The deep cervical fascia neck lift

The main and more frequent problem in face lift is recurrence of neck bands. To improve face lift stability, a new aging analysis is proposed. The visible sign of face aging is skin excess. Superficial musculo aponeurotic system (SMAS) retraction is a much less visible sign. Nevertheless, botulinum toxin injections elongate muscles of the SMAS and rejuvenate the face. In the Face Recurve Concept, MRI studies prove the mimic muscles retraction that comes with aging. Face lift techniques include SMAS plication, traction or excision, which increases discrepancy between the envelope, the skin and the core, the SMAS. As skin excision is poorly efficient because performed posteriorly, far from the anterior skin excess located at the medial neck, the association to SMAS retraction exacerbates the gradient difference between envelop and core. This analysis shows that it is paramount to preserve the SMAS. (1) The sub-skin dissection has to be executed moving beyond the marionette fold and the paramedian neck bands; (2) no action is performed on the SMAS, only an horizontal section of the platysma at the hyoid height that will avoid platysma band recurrence. A botulinum toxin injection performed herein just after, blocks muscle regeneration; (3) the skin is pulled backward with a clear posterior transposition to the platysma. The skin at the cervico-mental angle and all along the cervico-mental crease is fixed to the deep cervical fascia, in the gap between the edges of the sectioned platysma, blocking muscle recreation. A resorbable barbed thread is used, with a first bite made at the cervico-mental angle through the deep cervical fascia then in the direction of the mastoid, with long bites through the deep cervical fascia versus short subcutaneous bites. Thanks to this strong shift, the cervico-mental crease is definitely recreated with no need of pre-auricular skin tension. Thirty-two patients have been operated with this technique on a one-year period. The results are a lot more stable and swelling is lowered down to the minimum.

Advances in Face-Lift Surgical Techniques: 2016-2021

BACKGROUND

Face-lift surgery is the most crucial and constantly evolving technique of facial rejuvenation. Periodic reviews synthesizing the latest face-lift techniques may help surgeons sharpen their surgical procedures.

METHODS

A literature search was conducted of the PubMed databases using the search term "face lift" and "rhytidectomy." Articles reporting rhytidectomy of the forehead/brow, midface, lower face, and neck were included. Sixty-nine articles were selected after independent screening by three of the authors. The Oxford Centre for Evidence-based Medicine scale was used for evaluating evidence level.

RESULTS

Of the 69 candidate articles, 10 studies (15%) reported techniques of neck lifting; 10 studies (15%) introduced techniques of endoscopic brow lifting; 7 studies (10%) pertained to brow lifting without endoscopic techniques. The most frequently reported locations of rhytidectomy were the brow/forehead (20%), neck (19%), and face-neck (17%). Additionally, articles regarding Asian face-lifts (14%) have been increasing. The evidence level of the articles was generally low, with only 10 articles assessed as level 1-3 with 59 articles as level 4-5.

CONCLUSIONS

Face-lift articles with high-level evidence are still lacking. Prominently, forehead lifting and neck lifting have become upward trends of rhytidectomy in recent years, and the techniques of short-scar face-lift have been more valued.

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 .

The Three-Triangle Rotation Flap Technique for Aesthetic Ear Lobule Reduction

BACKGROUND

Although the effect of normal aging on the appearance of the ear lobule is well known and defined, this often a neglected aspect of facial rejuvenation. Rhytidectomy offers a great opportunity to surgically enhance the aging earlobe. The objective of this study was to provide a step-by-step description of the execution of the three-triangle rotation flap technique for aesthetic ear lobule reduction.

METHODS

The three-triangle rotation flap technique is described in a step-by-step fashion and illustrated by photographs and videos. All ear lobule reduction procedures that took place at our practice from December 2016 to February 2020 were retrospectively reviewed.

RESULTS

A total of 16 patients underwent bilateral ear lobule reduction during face lift, neck lift, or both, and 7 patients underwent bilateral lobule reduction in isolation. None of the patients experienced complications, and revisions were not performed or required.

