Necklift Byrne

Stephen W. Perkins, M.D.*, Rami K. Batniji, M.D.#

*Perkins/Van Natta Center for Cosmetic Surgery, Meridian Plastic Surgery Center, 170 W. 106th Street, Indianapolis, IN 46290, USA. Corresponding author.

sperkins@perkinsvannatta.com

#Batniji Facial Plastic Surgery, 361 Hospital Road, Suite #329, Newport Beach, CA 92663, USA

Introduction
The desire to achieve a more youthful neckline is one of the more common reasons for a patient to seek out facial plastic surgery. At times, the patient would benefit from a proper facelift to address aging changes to the face and neck. However, there are instances when an isolated necklift is indicated. While an individualized approach to the aging neck is prudent to address the variety of issues resulting in the appearance of the aging neck, this chapter will focus on necklift surgery which typically involves cervical liposuction, cervical lipectomy with plication of the platysma muscle anteriorly, and suturing of the platysma muscle to the mastoid periosteum posteriorly to provide a corset platysmaplasty and restore a more youthful neckline.

Anatomy
The platysma is a broad-based, flat, thin muscular sheet that originates from the fascia of the pectoralis major and deltoid muscles; it ascends the neck and inserts on the inferior border of the mandible. Superiorly, the platysma is continuous with the superficial musculoaponeurotic system (SMAS). Posteriorly, the platysma and SMAS are continuous with the sternocleidomastoid muscle fascia. The medial fibers of the platysma muscle are interlaced at the midline, forming an inverted V. The platysma muscle is innervated by the cervical branch of the facial nerve and aids in facial expression by lowering the inferior lip.

With age, the platysma becomes flaccid; however, the medial portion actually becomes fibrous and contracted, resulting in platysmal banding. Dehiscence and excess laxity of the platysma in the anterior neck result in banding. The platysma is covered with a layer of fat; fat deposition may be congenital or acquired. Fat accumulation creates a localized bulging in the submental and submandibular areas.

Finally, collagen and elastin fibers degenerate with time, resulting in redundancy and sagging of skin with subsequent development of horizontal cervical rhytids and further effacement of the cervicomental angle.

Preoperative Assessment
During the initial consultation, it behooves the surgeon to identify the concerns of the patient and whether these concerns may be addressed with a necklift. As such, one must perform a thorough physical examination of the patient. The ideal candidate for a necklift is one who demonstrates a hyoid bone that is positioned superiorly and posteriorly, has a strong chin, and is not obese. If an obese patient presents for initial consultation and plans to lose weight, it would be prudent to entertain a necklift procedure after the weight loss. If the patient demonstrates significant jowls, a proper facelift may be necessary to address this area of concern.

Physical examination includes evaluation of skin including the amount of excess skin as well as the inherent qualities of skin, such as elasticity. One must assess the amount of fat in the submental and submandibular regions. The presence of platysmal banding should be noted. In the submandibular region, the astute surgeon should assess the submandibular glands and whether ptosis of these glands contribute to the full appearance in this region; it is important to note this finding to the patient and the limitations that necklift surgery presents in this unique situation. Whereas some surgeons may elect to perform partial submandibular gland resection, we do not perform this.

A three-way mirror and/or computer imaging facilitates the patient’s understanding of the anticipated outcome from a necklift; however, the surgeon must not overcorrect the neck angle on imaging with respect to the true position of the hyoid bone so as not to convey an unrealistic impression of the outcome from surgery. Imaging may also aid the patient understand the benefit a chin implant or prejowl implant for those individuals with a weak chin or prejowl sulcus, respectively.

Surgical Technique
In the preoperative holding area, the surgical markings for planned incisions and planned undermining are made using a surgical marker (Figure 1). The markings for planned incision starts at the ear lobule and is placed on the posterior surface of the concha rather than within the postauricular sulcus. At the level of the helical insertion or eminence of the concha, the marking is then directed posteriorly with a gentle curve into the hairline but not parallel to the hairline (Figure 2a). If there is significant redundant neck skin and, as such, one plans to remove a significant amount of excessive skin, then the surgical marking is designed so that the incision parallels the hairline prior to extending into the hairline (Figure 2b). The platysmal bands are also marked in the preoperative holding area.

Necklift is typically performed under monitored anesthesia care. The areas for planned incisions are infiltrated with 1% lidocaine with epinephrine (1:50,000) while areas for planned undermining are infiltrated with 0.5% lidocaine with epinephrine (1:100,000).

