Introduction

Loss of neck contour, especially at the cervicomental and cervicomandibular angles, is a common sign of aging. Procedures to rejuvenate the face and neck are among the most commonly performed cosmetic surgical procedures in the United States. The delineation of the cervicomandibular angle is an important factor in facial harmony and an overall youthful appearance.^1,2 Rejuvenation of the aging neck gives a more pleasing appearance to the soft tissues in that area, and can cause the face to appear more youthful as well. The goal is to provide an even, smooth platysmal layer that closely invests the thyroid cartilage, hyoid, and floor of the mouth. Procedures to lift and redefine the jaw line and submental region are often used as adjuncts to rhytidectomy.

Indications

Indications include young patients with a prematurely aged neck, or patients with the neck as a prominent aspect of facial aging. Other indications include those patients undergoing other aesthetic facial surgical procedures which otherwise accentuate the neck laxity.

Submandibular fullness results from increased glandular ptosis as muscular and fascial support of the gland weakens or glandular hypertrophy. SMAS plication in rhytidectomy or platysmal suspension may indirectly address this fullness because these techniques reestablish fascial support, but they have not proven helpful long term. However, residual submandibular gland ptosis often persists after platysmal, cervical fat, and skin laxity surgical objectives have been met, and tightening of the overlying tissues may accentuate the deformity.

Patients with lesser degrees of submandibular gland fullness may benefit from suspension, whereas those with very significant submandibular gland ptosis or hypertrophy may be candidates for partial resection.⁶ The idea of aesthetics as an indication for submandibular gland resection, which is a technically challenging operation, is controversial.^2,7 The primary criticism for resecting the gland is the risk of nerve injury. Prior to their widespread acceptance, SMAS-rhytidectomy techniques were similarly criticized for their risk to the facial nerve. Through multiple studies documenting the anatomy of the facial nerve and refining the surgical approach to it, SMAS procedures were accepted. Similar studies of the submandibular gland have been undertaken, but controversies remain.⁴ All of the nerves in the area of the gland, with the exception of the autonomic plexus, are found exterior to its capsule.

Preoperative History and Considerations

After understanding the patient’s goals and expectations, the patient’s face is assessed from the front and profile views with the chin and face held in repose and tilting down (reading position, as coined by Connell). The skin, underlying layers of fat, and the submandibular glands are palpated. The patient is asked to tighten the platysma by trying to depress the corners of the mouth and the platysmal bands are observed. If the neck bands become tighter by this type of animation, they are dynamic bands and would respond favorably to surgery or injection of botulinum toxin. If the bands do not become tighter, the skin folds would require skin tightening. The anterior belly of the digastric muscles are palpated to detect hypertrophy.

Operative Approach

Intravenous sedation and injection of lidocaine with 1 : 200 000 epinephrine is sufficient for most patients, even those who undergo partial or complete removal of the submaxillary glands. The standard protocol includes a thorough betadine prep of the neck and oral cavity followed by intraoral administration of local anesthesia to block the area.

Neck exposure is gained through an inconspicuous 3.5 cm submental incision in the shadow posterior to the submental skin crease. This allows access to the platysmal plane. Laterally the neck is