CONCLUSIONS

The three-triangle rotation flap technique relies on simple principles that can be adjusted to address all shapes and degrees of true ear lobule ptosis, as well as patient desire. It is employed in isolation or synchronous with rhytidectomy. When performed during rhytidectomy, it provides lobule stability and fixation.

LEVEL OF EVIDENCE V

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 .

Incorporating Midline Platysmaplasty with Lateral Superficial Muscular Aponeurotic System Facelifting

Management of the platysma is key to achieving an ideal neck contour during rhytidectomy. This article reviews platysmal anatomy, indications for platysmaplasty, preoperative patient assessment, surgical technique for midline platysmaplasty, postoperative management, long-term outcomes, and the senior author's experience and philosophy on midline platysmaplasty in the setting of lateral superficial muscular aponeurotic system facelifting.

Less Invasive Superficial Musculoaponeurotic System Approaches in Rhytidectomy: How, When, and Why

As a facial plastic surgeon gains experience, further improvements can be gained with more aggressive surgery, but complications begin to occur when more aggressive measures are undertaken. Therefore, the ideal technique is one that maximizes rejuvenation while minimizing adverse effects. The senior author has found that the aggressive techniques in the region of the neck have improved dramatically the overall initial and long-term results for the neck portion of the rhytidectomy. More aggressive treatment of the midface during the modified deep plane rhytidectomy does not necessarily improve the overall long-term results, however, and can increase the complication rate.

Management of the Submandibular Gland in Neck Lifts: Indications, Techniques, Pearls, and Pitfalls

Neck contour deformities are common among patients who present for facial rejuvenation. A thorough physical examination and photographic analysis, including an upward view of the flexed neck, enable the surgeon to determine which structures should be treated. Common causes of neck concerns include hypertrophy of the subplatysmal fat, the anterior belly of the digastric muscle, and/or the submandibular salivary glands. Partial removal of the submandibular salivary glands requires advanced knowledge of subplatysmal anatomy and surgical expertise but can be performed safely and reliably to yield favorable results of neck rejuvenation.

Hyo-neck lift evolution: Neck lift with fixation of the platysma to the deep cervical fascia

The aim of any neck lift obviously includes the restoration of an acute cervicomandibular angle. The hyo neck lift, first published in April 2016, did proposed a new technique of neck lift with a sub-cutaneous neck dissection and suture of the platysma to the hyoid through this sub-cutaneous approach. To enhance results and efficiency, a major change of the hyo neck lift technique is herein proposed with a vertical anterior sub-platysmal and sub-platysmal fat opening and dissection. This anterior dissection ensures a precise and efficient fixation of the platysma to the deep cervical fascia on direct visual control. This permits to create an horizontal and posterior vector of tension on both platysma and skin, which induces flattening of the submental area and consequently creates or recreates an acute cervicomandibular angle. The sub-cutaneous dissection is no more necessary at the hyoid level. In addition, the posterior border of the anterior platysmal flap is suspended to the mastoid fascia. If necessary, the submandibular gland, through this lateral approach, can be partially excised inside it's capsule, after strong bipolar coagulation. A botulinum toxin injection, realized in early post-op, will definitively stabilize the platysma to deep cervical fascia fixation. Fifteen patients underwent the new technique of neck lift with fixation of the platysma to the deep cervical fascia and suspension of the lateral platysma (Platysma Fixation Platysma Suspension: PF PS) and were evaluated at one year post-op and compared to the results obtained with the first preliminary prospective study "hyo neck lift technique" published in April 2016. As now subcutaneous dissection is limited, recovery is faster. No transient nerve damage happened because dissection planes are designed to be far from nerve branches.

CONCLUSIONS

The simplest way to obtain an acute cervicomandibular angle is to reattach the platysma to the deep cervical fascia along the platysma cords. The new neck lift with fixation of the anterior platysma to the deep cervical fascia and suspension of the lateral platysma, is faster to perform, induces a faster recovery and is safer and more efficient than the subcutaneous hyo neck lift and other described types of anterior platysma plasties.

