The Functional Anatomy and Innervation of the Platysma is Segmental: Implications for Lower Lip Dysfunction, Recurrent Platysmal Bands, and Surgical Rejuvenation

Decreasing edema with platysma exercises following third molar extraction surgery: A randomized controlled trial

BACKGROUND AND PURPOSE

The extraction of lower third molars is a routine procedure in dental practice however, it can lead to complications such as pain, edema and trismus. The aim of this study is to investigate the effects of platysma exercises applied after lower third molar tooth extraction on edema, while observing the differences in pain and trismus.

MATERIALS AND METHODS

This randomized controlled trial was conducted at the Faculty of Dentistry, Ankara University. Thirty-one participants, aged 18-40, requiring impacted lower third molar extraction were randomly assigned to an intervention group following surgery (receiving platysma exercises and pharmacological treatment) or a control group (receiving pharmacological treatment only). Postoperative outcomes, including edema, pain, and trismus, were evaluated at four time points: preoperatively, and on postoperative days 1, 3 and 7. Edema was assessed via standardized facial measurements, pain using a visual analog scale, and trismus by measuring maximum inter-incisal distance.

RESULTS

The intervention group exhibited a significant reduction in edema compared to the control group by the seventh postoperative day (p < 0.05). No significant differences were observed in trismus or pain levels between the groups, although a trend towards lower pain scores was noted in the intervention group.

CONCLUSION

Platysma exercises effectively reduce postoperative facial edema without exacerbating pain or trismus. This simple, cost-effective approach can be considered a valuable adjunct in the postoperative management of lower third molar extractions.

Refinements in cervical-to-marginal mandibular nerve transfers for late and chronic facial palsy cases: A pilot study

Marginal mandibular nerve palsy is among the most common facial nerve iatrogenic injuries and has significant functional and aesthetic consequences. In a case series of four patients (n = 4) with iatrogenic and acquired marginal mandibular nerve injuries, we performed a cervical branch facial nerve (VIIc) fascicular transfer to the marginal mandibular nerve (VIIm) for late and chronic facial palsies. Pre-and post-op videos were then analysed to determine the return lower lip depression, using the Terzis lower lip score and smile index was used for objective assessment. Overall, 75% of the cases were secondary to iatrogenic injuries viz., two post-neck dissections and one post-submandibular gland excision, while one case had non-flaccid facial paresis. In all four cases, the depressor labii inferioris (DLI) function returned during open mouth smile activation. Cervical-to-marginal mandibular (VIIc-VIIm) nerve transfers are indicated in acute VIIm injuries (<18 months post-onset) and in long-term cases of DLI paresis. However, it is not useful in patients with complete DLI paralysis, for which conventional methods are better suited. However, in the future, it may be considered for the management of congenital unilateral lower lip palsies, wherein the DLI is paretic.

Compartmental surgery for squamous cell carcinoma of the buccal mucosa: description of a new surgical technique

BACKGROUND

Oral squamous cell carcinoma (OSCC) is the sixth most common cancer globally. Patient survival varies depending on tumour stage and oral cavity subsites. Buccal mucosa neoplasia is rare and burdened by worse prognosis than other oral subsites, showing a high rate of loco-regional relapses within six months after treatment. According to NCCN guidelines, the gold standard treatment is radical surgery. In the oral cavity, the buccal mucosa subsite lacks anatomical barriers opposing neoplastic growth. At this level, the tumour cells could hypothetically spread along the fibres of the platysma muscle or the lymphatic networks of the peri-facial vessels without encountering any resistance. Due to the aggressive locoregional spread, radical surgery is mandatory to improve patient survival.

