The Neck

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The delineation of the cervicomandibular angle plays an important role in the appearance of the attractive, youthful neck [11, 12]. Occasionally, patients are more concerned with the appearance of their necks than that of their faces. As a direct continuation of the aging process of the lower face, the aging neck is mainly attributed to loss of platysmal tone, loose skin, together with periplatysmal fat deposits.

We manage most necks today by combining lipo-suction with lateral muscle tightening and skin re-draping.

When indicated, a medial plication is added, and in heavy necks or with active platysmal bands, a complete corset platysmaplasty is undertaken as described by Feldman [13] (Fig. 64.10). Lateral platysma plication helps define the jawline at the mandibular angle and improves contouring in the submandibular region.

We use close suction-assisted lipectomy (SAL) to defat the submental area and jowls, both "close" at the onset and "open" prior to skin redraping. Special attention is directed to fat deposits often found between and under the platysmal bands (subplatysmal fat). This fat cannot be addressed by liposuction and should be treated by direct excision using the electro-cautry needle as it is quite vascular.

Care should be taken to stay conservative when addressing the subplatysmal fat to avoid creating an unsightly depression under the chin.

As more skin is required to cover a sculpted neck with an acute cervicomental angle than to drape a heavy neck with an obtuse angle, excess skin is rarely a problem in younger patients with good skin elasticity. When there is excess skin, along with poor skin elasticity, there is a need for skin excision. In these patients a postauricular, full extent, hairline incision is recommended, in order to accommodate skin excision without distorting the posterior hairline integrity.

Partial submandibular gland excision is fraught with controversy, as is resection of the anterior belly

Fig. 64.10. Face lifting with complete corset platysmaplasty and suture suspension: Left to right: Preoperatively, 10 days postoperatively, 5 years postoperatively

of the digestric muscles [14, 15]. Though the submandibular glands are often visible, most cases of prominent glands are mild, and patients are unaware of its existence. Nevertheless, we always notify the patients that the fullness created by a visible gland preopera-tively may be more noticeable after rhytidectomy. Our attitude towards the ptotic submandibular glands and digestric muscles is conservative, which means we leave them untouched.

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