SMAS suspension/platysmal plication

The anterior platysma is approached through a transverse submental incision (Fig. 22.1). The submental skin and a smooth, consistent layer of adjoining fat are then undermined inferiorly to the level of the cricoid. To correct the platysmal bands, the muscle is freed on the edges from the deeper subplatysmal fat and anterior bellies of the digastric muscles. The platysmal edges are grasped with forceps and brought together in the midline. The excess tissue is then resected as described below, and the edges brought together with interrupted and then a running suture from inferior to superior.

Fig. 22.1 Coronal view demonstrating key periglandular anatomic relationships and structures. Note the submandibular ptosis associated with the aging neck. Redrawn from Aesthetic Surgery Journal, Patrick K. Sullivan, M. Brandon Freeman and Scott Schmidt. Contouring the aging neck with submandibular gland suspension July–August 2006. With permission from Elsevier.

Release of the platysma is performed low in the neck. The muscle is then redraped, providing a deeper, more aesthetically pleasing cervicomental angle. If released or incised too caudally, the platysma can “window-shade” over the submandibular glands, or may be denervated and cause lower lip dysfunction.

Subplatysmal fat contouring

Subplatysmal fat may add significant cervicomental angle convexity. The degree of subplatysmal fat is typically an inherited feature, but is also a reflection of total body fat in certain patients. In a subset of patients, the midline subplatysmal fat is the most prominent visible feature of aging in the cervicofacial area. These patients may benefit from a subplatysmal fat contouring through conservative resection and platysmaplasty alone, requiring only a submental incision. We have found this particularly beneficial in some of our young patients. Although the submental incision provides good exposure medially, the additional aspects of the aging neck in most older patients require lateral approaches as well. Any suction lipectomy of the preplatysmal fat must be done conservatively as over-resection is very easy to do and extremely difficult to repair.

A short scar technique is frequently used if skin elasticity is good as we find the exposure frequently allows us all the access we need.

We usually wait to perform preplatysmal fat excision after the final muscle position is set, as we want to prevent the advancement of fat-excised areas above the mandibular border and onto the face. If this occurs, contour deformities may be apparent on the face.

Elevating the platysma in the vertical midline allows visualization of the deeper subplatysmal fat deposits. Interposed between the platysma and the anterior bellies of the digastric muscles, this fat is conservatively resected with cautery or scissors. Some surgeons feel open or closed liposuction techniques may be useful adjuncts to neck and facelift, but we use them very selectively. Residual fat globules that have already been excised may be removed under direct vision with a flat liposuction cannula with a large single hole, but we prefer to directly contour down the fat with scissors. Some authors recommend the resection of the anterior digastric muscle bellies if residual fullness exists, but we have not used this technique as we feel it may lead to an overdone appearance.

Submandibular gland suspension and resection

Weakened muscular and fascial support of the gland, and subsequent increased glandular ptosis are manifest as submandibular fullness. SMAS plication in rhytidectomy or platysmal suspension may indirectly address this fullness, but these techniques to re-establish fascial support have not proven effective over the long-term. In fact, submandibular gland ptosis often persists after platysmal, cervical fat, and skin laxity surgical objectives have been met. Counter-intuitively, in patients with submandibular gland ptosis, tightening of the overlying tissues may accentuate the deformity. These patients may be candidates for submandibular gland suspension or resection.

As before, the neck is approached through a submental incision. The dissection is continued beneath the platysma, where the submandibular gland has been marked out preoperatively. In this way, the surgeon can obtain direct visualization of the submandibular capsule. A 1.5 cm incision is made in the capsule along the anterior-inferior surface, parallel to the body of the mandible. Careful dissection around the gland releases any inferior or lateral capsular adhesions and results in mobilization of the gland within the capsule. A blunt snap is inserted until the inferior border of the mandible is encountered, and then is advanced along the lingual aspect of the mandibular body in a subperiosteal plane. This is continued until the oral mucosa tents over the tip of the snap. At this point, a 2–3 mm incision is carefully made with a #15 scalpel. The instrument tip is then delivered into the oral cavity and a 2-0 suture end is grasped and brought back out through the neck incision (Fig. 22.2).

Fig. 22.2 Suture delivery of the first pass through the lingual mucosa, mandibular subperiosteal tunnel, and submandibular capsule in a cephalad to caudal direction. Redrawn from Aesthetic Surgery Journal, Patrick K. Sullivan, M. Brandon Freeman and Scott Schmidt. Contouring the aging neck with submandibular gland suspension July–August 2006. With permission from Elsevier.

A second pass is then performed, also from within the glandular capsule, but lateral to the gland this time. The periosteal tunnel created for this suture is parallel to, but 3 cm anterior to, the initial pass. The opposite end of the free suture is grasped and pulled down into the neck (Fig. 22.3). After both ends of the suture have been retracted caudally, mild traction on the suture ensures adequate purchase of a sling of periosteum to provide support for the gland (Fig. 22.4). This is the zone of periosteal adhesion. The gland is elevated to the level of the posterior belly of the digastric muscle and the inferior border of the mandible with gentle digital pressure. The knot is then cinched, tied, and the gland’s elevated position secured (Fig. 22.5).

Fig. 22.3 Passage of the remaining intraoral free end of the suture caudally, creating a second pass subperiosteal tunnel at a position on the mandible 3 cm anterior to the first pass, establishing a suspension arc or zone of periosteal attachment. Redrawn from Aesthetic Surgery Journal, Patrick K. Sullivan, M. Brandon Freeman and Scott Schmidt. Contouring the aging neck with submandibular gland suspension July–August 2006. With permission from Elsevier.

Fig. 22.4 An oblique view demonstrating anterior and posterior tunnels on the lingual surface of the mandible. Redrawn from Aesthetic Surgery Journal, Patrick K. Sullivan, M. Brandon Freeman and Scott Schmidt. Contouring the aging neck with submandibular gland suspension July–August 2006. With permission from Elsevier.

Fig. 22.5 Elevation of the gland into a youthful position while keeping the suture taut. Redrawn from Aesthetic Surgery Journal, Patrick K. Sullivan, M. Brandon Freeman and Scott Schmidt. Contouring the aging neck with submandibular gland suspension July–August 2006. With permission from Elsevier

After obtaining a durable suspension, the incised glandular capsule is imbricated with permanent suture to bolster the suspension sling inferiorly. Hemostasis is verified and the intraoral incision closed with a chromic suture. The submental and rhytidectomy incisions are closed in layers, with the last being a fine running nylon suture. The incision is cleaned and dressed.

Fig. 22.6 Photographs of a 59-year-old male patient with a ptotic submandibular gland, who underwent submandibular gland suspension. A, Preoperative photograph, anterior view. B, Postoperative photograph, anterior view. C, Preoperative photograph, oblique view. D, Postoperative photograph, oblique view. E, Preoperative photograph, lateral view. F, Postoperative photograph, lateral view. Redrawn from Aesthetic Surgery Journal, Patrick K. Sullivan, M. Brandon Freeman and Scott Schmidt. Contouring the aging neck with submandibular gland suspension July–August 2006. With permission from Elsevier.

Fig. 22.7 Photographs of a 43-year-old female patient who underwent pre- and subplatysmal fat contouring without contouring of the submandibular gland. A, (Female AP preop): Preoperative photo, anterior view. B, (Female AP postop): Postoperative photo, anterior view. C, (Female oblique preop): Preoperative photo, oblique view. D, (Female oblique postop): Postoperative photo, oblique view. E, (Female lateral preop): Preoperative photo, lateral view. F, (Female lateral postop): Postoperative photo, lateral view.