METHODS

This technical note describes the cheek compartmental surgical approach step by step. For intermediate-advanced stage cancer, the surgery should include the resection of the tumour with adequate free margins, the dissection of neck lymph nodes and the lymphatic network with the structures between the tumour (T) and the neck (N), the so-called "T-N tract". The buccal mucosa compartment may be defined as a three-dimensional space between the oral cavity mucosa, the vessel plane, and the lymph nodes of the neck (levels I-IV). These structures, connected by the platysma muscle and the facial vessels, may be considered the T-N tract of the mucosal cheek compartment.

RESULTS

By removing all the possible pathways of tumour spread via compartmental surgery (en-bloc resection of the tumour with T-N tract and lymphatic network and lymph nodes) for buccal mucosa cancers, one could provide better locoregional control of disease in intermediate-advanced stages.

CONCLUSION

This surgical technique may enable a more accurate control of the surgical margins, especially the deep margins.

Improving Neck and Jawline Aesthetics With OnabotulinumtoxinA by Minimizing Platysma Muscle Contraction Effects: Efficacy and Safety Results in a Phase 3 Randomized, Placebo-Controlled Study

BACKGROUND

Platysma prominence (PP) describes the noticeable appearance of the platysma muscle upon contraction, causing a less defined jawline contour and vertical neck bands.

OBJECTIVES

The objective of this study was to assess the safety and efficacy of onabotulinumtoxinA for improvement of PP in adults.

METHODS

Participants with moderate to severe (Grade 3 to 4) PP at maximum contraction received onabotulinumtoxinA or placebo on Day 1 and were monitored for 120 days. OnabotulinumtoxinA dosage (26, 31, or 36 U) was customized based on baseline PP severity on each side of the neck.

RESULTS

Efficacy analyses were conducted in the intent-to-treat (ITT) population (all randomized participants), and modified ITT population (mITT; psychosocially impacted by PP appearance). Results from ITT and mITT populations were comparable. As assessed by investigators, 76.7% of onabotulinumtoxinA mITT participants achieved ≥1-grade improvement vs 21.2% in the placebo group, and 41.0% vs 2.2% (P < .0001) achieved ≥2-grade improvement at Day 14. As assessed by participants, 79.9% of onabotulinumtoxinA mITT participants vs 21.8% in the placebo group and 40.8% vs 3.9% (P < .0001) achieved ≥1- or ≥2-grade improvement, respectively, at Day 14. OnabotulinumtoxinA responder rates remained higher than placebo through Day 120, gradually declining over time. OnabotulinumtoxinA participants reported significantly higher satisfaction with treatment effect, less bother from jawline and vertical neck bands, and lower psychosocial impact from PP than placebo at Day 14 (P < .0001). OnabotulinumtoxinA effectively improved self-perceived jawline definition and was well tolerated.

CONCLUSIONS

OnabotulinumtoxinA was well tolerated and effective at improving moderate to severe PP, including neck bands and jawline definition.

LEVEL OF EVIDENCE: 1 (THERAPEUTIC)

Are There Hidden Adverse Events in Hypoglossal Nerve Stimulation: Comparing Social Media and a Federal Database

OBJECTIVE

Hypoglossal nerve stimulation (HNS) can be an effective treatment for moderate to severe obstructive sleep apnea (OSA) in positive airway pressure (PAP) intolerant patients. To better understand patient experiences with HNS therapy, we explored reported events from HNS-related Facebook groups and the Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

A retrospective analysis of HNS-related Facebook posts from three groups pertaining to HNS therapy, from October 1, 2022 to October 1, 2023, was performed. Posts were analyzed for patient-reported adverse events. Concurrently, the MAUDE database was reviewed for HNS-related events during the same timeframe.

RESULTS

From 737 Facebook posts, 132 (17.55%) adverse events were identified. Adverse events included pain (34.85%), stimulation discomfort (14.39%), lip weakness (6.82%) and issues related to lead tethering or tight leads around the neck (3.79%). Analysis of the MAUDE database found 428 adverse events, including pain (24.07%), lip weakness (0.44%), and lead tethering (1.64%).

