Managing submandibular glands

Published on 22/05/2015 by admin

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Last modified 22/05/2015

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CHAPTER 22 Managing submandibular glands

Patrick K. Sullivan, Erik A. Hoy, Brandon Freeman

History

In search of the artistically pleasing neck through the addition of subplatysmal fat contouring and submandibular gland treatment

Early in the development of rejuvenation of the face and neck, the adjacent areas were approached separately. Increasingly, neck rejuvenation procedures are paired with facial rejuvenative procedures, to obtain results that are usually superior to either procedure alone. The following include innovations in neck rejuvenation techniques:

Physical evaluation

• Key features of the aged neck include platysmal banding, pre- and/or subplatysmal fat deposits, skin laxity, and submandibular gland ptosis.

• Indications include young patients with a prematurely aged neck, or older patients with the neck contour issues as a prominent aspect of facial aging.

• Signs of cervicofacial aging may initially manifest as faint vertical platysmal bands overlying the thyroid cartilage and hyoid.

• These progress to longer, more pronounced bands as more support is lost from the retaining ligaments and the platysma descends further.

• A cervical obliquity, which may be composed of pre- and subplatysmal fat deposits.

• Submental fullness may be addressed with conservative contouring of pre- and or subplatysmal fat, but one must be concerned that this does not unmask submandibular gland ptosis.

• Fullness laterally below the mandible, may be the result of the ptotic submandibular gland, and this may be addressed via gland resection or suspension.

• Patients undergoing other aesthetic facial surgical procedures may accentuate the appearance of untreated submandibular gland ptosis.

Technical steps

Over the last decade, our anesthesia treatment of choice has been intravenous sedation without intubation, paralytic drugs, or general anesthesia. This has proven particularly effective for pre- and subplatysmal fat contouring. However for submandibular gland suspension general anesthesia may be beneficial, at least the first time the procedure is being performed by the surgeon.

A thorough betadine prep of the oral cavity and intraoral administration of local anesthesia is routine. Exposure to the neck is via an inconspicuous 3.5 cm submental incision, in the shadow posterior to the submental skin crease. This provides access to the platysmal plane. Careful pre- and posterior auricular rhytidectomy incisions give access to the face and lateral aspects of the neck. The inferior border of the mandible is in clear view, and this approach provides an avenue for directly visualized lipectomy of the neck.

Ligaments in the neck, analogous to the retaining ligaments in the cheek, help suspend the soft-tissues. The mandibular ligaments affix the overlying skin to the inferior aspect of the mandible, and help to define the anterior aspect of the jowls in the aged face. The thin fascial support in the preauricular region is the platysma-auricular ligament, and attaches the posterosuperior platysma to the skin. Anteriorly, the skin is tethered to the superficial musculoaponeurotic system SMAS and platysma via the anterior platysma–cutaneous ligaments. These ligaments check the descent of the soft-tissues of the neck in aging, and are disrupted to allow for proper redraping of the skin during neck rejuvenation.

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.

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