bipolar radiofrequency
subcutaneous lipolysis 116
Bipolar radiofrequency
tightening 115
Bipolar RF 128 Deep plane face and neck lift
Blood pressure (BP) 26 73
Botulinum toxin 14 Deep plane neck lift concepts
Botulinum toxin A 147 and technique
BP, see Blood pressure (BP) – bad results/common pitfalls,
avoiding 81
– case examples 82
C – contraindications 72
– indications 72
Cable sutures 89, 91, 94
– patient considerations 71
Calcium hydroxylapatite 147
– technique
Caprini score 59
–– deep plane face and neck
Carotid sheath 2
lift 73
Cervical skin flap 91
–– internal neck lift 81
Cervical triangles 1
– technique 73
Chemical peels 146, 154
– technique to be used 72
Chin 13
Deep plane neck lift concepts
Clinician-Reported Submental
and technique 71
Fat Rating Scale (CR-
Deep plane technique 73
SMFRS) 155
Deep vein thrombosis (DVT)
CM angle, see Cervicomental
26, 59
(CM) angle
Demographic of neck lift/
2-cm rule 172
rejuvenation procedures
Cobra neck deformity 174
11
Complications, in neck
Deoxycholic acid 16, 155,
rejuvenation
155, 156, 158, 161
– case example 178
Depressor anguli oris 3–4
– dystonia 178
Depressor labii inferioris 3
– hematoma 177
Dermal fillers 150
– infection 178
Dermal microneedling 116
– nerve injury 178
Dermarolling 154
– recurrent platysmal bands
Digastric muscle excision
178
18
– scars 178
Digastric muscles, anterior
– skin necrosis 178
bellies of 7
Complications, in neck
Digastric muscles 13, 58, 109
rejuvenation 177
Dimethyl sulfoxide (DMSO)
CONTOUR study 155
26
Corset platysmaplasty 19, 74
Dissection 36
Cosmeceuticals 146
DMSO, see Dimethyl sulfoxide
CR-SMFRS, see Clinician-
(DMSO)
Reported Submental Fat
Dug out deformity 174
Rating Scale (CR-SMFRS)
DVT, see Deep vein
Crevasse technique 79
thrombosis (DVT)
Critical structures surrounding
Dynamic Platysmal Band
neck muscles
Photonumeric Assessment
– external jugular vein 4
Scale 149
– superficial veins 4
Dyschromia
Critical structures surrounding
– chemical peels 146
neck muscles 4
– cosmeceuticals 146
– lasers and energy-based
devices 147
D Dyschromia 146
Dystonia 178
Deep fasciae 2
181
 Index
E
Ear deformity 174
Epinephrine 24, 116
Evaluation of neck
– adiposity 13
– chin 13
– digastric muscle 13
– platysma 13
– skin 13
– submandibular gland 13
Evaluation of neck 12
External jugular vein 4
F Lesser occipital nerve 5
Facelift 122, 168–169, 170
Facelift flaps 56
FaceTite 115–116, 116, 118,
128
Facial analysis and applied
anatomy 105
Facial nerve and lower lip,
mandibular and cervical
nerve branches 8
Facial nerve and lower lip 8
Facial rejuvenation,
radiofrequency for
– case examples 128
– common pitfalls 128
– patient considerations 127
– postoperative care 128
– technique 127
Facial rejuvenation,
radiofrequency for 127
Facial shrug 4
Facial/neck analysis 36
Fasciae of neck
– carotid sheath 2
– deep 2
– infrahyoid muscle fascia 2
– prevertebral fascia 2
– superficial 1
– visceral fascia 2
Fasciae of neck 1
Fasil Face and Neck Laxity
Grading Scale 149, 151
Fat compartments 57
Fat grafting
– patients and methods 134
– problem-based examples/
cases 137
– surgical technique and fat
processing and grafting
134
Fat grafting 133
Fat layer 107
182
FDA, see Food and Drug
Administration (FDA)
Fibroplasia 12
Fillers 147
Fitzpatrick skin types 12, 15
Five-point Allergan Transverse
Neck Lines Scale 147
Food and Drug Administration
(FDA) 151
Fractional RF 128
Fraxel Re:Store DUAL 147
Five-point Dynamic Platysmal
Band Photonumeric
Assessment Scale 149
G Infection 178
Great auricular nerve 4, 59,
178
H IPL, see Intense pulsed light
Helium plasma 134
Hematomas 177, 177
History of neck rejuvenation
– aging neck, criteria for 12
– demographic of neck lift/
rejuvenation procedures 11
– evaluation of neck
–– adiposity 13
–– chin 13
–– digastric muscle 13
–– platysma 13
–– skin 13
–– submandibular gland 13
– evaluation of neck 12
– nonsurgical procedures
–– botulinum toxin 14