Initial treatment of the neck involves correction of lipoptosis with liposuction. The extent of liposuction depends upon the amount and location of lipoptosis as determined during the preoperative examination; this may range from liposuction of the jowls, submandibular, and/or submental regions to full neck liposuction. Even patients with minimal cervical fat obtain a better recontouring with the use of liposuction because of the tunneling action of the cannula elevates the submental and submandibular skin and allows better redraping. Using a #15 Bard Parker blade, a 3-4 centimeter submental incision is made; this incision is placed within a submental crease, when present, and is slightly curvilinear so as to avoid extension of the incision to the mandibular rim. Radial tunnels are then made throughout the neck with a blunt-tipped 3 millimeter (mm) suction cannula; no suction is applied at this time (Figure 3a). The tunnels are formed in a fan-like fashion from one jowl the opposite jowl (Figure 3b). Once the radial tunnels are completely formed, the cannula is connected to wall suction and liposuction is performed; the non-dominant hand lifts the tissues into the cannula. The cannula opening is rotated from side-to-side during liposuction; however, the opening is not directed at the dermis so as to avoid dermal injury, subdermal scarring, and subsequent banding. Furthermore, the liposuction cannula is moved quickly in the jowl regions to avoid overzealous liposuctioning and subsequent dimpling. If excessive lipoptosis is present in the submental and/or submandibular regions, a 6 mm suction cannula is used to obtain adequate removal and contouring (Figure 4). Once liposuction is complete, bimanual palpation is required to determine the symmetry of liposuction. A thin layer of subcutaneous fat is required to give supple skin contour (Figure 5).

Once liposuction is completed, the neck flap is elevated with Metzenbaum scissors (Figure 6). Throughout the remainder of the necklift surgery, hemostasis is achieved with bipolar cautery. Then, platysmaplasty is performed with a Kelly clamp technique in the following manner. First, a grasping forceps and a long, curved Kelly clamp are used to grasp loose, redundant tissue in the submentum; this tissue includes not only submental fat (both above and deep to the platysma muscle) but also a small strip of the anterior border of the platysma muscle (Figure 7a). Second, a small segment of the redundant tissue is cauterized with bipolar cautery and cut with Metzenbaum scissors (Figure 7b and c). Third, the anterior edges of the platysma muscle are sutured to each other with 3-0 polyglactin in a mattress fashion (Figure 7d). This process of cauterizing, cutting, and suturing is performed in a stepwise approach until the entire portion of redundant tissue is excised and the anterior edges of the platysma muscle are appropriately sutured. Occasionally, back cuts are made at the most inferior aspect of the platysma muscle to not only avoid banding in these regions, but also facilitate an optimum contour at the cervicomental angle.

The earlobe and postauricular incisions are then made; the incision is beveled in hairbearing regions so as to preserve the hair follicles. Using the Kahn facelift dissecting scissors, the posterior flap is elevated. Non-penetrating towel (Backhus) clamps are placed on the edge of the skin flap; the surgeon holds these clamps to provide posterior counter-traction while the assistant provides anterior traction of the skin flap. The plane of dissection in the hairbearing region is kept deep to the roots of the hair follicles and superficial to the fascia of the sternocleidomastoid muscle. The scissors are used in an advance-spreading motion to achieve flap elevation. This undermining is completed so that it communicates with the undermining that was previously performed through the submental incision (Figure 8).

After undermining of the neck has been achieved, the SMAS and platysma are addressed. The SMAS is incised with a #15 Bard Parker blade starting 2 centimeters (cm) below the earlobe and extended inferiorly along the anterior border of the sternocleidomastoid muscle. One must be cognizant to avoid injury to the greater auricular nerve during this incision; this incision should only include the SMAS and platysma muscle. The SMAS and platysma muscle are then undermined. The degree of this undermining will be dictated by the need for lifting of the platysma muscle to restore a more youthful cervicomental angle; one may assess this by evaluating the result achieved at the cervicomental angle when advancing the SMAS/platysma flap posteriorly and superiorly. When the appropriate effect is achieved, the SMAS/platysma flap is advanced in a posterior and superior direction and sutured with a 0-polyglactin suture to the mastoid periosteum. This posterior treatment of the platysma muscle provides a corset-like effect when done in conjunction with the anterior treatment of the platysma muscle performed earlier through the submental incision. The result is a more youthful cervicomental angle. Redundancies of platysma and SMAS are trimmed and supporting sutures from the SMAS/platysma to the sternocleidomastoid muscle fascia are placed with 3-0 polydiaxanone suture in an interrupted fashion. If significant tension of the flap is appreciated, then 3-0 Tevdek (a braided polyester suture impregnated with polytetrafluoroethylene) sutures are used as well.

