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Treatment of Anterior Neck Aging without a Submental Approach: Lateral Skin-Platysma Displacement, a New and Proven Technique for Platysma Bands and Skin Laxity

Pelle-Ceravolo, Mario M.D.; Angelini, Matteo M.D.; Silvi, Erminia M.D.

Plastic and Reconstructive Surgery: February 2017 - Volume 139 - Issue 2 - p 308–321
doi: 10.1097/PRS.0000000000003030
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Background: A high rate of recurrence of anterior platysma bands and anterior skin laxity was reported at the 1-year follow-up of 150 patients who underwent complete neck undermining and full-width platysma transection for neck rejuvenation. The authors propose a new technique—lateral skin-platysma displacement—to treat these two aesthetic problems using only a lateral approach to avoid “opening” the anterior neck. The authors’ objective was to compare outcomes following full-width platysma transection technique and lateral skin-platysma displacement technique in terms of patient satisfaction, complications, and long-term effectiveness in the treatment of bands and anterior skin laxity.

Methods: A prospective study was carried out on 100 patients. All patients were operated on by the senior surgeon (M.P.C.). Patient questionnaires were used to assess their levels of satisfaction.

Results: Patient satisfaction was extremely high following both techniques. Successful correction of bands at 1 year was observed in 83.5 percent of the lateral skin-platysma displacement patients and 56 percent of the full platysma section patients. Regarding recurrent skin laxity, 68 percent of those who underwent lateral skin-platysma displacement did not show any obvious recurrence of excess skin at 1 year compared with 52 percent of the full platysma section group. Prolonged edema was the main complication and was considerably more frequent in the patients undergoing complete neck undermining.

Conclusions: The 1-year patient satisfaction ratings were higher for those treated with the lateral skin-platysma displacement technique. The lateral skin-platysma displacement technique has proved to have a much shorter recovery and better outcomes in the correction of platysma bands and of the anterior neck skin laxity.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Supplemental Digital Content is available in the text.

Rome, Italy

From the University of Padua; and private practice.

Received for publication June 1, 2016; accepted July 26, 2016.

Disclosure: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for the work presented in this article.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

Mario Pelle-Ceravolo, M.D., University of Padua, 35, Via Giovanni Severano, 00161 Rome, Italy, mario.pelleceravolo@live.it

Disappointed by conservative techniques,1,2 for many years we have used a neck plasty technique to treat platysma bands and anterior skin laxity based on full neck undermining and full-width platysma transection, similar to that published by Connell and subsequently by Marten3–5 but with some variations.6,7 We carried out a prospective evaluation of 150 patients who underwent neck rejuvenation operations to evaluate patients’ levels of satisfaction and the aesthetic outcome of this technique.8 At 1 year postoperatively, 35.4 percent of patients (34 of 96) exhibited obvious platysma bands and 43.7 percent (42 of 96) exhibited obvious skin laxity over the anterior neck. Only 56.2 percent of patients (54 of 96) were band-free, and only 43.7 percent (42 of 96) showed no skin excess over the anterior neck at 1 year. It was disappointing to find that the most invasive neck rejuvenation procedure (i.e., complete neck undermining combined with full-width platysma section), which involves a long surgical time, a certain risk because of the extent of skin undermining, and entails a long postoperative recovery, still did not achieve the predictable correction of platysma bands and anterior skin laxity in a certain number of patients.

Starting in 2010, we adopted a new technique using a different approach to the platysma without opening the anterior neck. This technique achieved extremely good results, decreased the operating time and complication rate, and provided a much faster postoperative recovery.

Guerrerosantos9,10 and Gonzales11,12 have published a technique based on a similar rationale but with different technical details. Regarding platysma bands, our strategy was to use only lateral access without performing any skin undermining over the anterior neck. The technique involved approaching the platysma on its mid-body and not on its posterior border, undermining completely the muscle up to its medial border to render it mobile, transecting it horizontally, pulling the skin-muscle flap in a lateral direction, and then suturing it to the mastoid fascia using cable stitches. This maneuver would skew the anatomy of the platysma by relocating the muscle in a more lateral and horizontal position, thus strongly decreasing the risk of band recurrence

Most classic techniques13–20 pull the skin or skin/muscle cervical flap in one or two separate layers from its lateral border to redrape the skin of the anterior neck. 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). (See Video, Supplemental Digital Content 1, which shows the rationale of applying the traction on the midbody of the platysma by means of animation, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B990. See Video, Supplemental Digital Content 2, which shows the rationale of applying the traction on the midbody of the platysma on a living patient, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B991.)

