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).
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.
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.
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).
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).
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:
- 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).
- 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.
- 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).
- 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.
- 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.
- 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.
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.”
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:
- It entails limited neck undermining.
- It avoids a scar on the submental area.
- It has a shorter operating time.
- It has extremely low, if any, risk of nervous injury.
- It entails a faster patient recovery period.
- 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.)
- It allows an easier reduction of the submandibular gland through the retroauricular approach than through the submental approach (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.
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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