Dimitrije E. Panfilov
Mostly we can achieve fairly good definition of the mento-cervical angle by lateral mobilization and fixation of skin and platysma and by liposuction of the submental region. Sometimes, however, it will not be enough to harmonize the entire neck. We can excise a spindle-like part of the submental skin and subcutaneous fat to tighten the skin.
If there are platysma bands with muscle fibres we can mobilize them, cut them, or suture them together.
We can provoke the real platysma bands by asking the patient to tighten his/her neck muscles or to a make disgusting facial expression. Skin excision, "corseting", and "notching" will improve the neck harmony.
Notching is procedure popularized by Ziya Saylan which is very simple. Preoperatively we palpate pla-tysma bands and make markings where horizontal neck wrinkles cross these bands. Intraoperatively we cut the skin superficially over these markings and catch the muscle band with a small Dechemp hook. Now we cut muscle fibres preferably with radiowaves. In such a way we do not cause bleeding.
Fig. 54.4. a Real platysma bands, left more than right. b Ten days after face-neck-lift and notching of platysma bands. Stretching the skin, we clasp the muscle and divide it into c the upper and d the lower part of the neck
Sometimes the hypertrophic digastric muscle produces a turkey neck without a mento-cervical angle. In that case we detach the mental attachments of both digastric muscles in the same way as we do in notching.
When we have a "heavy neck" we must sometimes do additionally partial resection of the submandibu-lar gland (see Chap. 55 by Farzad Nahai and Foad Na-hai). This is the case in less than 1% of all our facelifts and we perform digastricus detachment in less than 2% of all cases.
If the turkey neck is combined with hypognathy, we should add also chin augmentation. For this purpose we prefer a "horseshoe" silicone chin implant, but patients in Germany sometimes insist on autolo-gous bone graft, which we take from the iliac crest.
There is also a simple method of neck-tightening by "star excision" and zigzag "Zorro scar" in the middle of the neck for those patients who are ready to accept this type of scar. We should check if the patient already has unobtrusive scars somewhere else on the body. It is of some comfort that the older we are, the more cell activity decreases, and the scars we produce are less visible with increasing age.
First we palpate the skin and underlying fat with one hand and we mark an oval or spindle-like vertical picture in the middle of the neck. Then we mark the legs of distant multiple Z-plasty (see Figs. 54.8 and 54.10 and also Chap. 51 by Ulrich Kesselring). Then we cut it preferably with radiosurgery and suture it. Additionally we apply adhesive bandages to reduce the tension on the wound edges.
Both patient and surgeon should have patience for the first couple of weeks and months. After the tenth postoperative day, the scar should be hidden with cosmetic camouflage.
We can do this kind of surgery at the same time as facelift surgery, some time later, or isolated, just for neck-tightening.
Please see the general bibliography at the end of this book.
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