Video 1

Video 1

Video 2

Video 2

One of the most important steps in our approach is the wide undermining carried out on the muscle, which allows us to mobilize it freely and to displace it steadily in a more lateral position. Furthermore, greater and more dramatic remodeling of the anterior skin is obtained if traction on the undermined platysma is exerted, by tacking the muscle at a shorter distance from the midline and pulling on the platysma, to which the skin remains attached, as the anterior skin moves farther laterally.

The idea of creating a composite skin-muscle flap has been advocated by many authors,18,21–24 but the limited undermining of the platysma in most of these techniques does not allow adequate mobilization of the flaps and thus satisfactory neck remodeling. This is because of the presence of the cervical retaining ligaments, which restrict the mobility of the platysma.25,26 Furthermore, starting the subplatysmal dissection at the posterior border of the platysma, as advocates of most of these techniques propose, entails an increased risk of injuring the great auricular nerve27 posteriorly and the cervical nerve more anteriorly. Oppositely, approaching the platysma at the level of the mandibular angle and 4 cm below it, besides having a stronger effect in remodeling the anterior neck, also eliminates the risk of damaging the great auricular nerve (which runs far more laterally) and the connecting branch which from the cervical nerve goes to the mandibular nerve to innervate the perioral muscle (which runs more cranially to our incision).28

Lateral skin-platysma displacement is nowadays our first-choice technique only when no other factors are responsible for the inaesthetism over the anterior neck (e.g., digastric muscles hypertrophy, presence of perihyoid fascia). This article describes the rationale for this technique and provides a preliminary evaluation of its results.

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PATIENTS AND METHODS

This prospective study involved 100 patients who underwent surgery for neck rejuvenation performed by the senior author (M.P.C.) from 2010 to 2014 using the technique described below. The age of the patients ranged from 40 to 81 years, with a mean age of 62 years and a median age of 60 years. The patient population contained 82 women and 18 men. Only primary patients were included in this study. Patients who presented indications for deep work over the anterior neck (i.e., on digastric muscles or perihyoid fascia) were excluded from this study. Eight-five patients received general anesthesia, and 15 received local anesthesia with sedation. Twenty-eight patients (28 percent) underwent associated closed liposuction of the neck. In 24 patients, we performed a submandibular gland reduction through the lateral approach. Drains were used in 95 patients. A light compressive elastic mask was routinely used as a dressing for the first 24 hours after surgery.

Follow-up was from 6 months to 4 years, with a mean of 21 months. The technique underwent a certain evolution in terms of the number, material, and direction of the sutures, but the basic principles did not vary substantially. To evaluate the level of satisfaction and the main complaints from the operation, during the consultation at 3 months and at 1 year, all patients were given a questionnaire and a stamped self-addressed envelope to return the questionnaire to our office anonymously, encouraging sincere answers to the questions without being influenced by the patient-physician relationship (Table 1).

Table 1

Table 1

Of the 100 patients, 94 (94 percent) reported for the 3-month consultation, and 73 (73 percent) reported for the 1-year consultation. Eighty-five questionnaires were received after the 3-month consultation, and 64 were received after the 1-year consultation.

Consultations were planned at 3, 6, 9, and 12 months. During each visit, photographs were taken, and on each chart, the two issues (presence of anterior platysma bands and presence of anterior skin laxity) were evaluated with three possible notes in checkboxes: “yes,” “no,” or “perhaps” (Table 2).

Table 2

Table 2

The senior surgeon checked these boxes after a careful examination of each case. The box “perhaps” was checked in cases in which the presence of bands or of excess skin was debatable but not certain.

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Surgical Technique

Preoperative markings were drawn with the patient in the upright position (Fig. 1). The anterior vertical platysma bands were marked, and a 5-cm vertical line indicating the incision into the midbody of the platysma was 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 joining the previous two vertical lines was marked at 2 cm below the upper border of the thyroid cartilage to indicate the line of the platysma transection.