–– cryolipolysis 15
–– deoxycholic acid 16
–– lasers/radiofrequency
devices 15
–– microfocused ultrasound
system 15
–– stromal vascular gel 16
– nonsurgical procedures 14
– surgical procedures
–– liposuction 16
–– submental anterior neck
lift 17
– surgical procedures 16, 17
– youthful aesthetically
pleasing neck, criterion for
11
Horizontal/transverse
necklines
– fillers 147
– lasers and energy-based
devices 148
– neuromodulators 147
Horizontal/transverse
necklines 147
Hyo neck lift 19
Hyoid bone 90, 91
Hyoid ligament 7
Hypertension 177
Hypertonic bands 107, 112
Hypotonic bands 107
I triborate (LBO) laser
Incision 36
Incisivus labii inferioris 3
Inferomedial platysma 37
Infrahyoid muscle fascia 2
Intense pulsed light (IPL) 147
Internal neck lift 81
(IPL)
Isotonic saline 135
K anatomy of 55
Knize’s classification system
62
KTP, see Potassium titanyl
phosphate (KTP)
L M
LAL, see Laser-assisted
liposuction (LAL)
Laser and energy-based
devices 158
Laser-assisted liposuction
(LAL) 16
Lasers and energy-based
devices 147–148, 151
Lasers/radiofrequency
devices 15
Lateral and medial
sternomastoid-cutaneous
retaining ligaments 7
Lateral cervical region,
treatment of 48
Lateral neck 36
Lateral platysmal window 37
Lateral skin-platysma
displacement (LSD)
technique
– avoidance of inadequate
results in difficult necks 97
– contraindications 89
– indications 89
– limitations 99
– patient consideration 89
– rationale of 90
– submandibular gland (SMG)
resection 96
– technique 90
– technique to be used 89
– vectors of traction 91
Lateral skin-platysma
displacement (LSD)
technique 89
LBO laser, see Lithium
Le Louarn, Claude 19
Lidocaine 24
Lipectomy 64
Lipodystrophy 64
Liposuction, incision 44
Liposuction 16, 44, 44, 45,
65–66, 115, 129, 134
Lithium triborate (LBO) laser
147
Loose neck skin 115
Lower face and neck, surgical
LSD technique, see Lateral
skin-platysma displacement
(LSD) technique
Luer-Lok syringe 134
Mandibular and cervical nerve
branches 8
Mandibular ligaments 6
Massive weight loss (MWL)
115
Mastoid fascia, fixation to 37
Mastoid-cutaneous ligaments
7
McKinney’s point 59
Medial platysma-cutaneous
filaments 7
Medial sternomastoid-
cutaneous filaments 7
Mentalis 3
Mercedes cannula 24
Methicillin-resistant
Staphylococcus aureus
(MRSA) 26
MFU-V, see Microfocused
ultrasound with
visualization (MFU-V)
Microbotox technique 149
Microfocused ultrasound 148,
152

Microfocused ultrasound Neck liposuction 24, 61
system 15 Neck Rejuvenation: Evaluation
Microfocused ultrasound with and Management 11
visualization (MFU-V) 154 Neck skin laxity 63, 63
Microfocused ultrasound with NeckTite system 15
visualization (MFU-V) 148, Nefertiti lift 149
152–153 Nerve injury 178
Microneedling 154 Neuromodulators 147, 149
Middle fascia 2 Nitroglycerin 26
Midline ridge deformity 173 Nonablative fractional
MonoNylon (MN) 2–0 sutures photothermolysis 147
47–49 Noninvasive neck rejuvenation
MonoNylon (MN) 3–0 sutures techniques
46, 46–48 – aging neck 145
Monopolar capacitive-coupled – contraindications 146
radiofrequency (MRF) 154 – dyschromia
Monopolar capacitive-coupled –– chemical peels 146
radiofrequency (MRF) 148, –– cosmeceuticals 146
151, 153 –– lasers and energy-based
Monopolar radiofrequency devices 147
151, 161 – dyschromia 146
Morpheus8 116 – horizontal/transverse
MRF, see Monopolar necklines
capacitive-coupled –– fillers 147
radiofrequency (MRF) –– lasers and energy-based
MRSA, see Methicillin- devices 148
resistant Staphylococcus –– neuromodulators 147
aureus (MRSA) – horizontal/transverse
MWL, see Massive weight loss necklines 147
(MWL) – indications 146
Mycobacteria 178 – patient considerations 146
Mylohyoid muscles 8 – platysmal banding,
neuromodulators 149
– platysmal banding 149
N – skin laxity
–– chemical peels 154
Neck lift
–– dermal fillers 150
– patients and methods 134
–– dermarolling 154
– problem-based examples/
–– lasers and energy-based
