Introduction

“Look Doc, I don’t want a facelift, just fix this,” is the expression heard probably three or four times a year by surgeons doing facial rejuvenation surgery. The patient says this as he grasps the tissue underneath his chin with a forefinger and a thumb. In most instances the patient is the husband or a close friend of a woman who has had the complete facial rejuvenation procedures, including face, neck, brow and eyelids, probably accompanied by fat injections, as well as surface treatment of the skin. He knows that he does not want that extensive amount of surgery, but he does want resolution of the problem under his chin which he feels is obtrusive.

History

In the evolutionary process of facial rejuvenation surgery, we have come a tremendous distance in the last several decades. Early on it was a matter of an incision with undermining and stretching of the skin so as to minimize the redundancy that was a result of gravity and loss of volume. As the twentieth century ended and the newer concepts came upon us, we became more conscious of the multifaceted nature of facial aging and the role loss of volume played in the aging process. We became aware of skin surface irregularities and skeletal defects both unimproved with skin stretching. These revelations resulted in specific treatments for each situation, with each case being a separate problem. This unique approach to every case could be summarized by the comment that, “No key fits every lock.”

The male neck was a specific problem that was unsuccessfully addressed until 1970 when the treatment of the male “Turkey gobbler neck” was introduced at the ASAPS meeting in Los Angeles. It was at that time the operation that will be described in this chapter was presented to the world.

Physical evaluation

As we learned in the second year of medical school, the history and physical is an extremely significant aspect in the treatment of any and all problems that prompt a person to seek medical care. The chief complaint was the statement made by the patient having to do with why he or she has sought consultation. The history of present illness is a discussion of the problem itself along with its origin and its development, as well as the various aspects of its effect on the patient’s wellbeing. The past history has to do with previous medical problems including whatever surgery or less invasive procedures may have been introduced in the treatment of the specific chief complaint. A family history and review of systems are essential in that they may play a role in better understanding of the chief complaint, or they may play a role as subsequent examinations evolve.

The physical examination itself, which is a general examination in most instances, will focus more specifically upon the problem outlined in the present illness. It is this particular situation that the examination of the neck reveals the anatomy about which the patient is concerned. This involves redundant skin, laxity of the neck muscles and the presence or the lack of presence of subcutaneous and or subplatysmal fat. All these structures are those which will be addressed in the subsequent description of the operation. These are the structures prompting the patient’s chief complaint, “I don’t want a facelift, Doc. Just fix this.”

Anatomy

The preoperative markings

With the patient in the upright position, the redundant skin is grasped with the index finger and thumb. These points are established and two other points are made, one just beneath the angle of the chin and the other in the midline of the neck at the cephalic border thyroid cartilage. These dots are connected with lines to create an ellipse. It is important that the width of this ellipse be slightly less than the skin that was pinched with the index finger and thumb, because the last step of the operation involves the creation of a large Z and it is imperative that this not be so tight as to preclude the rotation of the Z flaps (Fig. 21.1). It is also important that this marking process be carried out with the patient in the upright position, because when the patient assumes the recumbent position these tissues rotate in a cephalad fashion, which would result in a scar below the thyroid cartilage if the marks were made with the patient in this recumbent position. It is the effort of the surgeon to keep the entire scar between the submental crease and the upper level of the thyroid cartilage so as not to be obtrusive.

Fig. 21.1 Preoperative markings. Blue: Midline and the line of the maximal angle above the thyroid cartilage. Green: Amount of pinched skin. Red: Amount of skin to be excised. Black: Z-plasty flaps.

Technical steps

The patient is taken to the operating room and with either general anesthesia or with sedation and local anesthesia, the elliptical excision of the previously marked skin is carried out (Fig. 21.2). This ellipse includes skin and subcutaneous fat. After the ellipse is excised the skin and subcutaneous tissue is undermined laterally to a distance approximating the angle of the mandible. Redundant subcutaneous fat which is preoperatively determined to be obtrusive is excised. Likewise, the subplatysmal fat is evaluated and if it is determined that this fat is obtrusive it is likewise excised, keeping in mind the fact that significant anatomical structures are in this area and dissection carries with it some element of risk. This is determined by the surgeon as to the necessity for excision of subplatysmal fat (Fig. 21.3).

Fig. 21.2 Excision of the skin and subcutaneous tissue.

Fig. 21.3 Excision of the excess of subplatysmal fat.

After the skin has been undermined and the redundant fat has been removed, the platysmal flaps are evaluated. The subsequent project is to get the platysmal flaps closed in a tight fashion so as to facilitate the creation of the angle of the neck above the thyroid cartilage. This closure can be carried out in one of three ways. The edges can be sutured side to side or, in the case of a thin platysma with significant redundancy, they can be closed in a vest-over-pants type of procedure. In most instances, however, the preferred method of getting platysmal tightening is with a large Z-plasty in the muscle itself (Figs 21.4 and 21.5). This is designed so as to create the maximal angle just above the thyroid cartilage.

Fig. 21.4 Identification of medial platysmal borders.

Fig. 21.5 Platysmaplasty. Z-Plasty at the level of maximal angle and suture of the medial borders.

After the platysma has been closed, the elliptical excision is closed in a temporary fashion so as to allow us to determine the location of the Z-plasty to be performed in the skin. The Z-plasty is designed to be the mirror image of the Z-plasty in the platysmal edges (Fig. 21.6). It is imperative that the cross mark of the Z be at the maximal angle that is to be desired, above the thyroid cartilage. Furthermore, the Z is to be made as large as possible so as to interrupt the scar’s extending from the submental angle to the thyroid cartilage. After designing these Zs, and after their incision, they are rotated and sutured with a minimal number of subcutaneous sutures followed by skin closure of the surgeon’s preference (Fig. 21.7).

Fig. 21.6 Z-plasty of the skin at the level of maximal angle.

Fig. 21.7 Immediate postoperative result.

Postoperative care

No drains are necessary following this operation, and only a minimally occlusive dressing is preferred. This dressing can be removed after the first postoperative day and the operative site can be bathed in a normal fashion.

This is an operation designed to diminish the transverse redundancy of the skin through a vertical excision of skin, with a closure that is designed through Z-plasty to abrogate the scar across the concave surface of the angle of the neck above the thyroid cartilage. This prevents the development of a hypertrophic scar and contracture across this concave surface. It is the authors’ experience that an occasional hypertrophic scar can be present in one or more of the Z-plasty flaps and over many years’ experience very few of these have necessitated excision, but when they do occur this can be carried out under local anesthesia as an office procedure.

Follow-up care is minimal. The scars go through the normal process of resolution with approximately six months being required before the scar softens and 12 months before maximal resolution of the scar has occurred. The authors have seen no hematomas, nor have they seen nerve damage in the use of this technique.

Fig. 21.8 Preoperative and postoperative appearance.

Fig. 21.9 Preoperative and six months postoperative appearance.