Fig. 1

Fig. 1

After having prepared and infiltrated the area to be undermined with 250 cc of saline containing 20 cc of mepivacaine 2% and 2 mg of epinephrine, we carried out cutaneous undermining, which, in the neck area, extended to approximately 1 cm beneath the marked vertical incision on the platysma. Thus, approximately 5 to 6 cm of anterior neck skin on each side was not undermined and remained attached to the platysma.

After good hemostasis, we made a 5-cm vertical eyelet using a Metzenbaum scissor on the platysma parallel to its fibers, following the preoperative marking (i.e., 1 cm lateral to the limit of the cutaneous undermining). The highest point of this incision was never closer than 4 cm to the mandibular border to avoid any injury to the mandibular branch (Fig. 2).

Fig. 2

Fig. 2

The tips of scissors were used to spread the platysma fibers while entering the subplatysmal plane, developing a horizontal tunnel under the muscle. The scissors, then, undermined bluntly the whole anterior platysma from lateral to medial up to a point beyond the medial border of the anterior platysma band (Figs. 3 and 4), taking care not to injure the facial vein, which is frequently visible underneath the muscle at the level of the posterior border of the submandibular gland. This maneuver is essential to obtain adequate mobilization of the platysma.

Fig. 3

Fig. 3

Fig. 4

Fig. 4

At this point, we divided the platysma in its full thickness horizontally to its medial border, ensuring that all medial platysma fibers were sectioned (Figs. 5 and 6). (See Video, Supplemental Digital Content 3, which shows incising, undermining, and transecting the platysma, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B992.)

Fig. 5

Fig. 5

Fig. 6

Fig. 6

Video 3

Video 3

The vertical and horizontal incisions on the platysma created two skin-muscle flaps, as the platysma was still attached to the anterior neck skin. At this point, we passed a suture of a 2-0 nonabsorbable polyester braided thread (polyester 2-0 3/8 needle 26 mm) into the mastoid aponeurosis. The needle then took a solid bite into the lower myocutaneous flap and then was passed again into the mastoid aponeurosis (at approximately 5 cm behind and 10 to 12 cm below the tragus) in an area posterior to the course of the great auricular nerve. The suture was not tied at this time. A second similar suture was placed to reinforce the first between the lower flap and a site 1 to 1.5 cm cranial from the first one on the mastoid fascia.

Two additional sutures were placed between the upper myocutaneous flap and mastoid 1 to 1.5 cm cranially to the previous ones. At the end of suturing, pulling on the sutures ensured that adequate traction could be obtained. (See Video, Supplemental Digital Content 4, which shows placing the cable sutures, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B993.)

Video 4

Video 4

We used “cable” sutures to the mastoid aponeurosis for a strong support, to hold the muscle in position without the tips of the triangular tips reaching the mastoid. Once the four sutures were in place, they were tied, starting with the lower ones, securely but not tightly to avoid cheesewiring the muscle. (See Video, Supplemental Digital Content 5, which shows the tunnel, the transection, and the sutures on a specimen, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B994.)

Video 5

Video 5

Each suture was passed back and forth (catching first the mastoid fascia, then the platysma, and again the mastoid fascia), leaving approximately 1 cm of space between the two threads to decrease the amount of fat bulging through the stitches (differently as shown in the Supplemental Digital Content 5 on the specimen). Once all sutures are tied, any irregularities from fat bulging between the sutures were flattened either by applying an additional suture or by cautery aiming at obtaining an even neck contour. (See Video, Supplemental Digital Content 6, which shows a full through-and-through vision on a specimen of the platysma displacement, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B995.)

Video 6

Video 6

This 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. [See Video, Supplemental Digital Content 7, which shows the final contouring maneuvers (additional sutures and fat sculpting), available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B996.] Eventually, little platysma is left over the anterior neck (Fig. 7), which explains why this technique entails a low risk of band recurrence.

Fig. 7

Fig. 7

Video 7

Video 7

As the platysma maintained its attachments to the skin of the anterior neck, traction on the platysma created a powerful pull on the anterior neck skin, which was displaced laterally. The sutures on the lower myocutaneous flap were used in most of the patients, aiming to treat the excess skin on the lower neck. In eight patients, however, who did not present this problem, only three sutures were applied only to the upper myocutaneous flap, whereas the lower myocutaneous flap was left untouched.