CONCLUSION

Facebook group members reported higher rates of lip weakness and lead tethering than recorded in the MAUDE database. These findings illustrate how diverse data sources, such as social media, can enhance our understanding of patient experiences and identify gaps in patient education with HNS therapy.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:5217-5222, 2024.

Anatomical Guidelines and Technical Tips for Neck Aesthetics with Botulinum Toxin

Botulinum toxin can be used for various purposes to enhance neck aesthetics, addressing concerns such as platysmal bands, optimizing the cervicomental angle, preventing worsening of horizontal neckline and decolletage lines during aging, submandibular gland hypertrophy, and hypertrophied superior trapezius muscle. Understanding the anatomy of muscles such as the trapezius, platysma, and submandibular gland is crucial for achieving desirable outcomes with botulinum toxin administration. Techniques for injecting botulinum toxin into these muscles are discussed, emphasizing safety and efficacy. Specific injection points and methods are detailed for treating platysmal bands, optimizing the cervicomental angle, addressing submandibular gland hypertrophy, and managing hypertrophied superior trapezius muscle. Careful consideration of anatomical landmarks and potential complications is essential for successful botulinum toxin injections in these areas.

Anatomical Insights on the Cervical Nerve for Contemporary Face and Neck Lifting: A Cadaveric Study

BACKGROUND

Despite the significant roles it plays in the functions of the platysma and lower lip, the cervical branch of the facial nerve is often overlooked compared to other branches, but its consideration is critical for ensuring the safety of neck surgeries.

OBJECTIVES

The aim of this study was to clarify the anatomical discrepancies associated with the cervical branch of the facial nerve to enhance surgical safety.

METHODS

The study utilized 20 fresh-frozen hemiheads. A 2-stage surgical procedure was employed, beginning with an initial deep-plane facelift including extensive neck dissection, followed by a superficial parotidectomy on fresh-frozen cadavers. This approach allowed for a thorough exploration and mapping of the cervical nerve in relation to its surrounding anatomical structures.

RESULTS

Upon exiting the parotid gland, the cervical nerve consistently traveled beneath the investing layer of the deep cervical fascia for a brief distance, traversing the deep fascia to travel within the areolar connective tissue before terminating anteriorly in the platysma muscle. A single branch was observed in 2 cases, while 2 branches were noted in 18 cases.

CONCLUSIONS

The cervical nerve's relatively deeper position below the mandible's angle facilitates a safer subplatysmal dissection via a lateral approach for the release of the cervical retaining ligaments. Due to the absence of a protective barrier, the nerve is more susceptible to injuries from direct trauma or thermal damage caused by electrocautery, especially during median approaches.

Progressive Contouring of the Platysma With Barbed Sutures

BACKGROUND

As the prevalence of neck lift surgeries increases, the field is continually enriched by evolving techniques for enhancing neck aesthetics. While many recent publications focus on deep neck procedures, it is essential not to overlook the significance of platysmal contouring as an integral aspect of neck rejuvenation surgery. Accordingly, we would like to elucidate our unique approach to contouring the platysma.

OBJECTIVES

This study was designed to assess the efficacy of the progressive contouring concept, a technique in which the neck is reshaped with barbed sutures synergistically with other treatment strategies.

METHODS

Our study encompassed 337 patients who received neck rejuvenation treatment with the progressive contouring technique from 2014 to 2021. We conducted a retrospective review to evaluate the change in cervicomental angle (CMA) with Mirror software during the preoperative and postoperative stages.

RESULTS

The study sample predominantly comprised females (304 out of 337), with a median age of 61 years (24-88). Most patients (95%) underwent deep cervicoplasty, with a surgical net applied in all cases for skin adaptation. After a median follow-up of 14 months, significant improvements were observed in CMA values (reduced from 149.8° to 106.7°). This demonstrated statistically significant differences when comparing preoperative and postoperative outcomes.