cases 137
devices 151
– surgical technique and fat
–– microneedling 154
processing and grafting
–– platelet-rich plasma 154
134
– skin laxity 149
Neck lift 24, 26, 116, 133
– submental fat and fullness
Neck lift after massive weight
–– cryolipolysis 158, 161
loss
–– deoxycholic acid 155, 156,
– considerations 115
161
– indications 115
–– laser and energy-based
– isolated neck lift
devices 158
–– AccuTite 116
– submental fat and fullness
–– FaceTite 116
154
–– Morpheus8 116
Noninvasive neck rejuvenation
–– Submental Z-plasty 120,
techniques 145, 145, 162
121, 121, 123–124
Nonsteroidal anti-
– isolated neck lift 116
inflammatory drugs
– role of facelift for neck
(NSAIDs) 59, 177
excess 122
Nonsurgical procedures
Neck lift after massive weight
– botulinum toxin 14
loss 115
– cryolipolysis 15
– deoxycholic acid 16
– lasers/radiofrequency
devices 15
– microfocused ultrasound
system 15
– stromal vascular gel 16
Nonsurgical procedures 14
NSAIDs, see Nonsteroidal anti-
inflammatory drugs
(NSAIDs)
O Platysmal muscle sling 19
Occipital hairline step-off
deformities 172
Orbicularis oris 3
Osteofasciocutaneous
mastoid-cutaneous
ligament 7
P Reported Submental Fat
PAH, see Paroxysmal adipose
hypertrophy (PAH)
Paroxysmal adipose
hypertrophy (PAH) 15
Pars labialis platysma 3
Pars mandibularis platysma 3
Pars marginalis 3
Pars modiolaris platysma 3
Pars peripheralis 3
Patient-Reported Submental
Fat Rating Scale (PR-
SMFRS) 155
PE, see Pulmonary embolism
(PE)
Pixie ears 170, 174
Platelet-rich plasma 154
Platysma 13, 90, 92
Platysma and preplatysmal fat,
anatomical relationship
between 13
Platysma bands 107
Platysma flap 99, 101
Platysma flap cervical
rhytidoplasty 19
Platysma muscles 3, 45–46,
47, 57, 58, 107
Platysma window for neck
contouring
– candidate 35
– case example
–– approach 39
–– goals 39
– case example 39
– central neck 35
Index
– common pitfalls, avoiding
37, 38
– contraindications 36
– platysmal bands 35
– technique 36
– technique to be used 36
Platysma window for neck
contouring 35
Platysma-auricular ligament
7, 58
Platysmal banding,
neuromodulators 149
Platysmal banding 149, 173
Platysmal plication 36
Platysmal surface, palpation
of 36
Platysmaplasty 64
Poly-L-lactic acid 150
Potassium titanyl phosphate
(KTP) 147
PR-SMFRS, see Patient-
Rating Scale (PR-SMFRS)
PrecisionTx 15
Prejowl notch 6
Prevertebral fascia 2
Prominent submandibular
glands 110, 115
Pseudomonas aeruginosa 178
Pulmonary embolism (PE) 26
R
Radiofrequency for facial
rejuvenation
– case examples 128
– common pitfalls 128
– patient considerations 127
– postoperative care 128
– technique 127
Radiofrequency for facial
rejuvenation 127
Radiofrequency microneedling
(RFMN) devices 153
Radiofrequency-assisted
liposuction (RFAL) 17, 129–
130
Recurrent platysmal bands
178
REFINE clinical trials 155
REFINE-1 and REFINE-2 trials
155, 158
Renuvion device 139
Renuvion system 134
Reoperative neck lift,
technical considerations in
171
183
 Index
Reoperative neck lift 169
Retaining ligaments
– and filaments 58
– of face and neck 6
Retaining ligaments 56
Revisional and secondary neck
lifts
– expert commentary 174
– patient considerations
–– factors influencing
longevity and outcomes
170
–– identification of deformity
170
– patient considerations 170
– problem-based technical
considerations
–– ear deformity 174
–– midline ridge deformity
173
–– platysmal bands 173
–– scar placement 171
–– scarred tissue planes 173
–– subauricular band
deformity 174
–– submental hollowing 174
–– vertical band deformity
174
– problem-based technical
considerations 171
Revisional and secondary neck
lifts 167
Revisional neck lifts 167
RFAL, see Radiofrequency-
assisted liposuction (RFAL)
RFMN devices, see
Radiofrequency
microneedling (RFMN)
devices
Rhytidectomy 43, 172
Rhytidectomy technique 170
Right and left anterior jugular
veins 4
Risorius 3
S Subcutaneous fat 170
SAL, see Suction-assisted