Discussion-Cervico-Mental Angle Suspensory Ligament: The Keystone to Understand the Cervico-Mental Angle and the Aging Process of the Neck

This is a commentary and discussion in response to a cadaveric study entitled, "Cervico-mental angle suspensory ligament: The keystone to understand the cervico-mental angle and the aging process of the neck." While highlighting the cervico-mental angle suspensory ligament has the potential to give rise to new surgical technique in neck rejuvenation surgery, the authors caution readers of the study's major limitation. Without well-documented results aligning with aesthetic ideals or reports of the safety and longevity of the procedure, it seems too early to consider this ligament the keystone to understand the aging neck. An actual surgical technique must be described and further clinical studies need to be performed before this ligament can be included in the armamentarium of neck rejuvenation surgery. As the goal of surgery should be a natural result that restores aesthetic ideals of the youthful neck, regardless of the significance that this ligament will carry, its application should be tailored to the patient to avoid overly aggressive treatment. Level of evidence V 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 .

Hyo neck lift: Preliminary report

BACKGROUND

The aim of neck lift is to recreate an acute cervicomandibular angle. Surgical neck rejuvenation typically is associated with posterosuperior traction on the platysma (PLA) with an anterior vertical PLA corset or a digastric corset. Medium-term instability can exist with these procedures.

OBJECTIVES

A novel platysmaplasty technique called the hyo neck lift is described and its surgical efficacy is compared with those of previously described techniques.

METHODS

Ten patients underwent hyo neck lift and were evaluated in a preliminary prospective study. Hyo neck lift involved horizontal suturing of the PLA towards the hyoid and then to the skin to recreate a youthful cervicomandibular angle and to place tension on the submental area.

RESULTS

Six months postoperatively, all patients showed improvement in the definition and flattening of the submental area and in ptosis of the submandibular gland. Hyo neck lift is less invasive, without any specific dissection, like in the digastric corset.

CONCLUSIONS

The simplest way to achieve an acute cervicomandibular angle is to reattach the PLA and skin to the hyoid. Hyo neck lift is logical and efficient and produced satisfactory aesthetic and functional outcomes in this preliminary study.

Complications/sequelae of neck rejuvenation

Neck lift surgery performed in isolation or in conjunction with a facelift provides a more youthful cervicomental angle. Complications related to neck lift surgery vary from contour irregularities that may improve with time or conservative measures,to contour irregularities that persist and may benefit from delayed surgical intervention, to expanding hematomas that require immediate surgical intervention. This article reviews complications of neck lift surgery and their etiologies, methods to minimize the incidence of these complications, and management.

Neck skin rejuvenation

The author of this article uses the pulsed ablative CO2 laser for resurfacing of the neck and face, based on the gold standard status of the CO2 laser and a novel post-treatment plan that greatly reduces adverse effects traditionally associated with fully ablative resurfacing. The croton oil peel is an inexpensive and effective modality for rejuvenating neck skin. The use of either technique as an adjunct to neck lift surgery, with or without facelift surgery, permits surgeons to fulfill the expectations of patients who want the skin of their face and neck to be homogeneous and more attractive.

Isolated management of the aging neck

The contour of the neck is a very important determinant of facial aesthetics. Precise knowledge of neck anatomy is essential for adequate planning and execution of this procedure. There are three anatomic and surgical planes involved in the management of the aging neck; the superficial plane (subcutaneous fat), the intermediate plane (platysma muscles and the fat between the two muscles), and the deep plane (subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands). These planes need to be thoroughly evaluated in the preoperative assessment and dealt with according to each patient's needs. Even though this article focuses on isolated management of the aging neck, careful evaluation of the neck and its relationship to the lower third of the face is fundamental. If there is significant jowling and descent of the neck-face interface, an isolated neck-lift procedure will not address that problem and will lead to a suboptimal result. In these patients, a face and neck lift is a more appropriate operation.