The lateral portion of the platysma was mostly left undisturbed unless some lateral platysma bands required treatment. In this case, we removed a horizontal strip of the lateral platysma, interrupting its continuity starting from its lateral border at 5 to 6 cm from the lower mandibular border to avoid injury to the mandibular nerve, which runs more cranially to this point. (See Video, Supplemental Digital Content 8, which shows treating a lateral platysma band, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B997.)

Video 8

Video 8

When supraplatysmal excess fat was present, it was removed by liposuction via a submental incision at the beginning of the procedure (i.e., before the skin undermining phase). When submuscular fat was to be removed, it was done after having undermined the platysma, by introducing a liposuction cannula into the subplatysmal plane. Using only this lateral approach (Fig. 8)(see Video, Supplemental Digital Content 9, which shows submandibular gland reduction, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/B998), we reduced the submandibular gland in 24 patients in whom an obvious bulge was present. The lateral approach for submandibular gland reduction has been described in the literature,12,29 but most surgeons dealing with the submandibular gland prefer to reduce the gland through the submental approach.4,5,30–32

Fig. 8

Fig. 8

Video 9

Video 9

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RESULTS

No general complications were observed. No major hematoma (requiring drainage in the operating room) occurred, and two small (3 to 5 cc) hematomas over the retroauricular area were evacuated by a syringe.

There was no incidence of skin necrosis or muscular weakness, even transient, from facial nerve injury. Six patients who declined submandibular gland reduction showed some bulging of the submandibular gland postoperatively. One patient showed an irregular contour depression below the mandible angle, which was subsequently corrected using fat grafting. Four patients, among the first ones operated on with the lateral skin-platysma displacement, presenting a thin subcutaneous layer, showed a certain protuberance below the mandibular border and parallel to it because of inadequate mobilization of the platysma. To compare the lateral skin-platysma displacement with the full neck undermining and platysma transection technique, we sought to report the results of this series of patients (operated on through the former technique) together with a previous recently published8 series operated on through the latter technique in a comparative manner.

The patients who underwent full neck undermining and full-width platysma section are called group A, and the patients who underwent lateral skin-platysma displacement are called group B. A summary of the evaluation of patient satisfaction is provided in Tables 3 through 5, which report the answers to the questionnaires received from the patients.

Regarding patient satisfaction, whereas the results (Table 3) were nearly identical at 3 months (good or better), at 1 year, all patients in group B still reported “good” to “beyond expectations,” whereas in 23 percent of patients in group A, their evaluation decreased to only “fair” or “average” (Table 4). There appears to be a statistically significant difference between the two groups (p = 0.001). The longer recovery of the patients in group A may have influenced these results. With regard to patients’ main complaints (Table 5), a lack of neck feeling was understandably a more frequent complaint for patients who had undergone complete neck undermining, and was nearly twice as common as in group B (p = 0.001).

Table 3

Table 3

Table 4

Table 4

Table 5

Table 5

The feeling of a “hard neck” was very common (67 percent) among group A patients, in which complete neck skin undermining was performed, whereas it was only present in 10.5 percent of group B patients (p = 0.0001). There was also a significant difference in the complaints about the length of the recovery period (80.9 percent of group A patients compared with only 36.4 percent in group B; p = 0.0001).

With regard to the complication rate (Table 6), there was no major difference between the two groups. Indeed, 1.3 percent of patients in group A exhibited small superficial periauricular necrosis (with some dyspigmentation) because of extended undermining, whereas there was no incidence of any necrosis in group B. However, this difference was not statistically significant.

Table 6

Table 6

The only macroscopic difference was observed in the prolonged (>2 months) edema of the neck, which was three times more frequent in group A patients (15.9 percent) than in group B patients (4.7 percent; p = 0.011). All group B patients who presented prolonged edema had been submitted to liposuction to remove some fat from the anterior neck.

There were also fewer contour irregularities in group B. The decreasing aggressiveness of the surgeon toward fat removal in later years may have influenced these data.

The operating time could not be calculated in all patients because of the different maneuvers involved in each operation. In Table 7, we report a limited sample of length of the operating time in 20 patients (last 10 patients of group A and of group B). The operating time reported refers only to the face-lifting procedure (superficial musculoaponeurotic system plication was carried out in all of these patients) without any other associated surgery. The patients who underwent lipectomy or liposuction were excluded from this group.