liposuction (SAL)
Scarred tissue planes 173
Scars 178
SCM muscle, see
Sternocleidomastoid (SCM)
muscle
Secondary neck lifts 168
SEL, see Stromal enriched
lipograft (SEL)
184
Sensory distribution in the
neck
– great auricular nerve 4
– lesser occipital nerve 5
– spinal accessory nerve 6
Sensory distribution in the
neck 4
Seromas 26
Skin 13, 107
Skin crease retaining
filaments 7
Skin laxity
– chemical peels 154
– dermal fillers 150
– dermarolling 154
– lasers and energy-based
devices 151
– microneedling 154
– platelet-rich plasma 154
Skin laxity 149
Skin necrosis 178
Skin-platysma flap 93
SMAS, see Superficial
musculoaponeurotic system
(SMAS)
SMFRS, see Submental Fat
Rating Scales (SMFRS)
SMG, see Submandibular
gland (SMG)
Sodium bicarbonate 116
Soft-tissue contraction 128,
134
Spinal accessory nerve 6
Sternocleidomastoid (SCM)
muscle 23, 76, 116
Steven’s Kaye scissors 76–77
Stromal enriched lipograft
(SEL) 133, 135, 137
Stromal vascular fraction
(SVF) 16, 133, 135
Sub-superficial
musculoaponeurotic system
(sub-SMAS) techniques
178
Subauricular band deformity
174
Submandibular gland (SMG)
13, 58, 96, 112, 155
Submental access 74, 81
Submental anterior neck lift
17
Submental cryolipolysis 158–
159
Submental fat 13, 14, 15
Submental fat and fullness
– cryolipolysis 158, 161
– deoxycholic acid 155, 156,
161
– laser and energy-based
devices 158
Submental fat and fullness
154
Submental Fat Rating Scales
(SMFRS) 158
Submental hollowing 174
Submental Z-Plasty 115, 120,
121, 121, 123–124
Submentalplasty 24
Subplatysmal fat 7, 18, 99,
108–109
Subplatysmal techniques for
treatment of aging neck
– facial analysis and applied
anatomy 105
– patient evaluation and
surgical goals 107
– surgical techniques
–– fat layer 107
–– platysma muscle and
subplatysmal structures
107
–– skin 107
–– submandibular glands
112
– surgical techniques 107
Subplatysmal techniques for
treatment of aging neck
105
Suction-assisted liposuction
(SAL) 16
Superficial fascia 1
Superficial musculoaponeurotic
system (SMAS) 1, 18, 25, 36,
43, 56, 81, 110, 125, 133, 168,
170
Superficial veins 4
Surgical approach to neck
rejuvenation
– anatomy 56
– anatomy of neck
–– digastric muscles 58
–– fat compartments 57
–– great auricular nerve 59
–– platysma muscle 58
–– retaining ligaments and
filaments 58
–– submandibular glands 58
– anatomy of neck 57
– classification system 61
– clinical assessment 61
– complications 67
– evaluation of neck lift
patient 59
– lower face and neck,
surgical anatomy of 55
– operative technique 65
– patient selection 61
– postoperative care 67
– retaining ligaments 56
Surgical approach to neck
rejuvenation 55
Surgical procedures
– liposuction 16
– submental anterior neck
lift 17
Surgical procedures 16, 17
Surginet 25
Suspension sutures 19
SVF, see Stromal vascular
fraction (SVF)
T
ThermiTight system 15
Tranexamic acid (TXA) 177
Transverse Neck Lines Scale
scores 148
Triple suture for neck
contouring
– case examples 49
– indications 43
– technique
–– infiltration 44
–– lateral cervical region,
treatment of 48
–– liposuction 44, 44, 45
–– marking 44
–– position 44
–– triple-suture technique 46
– technique 43
Triple suture for neck
contouring 43
TXA, see Tranexamic acid
(TXA)
U
UAL, see Ultrasonic-assisted
liposuction (UAL)
Ulthera microfocused
ultrasound system 15
Ultra-violet radiation (UVR)
exposure 145
Ultrasonic-assisted liposuction
(UAL) 16
Upper lateral sternomastoid-
cutaneous ligaments 7
UVR exposure, see Ultra-violet
radiation (UVR) exposure
 Index

Visceral fascia 2 Youthful neck, characteristic

V X
VitaCyte LLC 135 of 12
Vascular endothelial growth Xylocaine 116
factor (VEGF) 127
Vector planning 20 W Z
VEGF, see Vascular endothelial Y
Weekend lift 81, 82 Z-plasty 115
growth factor (VEGF) Youthful aesthetically pleasing
Vertical band deformity 174 neck, criterion for 11
Vicryl 4–0 113

185
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