Once hemostasis is confirmed, the skin is then closed via incremental cuts and suspension points in the postauricular area with autosuture staples. The first suspension point is at the hairline; attention to the re-alignment of the hairline is important to avoid a step-off in the hairline. Redundant skin is excised. The postauricular incision is closed with staples in the hairbearing region. The excess skin around the earlobe is trimmed so that there is no tension upon the lobule; this maneuver minimizes the risk of a pixie ear deformity. Two 6-0 nylon sutures are placed at the earlobe. A closed system drain is used and exits posteriorly in the hairbearing region. The remainder of the incision, including the postauricular aspect, is then closed 5-0 plain catgut in a running-interlocked fashion. This procedure is then repeated on the contralateral side.

A Bacitracin impregnated nonstick dressing is cut to conform to the postauricular incisions. A light pressure dressing is then applied; care is used to avoid excessive pressure on the postauricular skin flap. Half-inch tan micropore tape is placed over the submental sutures.

Postoperative Care
The patient is placed on Cephalexin for prophylaxis; this antibiotic regimen is started the day before surgery and is continued for five days. During the morning of the first postoperative day, the patient is evaluated and the dressings are removed. Instructions regarding wound care are reviewed with the patient and caregiver. The sutures around the earlobes and in the postauricular regions are cleaned four times a day with a cotton tipped applicator soaked with hydrogen peroxide; the sutures are then covered with petroleum ointment, such as Vaseline. The staples and sutures in the hairline are cleaned with shampoo when the patient showers, starting on the second postoperative day. The patient is instructed to avoid putting hydrogen peroxide and petroleum ointment on sutures and staples that are in the hairline. A chin strap is placed until the second postoperative day. The patient and caregiver are instructed to contact the office if there is any fluctuant swelling that may indicate the development of seroma or hematoma. Otherwise, the patient returns one week after surgery for removal of all staples and sutures, with the exception of the nylon earlobe sutures, which are removed on the tenth postoperative day. Figures 9 and 10 demonstrate results following necklift procedure.

Complications
Injury to the greater auricular nerve during necklift is possible. If this injury is identified intraoperatively, it behooves the surgeon to repair the nerve primarily. This injury may be minimized by following the anterior border of the sternocleidomastoid muscle when making the SMAS/platysma incision.

Seroma and/or hematoma formation may be minimized by avoidance of medications such as aspirin, nonsteroidal anti-inflammatory agents, and certain herbal medications. Likewise, aggressive management of hypertension during the perioperative period, meticulous hemostasis with bipolar cautery, and light pressure dressing also decrease the incidence of this complication. The patient is instructed to contact the office if any fluctuant swelling develops; immediate evaluation of the patient and drainage of fluid collection with an 18 gauge needle will decrease the likelihood of thickened scar in the area of the fluid collection. Scar banding may also develop as a result of trauma incurred to the dermis during liposuction; one may avoid dermal injury by keeping the opening of the cannula away from the dermis. If the patient does develop thickened scar banding, this area is infiltrated with triamcinolone 10 and re-evaluated in three weeks for possible re-injection. Also, the patient is instructed to aggressively finger massage this thickened scar band in the interim.

Other potential complications include a step-off at the hairline and pixie ear deformity. These complications are minimized by proper intraoperative technique, including a tension-free closure of the skin. A cobra deformity results from overzealous submental lipectomy and appears as a central submental concavity. One may avoid this complication by avoiding excessive submental lipectomy. As well, platysma muscle plication at the anterior borders will minimize this appearance. Finally, maintenance of a thin layer of fat on the dermis coupled with avoidance of direct contact of the cannula aperture to the dermis will avoid dermal injury, scar, and subsequent banding that will accentuate this deformity.

For those patients who develop rebound relaxation of skin and soft tissue, return of platysmal banding, and or recurrent/residual submental and submandibular fat, a revision submentoplasty procedure is offered. This revision procedure is performed six months to one year after the initial surgery and is comprised of undermining and redraping of the skin through the submental incision. If there is submental and/or submandibular fat, liposuction may be performed. As well, direct lipectomy, resection of the anterior platysma muscle with midline suturing is performed on an as needed basis, such as the presence of platysmal banding. The same maneuvers are used in submentoplasty as in the primary necklift. Previous posterior tightening creates a stable platform; as such, the surgeon is able to focus exclusively on the anterior cervical deformities via the submental incision. The notable exception; however, is the need to extend a short midline vertical limb from the submental incision, thus creating a T-shaped incision, to allow for better redraping of skin (Figure 9). The wound is closed with subcutaneous 5-0 polyglycolic acid suture and the skin is reapproximated with 5-0 plain catgut in a running inter-locked fashion. Following the revision submentoplasty, the patient wears a chin strap for one week to minimize the risk of postoperative seroma and/or hematoma formation.