Table 7

Table 7

There is little doubt that the lateral skin-platysma displacement is a much shorter procedure than the full neck undermining with complete platysma transection technique, and the average time difference in carrying out the two different techniques is approximately 1 hour. As far as results are concerned, it is difficult to set up an objective measurement protocol to compare the outcome of these two techniques in correcting the two most important aesthetic concerns of the aging neck (i.e., anterior platysma bands and skin laxity), for several different reasons. The only data are derived from the opinion of the operating surgeon, which may not be completely reliable and has limited scientific value.

The operating surgeon’s opinions are based on the 1-year photographs of the two different groups of patients, including 96 patients in group A reviewed in the 2005 study and 73 patients from group B and on the physical examination, which is more precise than photographic documentation when evaluating recurrence of bands or skin laxity. In group A, only 56.2 percent of the patients were band-free at 1 year compared to 83.5 percent in group B. Thirty-four patients (35.4 percent) in group A had visible recurrent platysma bands at 1 year, whereas only eight patients (11 percent; p = 0.0001) in group B exhibited some obvious bands (Table 8).

Table 8

Table 8

With regard to the recurrence of skin laxity in group A, 43.7 percent of patients showed visible excess skin on the anterior neck, whereas only 26 percent of patients in group B had this problem. This value is close to statistical significance (p = 0.059) (Table 9).

Table 9

Table 9

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DISCUSSION

After reviewing the results of our study on the outcome of neck plasty technique based on full platysma transection, we were disappointed by our long-term results regarding the recurrence of platysma cords and anterior skin laxity, especially considering the aggressiveness of the technique used. Hodgkinson33 and Rosenfield34 drew similar conclusions.33 Undermining the entire neck and full-width severing of the muscle, besides requiring time and energy, entails certain risks, such as blood flow impairment–related abnormality, perioral muscular disturbances, visible irregularities, and certainly a long recovery, because of the extensive undermined area in some cases (“leather neck”). The risk of perioral muscular dysfunction is always present in most of the techniques dealing with platysma manipulation, especially when platysma undermining and full-width transection are carried out. However, this complication, even if it is uncommon and transient, represents a challenging episode for both patient and surgeon.

In addition to the aggressiveness and risks that are related to all full neck undermining tech niques,3–6,13–15,17,20,30–41 another drawback is that a certain number of patients cannot be treated with this technique because of other factors, such as smoking, different therapies, and skin conditions that increase the risk of long flaps. The length of the postoperative recovery period is one of the most important factors influencing the patient’s decision in our practice. The patient’s happiness is frequently related to the time necessary to return to a normal working or social life. The full neck undermining technique is becoming anachronistic, as it constitutes an extended withdrawal from normal life, a condition that is either unacceptable or impossible for many patients. During recent years, we have been dedicated to identifying a technique that can provide a good outcome but with fewer drawbacks in terms of recovery and unacceptable rates of recurrence.

Guerrerosantos9,10 and Gonzales11,12 described two similar techniques with a direct approach to the anterior platysma but different surgical details. Guerrerosantos was the first to suggest an approach to the anterior platysma, but he used full neck skin undermining, which nullifies the principle of the composite skin-platysma flap and renders the traction of the muscle on skin redraping ineffective.

Gonzales supported the idea of the composite skin muscle flap, but he suggested a limited (1 to 2 cm) undermining of the platysma associated with multiple incisions of the muscle. In contrast, we undermine the platysma widely to its medial borders and transect it completely to allow for a complete lateral shift of the muscle, as we believe that if the muscle is not completely free it will have a tendency to return to its previous position. Furthermore, he suggested plicating the muscle on itself right below the mandibular angle, whereas we anchor it through cable stitches to the mastoid fascia. We prefer this type of anchoring for two different reasons: first, because the fascia is definitely stronger than the muscle, and second, because the area below the submandibular angle is occasionally crossed by the marginal nerve and often crossed by the cervical nerves, which anatomize with the marginal mandible. Many cases of temporary dysfunction of the lip muscles are related to injury of these nerves.20 Our judgments on lateral skin-platysma displacement are based on the following issues:

  1. Lateral skin-platysma displacement is in our hands the only alternative technique to the complete neck undermining with full platysma section to treat platysma bands and neck skin laxity, but the latter is a more difficult and time-consuming technique (Table 7).
  2. The notable decrease in the length of the postoperative recovery period of the lateral skin-platysma displacement procedure (Fig. 9, left and center) when compared to other techniques with similar results, which for this reason are not easily accepted by the majority of our patients.
  3. The answers to the questionnaires in relation to patient satisfaction, which confirm that the results of the lateral skin-platysma displacement technique, although similar at 3 months, are superior at 1 year compared with the full neck undermining technique (p = 0.001).
  4. The evaluation carried out on our patients, which showed that at 1 year, the recurrence rate of platysma bands and, to a lesser extent, of anterior neck skin laxity is lower in patients treated with the lateral skin-platysma displacement technique compared with the full neck undermining technique.
  5. The complete absence of even transient impairment of the perioral muscular function caused by nervous injury in all of the patients submitted to this technique avoids the occurrence of a temporary but difficult and unpleasant event for both patient and surgeon.
  6. The transplatysmal route (Fig. 8) allowed us to reduce the submandibular gland more easily and provided results similar to the submental approach, which we have used for many years.6 Indeed, from the year 2010 onward, we began to use the retroauricular transplatysmal approach routinely to reduce the gland, as we found this to be an easier and faster procedure. Submandibular gland reduction is disliked by many surgeons who consider it too aggressive to be combined with a face lift. In our opinion, which is shared by many other authoritative colleagues,4,5,11,30–32 this treatment is indicated in a considerable number of patients, and in many of them, it represents a “conditio sine qua non” if satisfactory results cannot be obtained. Even slightly visible glands preoperatively become obvious after neck contouring maneuvers.
Fig. 9

Fig. 9

Our data are flawed by different biases that do not render them completely objective, especially regarding the examination of the patients, which was performed by the operating surgeon alone, and the difficulty in defining objective parameters such as “a recurrent band” or “skin laxity.”

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CONCLUSIONS

Currently, patients’ demands include not only the surgical outcome but also the length of postoperative recovery period. The duration of the period for which patients must abandon their normal life constitutes a critical issue in making treatment decisions.

The lateral skin-platysma displacement technique has become our most frequently used approach for the following reasons:

  1. It entails limited neck undermining.
  2. It avoids a scar on the submental area.
  3. It has a shorter operating time.
  4. It has extremely low, if any, risk of nervous injury.
  5. It entails a faster patient recovery period.
  6. It provides optimal results on platysma bands and skin laxity (Figs. 9 through 12). [See Figure, Supplemental Digital Content 10, which shows a 68-year-old woman, anterior view (left) preoperatively. Significant anterior neck skin laxity and platysma bands are visible. (Right) One year postoperatively after the lateral skin-platysma displacement technique. Good remodeling of the skin is noticeable, http://links.lww.com/PRS/B999. See Figure, Supplemental Digital Content 11, which shows the same patient as in Supplemental Digital Content 1, on a three-quarters view (left) preoperatively. Significant anterior neck skin laxity and platysma bands are visible. (Right) One year postoperatively after the lateral skin-platysma displacement technique. A well-contoured neck is visible, http://links.lww.com/PRS/B1000. See Figure, Supplemental Digital Content 12, which shows the same patient as in Supplemental Digital Content 1 and 2 on a lateral view (left) preoperatively. An oblique jugulomental line is present (right) 1 year postoperatively. The lateral skin-platysma displacement has created horizontal and vertical well-defined neck segments, http://links.lww.com/PRS/C2.)
  7. It allows an easier reduction of the submandibular gland through the retroauricular approach than through the submental approach (Fig. 13).
Fig. 10

Fig. 10

Fig. 11

Fig. 11

Fig. 12

Fig. 12

Fig. 13

Fig. 13

Until 2011, we opened the neck in approximately 65 percent of our patients during a cervicofacial face lift. After the year 2011 (i.e., when we started using lateral skin-platysma displacement routinely), the percentage of neck openings dropped to approximately 10 percent because of the advantages provided by this technique.

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ACKNOWLEDGMENTS

The authors acknowledge the photographic support offered by Norbert Foch, M.D., at the Anatomy Department of Vienna University directed by Prof. Hannes Traxler, where most of the cadaver dissections were carried out during the master classes held by the senior surgeon (M.P.C.).

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