CONCLUSIONS

Progressive shaping of the neck with barbed sutures is an effective technique in neck rejuvenation. It utilizes multipoint and multivector plication, particularly when integrated with other adjunctive surgical maneuvers.

LEVEL OF EVIDENCE: 3

Sonoanatomy of the platysmal bands: What causes the platysmal band?

BACKGROUND

The platysmal band is created by the platysma muscle, a thin superficial muscle that covers the entire neck and the lower part of the face. The platysmal band appears at the anterior and posterior borders of the muscle. To date, no definite pathophysiology has been established. Here, we observed a lack of knowledge of the anatomy of the platysma muscle using ultrasonography in this study.

METHODS

We conducted a descriptive, prospective study observing the platysmal band in resting and contraction states to reveal muscle changes. Twenty-four participants (aged 23-57 years) with anterior and posterior neck bands underwent ultrasonography in resting and contracted states. Ten cadavers were studied aged 67-85 years to measure the thickness of the platysma muscle at 12 points: horizontally (medial, middle, lateral) and vertically (inferior mandibular margin, hyoid bone, cricoid cartilage, superior margin of clavicle).

RESULTS

The anterior and posterior borders of the platysma muscle were thicker than the middle of the platysma muscle when in a contracted state, and the muscle also had a convex shape when contracted. The thickness of the platysma muscle was not significantly different over 12 points in the resting state. During contraction, the platysma muscles contracted in the medial and lateral margins of the muscle, which was more significant in the posterior bands.

CONCLUSION

The anterior and posterior platysmal bands are related to muscle thickness during contraction. These observations support the change in platysmal band treatment only at the anterior and posterior border of the muscle.

Surgical Management of Platysma Bands: A Narrative Review of Evolving Concepts and Changing Techniques for Neck Rejuvenation

INTRODUCTION

Platysmal bands are an unappealing feature of the aging face. Incomplete understanding of anatomy and physiology of platysmal bands has led to a long period of flawed or incomplete treatment. This review aims to elucidate the correct study of platysmal bands along with the most recent surgical treatments.

MATERIALS AND METHODS

To identify all articles related to the topic of surgical management of platysmal bands, an extensive search was performed on PubMed and Medline databases for all articles related to platysmal bands from 1990 to 2023. The articles were then reviewed by 2 independent reviewers, and all relevant articles were selected. The search was narrowed down to clinical trials and cohort studies.

RESULTS

6130 articles were identified, of which 21 articles matched the inclusion criteria and were selected for the study totaling 2331 patients. Different surgical procedures were mentioned. Assessment of results was mostly subjective and done by the surgeon.

CONCLUSION

Composite platysma-skin flap repositioning as opposed to wide skin undermining with or without submental incisions is being gradually accepted as a valid approach, with closed platysma myotomy and platysma denervation emerging as effective less invasive surgical modalities. Nevertheless, merits of more extensive procedures involving wide skin undermining and anterior platysma plication must not be lightly forgotten.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Aesthetic Units and Zones of Adherence: Relevance to Surgical Planning in the Head and Neck

Background

Aesthetic units (AUs) and zones of adherence (ZA) have been previously described in the face; however, a systematic classification of AUs and ZAs together with a unified approach to planning surgery has not been previously described for head and neck surgery. The five principles of surgical planning necessitate respect for AUs, ZAs, and flexion creases; correct scar orientation; and replacing tissue "like for like" by adhering to the four "Ts" of reconstruction (tone, texture, type, and thickness of skin and subcutaneous tissue).

Methods

Images of male and female patients and stock images (from iStock) were reviewed and analyzed.

Results

AUs and ZAs were described and tabulated.

Conclusions

Surgical planning necessitates respect for AUs and ZAs and avoidance of maneuvers that will transgress aesthetic unit interfaces or eliminate AUs. An aesthetic atlas of AUs and ZAs is useful for planning surgery, preventing errors, and optimizing aesthetic results.