Future Considerations
The aforementioned techniques of liposuction, cervical lipectomy with platysma muscle plication and suturing of the platyma muscle posteriorly to the mastoid periosteum to create a corset platysmaplasty effectively results in a more youthful neckline that provides lasting results. While current trends in facial plastic surgery focus on less invasive techniques, such as barbed suture and non-ablative laser therapy, to provide tightening of the neckline, the necklift is a well tolerated procedure with excellent result when performed properly.

Acknowledgements
The authors would like to acknowledge Nancy A. Rothrock for her assistance in the preparation of the digital images used in this article.

Table 1. Treatment Options

1. Liposuction
   • Advantages
     1. Addresses excessive fat
     2. Eliminates the need for large incisions
   • Disadvantages
     1. If done improperly, can lead to dimpling
     2. Does not address wrinking of the skin, ptosis of the muscular sling, or prominent platysmal bands. Inelastic skin fails to redrape properly when liposuction performed as an isolated procedure.
2. Lipectomy with platysma plication
   • Advantages
     1. Addresses excessive fat in submental region
     2. Assists in the development of a more youthful cervicomental angle by not only removing excess fat in the submental region, but also re-approximating the platysma muscle anteriorly.
   • Disadvantages
     1. If too much fat is removed and/or the platysma muscle plication is done improperly, a cobra deformity may result.
3. Posterior approach necklift
   • Advantages
     1. When performed in conjunction with platysma muscle plication, effectively results in more youthful neckline.
     2. Excellent method of removing excess skin.
   • Disadvantages
     1. Will not treat jowling; proper facelift needs to be done.

Figure Legends

Figure 1. Area for undermining and liposuction are demarcated with dashed lines (a). Incision lines are marked out as well; this line extends from the lobule along the posterior surface of the concha and extends into the hairline (b).

Figure 2a. At the level of the helical insertion or eminence of the concha, the marking is then directed posteriorly with a gentle curve into the hairline but not parallel to the hairline.

Figure 2b. This patient demonstrates significant redundant neck skin. In order to address the excessive skin that will be removed, the surgical marking is designed so that the incision parallels the hairline prior to extending into the hairline.

Figures 3. A blunt-tipped 3 mm suction cannula is used to make radial tunnels throughout the neck in a fan-like fashion from one jowl the opposite jowl. Once the radial tunnels are completely formed, the cannula is connected to wall suction and liposuction is performed. The cannula opening is rotated from side-to-side during liposuction; however, the opening is not directed at the dermis so as to avoid dermal injury, subdermal scarring, and subsequent banding. Furthermore, the liposuction cannula is moved quickly in the jowl regions to avoid overzealous liposuctioning and subsequent dimpling.

Figures 4a and b. If excessive lipoptosis is present in the submental and/or submandibular regions, a 6 mm suction cannula is used to obtain adequate removal and contouring.

Figure 5. Preoperative photograph (a) and postoperative photograph (b) following cervical liposuction. Note the improvement upon the cervicomental angle with liposuction alone.

Figure 6. Once liposuction is completed, the neck flap is elevated in the subcutaneous plane with Metzenbaum scissors from just inferior to the jaw line across the submental region to the contralateral jaw line.

Figure 7. The Kelly clamp technique. A long, curved Kelly clamp is used to grasp loose, redundant tissue in the submentum; this tissue includes not only submental fat (both above and deep to the platysma muscle) but also a small strip of the anterior border of the platysma muscle (a). Second, a small segment of the redundant tissue is cauterized with bipolar cautery and cut with Metzenbaum scissors (b and c). Third, the anterior edges of the platysma muscle are sutured to each other with 3-0 polyglactin in a mattress fashion (d).

Figure 8. The plane of dissection in the hairbearing region is kept deep to the roots of the hair follicles and superficial to the fascia of the sternocleidomastoid muscle. The scissors are used in an advance-spreading motion to achieve flap elevation. This undermining is completed so that it communicates with the undermining that was previously performed through the submental incision.

Figure 9. Before (a) and after (b) example of necklift.

Figure 10. Before (a) and after (b) example of necklift.

Figure 11. Revision submentoplasty and creation of vertical limb at submental incision to address redundant skin.

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